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Breast ImagingMedical School Lecture
November 18, 2015Susan Peddle, MDAssistant ProfessorUniversity of Ottawa
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Disclosure
You may only access and use this PowerPoint presentation for educational purposes. You may not post this presentation online or distribute it without the permission of the author.
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Overall Objectives
• Review the background and evidence supporting the use of screening mammography, ultrasound (US) and magnetic resonance imaging (MRI)
• Describe Canadian population‐based screening programs, their performance indicators and their costs
• Provide an overview of mammographic abnormalities and their work‐up
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• Screening versus Diagnostic mammography
• BI-RADS
• Review of mammographic abnormalities that warrant further work-up
• Diagnostic work-up
• Features of benign versus malignant lesions on ultrasound
• Breast Intervention
• Role of MRI in breast imaging
• Current recommendations for breast screening
Objectives
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• Screening versus Diagnostic mammography
Objective 1
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• Screening MG: to find cancers smaller than those detected at BSE or CBE
Sensitivity of BSE: Unknown
Sensitivity of CBE: Unknown
Sensitivity of screening MG: 75-90%
• Diagnostic MG: to further evaluate a screen detected abnormality, symptom or clinical finding
Pain
Palpable lump
Nipple Discharge
Others (skin changes, nipple inversion, shrinking breast, enlarging breast)
Screening MG versus Diagnostic MG
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pectoralis muscle
inframammary fold
lymph node
fat
glandular tissue
vessel
skin
Cooper’s ligaments
subareolar lactiferous
ducts
Mammographic Mammographic AnatomyAnatomy
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Typical Mammography Unit
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Routine Mammographic Views
CC
MLO
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MLO CC
Upperquadrant
Lowerquadrant
Outerquadrant
Innerquadrant
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12:00
9:00 3:00
6:00
MedLat
O’clock Position used for Localization
6:00
3:009:00
12:00
Right Breast Left Breast
Med Lat
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Technical Limitations
• Breast Density
• Patient anxiety, discomfort, physical limitations
• Post-therapeutic changes
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Breast Density
fatty replaced0-25%
scattered25-50%
heterogeneous50-75%
extremely dense
75-100%
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• BI-RADS
Objective 2
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BI-RADS
• Breast Imaging Reporting and Data System
• Helps achieve uniformity in breast imaging reports which improves their clinical utility by communicating findings in a standardized way
• Help determine clear management
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• 0: Needs further evaluation
• 1: Normal
• 2: Benign finding
• 3: Probably benign
• 4: Suspicious abnormality
• 5: Probable cancer
• 6: Biopsy proven cancer
BI-RADS
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• 0: Needs further evaluation - additional mammographic views, +/- US, +/- MRI
• 1: Normal - Return to screening
• 2: Benign finding - Return to screening
• 3: Probably benign - > 98% likelihood of being benign. Short interval follow-up recommended in 6 months.
• 4: Suspicious abnormality - Biopsy needed
• 4A - 10-50% likelihood of being malignant
• 4B - 50-95% likelihood of being malignant
• 5: Probable cancer - Biopsy and surgical consultation needed (> 95% likelihood of being malignant)
• 6: Biopsy proven cancer
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• Review of mammographic abnormalities that warrant further work-up
Objective 3
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4 Main Mammographic Abnormalities
• Microcalcifications
• Architectural distortion
• Mass
• Asymmetries
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Microcalcifications
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Microcalcifications• Microcalcifications can be an
indicator of cancer, although they are often benign
• Detected mammographically
• Characterized by morphology (appearance), distribution, and change over time
• Analysis helps radiologist determine the likelihood of underlying benign versus malignant pathology
image
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Terminal Ductal Lobular Unit (TDLU)
• Basic functional unit in the breast
• Consists of 10-100 acini that drain the terminal duct
• Terminal ducts drain to larger and larger ducts, and eventually to the nipple
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TDLU - site of origin of most cancers
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Lobular Calcifications- form in acini -
Intraductal Calcifications- form in ducts -
Almost always benignSuspicious for malignancy
Due to calcified cellular
debris or secretions
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Skin
Vascular
Coarse or “Popcorn”
Rim or “Eggshell”
Benign Calcifications
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Fine Pleomorphic
“Variable in size, density and shape”
Suspicious Microcalcifications
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“Thin, linear or curvilinear irregular”
Fine linear or branching
Suspicious Microcalcifications
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Architectural Distortion
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Architectural Distortion
• Normal architecture is distorted with no definite visible mass
• Look for abnormal straight lines or spiculations radiating from a point
• Differential diagnosis:
• Carcinoma vs scar tissue
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Right - recurrence with IDC Left - IDC
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Right - recurrence with IDC Left - IDC
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Mass
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Mass• A space occupying
3D lesion seen in two different projections
• 3 important descriptive terms:
• Shape
• Margin
• Density
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•Benign features
• Round or oval
• Circumscribed
• Low density
•Suspicious features
• Irregular
• Microlobulated, indistinct, spiculated
• High density
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Typically Benign
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Typically Malignant
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Asymmetries
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Asymmetries• Unilateral deposits of
fibroglandular tissue with NO mirror-image correlate in the opposite breast
• A discrete mass is not seen on the initial MLO and CC views
• True pathology versus overlapping normal tissue?
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Asymmetry
??
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Rt MLO Lt MLO
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Focal Asymmetry
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Global Asymmetry
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Objective 4
• Diagnostic work-up
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“Work-up”
• Refers to additional testing required to determine the origin of an imaging or clinical abnormality
• Comprised of additional mammographic views, US, MRI and/or biopsy
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Abnormal Mammogram
Additional mammographic views
? True abnormality
+/- Ultrasound
? Mass
+/- Biopsy
? Suspicious
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• Straight lateral or 90 degree view
• Coned compression views
• Magnification views
• Pinched (Eklund) views
• Rolled view
• Extended CC view
• Cleavage view
• Tomosynthesis
Additional Mammographic Views
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Magnification Views • Performed for better characterization of microcalcifications
• Focal spot = 1.6 times
• 2 views: CC and straight lateral (90 degree)
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Magnification ViewLt MLO
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Coned Compression Views
• Performed to differentiate normal overlapping parenchyma from a true abnormality
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Coned Compression
Lesion does not persist on coned compression views in keeping with normal
fibroglandular tissue
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Lesion persists on coned compression views in keeping with a true lesion
Coned Compression Views
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Ultrasound confirms the presence of a mass suspicious for malignancy
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Tomosynthesis
• - New technique created to produce a 3D picture of the breast using X-rays
• - Designed to reduce overlapping tissues in mammography
• - Results in high-resolution images at mammographic doses
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Breast
Reconstructed planes
2D 3DTomosynthesis
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Stationary breast
platform
X-ray tube swings during
tomo
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QuickTime™ and a decompressor
are needed to see this picture.
Tomosynthesis
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• Ultrasound features of benign versus malignant lesions
Objective 5
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Ultrasound
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Benign vs Malignant Features
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Simple Cyst
• Always benign
• Features:
• Anechoic (black)
• No wall
• “Through transmission”
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Ultrasound Features of Solid Masses
Classic maligna
nt
Classic benign
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Benign Breast Lesions
• Well circumscribed - doesn’t invade
• Wider than tall - obeys normal tissue planes
• Thin echogenic pseudocapsule - compresses adjacent tissue
• Gentle macrolobulations
• Intensely echogenic - contains fat
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• Angular margins
• Spiculations
• Microlobulations
• Taller than wide
• Posterior shadowing
• Ductal extension/Branch pattern
• Microcalcifications
Malignant Breast Lesions
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Margins: Angulated
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Margins: Microlobulated
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Ductal extension
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Shadowing
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Can we make the diagnosis of cancer based on ultrasound
features only?
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Case 1: 83 yo, palpable mass medial left breast
Case 2: 88 yo, palpable mass UOQ left breast
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Case 1: 83 yo, palpable mass medial left breast
Case 2: 88 yo, palpable mass UOQ left breast
Cancer Fibroadenoma
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Invasive ductal carcinoma Involuted calcified
fibroadenomas
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Always start with a MG in women 35
years old and greater!
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• Breast Intervention
Objective 6
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• Tissue diagnosis mandatory for diagnosis of breast cancer
• In the US, 1 million breast biopsies are performed annually to diagnose 200,000 breast cancers
• Avoids unnecessary benign surgical excisions and allows surgeons to plan appropriate surgery in the setting of cancer
• Extremely beneficial for patients and for the health care system in general
Breast Intervention
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• How do we perform breast biopsies?
• Ultrasound guided biopsy
– Solid and complex solid-cystic masses
• Stereotactic biopsy
– Suspicious or indeterminate microcalcifications seen on MG
– Persisting suspicious asymmetries on MG with no sonographic correlate
• MRI guided biopsy
– Lesions identified only on MRI with no mammographic or sonographic correlate
Breast Intervention
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Ultrasound Guided Biopsy
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FNA(uncommon
) CNB VAD
Core Needle Biopsy
Fine needle aspiration
Vacuum-assistedDevice
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Core Biopsy
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Vacuum Assisted Biopsy
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Stereotactic Guided Biopsy
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Technique
• Scout image taken to locate lesion in biopsy window
• “Stereo Pair” obtained after moving x-ray tube +15° and −15° relative to 0° position
• X, Y and Z (depth) coordinates calculated by computer
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Specimen radiograph confirms microcalcifications in the
specimen
Final diagnosis: DCIS
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Pre biopsyPre biopsy
Post biopsyPost biopsy
Persisting focal asymmetry
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Deploy marker clip at the site of biopsy
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Preoperative Image Guided Localizations
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• Pre-operative localization is used to ensure complete excision of nonpalpable breast lesions
• Localization device is inserted pre-operatively using mammographic or ultrasound guidance
• Helps guide the surgeon in the OR, improving clear margin and breast conservation rates
Preoperative Image Guided Localizations
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MG or Ultrasound Guidance
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46 yo - Multifocal Disease UOQ
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2 wires inserted to guide surgical
excisions
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Radioactive Seed Localization
• Low-dose I125 titanium prostate seed is placed at the target using mammographic or ultrasound guidance
• Surgeon uses radioactivity probe to localize, dissect and remove breast lesion
Image courtesy of The Mayo Clinic
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Post-procedure mammogram
confirms accurate seed
placement adjacent to clip
X-ray of lumpectomy specimen to
confirm excision
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• Role of MRI in breast imaging
Objective 7
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• MRI has a high sensitivity
• Main roles include:
– High risk screening:
– BRCA 1 and 2 mutation carriers
– > 25% lifetime risk of developing breast cancer
– Radiation to anterior chest wall for treatment of lymphoma
– Local staging of breast cancer
– Assess response to chemotherapy
– Problem solving
Role of MRI in Breast Imaging
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43 yo – BRCA1 carrier
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Baseline Screening MRI
Bilateral breast cancer not seen mammographically
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Left breast
Clinical: • Upper outer quadrant • Palpable abnormality
MG: • Pleomorphic microcalcifications (BI-RADS 5)
Stereotactic Biopsy:
Final diagnosis: DCIS high grade
CC MLO
Local Staging with MRI
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MRI: • Non mass enhancement (arrow) • Additional retroareolar mass (circle) for which US guided biopsy was performed
Mastectomy and SLNB wereboth performed
Final pathology: Invasive ductal carcinoma and ductal carcinoma in situ (DCIS)
(Total extent 8.0 cm)
2 min C+
2 min C+
2 min MIP
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January 2012 July 2012
Post 6 cycles of chemotherapy
Assess response to chemotherapy with MRI
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• Current recommendations for breast screening
Objective 8
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– Who should have mammograms?
– At what age should screening be initiated?
Current Recommendations for Screening
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Benefits of Screening Mammography
• - Reduction in breast cancer mortality by 40%
• - Lower rate of mastectomy, radiation therapy and axillary lymph node dissection
• - Less expensive treatment and less time off work
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Limitations of Screening
Mammography...”Harms”• False Negatives
• 10-20% of breast cancers are only detected at breast self-exam or physical exam
• False Positives
• Only 5-40% of lesions are detected at screening and recommended for biopsy
• Over-diagnosis
• 11% of cancers found never progress
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• Asymptomatic women 40-49 years - Annual screening MG
• Asymptomatic women 50-74 years - Every 1-2 years
• Women over 74 years - Every 1-2 years, if in good health
CAR Guidelines – Screening Mammography
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When to Start Screening?
• - CTFOPH recommends screening women 50-74 and having a discussion about screening with women 40-49
• • - OBSP screens women 50-74
• - Canadian Association of Radiology, American Cancer Society, National Comprehensive Cancer Network, American College Radiology, College Obstetricians and Gynecologists, recommend screening women 40-74 +
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Should I Screen after age 74?
• - For all ages, the mortality benefit from mammographic screening begins to be seen 5-7 years after the onset of screening
• - Mammographic screening can be continued as long as there is reasonable expectation of a life expectancy of at least seven years
• - Average life expectancy for an 80 year-old woman is 8.6 years which means that the healthiest quartile can be expected to live considerably longer
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What is the Chance of Developing Cancer between 40-50 years old?
• - 1 in 69 women will be diagnosed with invasive breast cancer in their 40s
• - Breast cancer is the leading cause of cancer death in women < 50 years
• - There is a very low incidence of breast cancer below age 30
• There is no abrupt change at age 50
Annual U.S. breast cancer incidence rates
per 100,000 women as a function of age for invasive + in-situ
cancers
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Numbers of Breast Cancers by Age
SEER, 2010, http://seer.cancer.gov/csr/1975_2007/
77% > 50 years
18% 40 - 49 years
• 5% < 40 yrs
• 18% 40-49 yrs
• 23% 50-59 yrs• 26% 60-69 yrs• 28% 70-79 yrs
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No Role for Screening with
Ultrasound
• Average risk women - Screen with mammography
• High risk patients - Screen with mammography and MRI
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• Screening versus Diagnostic mammography
• BI-RADS
• Review of mammographic abnormalities that warrant further work-up
• Diagnostic work-up
• Features of benign versus malignant lesions on ultrasound
• Breast Intervention
• Role of MRI in breast imaging
• Current recommendations for breast screening
Objectives
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Thank you