1. Breast Histopathology : Mammography
I have designed a series of articulate modules to provide you with content to help you meet the block's objectives dealing with breast disease. 
Each articulate module is designed for 10 to no more than 30 minutes.
Each module contains review questions for you to answer.
We will start with normal breast structure and proceed through the objectives dealing with Pathologic Changes of The Breast.
   
Good listening Med 2s.
Dr. Charles Hitchcock, MD, PhD

2. Mammographic Screening
Primary Learning Objective
Discuss the identification and management of individuals at risk for breast cancer
Secondary Learning Objective
Discuss the use and significance of mammography as a tool for breast cancer screening
Discuss issues related to breast cancer screening
This Articulate Module addresses the following learning objectives as they pertain to mammographic screening for breast cancer
Discuss the use and significance of mammography as a tool for breast cancer screening
Discuss issues related to breast cancer screening
Answer these two questions.
Why is the diagnostic accuracy of this test improved with advancing age?
What is the significance of densities and calcifications in mammography?

3. Mammography remains the Gold-Standard, First-Line Breast Imaging Screening Modality
Screening Mammography
Asymptomatic patient
Negative clinical breast exam
Starting at age 40; annually thereafter
Diagnostic Mammography
Symptomatic patient
Suspicious findings on clinical breast exam

4. Mammographic Screening for Breast Cancer
This is a figure from an article in the Huntsville (Alabama) Times.
It clearly demonstrates that the mortality rate from breast cancer has significantly decreased since 1990.
This decrease is due to both the use mammographic screening of women leading to early detection of cancer and improved treatment regimens for women with breast cancer.

5. Warner, E. Breast Cancer Screening New Eng J Med 365, 1025-1032, 2011.
This table demonstrates that the current guidelines for screening mammographies varies with the organizations making the guidelines.
Each guideline agrees that women between the ages of 50 and 69 should be screened; however, whether or not it is every year or every other year varies.
In the 50 to 69 age group, mammography has been reported to reduce breast cancer-related deaths by up to 30%.
For women 70 years or older, the decision about screening should be individualized. Consideration must be given to co-morbidities.
For of women between 40 and 49 years of age , the decision about screening should be individualized based on the patient’s risk factors.
In this age group, mammography has been reported to reduce breast cancer-related deaths by up to 17%.
TITLE: Breast Screening Guidelines
Warner, E. Breast Cancer Screening
New Eng J Med 365, , 2011.

6. This illustration, with its associated mammogram, shows the soft tissue structures typical of a normal pre-menopausal breast.  
The mammogram demonstrates a thin skin margin with no retraction of either the skin or the nipple.
The glandular tissue is interspersed with fat and there are regular bands of suspensory ligaments known as Cooper's ligaments.
There is no dominant or irregular mass and no evidence of microcalcifications that would indicative of a lesion.
TITLE: Breast Structures on Mammograms

7. Breast Density vs. Mammography Findings
The sensitivity and specificity of mammograms varies with age, being as high as 95% in post-menopausal women.
This variability is directly related to the breast density.   
Increased breast density of a pre-menopausal breast decreases the ability of the technique to resolve masses and microcalcifications from normal glandular tissue. Both are seen as white areas.
This problem is demonstrated by the mammogram on the left taken from a younger woman. It clearly demonstrates the dense white areas typically seen in this patient population, especially in those young women who never have been pregnant.
In contrast, the mammogram on the right is from a post-menopausal woman. The fibroadipose tissue that replaces glandular tissue has little density. on mammograms.
   
In younger patients, additional tests such as ultrasonography, nuclear medicine study, and MRI have been useful in resolving breast lesions

8. Mammography Terminology
Analog Mammography (Plain Film Mammography)
- x-ray beam directly captured on a film cassette.
- outdated and obsolete.
2D Digital Mammography (Digital Mammography)
x-ray beam captured on digital detector → converts x-ray beam into electronic signal → transferred to a computer → viewed on high- resolution monitor → allows for > image manipulation.
can allow for 30% to 40% decrease in radiation dose.
should be used as Gold-Standard method for screening and diagnostics.

9. Digital vs. Conventional Mammography
These are two mammograms of the same breast. The one on the left is a digital mammogram and the one on the right is a conventional film mammogram. The ability to resolve abnormal lesions from normal breast tissue is best seen with digital mammography.
Although more expensive, digital mammography offers a distinct advantage for detecting lesion in women with dense breasts, with a reported sensitivity of 78% vs. 51% for film.

10. Analog versus 2D Digital Mammogram
Less Dense Breasts
Analog Mammogram
2D Digital
Mammogram
More Dense Breasts
Analog
Mammogram
2D Digital
Mammogram

11. Mammography Terminology
3D Digital Mammography (Breast Tomosynthesis)
- camera moves over breast, taking multiple-angle images, creating a 3D image, and thus minimizing the impact of overlapping breast tissue.
- allows for even > image manipulation.
- earlier detection of smaller breast cancers.
- be care in ordering! → it may NOT get paid for!

12. Screening for Breast Cancer
This figure, from a recent New England Journal of Medicine article on Breast Cancer Screening, demonstrates that in the last 20 years there has been a steady decrease in the incidence of invasive breast cancer. The article states that this is equally due to improved adjuvant therapies and to increasing use of screening mammography.
The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In a cost-benefit assessment screening for breast cancer leads to reduced risk of death resulting in a gain in the number of life-years.
The article points out that the costs include: financial, risk of radiation, patient inconvenience, and anxiety, the cost of a diagnostic workup in false positive cases and in over diagnosed the case. The ratio of benefit to cost varies with age of the patient.
Screening mammography for women 50 to 69 years of age has been universally recommended; in large part due to increased sensitivity of the mammography due to reduced density and possibly due to slower tumor growth. However, there is little cost-benefit to screening women beyond 74 years of age, due to life expectancy of 5-10 years.
Warner, E. Breast Cancer Screening, New J Med 365, , 2011.

13. Mammography
Three mammographic abnormalities that are suspicious for cancer include:
Mass
Microcalcifications
Asymmetric Density
Mammographic abnormalities suspicious for cancer include: mass, microcalcifications and/or an asymmetric density
Screening mammograms are two x-rays are taken of each breast. One is side-to-side (medial-lateral) and the other is from top to bottom (cranial - caudal).
The breast is pressed between two pieces of plastic just enough so breast tissue can best be seen on the mammogram. This process lasts for a few seconds and is not harmful and minimizes the necessary x-ray dose. The amount of radiation exposure during mammography is about the same as receiving a dental x-ray.
It has been estimated that if 10,000 women have yearly mammograms for ten years, the radiation from mammograms will cause one
additional breast cancer death.

14. Mammography
Average-size lump found by woman practicing occasional breast self-exam (BSE)
Average-size lump found by woman practicing regular breast self-exam (BSE)
Average-size lump found by first mammogram
Average-size lump found by getting regular mammograms
Mammography is better at detecting breast lesions that self exam.    
Smaller breast lesions are commonly found on routine self exam as compared to occasional self exam.
Similarly, smaller lesions are detected with routine mammograms as compared to the first mammogram.
Overall, mammograms can detect a lesion well before they are clinically evident.
This is demonstrated in this mammogram that depicts a small, irregular, mass that was not palpable.

15. Microcalcifications
Microcalcifications are seen on mammograms as small white dots.
Their presence is often indicative of ductal carcinoma in situ.
The diagnosis of ductal carcinoma in situ (DCIS) was rare before the introduction of screening mammography.
DCIS accounts for approximately 25% of all cases of breast cancer, with more than 90% of them being detected only by imaging.
The risk of cancer is 75% when the microcalcification have a ductal distribution, are fine, and/or have a linear and branching appearance.
There a 30% risk of cancer when the calcification are clustered, fine, irregular, and/or granular.
(Ref: Adapted from DeMay RM: The Art & Science of Cytopathology, ASCP Press, Chicago, 1996)

16. Infiltrating Carcinoma
Mammography
Clinical Finding
Infiltrating Carcinoma
(%)
Mean (cm)
Nodal Metastases
DCIS
Microcalcifications on Mammogram 26
0.6 6 71
Density on
Mammogram 94
1.1 14 4
Palpable Mass
2.4 58 2
After Table 23.1 in Robbins
This table correlates the clinical findings with the subsequent pathology.
DCIS rarely presents as a palpable mass or as a density on a mammogram. However, it is commonly identified by the presence of microclcifications on a mammogram.
In contrast, a mammographic diagnosis of infiltrating carcinoma is primarily made by the presence of a dense lesion rather than by the presence of microcalcifications.

17. BIRADS: Breast Imaging, Reporting, and Data System
Originally designed to utilize standardized descriptors to characterize mammographic findings, including:
Densities/Nodules/Masses/“Asymmetries”
Calcifications
Associated Changes (skin thickening, skin retraction, nipple retraction, architectural distortion, axillary adenopathy)
Categorized findings as BIRADS Category 0-5
Later adapted for image reporting of Ultrasound and MRI

18. BI-RADSTM Mammogram Categories
Category
Assessment
Recommendation
Incomplete assessment
Additional Imaging Needed 1
Negative
Routine screening 2
Benign / stable findings 3
Probably benign
Short interval follow-up 4
Suspicious abnormality
Biopsy recommended / urged 5
Highly suggestive of malignancy
Appropriate action to be taken
This table is for your own information. What is your interpretation and which category would you put it in?

19. Breast Ultrasound
Best performed in a targeted-fashion to a particular area of interest in the breast and not in a screening fashion to the entire breast.
Breast modality to distinguish cystic versus solid lesions.
Best modality to characterize solid lesions.
Useful in detecting and defining intraductal lesions in the evaluation of suspicious nipple discharge.

20. Breast MRI
Should be utilized selectively in appropriate selected patients.
Two categories for utilization:
Potential Diagnostic Utilities
Potential Screening Utilities

21. Breast MRI - Diagnostic Tool
Evaluating a patient with a “difficult” clinical breast exam and dense breasts on mammography.
Characterizing breast anatomy in the absence of a mammographic or ultrasound lesion (BI-RADS 2 breast imaging) in a patient with a clinically suspicious finding on clinical breast exam.
Evaluating clinical concerns in a breast with an augmentation / implant.
Evaluating clinical concerns a mastectomy patient with implant reconstruction.
Evaluating clinical concerns a mastectomy patient with autologous tissue flap reconstruction.
Ruling out multicentric ipsilateral disease or concurrent contralateral disease in a patient with a newly diagnosed breast cancer.
Monitoring tumor response to preoperative neoadjuvant systemic chemotherapy in a patient with newly diagnosed breast cancer.

22. Breast MRI - Screening Tool
Annual screening of any patient with a documented hereditary breast cancer gene mutation. YES! YES! YES!
???Annual screening of a patient with a strong family history of breast cancer but who has had documented negative genetic testing??? CONTROVERSIAL?
???Annual screening of a patient with a strong family history of breast cancer but who has declined genetic testing??? CONTROVERSIAL?
???Annual screening of a patient with a personal history of breast cancer??? CONTROVERSIAL?
???Annual screening of a patient with a personal history of radiation therapy to the chest for another type of cancer, such as Hodgkin’s disease, when treated between the ages of 10 and 30 years old??? CONTROVERSIAL?

23. Recap of Key Points
Mammography is best in post-menopausal women because of reduced density.
It identifies abnormal microcalcifications in most ductal carcinomas in-situ that can’t be identified on physical exam
It is capable of identifying smaller lesions that would go undetected by palpation.
Use ultrasound in a targeted manner not as a screening method
MRI uses include:
Hereditary breast cancer gene mutation
Patients with implants
R/O multicentric disease
Monitoring chemo effects before surgery
Mammography is best in done on post-menopausal women because of reduce density.
Abnormal microcalcifications identify most ductal carcinomas in-situ that can’t be identified on physical exam
Mammography is capable of identifying smaller lesions that go undetected by palpation.

24. Mammography Quiz

25. Contact me if you feel that your grasp of this material isn’t strong enough.

26. Survey
We would appreciate your feedback on this module. Click on the button below to complete a brief survey. Your responses and comments will be shared with the module’s author, the LSI EdTech team, and LSI curriculum leaders. We will use your feedback to improve future versions of the module. The survey is both optional and anonymous and should take less than 5 minutes to complete.
Survey