Mammogram update

Slide 1

NHU ANH

Mammograms dont look fun but they can save a life! CC LOI NA- NA tm sot- NA chn on- NA theo diBS CK2. L HNG CCKhoa CHA, BNH ViN UNG BU

Hnh v cch nhau 10 nm: nh nhng thay i v k thut nn hnh nh v ngy cng r nt hn. T VN Nh nh (NA) c th thy c ung th v khi kch thc cn rt nh, 2-3 nm trc khi c biu hin lm sng Tm sot ung th v da vo NA v gi thnh thp, nhim tia t, v c nhy tt, d pht hin v iu tr sm ung th v. 1992, MQSA (Mammography Quality Standards Act) c thnh lp nhm m bo mi ph n u c c NA ng cht lng tm sot v theo di. Khng 1 cng c tm sot no t hiu qu 100%, nhng vi nh nh cht lng tt c th t c 85-90%

(Diagnostic Radiology Imaging Physics Course 2008-2009 ) Kv cao Chm tia cng

K thut phim-tm chn u tin p t

Kv thp

Chm tia ph hp

K thut phim-tm chn hin nay

p tt hn

2

NGUY C V LI CH CA NA- Nhim tia trn m v khi chp NA tm sot gim dn theo tui:- 10-19t: 2,95% Sv-1- 20-29t: 0,52% Sv-1- 30-39t: 0,43% Sv-1- 40-49t: 0,20%Sv-1- 50-59t: 0,06% Sv-1- 60-69t: 0,00% Sv-1

Liu tia trung bnh cho m v/ln pht tia 2mGy, gim 30% i vi NA k thut s.

Nguy c ung th v n 45t chp NA 2 bn (2 th/bn) l 0,0055%. Nu chp nh k mi nm t 40t th nguy c ung th v sau 20 nm 10-10,06%

NA ng k thut lm gia tng nguy c ung th v do nhim tia l 6/1.000.000 ph n, tng ng vi nguy c t vong do tai nn xe t khi i vi vn tc 30km/h.

Tm sot 1.000.000 ph n s pht hin 3000 ca ung th v.

T sut ca ung th v khong 50%, nu c tm sot t sut gim cn 40%, tng ng vi 600 ngi (10%) c sng cn nh tm sot ung th v.

C 1 ung th v gy ra (hu qu sau 20-30nm) do chp NA nh k mi nm t 40t th c 300 ung th v c pht hin, 600 ngi sng cn nh NA tm sot

(c.Huda. Review Radiologic Physics, 2nd ed., p.112-113)

GiI HN CA NA- Mc d tm sot ung th l phng tin tt nht pht hin sm ung th nhng khng phi c hi sng ca mi ph n nh nhau.NA c th pht hin cc ung th v rt nh nhng khng phi sau iu tr lun ht bnh hon ton. m tnh gi: 1 trong 5 ung th v. Hay gp /v v qu dy, nht l i vi n tr. Dng tnh gi: NA thy c bt thng nhng thc t khng c bt thng (dng tnh gi) sau khi i chiu vi NA chn on, SA, MRI, thm ch sinh thit. Thng gp n tr, v qu dy, c sinh thit v, c tin cn gia nh, dng oestrogen. Nu c i chiu vi kt qu c s gim 50% dng gi. Chn on v iu tr qu mc

6

CC THNG S K THUT- Hnh1. ly gii khc nhau gia hnh chp vi 100kv v 25kv. Hnh 2. i vi kv thp, s phn bit m m, m tuyn v v ung th xm ln kh d dng, khi kv cng cao (>40kv) khng th phn bit c m tuyn v v ung th xm ln. Hnh 3. S tng phn ca ung th ng tuyn v gim dn khi kv cng tng cao.

123

TI SAO PHI P V? p v lm gim dy ca v ko theo gim s chng hnh trong v. M v c tri rng ra nn d nhn thy sang thng v, to s khc bit r gia m v bnh thng v bt thng p v gip tuyn v c nh lm gim s di ng ca v nn hnh nh c r nt. p v nn Kv xuyn qua v thp, MAs thp, kt qu l gim s hp thu tia X trn tuyn v.

LC P 10-20 Newtons, 22-44 pounds7

8TI SAO PHI P V? S pht tn tia (scatter radiation) lm gim s tng phn ca v, v gia tng theo b dy ca v. Nu khng loi b yu t ny tng phn ch t c 50-70% . Tuy nhin, tuyn v cng c p mng th s kh chu ca ngi ph n cng cao. (c.f.Bushberg, et al. The Essensial Physics of Medical Imaging, 2nd ed., p.209)

Vng vi ha thy c r hn khi p v nhiu hn

AAFPMoi 1-2 nam, t 50-69. N 40-49t co tien can gia nh hay ban than nen c thc hien nhu anh va kham lam sang. ACOGMoi 1-2 nam bat au t 40t, moi nam sau 50t.ACSMoi nam sau 40t. AMAMoi 1-2 nam t 40-49t, moi nam bat au t 50t.CTFPHCMoi 1-2 nam t 50-59t. NIHKhong co e ngh nhat nh cho phu n thap nien 40, ho t quyet nh thi iem ho can thiet chup nhu anh. USPSTFMoi 1-2 nam t 50-69.

AAFP = American Academy of Family Physicians; ACOG = American College of Obstetricians and Gynecologists; ACS = American Cancer Society; AMA = American Medical Association; CTFPHC = Canadian Task Force on Preventive Health Care; NIH = National Institutes of Health; USPSTF = U.S. Preventive Services Task Force.K HOCH TM SOT

NA TRONG CC TRNG HP C BiT

- NA n tr: rt kh c. i vi nhm nguy c trung bnh, chp NA tm sot t 40t.- N tr thuc nhm nguy c cao: MRI v v NA hng nm t 30t, tuy nhin tui bt u tm sot cn c bn bc k vi bnh nhn v cc bs chuyn khoa.

NA sau iu tr bo tn: 6 thng sau khi chm dt x tr. Nhng NA sau c lm mi 6 thng (hoc mi nm) x 2-3 nm v phi c so snh vi NA ny. V cn li vn phi c kim tra nh k. NA sau on nh: V cn li nn chp dnh k mi nm. Nu c phu thut on nh di da, phn cn li phi c chp nh kNu c ti to bng ti n hay t thn khng cn chp NA kim tra nhng c th kim tra bng SA hay MRI

TM SOT UNG TH V CC NC ANG PHT TRIN

Khng th c chng trnh chp NA tm sot cho cng ng v chi ph cao

Kt hp khm lm sng (CBE), siu m v FNA gip pht hin c phn ln cc ung th v c kch thc nh

Lu : Vit Nam nm trong cc nc c ung th v tui tr hn cc nc u M.

Mo m thau quang. Phan can quang thay c tren nhu anh la cac tieu thuy, ong tuyen, va mo lien ket. Ong tuyen co the thay nh mot ong thang pha sau quang vu

GI I PHU V

Tuyen vu tao hat , kho anh gia tren nhu anh.

NA QUY C NA KY THUAT SO

Kho phat hien ung th vu tren cac vu ac. American College of Radiology (ACR) a ra he thong Breast Imaging Reporting and Data System (BI-RADS) xep loai o ac cua tuyen vu thanh 4 loai nham chu y cac nha lam sang rang tuyen vu cang day th kha nang phat hien ung th cang t.NH GI DY V. BI-RADS 2003O 1 (75%)

NH GI S B TR KHI SI TUYN V. BIRADS 2013DNG A: V m hon ton. NA c nhy rt cao.

DNG C: V dy khng ng nht, dng ny c th che khut nhng tn thng nh c cn quang khng cao.

DNG B: C nhng vng khi si tuyn dy.

DNG D: V rt dy, nhy ca NA thp.

20 October 201420

CAC THE CHUP CAN BAN CC Craniocaudal au uoi.MLO Mediolateral oblique - Chech.ML Mediolateral- Trong ngoai. LM- Lateromedial Ngoai trong .

20 October 201421

MLO: vung mu la phan cao cua tren trong

22 (MAMMOGRAPHY LECTURE #1 rev 2010 Positioning & Anatomy)

TH MLO Thy c ton b v/ 1 th chp Thy c ui v, l vng b mt th CC. Khm ph vng sau v khung trn ngoi v, tuy nhin d c hnh nh xon vng trc, trung tm v trong ca v.

PHIM MLO T CHUN nh c ngc ln ngang n nm v Nm v ra ngoi Tuyn v tch ra khi thnh ngc xuyn thu m v va . tng phn v ly gii tt Khng xo nh Tn chiu th nm nch.

PHIM MLO KHNG CHUN Khng d c ngc ln Nghing khng . Khng nhn thy c phn sau ca v (m sau tuyn v). Np gp da che khut m vV nm qu cao hay qu thp trn phim. Khng thy IMF (Mobile Inframmary Fold)

20 October 201423

CC: vung mu la cc tren cua tuyen vu, uoi vu, ra ngoai vu

NH GI TH CC m bo phn v khng thy c th MLO s thy trn CC (phn ln nm vng trong ca v) Nm v nm trung tm hnh. Ly m v pha trong v ngoi nhiu nht c th c Nu thy c c ngc ln # thy y m v Thy c ton b phn sau ca v? (ng PNL/CC (Posterior Nipple Line) trong gii hn 1cm so vi PNL/ MLO) Tn chiu th phi lun nm h nch. 24

Yu im: - Hn ch nhn vng trn, bn v sau ca v - Khng thy c sang thng khi PNL vt qu gii hn 1cm so vi MLO - D to np gp trn da lm che khut m v

20 October 201425MLO t chun:Thy ht m vCNL ngang n nm vCNL rng, i xngNm v ra ngoi IMF thy cPNL trong vng 1cm so vi PNL ca CC

CC t chun: Thy ht m v B trong v thy rNm v ra ngoi v trn ng gia ca phimPNL trong vng 1cm so vi PNL ca MLO

nh gi cht lng phim NA: -P: perfect -G: good-M: Moderate -I: Inadequate

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MT S HNH NH GHI NHN C, C SAI ST V K THUT Np gp da chn v hai bn, che m v vng ny

Tng phn trong khi si tuyn km, c th do p v lng lo hay chm tia khng thch hpThiu c ngc ln hai bn. Tng phn m v kmThiu c ngc ln v IMF hai bn. Tng phn m v km

HAI CHIU TH C BN: MLO v CC c th ly m v, cn phi lu khi chp: Di chuyn phn v di ng (ngoi, di) n phn v c nh (trong, trn) Trnh c s di chuyn ca v khi p v. 28 NHNG L DO LM CHO PHIM NH NH KHNG TSAI LM TN SUTLy c ngc ln khng / MLO22%V nm qu thp trn th MLO14%M v pha sau khng thy c /MLO14%Np da ph ln m v 12%PNL/CC ngn hn PNL/MLO > 1cm10%Lch ngoi hoc trong qu mc/CC6%V nm qu cao trn receptor4%Mt phn ca v b ct ct 3%Vn khc 6%

Chp tm sot MLO bn T khng ng chun vi np gp da chn v IMF (mi tn cong) v ui v (=>). C NL (T) khng thy c n nm v. Kt qu (-). 2 nm sau, sang thng s thy c ngay ti IMF bn T (mi tn cong) b st do chp sai th. Xut hin thm sang thng mi (=>) dng khng i xng bn P. GPB: Carcinm OTV xm nhim

20 October 201430

ML (mediolateral): vung mu la uoi vu va phan sau cua tuyen vu.

20 October 201431

LAM THE NAO E OC PHIM NHU ANH? Chia tuyen vu thanh 4 vung, so sanh tng vung oi xng nhau e khong bo sot ton thng.

M T NH NH THEO BI-RADS 2013DNG PHN B M VA B C DKHIHnh thiBu dc Trn Khng uBRanh gii r B che khut a cung nh - Khng xc nh Gaim M - Thp - Bng - CaoKG I XNGTon b - Khu tr cn pht trinXO TRN CTXo trn nhu m nhng khng tm thy uVI HAHnh thiin hnh lnh tnhNghi ng

a dngTh khng ging nhauNh a dngng thng nh hay c phn nhnhPhn bLan ta Vng m ng ThyC iM KT HPCo ko da Co ko nm v Dy da Ph n - Hch nch Xo trn cu trc Vi ha

CC BT THNG LNH TNH CA V (BIRADS II):1. Nt da2. Hch trong v3. Cc tn thng c cha m:- Tn thng c v bao: bu m, hoi t m hnh thnh nang du, bc sa. - Tn thng m hn hp: hamartm, khi mu t.4. Nhiu khi cn quang trn5. Khi lnh tnh vi ha: - Vi ha th trung tm: bu si tuyn thoi trin- Vi ha ngoi bin: BST thoi trin, nang vi ha vch, hoi t m. - a bu nh vi ha.- Nang lng ng cht canci

CC BT THNG NA C TH C TNH (BIRADS IV):Nhng bt thng nghi ng:- Sang thng c b khng xc nh c- Sang thng c b a cung nh- XTCTV- Tng m vt thi gian- m vi vi ha- Vi ha thay i hnh thi

NHng bt thng c kh nng c tnh:- Khng i xng m v- Khng i xng ng tuyn v- Khng i xng tnh mch- Dy da v m li lin kt- Nm v b co ko hay chuyn hng- Ph i hch

20 October 201439CAC THE CHUP BO SUNG

LMO Lateromedial oblique chech ngoai trong.XCC - Lateral bias - Nghieng ngoai. XCC - Medial bias - Nghieng trong.3. FB - caudo-cranial uoi au.AT axillary tail - Cleopatra.CV - Cleavage view (Twin) - Chup hai vu.RL hay RM rolled view cuon SIO chech t tren ngoai en di trong.TAN Tiep tuyen.Spot (coned) compression chup khu tru.M - Magnification - Phong ai.Sponge Chup vi vat chem.ID implant displaced tui nc.

20 October 201440

1. LMO Lateromedial oblique chech ngoai trong.

Chup LMO kho do: pacemaker, phau thuat long ngc, xng c nho cao.

20 October 201441

2. XCC - Lateral bias - Nghieng ngoai. XCC - Medial bias - Nghieng trong.

Chup lech ra ngoai hay trong e thay c sang thng.

20 October 201442

20 October 201443

CCFBVu nho Nam gii Gu, hay co pacemaker Phong to cac sang thng nho di. Tm cac sang thng nam qua cao

FB (From Below)

20 October 201444 THE AT (Axillary tail) (CLEOPATRA): Sang Thng Vung uoi Vu.

20 October 201445

CV ( valley view, medial view): sang thng rat sau hay trc thanh ngc.

20 October 201446Spot (coned) compressionCHUP KHU TRU.

20 October 201447TAN - TIEP TUYEN

Khu tru cho da.

20 October 201448

M magnification - Phong ai

20 October 201449ANTEROPOSTERIOR VIEW Chest wall viewANH GIA THANH NGC, VUNG SAU TUYEN VU, HO NACH.

20 October 201450

ID implant displaced - Tui nc.

TN THNG TRN NACc tn thng trn NA c th n c hay kt hp vi nhau, bao gm:Dng khiDng viDng xo trn cu trcDng khng i xng m -Cc trng hp c bit-Cc tn thng i km

I. Dng khi: v tr, kch thc, hnh thi, ng b, m V tr: khung hoc 12gi; su 1/3 truc, gia, sau (khng bao gm vng trung tm v ui v).Hnh thi: Trn, bu dc, a cung hoc khng u. Kh nng c cng cao khi hnh thi cng khng u. Kch thc: ng knh ln nht ca khi (c v khng c gai) .- S lng: khi n c gii hn r hoc c to gai nhiu kh nng c tnh . Nhiu khi gii hn r thng lnh tnh, ngoi tr di cn. B: l mt phn cch gia sang thng v m chung quanh: u, a cung nh, b che khut (bi m chung quanh), khng xc nh c, gai.

Dng khi: v tr, kch thc, hnh thi, ng b, m

*B u thng lnh tnh nhng mt s t ung th v cng c th c b u: Car. Dng ty, nhy, trong nang, di cn, lymphm, sarcm. B a cung nh c th do ung th hay bu si tuyn, nangB gai hay kh xc nh: kh nng c rt cao (>95% b gai l ung th v), mt s b gai lnh tnh: so sau m, hoi t m, mu t, vim hay p-xe, vim to ht hay bnh si. m : cao (kh nng c) hay thp (kh nng lnh) hn m v, m m (lnh tnh: hot t m, hamartoma, bc sa, nang du, bu m). * Halo quanh khi hnh thnh do hiu qu khi gi lnh tnh nhng khng c hiu, c th thy trong car. trong nang, ung th v pht trin trn nn bu si tuyn.

FABI-RADS III

BI-RADS V

BI-RADS IV

Car. OTV hai bn

MOT SO HNH ANH IEN HNH LANH TNHHAMARTOM: xuc xch boBU MHACH LANH TNH: ron hach

BI-RADS II

HAMARTOM

BOC SA

Nang dau: mc dch dch cua m va nc

KHONG THE PHAT HIEN BENH LY

II. Vi ha: thng thy c/NA. Bn cht lnh hay c ca vi c th bit da vo hnh thi (kch thc, m , hnh dng), s phn b (ri rc hay thnh m) v sp xp (ng thng hay thy).

1/. Vi ha lnh: thng to hn, th, b nhn, d nhn thy hn vi ha c tnh. Vi ha lnh tnh in hnh bao gm vi ha ca da (thu quang trung tm), mch mu (ng //), dng bp n (bu si tuyn thoi trin), dng que to ( ng cht tit), vi trn (0,5-1mm ca tiu thy), vi ha vin (vi vch nang), sa canci vi ha (cn nang), hay vi nh (vi gii hn r, 0% nhng < 2%Theo di mi 6 thng/2-3 nm nu tn thng khng thay i BIRADS 2. (tui cao hay nhm nguy c c th lm sinh thit li trc khi theo di nh k d gii hn rt r). Nu tng kch thc BIRADS 4 hay 5 4C bt thng nghi ng c tnh, vi nguy c ung th 2-95%- Tn thng mang c im lnh tnh nhng gia tng kch thc.Tn thng khng th xp vo nhm 2,3 Tn thng trung gian hay khng hi tiu chun ca nhm 2,3 2 - 95% 4a. Nghi ng thp (>2% - 10%)4b. Nghi ng va (>10% - 50% - < 95%) Sinh thit

LOI BI-RADSKh nng c tnh (%)Khuyn co 5Rt nghi ng ung thNA: Nhiu dng bt thng nghi ng hay rt nghi ng kt hp nhau: nt m rt cao, b nhiu cung nh, gai, vi vi ha a dng SA: Tn thng c vi c im c cao hoc rt cao: halo (+), dy > ngang, b khng u hay to gc, gim m khng u, khng di ng>95 %Sinh thit 6Ung th c chn don100%iu tr

TH CHP NAChp tm sot MLO bn T khng ng chun vi np gp da chn v IMF (mi tn cong) v ui v (=>). C NL (T) khng thy c n nm v. Kt qu (-). 2 nm sau, sang thng s thy c ngay ti IMF bn T (mi tn cong) b st do chp sai th. Xut hin thm sang thng mi (=>) dng khng i xng bn P. GPB: C. OTV xm nhim



BIRADS 2013 = BIRADS cho NA v SAThng thng, khong 10-20% ung th v khng th nhn thy c trn NA, t l ny l 40-50% i vi m v dy.

C nhiu yu t nh hng n dy v: tui, mc ni tit, di truyn, tui mang thai u tin, s ln mang thai, dng ni tit thay th, bo ph. Theo NCI , nhy ca NA khang 75% trong 54% - 58% vi n 65t

Bads US trang 137, mammo 95-101

TH CHP NABads US trang 137, mammo 95-101



KHUYN CO CA ACS (AMERICAN CANCER SOCIETY ) TM SOT UNG TH V N 40t nn chp NA mi nm cho n khi sc khe vn cn tt. Mt s iu cn luu : + NA c th khng thy 1 s ung th nn cn phi so snh vi cc NA trc + D c gii hn nhng NA l cng c hiu qu gim t vong ca ung th v. - N 20t, 30t nn c khm lm sng mi 3 nm , t 40t khm mi nm.N trn 20t nn bit cch t khm v, nhn v cm nhn c nhng thay i trn v /v nhm nguy c cao: ( nguy c > 20-25% ,bn thn hay quan h 1 th h c gene BRCA1, BRCA2, tin cn x tr vo ngc lc 10-30t) CHT v NA, CBE mi nm t 30t . Khng khuyn co dng CHT v nh k cho nhm nguy c ). C: phng to khu tr

CH NH MRI V- N c chn on ung th v: o kch tc u chnh xc, tm ung th a hay a trung tm v v i bn.N nhm nguy c cao: MRI kt hp vi NA nh k, khng khuyn co ch dng MR n thun tm sot. Bads US trang 137, mammo 95-101

CNG HNG T

35% ung th khng pht hin c bng NA tm sot, SA b sung thm 30% trng hp. CHT l cng c h tr chn on quan trng ca hnh nh hc tuyn v

Phi kt hp chui xung huyt ng hc v chui xung v hnh thi T1 v T2

CH NH CNG HNG T

Tuyn v dy thng gp n tr hay do cc thay i si bc m NA v SA khng pht hin ra bt thng nhng trn lm sng c khi bt thng s thy c.

Khuyn chp i vi Bi-RADS 3, 4; di cn hch nch; ti nc phc tp

xc nh lan rng ca mt ung th bit, a , a trung tm. L phng php nhy v c hiu dng nh gi ti ch ca ung th v.

Phn bit so phu thut v khi ti pht bnh nhn iu tr ung th v, nh gi p ng vi ha tr

NA bt thng (BI-RADS 3,4,5) nhm nguy c cao.

theo di sau tn ha tr, phn bit so hay ti pht sau iu tr

M T NH NHS B TR M VM hon tonNHng vng phn tn ca khi si tuynDy khng ng nht, c th che khut khi vRt dy, nhy ca NA km. KHIHnh thiBu dc Trn Khng uBRanh gii r B che khut a cung nh - Khng xc nh Gaim M - Thp - Bng - CaoKG I XNGTon b - Khu tr cn pht trinXO TRN CTXo trn nhu m nhng khng tm thy uVI HAHnh thiin hnh lnh tnhNghi ng

a dngTh khng ging nhauNh a dngng thng nh hay c phn nhnhPhn bLan ta Vng m ng ThyC iM KT HPCo ko da Co ko nm v Dy da Ph n - Hch nch Xo trn cu trc Vi ha

M T SIU MTHNH PHN VM ng nhtSi tuyn ng nhtKhng ng nht. KHI

Hnh thiBu dc Trn Khng uBRanh gii r B che khut a cung nh - Khng xc nh GaiTrcSong song Khng song song hi mEcho trng Echo dy- Nang phc tp/ c echo km ng echo Khng ng nhtm pha sauKhng i Tng Gim Kiu kt hpVI HATrong u Ngoi u Trong ngC iM KT HPXo trn cu trc Dn ng Dy da Co ko da Ph n da Mch mu (khng c, trong, rim) n hiTRNG HP C BiTNang on gin Chm nang nh - Nang bin chng Khi trong hay trn da D vt (bao gm ti n) Hch trong v AVM Bnh Mondor T dch sau phu thut Hoi t m.

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Mammogram update