In The Nam of God

Role of imaging in diagnosis early breast cancer Dr. Mehri Sirous

* IMAGING * The standard techniques used for breast imaging are: Screen film x-Ray mammography. Real-Time ultrasound. Other new techniques include:

MRI Color Doppler Contrast ultrasound Digital Mammography Scintimammography

Mammography can find abnormalities between one and three years before they can be felt. Because the inherent attenuation differences between normal & diseased breast tissues is so small , high quality mammography required.

False Negative Rate is 5-10% Mammography Although mammography is the most sensitive exam available for detecting small breast ca. False Negative Rate is 5-10%

Breast cancers are most likely to develop in dense tissue, where they are most difficult to detect. Mammograms can result in false negative readings (particularly in younger women, who have dense breast tissue) or false positive readings

False negative rate ↓ * Clinical history and examination * Combination imaging Mammography standard views supplementary mammographic views Local compression views magnification views ultrasound * Needle biopsy * F.N.A.C * Or core biopsy

Review of old films : If old films are available, comparison is important to search for any changes. It is a good idea to compare studies that are of least 2 years apart.

Mammography tests are not perfect. Only the part of the breast that extends from the body can be imaged. This makes it easier to get an accurate picture of a larger breast than a smaller breast ! It also may be difficult to detect abnormalities that exist in the breast tissue adjacent to the chest wall.

Up to 20 percent of breast cancers are missed by mammograms, according to the National Cancer Institute

Full-field digital mammography (FFDM). Recently approved by the U.S. Food and Drug Administration (FDA), this technique involves taking digital images of the breast. Digital images are captured electronically and can be viewed on a computer. Their magnification, brightness and contrast can be adjusted and enhanced to better reveal abnormalities.

Advantages to having digital mammography Elimination of process or artifacts Contrast enhancement Ability to perform invasive procedures faster Potentially better resolution of breast tissue for women younger than 50 years Reduce examination time for patients Increased production of examinations Images are immediately available

Digital Mammography Detected up to 28% More Cancers in Certain Groups: • Women under the age of 50 • Women with heterogeneously dense or extremely dense breast • Women that are premenopausal or perimenopausal

Greater Access • The mammogram can be read where ever the radiologist is located • This also allows for physicians to consult with their peers

Review of Prior Images Before Procedure

BIRADS classification

Incomplete assessment Category 0: Additional imaging evaluation and/or comparison to prior mammograms needed. Possible abnormality may not be completely seen or defined and will need more tests, such as use of spot compression, magnification views, special mammogram views or ultrasound.

Complete assessment Category 1: Negative No significant abnormality to report. Breasts appear the same (symmetrical) with no masses, architectural distortion or suspicious calcifications. Category 2: Benign (Noncancerous).Also a negative mammogram, but with description of a finding known to be benign, such as benign calcifications, intramammary lymph nodes or calcified fibroadenomas. This ensures others viewing the mammogram will not misinterpret benign finding as suspicious.

Category 3: Probably benign - follow-up suggested, Findings have a very high probability (greater than 98%) of being benign. Findings are not expected to change. Follow-up with repeat imaging usually done in six months and regularly thereafter until finding is known to be stable (usually at least two years). Procedure helps avoid unnecessary biopsies while allowing for early diagnosis of a cancer should suspicious area change.

Category 4: 4A: finding with low suspicion of being cancerous Suspicious abnormality - biopsy suggested Findings could be cancer, with sufficient concern to recommend biopsy. Findings in this category have a wide range of suspicion levels. Some – though not all – physicians may divide category further: 4A: finding with low suspicion of being cancerous 4B: finding with intermediate suspicion of being cancerous 4C: finding of moderate concern of being cancerous, but not as high as Category 5

Category 5: Highly suggestive of malignancy – appropriate action necessary .Findings look like and have high probability (at least 95%) of being cancer. Biopsy is strongly recommended. Category 6: Confirmed Malignancy – Appropriate Action Should Be Taken .Used for findings on mammogram already determined to be cancerous by a previous biopsy. 

Breast ultrasound At the minimum, a 7.5 MHZ linear array probe should be used The original role of breast sonography is in the differentiation of cystic and solid lesions The role of ultrasound complements both clinical examination and mammography Ultrasound plays an important role in the triple assessment of symptomatic lesions the dense breast

It is the examination of choice in young women and is valuable in the assessment of mammography ‘ dense’ breast

BIRADS 1 Sonographically normal tissue that cause mammographic or clinical abnormality. BIRADS 2 Benign entities (intramammary LN, ectatic duct ,simple cyst ,definitively benign solid such as lipoma) BIRADS 3 Probably benign(<2% risk) complex cyst ,small intraductal papilloma ,fibroadenoma) BIRADS 4a Mildly suspicious(3%-49% risk) BIRADS 4b Moderately suspicious(50%-89% risk) BIRADS 5 Highly suspicious( >90% risk )

Management Rules BIRADS 1 ,2 Routine screening BIRADS 3 Three choices short interval sonographic F.U image guided needle biopsy surgical biopsy BIRADS 4a ,4b,5 Require biopsy

Imaging – guided practical procedures The type of imaging chosen depends principally on which method (ultrasound or mamography) shows the lesion clearly. Ultrasound is used for cysts and most soft – tissue lesions Mammography is used for microcarcification and for soft – tissue lesions that are not seen or are poorly visualized on ultrasound particularly distortions

Ultrasound – guided procedures Cyst aspiration (simple cysts with symptoms) Abscess aspiration (simple, unilocular abscess) Ultrasound – guided FNAC (solid lesions) Ultrasound guided core biopsy (small solid lesions)

Mammography – guided procedures Stereotactic – guided FNAC or core biopsy Preoperative localization of non – palpable lesions.

Indication for breast MRI Breast MRI is the technique of choice in the differentiation between postoperative scarring and local recurrence It has an important role in the assessment of the indeterminate mass because of its very high sensitivity for malignancy though at present, core biopsy is a more cost – effective approach.

Indication for breast MRI It is very accurate in the local staging of breast cancer in difficult cases (very dense breasts, mammographically occult tumours, suspected multi- focality or multicentricity and suspected chest wall involvement). It is the technique of choice in the evaluation of implant integrity and detection of cancer in the augmented breast. It is also accurate in the differentiation of axillary recurrence and brachial plexopathy post radiotherapy.

Indication for breast MRI Breast MRI appears highly accurate in the assessment of response to neoadjuvant and primary chemotherapy, predicting ulti- mate response before changes in tumour volume and differentiating between residual tumour and fibrosis. The place of breast MRI in screening high-risk patients has yet to be established

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