imaging in breast carcinoma

1. IMAGING INTERPRETESION OF
BREAST CARCINOMA
Dr Sushanta Kumar Sarkar
MBBS.BCS.MD(Radiology and Imaging)
Associate Professor and Head
Radiology and Imaging department,Shaheed Tajuddin
Ahmad Medical College,Gazipur.

2. Introduction
Breast carcinoma is the second leading cause of cancer deaths among
women. Globally each year 1.7 million women are diagnosed and 1 in
3 of those afflicted die of breast carcinoma. So, day by day necessity of
early rapid diagnosis of any breast disease, breast masses, benign
breast lesions for early evaluation and treatment is increasing.
Different modalities of breast imaging are very convenient and
recommended in this regards.

3. Incidence and Epidemiology of Breast Cancer
• Breast cancer comprises 10.4% of all cancer incidence among women.
• It is the 2nd
most common cause of cancer death world wide after lung
cancer.
• It is about 100 times more common in women than men.
Epidemiology:
 Women < 30 years : 0.3-2%
 Women between 30-40 years : 15%
 Women >40 years : 85%

5. Risk factors for breast carcinoma
• Gender: Female
• Age: Older age
• Positive family
history
• Genetics
• Obesity
• Benign Breast
lesions
• Hormonal therapy
• Dense breast
tissue
• Tobacco, alcohol.

6. BREAST ANATOMY
15-20 lobes , each lobe has a
main lactiferous duct of 2.0-4.5
mm opens in central portion of
nipple.
• Main duct: branches
dichotomously eventually
forming terminal ductal
lobular units
• Histology: epithelial cells,
myoepithelial cells surrounded
by extralobular connective
tissue with elastic fibers
• Terminal Duct Lobular Unit
(TDLU)

7. • Terminal Duct Lobular Unit (TDLU)
(1) Extralobular terminal duct
(2) Lobule:
(a) intralobular terminal duct
(b) ductules/acini
(c) intralobular connective tissue.
Significance: TDLU is site of fibroadenoma, epithelial cyst, apocrine metaplasia,
adenosis, epitheliosis (= proliferation of mammary epithelial cells within
preexisting ducts + lobules), ductal + lobular carcinoma in situ, infiltrating ductal
+ lobular carcinoma.

9. Common Breast Diseases
Benign Malignant
• Fibroadenoma
• Fibrocystic change
• Lipoma
• Simple cyst
• Breast abscess
• Mastitis
• Galactocele
• Duct ectasia.
Non-invasive:
• Ductal carcinoma in situ
• Lobular carcinoma in situ
• Intracystic papillary carcinoma in situ
Invasive:
• Invasive ductal carcinoma
• Invasive lobular carcinoma
• Mucinous carcinoma
• Papillary carcinoma
• Inflammatory breast carcinoma.

10. Different modalities of Breast Imaging
• Mammography
• Ultrasonography (USG)
• Magnetic Resonance Imaging (MRI)

11. MAMMOGRAPHY
• A mammogram is an x-ray picture of the breast.
• Mammograms can be used to check for breast cancer in women who
have no signs or symptoms of the disease. This type of mammogram
is called a screening mammogram.

12. MAMMOGRAPHY
• Indications :
• Screening asymptomatic women aged 50 years and over.
• Screening asymptomatic women aged 35 years and over who have a high risk
of developing breast cancer.
oWomen who have one or more 1st
degree relatives who have been diagnosed with
premenopausal breast cancer.
oWomen with histologic risk factors found at previous surgery:Atypical ductal hyperplasia.
• Investigation of symptomatic women aged 35 years and over with a breast
lump or other clinical evidence of breast cancer.
• Survillance of the breast following local excision of breast carcinoma.
• Evaluation of a breast lump in women following augmentation mammoplasty.
• Investigation of a suspicious lump in a man.

13. Screening Mammography
• What is a screening mammography?
• Screening mammography is a low-dose X-ray examination of woman’s
breasts used to detect breast cancer when that cancer is too small to
be felt as a lump.
• Screening mammography is carried out on women who do not have
any symptoms of breast disease.
• The aim of screening mammography is to reduce the death rate from
breast cancer by detecting unsuspected breast cancers at an early
stage

14. Role of Ultrasound in diagnosis of Breast
Carcinoma:
• Diagnosis of breast cancer has been widely improved since the
development of high-resolution ultrasound equipment.
• In the past, ultrasound was only considered useful for the diagnosis
of cysts. Meanwhile, it improves the differential diagnosis of benign
and malignant lesions, local preoperative staging and guided
interventional diagnosis.

15. Malignant features of Breast USG and Mammogram
• Spiculation and echogenic halo.
• Architectural distortion.
• Asymmetrical soft tissue density.
• Taller than wide(Larger antero-posterior than transverse dimensions)
• Angular margins.
• Markedly hypoechoic(compared with fat)
• Shadowing.
• Calcifications.
• Branch pattern.
• Micro lobulation.

16. Usg findings:

19. Fig:Breast Carcinoma on USG and Mammogram

21. Mammogram of Breast Carcinoma:

22. Role of Breast MRI:
• Indications:
• Young patient with positive BRCA(BRCA1 and BRCA2) screen.
• Dense breast+High risk lesion of LCIS(Lobular carcinoma in situ)
• Palpable mass+Negative mammogram+Sonogram
• Axillary node malignancy+Negative mammogram
• For staging of breast carcinoma
• Implant Imaging
• Follow up of cancer patient after surgery.

23. MRI of Normal Breast
This Photo by Unknown Author is licensed under CC BY
Fig:MRI OF BREAST CARCINOMA

24. MRI Findings Suggestiveof Metastatic Axillary LymphNodes in Patients with
Invasive Breast Cancer

25. MRI & BI-RADS
• While BI-RADS was initially used for communication in
mammography, in 2003 the system was adapted to use with
breast MRI, as the use of MRI for breast cancer detection and
characterization has increased dramatically over the past decade.
•
• This is important to know, since BI-RADS assessment categories and
recommendations have become the standard by which people can
communicate breast imaging results to referring physicians so that
they can determine the appropriate care for their patients.

26. BIRADS(Breast imaging reporting and data
system)
• What is BI-RADS?
• The American College of Radiology established a standardized reporting system, called
the Breast Imaging Reporting and Data System (BI-RADS), to describe breast imaging
findings and results on mammography, ultrasound, and MRI. The concept of BI-RADS
was first developed for mammography in the early 1990s to address the problems of
variable and ambiguous reporting practices as utilization of this modality increased.
Since its inception and evolution, BI-RADS has become central to the practice of breast
imaging. An important component of this reporting system is a defined assessment
category, numbered 0 through 6 based on the likelihood of malignancy, and a
corresponding clinical management recommendation to be used with each
assessment category. Use of this common language in breast imaging reports allows
radiologists to clearly communicate diagnostic conclusions and recommendations to
the patients’ primary physicians, surgeons and oncologists across practices.

27. Fig:Breast cancer on Mammogram ,Usg
and MRI

28. .
CamScanner

29. Time intensity Curve
Analysis
The time-intensity curve tool allows
you tovisualize the lesions
enhancement behavior
(eg:In BreastbMRI) By plotting the
surgicalintensity values over time
after theadministration of contrast
material.

31. ULTRASONOGRAM MRI
ging evaluation or prior
n:Spot
pecial views,ultrasound.
Need additional imaging : an ,MRI for
1.Palpable confirmed mass
2.Recurrence versus scar after lumpectomy.
Need additional ima
evaluation:eg,1)Technically u
2)Screening MRI without kine
3)Incomplete information.
breasts,no
ortion,suspicious
Negative: No mass,architectural
distortion,skin
thickening,microcalcifications.
Negative:Symmetric b
architectural distortion,a
enhancement or mass
ng calcified fibroadenoma,multiple
ramammary node,vascular
al distortion related to prior
Benign : Simple cyst,intramammary lymph
node,breast implant,stable postsurgical
changes,probable fibroadenoma.
Benign :Hyalinized none
fibroadenoma,cyst,scar,fat-co
cyst,lipoma,galactocele,mixe
hamartoma),breast implant.
BIRADS Categories(American College and Radiology)

32. To be continued:
5 Highly suggestive of
malignancy:
(>95% probability of cancer)
Appropriate action should be
taken:eg:lesion could be considered
for one stage surgical
treatment,however biopsy usually
required.
Highly suggestive of
malignancy(>95% probability of
cancer) Appropriate action should
be taken:
Image guided core needile biopsy
Highly suggestive of
malignancy(>95% probability of
cancer) Appropriate action should
be taken:
Almost certainly malignant.
6 Known biopsy proven
malignancy :eg:Mammogram during
neoadjuvant chemotherapy
comparing it to pre therapy
mammogram.
Known biopsy proven
malignancy :eg:prior to
chemotherapy ,lumpectomy,mastecto
my.
Known biopsy proven
malignancy :eg:malignancy
corresponding to the lesion imaged
with MRI.

33. Breast Cancer In Men:
• `Although it is rare, men can get breast cancer.
• Breast cancer is most often found in women, but men can get breast cancer too
out of every 100 breast cancers diagnosed in the United States is found in a ma
• The most common kinds of breast cancer in men are—
• Invasive ductal carcinoma.
• Ductal carcinoma in situ (DCIS)

36. MRI reports of Breast Carcinoma
(BI-RADS category 4)

37. Findings:
Left Breast :  Mammographic density of breast parenchyma is – type-a, almost entirely fatty
tissue.
 No mass lesion is seen.
 Skin thickness- normal.
 No nipple retraction is seen.
Left Axilla  Appear normal.
Right Breast :  Mammographic density of breast parenchyma is – type-a, almost entirely fatty
tissue.
 An irregular hyperdense mass lesion is seen in subareolar region of right
breast. Architectural distortion is noted surrounding the mass. No
calcification is seen.
 Skin thickness- normal.
 Right nipple is retracted.
Right Axilla  Two enlarged lymphnodes are seen in right axilla.

38. Impression:
 Suggestive of mass lesion in right breast with right axillary lymphadenopathy (BIRADS-5).
 Normal study of left breast.
Adv: Biopsy

39. 3 Tesla MRI of Both Breast
Clinical Information: Lumpiness of left breast.
Background enhancement: Moderate.
Findings:
 Irregular diffuse T1WI hypointense and T2WI hyperintense mass lesion having spiculate d
margin measuring about 03 x 03 cm in size is noted in the left breast at 05 to 06 O’clock
position and 03cm from nipple. After I/V contrast; Strong heterogeneous early enhancement
of the mass is noted. Evidence of perilesional spiculations producing diffuse disease. The
lesion show restricted diffusion on DWI and neovascularization on MIP sequence.
Underlying pecoralis muscle is separated from the mass.
 However no definite soft tissue mass or any lump could be detected in right breast.
 Both axilla are unremarkable.
 Nipples are not retracted.
 Overlying skin does not show any focal or diffuse thickening or retraction.
 Areola, skin, cooper ligaments, ducts, subcutaneous and retromammary spaces are unremarkable.
Impression:
 Complex SOL in left breast as stated – suggestive of Ca-breast.
Lesion Category:
 BI-RAD: 05.
Final assessment & Recommendation:
 Malignant lesion.
 USG Guided core biopsy for further evaluation.

40. Conclusion:
• As breast carcinoma is the 2nd
leading cause of cancer death in
women,early diagnosis and treatment of breast cancer is
mandatory to reduce mortality and morbidity
• Latest modalities of breast imaging especially MRI helping us a
lot.
• Nationally awareness and screening programme is recommended
thus Radio-surgical team work is essential to achieve the goal.