Breast Imaging
Olga Hatsiopoulou
Consultant Radiologist
Royal Hallamshire Hospital
Sheffield Breast Screening Unit
Sheffield Teaching Hospitals
Screening
Breast assessment in symptomatic FT
clinics
Case studies
Five-Year Breast Cancer Suvival Rates According to the
Size of the Tumor and Axillary Node Involvement
5 Year Survival, %
0 Positive
1-3 Positive
4 or More Positive
Nodes
Nodes
Nodes
< 0.5
99.2
95.3
59.0
0.5-0.9
98.3
94.0
54.2
1.0-1.9
95.8
86.6
67.2
2.0-2.9
92.3
83.4
63.4
3.0-3.9
86.2
79.0
56.9
4.0-4.9
84.6
69.8
52.6
? 5.0
82.2
73.0
45.4
Tumor Size, cm
Breast Cancer: Why Screen?
Improved outcome by treatment
during the asymptomatic period
Significant impact on public health
Mortality Reduction
50-69 y.o.: mortality reduction 16-35%
40-49 y.o.: mortality reduction 15-20%
– Lower incidence
– Rapidly growing tumors
– Dense breasts
Mortality Reduction
Due to detection of cancers at smaller
size/earlier stage
– Mammographically visible 3-5 years before
palpable
– Increased detection of DCIS
Early stage disease is curable
Diagnostic Accuracy of Screening
Mammography
• Sensitivity in women > 50 y.o.
• 98% fatty breast
• 84% dense breasts
• Specificity
• 82-98%
‘On the positive side, screening confers a
reduction in the risk of mortality of breast
cancer because of early detection and
treatment.
On the negative side is the knowledge that
she has perhaps a one per cent chance of
having a cancer diagnosed and treated that
would never have caused problems if she
had not been screened.’
Professor Sir Michael Marmot,
UCL Epidemiology & Public Health
Symptomatic clinic / fast track clinic
Triple assessment
Multidisciplinary team approach
Concordance
Concordance of triple assesment
P
M
U
B
Need for repeat biopsy or clinical core?
Digital mammography
Quicker to do mammo – almost instant
output on monitor
Better penetration of dense breast
Digital manipulation of image
Digital mammography
Proven to be better for younger/denser
breasts
Almost eliminates the need for
magnification views – can magnify digitally
and still have full resolution
•Standard view mammography
•Cranio-caudal projection (CC)
•Medio-lateral oblique projection
(MLO)
Calcification
Most are benign and can be dismissed
The goal is to identify new or increasing
calcifications or those with suspicious
morphology
Benign Calcifications
Malignant microcalcification
Linear, branching casts – comedo
Granular/ irregular – crushed stone
Punctate - powdery
Architectural Distortion
Core biopsy
All solid lumps and M3 MC get a biopsy
Replaces fine needle aspiration in most
cases
14g spring-loaded needle gun
Well tolerated
Main complication is haemorrhage
Core biopsy - histology
Can give grade of cancers and presence of
invasion
Can give definitive diagnosis of benign lesions avoid surgery
Ultrasound vs /stereo biopsy
Ultrasound is used for all lesions visible on
ultrasound – quick and accurate
Stereo biopsy is used for lesions not seen
on ultrasound –mainly microcalcification
(mostly screening women)
Same principle as stereoscopic vision –
two slightly different mammographic views
allow calculation of depth
Prone biopsy table
Woman lies prone on elevated table with
breast dependent through a hope in the
table
Biopsy is done from underneath
Access is 360 degrees
VAB
Used with either ultrasound or stereo
guidance
Vacuum-assisted biopsy, single needle
insertion, larger sample
Allows better non-operative diagnosis,
improved calc retrieval, more invasive
cancer detection in DCIS
VAB biopsy
11g, compared with 14g for core biopsy
8g can be used to remove benign lumps
Slightly greater risk of bleeding
Well tolerated
Can insert clip to mark site in case lesion
is totally removed
Why use such a large bore?
A larger sample is more likely to obtain a
definitive diagnosis:
– DCIS may be upgraded to invasive cancer
– ADH may be upgraded to DCIS
– Small/difficult lesions are more likely to be
adequately sampled
– - Therapeutic excision of B3 lesions
Wire localisation
Use U/S or stereo depending on how it is
best seen
Aim to get hook through the lesion
Specimen x-ray after excision to confirm
lesion remove
LIMITATIONS OF
MAMMOGRAPHY
As many as 5 – 15% of breast cancers
are not detected mammographically
A negative mammogram should not
deter work-up of a clinically suspicious
abnormality
FALSE NEGATIVES
Causes
–Occult on mammogram (lobular
CA)
–Finding obscured by dense tissue
–Technical
–Error of interpretation
RISK OF MAMMOGRAPHY
Average glandular dose from a
screening mammogram is extremely
low
Comparable risks are:
– Traveling 4000 miles by air
– Traveling 600 miles by car
– 15 minutes of mountain climbing
– Smoking 8 cigarettes
Breast MRI
Magnetic resonance imaging is used :
– For problem solving
– For assessing the extent of lobular or extensive
cancers
– For screening high risk women - high risk family
history and women who have had mantle
radiotherapy for Hodgkins’ disease
– Pre and post neoadjuvant chemotherapy
– For women with implants, to assess integrity
Detecting cancers on MRI
Dynamic scan – bolus injection of
Gadolinium and rapid sequence of images
Benign lesions can enhance
Need to create a graph showing pattern of
uptake over time
Cancers show rapid uptake and washout
The axilla
Ultrasound
– Level one nodes can be very low down
– Level three nodes may be best seen from an
anterior approach through the pectoralis
major muscle
Axillary node levels
Level one:
– lateral to lat margin of pectoralis major
Level two:
– under pectoralis minor
Level three:
– medial and superior to pectoralis minor, up
to clavicle
Why scan/ biopsy the axilla?
A pre-operative diagnosis of lymph node
metastases will prompt the surgeon to go
straight to an axillary node CLEARANCE
A negative axilla on imaging will mean the
woman has either:
– Sentinel node biopsy
– Axillary sampling (four nodes)
Advantages of axillary biopsy
Avoids two operations in women with
positive nodes
Alternative is axillary sample at time of
WLE, then second operation for clearance
What about PET
Indicated for the complex axilla/ brachial
plexus problem
May prove useful for looking for distant
mets but not accepted primary method
Resolution and specificity not good
enough to look for nodes
Importance of triple assesment
MDT approach
Concordance
Challenges around breast screening
A well informed patient