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Breast Imaging I.MS...

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Breast Imaging I.MS...

  1. 1. Breast Imaging I Medical Student Radiology Elective Katherine Dee, MD Assistant Professor, Breast Imaging THE BASICS OF BREAST IMAGING • Epidemiology • Risk Factors • Screening Guidelines • Screening versus Diagnostic exam • BIRADS terminology • MQSA • Indications for each modality • Image-guided procedures BREAST CANCER STATISTICS • 32% of cancers detected in women are breast cancers • Percent of all cancer deaths 19 %  second only to lung cancer in women • 1:8 lifetime risk • 75% occur in women with No Risk Factors • 184,000 cases of breast cancer diagnosed each year • Five year survival after treatment for early-stage breast cancer is 97% RISK FACTORS For Breast Cancer • Mild Increased Risk • Older Age • Early age at menarche • Late age at menopause • Nulliparity • Late age at 1st full term pregnancy (>30) • History of benign breast disease • Obesity
  2. 2. • Prolonged use of HRT • Greatly Increased Risk • Radiation to chest • Family history of breast cancer • BRCA1/BRCA2 • Personal history of breast cancer THE PRIMARY IMAGING MODALITIES • Mammography (screening vs. diagnostic) • Ultrasound • MRI • Nuclear Medicine • Ductography Screening Mammography • ACR/ACS guidelines:  Annual screening starting age 40 • Asymptomatic • Bilateral CC/MLO views • Very low radiation dose • Sensitivity 85-90% • 20-40% overall reduction in breast cancer mortality Risk Of Mammography Average glandular dose 0.2 rad 1:1,000,000 risk of inducing a cancer Comparable risks are:  traveling 4000 miles by air  traveling 600 miles by car  15 minutes of mountain climbing  smoking 8 cigarettes Screening Mammography • Approximately 5-10% call-back rate
  3. 3. • Diagnostic Mammogram and/or Ultrasound performed to further evaluate a lesion • ~1/3 of these will be recommended for biopsy • ~ 1/3 of biopsies will be malignant Diagnostic Mammography: problem-solving examination • Breast Problem:  Palpable Lump  Nipple discharge  Pain • Abnormal screening mammogram w/u • Follow-up  Lumpectomy patients  6mo. Follow-up of Probably Benign Lesions Diagnostic Mammography • Exam tailored to the diagnostic problem  Spot Magnification views  Tangential, Exaggerated, Cleavage, Cleopatra, Rolled, Step-obliques, etc. • Monitored by radiologist • May also perform ultrasound Breast Lumps • Patients 30 and Over:  Diagnostic Mammogram (+/- Ultrasound) • Patients Under 30  Ultrasound • If IMAGING is negative, must manage on CLINICAL basis  FNA if suspicious on examination  Follow-up breast examination  Referral to Breast Specialist for core biopsy or excisional biopsy Diagnostic Mammogram CLINICIAN’S INPUT
  4. 4. • NOT HELPFUL  omitted  lump in left breast • HELPFUL  2 x 3cm firm, non tender lump, Upper Outer Left breast @ 2:00, 3cm from the nipple. New finding since breast exam one year ago. BI-RADS: Breast Imaging Reporting And Data System “An organized system designed to standardize mammographic reporting, reduce confusion in breast imaging interpretations, facilitate outcome monitoring, and assure quality” BI-RADS Classification • BI-RADS Category 1:Normal • BI-RADS Category 2:Benign • BI-RADS Category 3:Probably Benign • BI-RADS Category 4:Suspicious • BI-RADS Category 5:Highly Suggestive of Malignancy • BI-RADS Category 0:Incomplete BI-RADS 1 • Normal • Follow-up in 1 year with regular screening mammogram BI-RADS 2 • Benign Finding  Benign calcification (i.e. Vascular)  Fat-containing mass (i.e. Lipoma) • Follow-up in 1 year with regular screening mammogram BI-RADS 3 • Probably Benign • Statistical probability of cancer less than 2%
  5. 5. • Short-interval Follow-up in 6 months BI-RADS 4 • Suspicious for Malignancy • Biopsy recommended  Under palpation  Ultrasound-guided  Stereotactic Biopsy (Mammographic-guided)  Wire Localization and Surgical excision BI-RADS 5 • Highly Suggestive of Malignancy • I’ll eat my hat if it’s not cancer • Recommend Excision • Most get percutaneous biopsy prior to definitive cancer surgery Mammography Quality Standards Act (MQSA) • Federal law • Film, processor, equipment, positioning, labeling, notification • Training for technologists and radiologists • Reporting (BI-RADS mandatory) • Outcome audit analysis • All facilities must be accredited Men with breast lumps • Mammogram:  Gynecomastia– most common cause • Medication • Alcohol/Marijuana • Liver Disease  Breast Cancer– exceedingly rare • Ultrasound not indicated unless mammogram is abnormal
  6. 6. Other Modalities • Ductogram • MRI  Implant Rupture  Trials: • Screening of High-risk patients • Breast Biopsy  Known CA: Extent of Disease • Nuclear Medicine  Sentinel node biopsy  PET  MIBI Ductography • Nipple discharge • Spontaneous • Unilateral • Single duct • Procedure: elicit discharge, canulate duct, inject contrast, obtain images • Most common cause of bloody discharge: papilloma Interventional Procedures • Stereotactic Biopsy • Ultrasound-guided Biopsy • Wire Localization prior to Surgical Excision • Ductogram Summary • Screening: Annual starting age 40 • Diagnostic: Breast problems • Palpable lumps:  Diagnostic mammogram-- age >=30  Ultrasound age-- <30 • BI-RADS 1-5 • MRI / Nuclear Medicine • Image-guided biopsy
  7. 7. Breast Imaging II Clinical Cases • How does Breast Cancer Present? • What are radiologists looking for? • What benign and malignant diagnoses do we find? Palpable Lump Pt > =30 Diagnostic Mammogram +/- Ultrasound Pt < 30 Ultrasound If mass is found: Needle Biopsy Palpable lump: what to do when work-up is negative • Diagnostic Mammogram: Negative • Ultrasound: Negative • Management of Lump:  Referral to Breast Specialist  FNA or Core  3 month f/u examination CALCIFICATIONS MORPHOLOGY • Typically Benign: skin (dermal), vascular, coarse or popcorn-like, large rod-like, round, lucent-centered, “eggshell” or “rim”, milk of calcium, suture, dystrophic, punctate (<0.5mm and well-defined) • Intermediate Concern: amorphous or indistinct • Higher Probability Malignancy: Pleomorphic or heterogeneous (granular), fine linear or fine linear branching (casting)
  8. 8. CALCIFICATIONS DISTRIBUTION • Grouped or Clustered (<2cc of tissue) • Linear • Segmental • Regional • Diffuse or Scattered • (Note: multifocal carcinoma is 2 or more foci in same quadrant separated by 2 cm of normal tissue unlike multicentric carcinoma which involves 2 or more foci in different quadrants, including bilateral carcinoma) MASSES • Margin: 1) circumscribed, well defined, or sharply defined, 2) microlobulated, 3) indistinct or ill defined, 4) obscured, or 5) spiculated • Location: side, clockface, quadrant, subareolar, central or axillary tail and Depth: anterior, middle, or posterior • Associated Findings BREAST DENSITY 1 The breast is almost entirely fat. 2 There are scattered fibroglandular densities. 3 The breast tissue is heterogeneously dense. This may lower the sensitivity of mammography. 4 The breast tissue is extremely dense, which could obscure a lesion on mammography. Other: Implant present Summary • Management of Breast Lumps • Presentations of Breast Cancer • Mammographic Findings
  9. 9.  Masses  Calcifications  Architectural Distortion  Asymmetry  Density
  10. 10.  Masses  Calcifications  Architectural Distortion  Asymmetry  Density

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