Modern Imaging in Breast Cancer
Dr Linda Hacking
Consultant Radiologist
October is Breast Cancer Awareness
Month
• Breast cancer is commonest cancer in UK
(excluding non-melanoma skin cancer)
• 46,000 new cases per year
• 300 men, remainder women
• 80% over 50 years of age
• 1 in 9 women will get it in their lifetime
Bad news/Good news
• Incidence has increased by 50% in last 25years
• 12,000 women and 70 men died from breast
cancer in 2008
• 1,300 deaths in women under 50
• More than half deaths are in women over 70
Bad news/Good news
• Since 1980s breast cancer death rates have fallen by
one third
• Breast cancer is no longer the commonest cause of
cancer death in women
• More than 8 out of 10 women survive beyond 5 years
(5 out of 10 in 1970s)
• Now twice as likely to survive 10 years as 40 years ago.
• 2 out of 3 women survive beyond 20 years
• Breast cancer death rates falling faster in UK than rest
of Europe
Reasons for improvements in
outcomes
• Screening
• Improved treatments (Tamoxifen etc)
• Improved cancer services including imaging
Why are these improvements
happening
• Breast screening?? (also increased diagnosis
rate)
• Improved treatments (tamoxifen etc.)
• Overall improvements in care (including
imaging)
Breast Screening
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NHS Breast Screening Programme (NHSBSP)
Began 1988-90
Not Blackpool Victoria.
Nearest centre Lancaster (vans, WGD)
Invited for Mammograms from age 50-69
Extended from 47-73 years from 2012 (target)
Past upper age limit, option to arrange
mammogram.
Breast Screening
• Will cause increase in incidence of cancer
• Early cancers and pre-cancer (DCIS) are found
that would never have led to a problem
For Breast Screening
• One woman will be over-treated for every
two lives saved
• 1000 lives a year saved
• Impact on population vs individual woman’s
life.
Against breast screening
• 10% of cancers are over-diagnosis and
therefore over –treatment
• It is impossible to estimate lives saved
because of all other factors
• Impact on population vs impact on individual
woman’s life
Today we are talking about diagnosis
The Symptomatic Breast Clinic
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Lump or thickening
Change in size or shape
Redness or rash in skin or nipple
Indrawing of nipple
Skin puckering or dimpling
Lump in armpit
Referral to Breast Clinic
• May simply need to see senior clinician- no
further –advice, no further investigations.
• Triple assessment/Double assessment
• See Senior Clinician (1)
• Imaging (2)
• Biopsy or needle test (FNA) (3)
Modern Imaging and Biopsy
• Tests to be done at first clinic appointment for
most patients
• Most patients will have a benign diagnosis
• Less than 1 in 10 patients attending our clinic will
have a malignant diagnosis
• 9 out of 10 will be benign
• In new clinic, results for patients seen Monday,
Tuesday available for Friday
• Wednesday, within a week
Modern Imaging and Biopsy
• Quick accurate diagnosis for the majority of
patients who will have a benign diagnosis
• As much information as possible about what
we are dealing with in the minority if patients
who have a malignant diagnosis
• Treatment can then be tailored to the
individual patient
Mammography
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Symptomatic patients
Women >35 years of age
Uses x-radiation
Invented in 1960s, modern type of machine 1969
Still not in universal use 1986 (when I started in
radiology)
• First unit Blackpool 1990 (Fylde Coast incl.NHS)
• Blackpool Victoria Mammography unit 1999.
• October 2010 Full Field Digital mammography
Mammography
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Problems
X-radiation
Dense breasts
Young women
Men
Implants
No imaging 100% accurate
Field Digital Mammography
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Better on all counts
Dense breast
Younger women
Less radiation
Ultrasound
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First imaging <35, and men
To clarify lumps and cysts on mammogram
To do image guided biopsy
To look at axilla (armpit)
Ultrasound
Cyst
Fibroadenoma
Ultrasound guided biopsy
Ultrasound guided biopsy
• Needle guided into abnormality under direct
vision
• Can be needle test (FNA)
• Or Core biopsy
• Uses local anaesthetic
• Takes 5-10 minutes
• “a bit like getting ears pierced”
• Complications- bruising, pain
Ultrasound guided biopsy
• Quick very accurate results
• A patient specific individual plan if surgery
required
• Tumour grade if malignant
• Hormone receptor status (Tamoxifen, herceptin)
• Size and extent of mass(es)
• Lymphnodes
• Test done Tuesday, results Friday
Core Biopsy Needle
Ultrasound guided biopsy
Mammographic stereotactic biopsy
• Mass seen on mammogram, not on ultrasound
• Micro-calcification “chalky bits”- can be benign,
can be malignant or pre-malignant (DCIS)
• No lump felt
• Standard core biopsy
• Vacuum assisted core biopsy
• Special devices
Mammographic stereotactic biopsy
• Previously may have needed general
anaesthetic surgery to remove abnormality
• Now outpatient procedure under local
anaesthetic
• Most turn out to be benign
Vacuum assisted biopsy
Vacora vs 14G biopsy
Sample can be x-rayed
Breast MR (magnetic resonance)
Breast MR
• Also major investment in breast coils and
software for new MR scanner
• Increased comfort
• Ease of interpretation (software)
Breast MR
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Recently in press
In UK not used in every case
Lobular carcinoma
Multifocal carcinoma
Problem solving when imaging/clinical/pathology
do not match
• Doubts about mastectomy/ local excision
• Question of recurrence
• Implants
Breast MRI
• Adds to planning of surgery
So far
We have been talking about diagnosis
Imaging also helps during surgery
Localisation of mass not felt
• Marker with ultrasound
• Wire with stereotactic mammography
• Mass can be x-rayed while patient still
anaesthetised
Excised specimen
Also during surgery-Sentinel Lymph
Node Biopsy (SLNB)
SNLB
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Small amount radioactivity injected into breast
On morning before afternoon surgery
Or afternoon before morning surgery
Also blue dye in theatre
Goes to first lymph node
Surgeon uses probe in theatre
No drain, much reduced complication rate
compared with Node Clearance
• Seroma, lymphoedema, pain, numbness
• Overnight stay vs several day stay
SLNB
• A small percentage will require further surgery
once node examined in lab
• Nodes examined with ultrasound and FNA
prior to surgery
• Not suitable for everyone
Surgical probe
The Future
• Tomosynthesis
• On table sentinel node diagnosis
• Answers about breast screening
http://www.youtube.com/watch?v=P5n3Avqq
o2c
To Summarise
• Blackpool Victoria has opened a brand new
breast clinic
• We have the latest technology available for
the best possible care for our patients
• The new clinic pathway for rapid access and
diagnosis will benefit all of our patients
• Most patients will have a benign diagnosis
delivered quickly
• For the few patients who unfortunately have a
malignant diagnosis
• They will be treated quickly, with all of the
latest technologies available
• We should be able to upgrade for the future
The outlook is good
Thanks to the team!