different methods of breast imaging

1. MODERATOR- PROF DR YASHPAL
RAMOLE(M.Ch)
PRESENTOR- DR ABHISHEK

2.  Imaging plays an important role in breast evaluation
– symptomatic , asymptomatic and high risk cases,
screening.
 In diagnosed cases of breast cancer it helps in
staging , monitoring , the response therapy and in
post treatment follow up
 It reliably differentiates between malignant and
benign breast lesions.
 No screening tool is 100 % accurate.

3.  MAMMOGRAPHY
 ULTRASOUND
 MRI
 PET

4.  It is the use of low voltage x rays to image breast.
 It has a sensitivity of 75 to 80 % and specificity of
90 to 95 %.
 Randomized, population- controlled breast cancer
screening trials using mammography have shown an
approximately 30% reduction in breast cancer
deaths in the women invited to screening compared
to women in the control group.
 American Cancer Society recommends annual
screening mammography for women age 40 years
and older.

5.  Screening mammography – refers to imaging of
asymptomatic women for detection of breast cancer
at early and potentially curable stage using the
standard craniocaudal and mediolateral oblique
views of each breast
 Diagnostic mammography – evaluation of
symptomatic patients or those recalled from
screening because of abnormal or specific
mammographic findings, includes spot compression
or magnification views.

6. MAMMOGRAPHY VIEWS
• Craniocaudal CC
• Mediolateral oblique MLO
• Mediolateral ML
• Lateral-medial LM
• Laterally exaggerated craniocaudal XCCL
• Medially exaggerated craniocaudal XCCM
• Cleavage view CV
• Rolled view laterally RL
• Rolled view medially RM

7. Views Used to Confirm or Exclude a Lesion
 Lateral view
 Spot compression
 Spot compression magnification
 Rolled views (with or without spot compression or
magnification)
 Repeat the same view
 Step oblique views

13. Mammography - Breast Imaging Lexicon
 Breast Composition
 Mass
 Architectural distortion
 Asymmetries
 Calcifications
 Associated features
 Special cases

14. BREAST COMPOSITION
 In the BI-RADS edition 2013 the assignment of the
breast composition is changed into a, b, c and d-
categories followed by a description:
 a- The breast are almost entirely fatty. Mammography is
highly sensitive in this setting.
 b- There are scattered areas of fibroglandular density.
 The term density describes the degree of x-ray
attenuation of breast tissue but not discrete
mammographic findings.
 c- The breasts are heterogeneously dense, which may
obscure small masses. Some areas in the breasts are
sufficiently dense to obscure small masses.
 d- The breasts are extremely dense, which lowers the
sensitivity of mammography.

15.  ASYMMETRY – soft tissue finding seen only in one
view, without matching tissue in a similar location in the
contralateral breast
 Focal asymmetry - soft tissue finding seen on two
projections lying at comparable depth
 Masses – 3 dimensional space occupying lesion with
consistent convex margin
 Oval masses are likely benign, irregular masses are
likely malignant
 High density masses are suspicious low density/fat
density are almost always benign
 Benign calcifications are – skin, vascular, popcorn ,
eggshell, fat necrosis
 Amorphous, coarse heterogenous , fine pleomorphic
calcifications , linear / fine branching calcifications are
more suspicious of malignancy.

25.  BI-RADS® is designed to standardize breast
imaging reporting and to reduce confusion in breast
imaging interpretations.
 It also facilitates outcome monitoring and quality
assessment.
 It contains a lexicon for standardized terminology
(descriptors) for mammography, breast US and
MRI.
 All mammographic, ultrasound, and breast MRI
findings and reports should closely adhere to the BI-
RADS lexicon and assessment categories.

28.  Sensitivity decreases significantly in denser breast.
 Tissue superimposition in dense breast
 Mammogram involves compressing breast between
two plates which causes overlapping of tissue and is
uncomfortable to some patients.
 It has high false positive and false negative rates
upto 20 %

29.  Ultrasound is a useful adjunct to mammography for the
diagnosis and management of benign and malignant
breast disease.
 Hand-held units should include a linear array, high-
frequency transducer operating at a frequency of 7.5 to
10 mhz or greater, which provides good tissue
penetration to 4 or 5 cm
 It should not be used as a sole modality for screening as
ultrasound does not always detect cancers that are
visualised mammographically.
 Can detect clinically and mammographically occult
cancers particularly when there is a higher possibility of
cancer.

30. INDICATIONS
 Effective tool for detection of masses in dense breast
 Primary modality for evaluation of palpable lesion in
young patients
 Useful in denser breast, pathological nipple discharge,
intraductal papilloma.
 Differentiate cystic versus solid lesion.
 Guided needle biopsy
 Breast lump in pregnancy and lactation
 Symptomatic breast diseases in women age less than 35
years

35.  Anechoic cyst – no internal echoes and most commonly not
always is a simple cyst
 Hypoechoic structure – low level attenuation suggestive of
complicated cyst or fibroadenoma.
 Complex echo pattern – complex mass or necrotic tumor
 Acoustic posterior enhancement – simple cyst
 Ultrasound features of benign lesion –
 Marked hyperechogenecity
 Ellipsoid shape
 Circumscribed margins
 Parellel orientation to skin
 Thin pseudocapsule

36.  Posterior shadowing
 Spiculated margins
 Hypoechoic texture
 non parellel
 Calcifications
 Microlobulated margins

37. Benign Characteristics
Ellipsoid shape
Thin definable
capsule
Two or three
lobulations
Hyperechogenicity

38. Solid Mass -
Malignant
• Irregular shape
• Irregular/ill-defined
borders
• Almost anechoic
• Angular margin
• Taller than wide

39.  Multifocality
 Multicentricity
 Invasion of fascia in patients with invasive carcinoma
and ductal carcinoma in situ
 Screening of contralateral breast
 Screening women with high risk of breast malignancy
wiz strong family history, radiation exposure history,
genetic predisposition
 Recurrent breast cancer
 Study of breast with breast implants integrity in follow
up

40.  MRI is not a substitute to mammography or biopsy
 Lack of contrast enhancement has high negative
predictive value for malignancy.
 LIMITATIONS –
 Cost restraints
 Claustrophobia
 Cant be used in metallic implants

41. Signals from Water:
 tissues with a long T2 are presented as bright signals on T2-
weighted images. Thus, cysts (that contain fluid) with long T1 are
dark on T1-weighted images and those with long T2 are bright on
T2-weighted images.
On MRI this cyst had a characteristically low signal intensity
(black) on this T1-weighted image (A) and a high signal
intensity (white) on the T2-weighted image (B).

42. Breast cancers are usually irregular in shape
and heterogeneous in their enhancement on
MRI.

43.  Detects angiogenesis associated with lesions
 Two types – digital substraction
mammography ( DSM ) – in which a single
view image of single breast is acquired before
and after contrast injection
 Contrast enhanced spectral mammography
(dual energy mammography )

44.  Detects abnormal metabolic activity of various
organs
 Diagnosis , staging and restaging
 Detection and localization of metastasis
 Monitoring treatment response
 Early detection of recurrence
 Localizing primary tumor with metastasis in case of
indeterminate usg or mammogram

45.  Noninvasive technique
 Measure changes in temperature overlying skin over
breast lesions
 Images are displayed as color patterns
 Can be contact or telethermography
 Newer technique not gained much accpetance.

46.  Using ultrasound, elastography shows cancers,
which are generally stiffer than normal soft breast
tissue, as darker and larger than on the B-mode
gray-scale ultrasound.
 Benign masses are soft and less stiff than cancers.
 The elastogram shows benign masses as smaller on
elastography than on B-mode grayscale images

47.  It is a technique used to produce 3 d images from 2
d scans using 360 degree x ray arc
 Minimizes the radiation exposure
 Corrects drawbacks of mammography like
overlapping, compression of breast uncomfortable
to women
 Only approved in european union