This document provides an overview of various breast imaging modalities including mammography, galactography/ductography, stereotactic guided procedures, digital tomosynthesis, ultrasound elastography, and MRI of the breast. Key imaging techniques are described such as mammography positioning, ductography technique, stereotactic biopsy procedures, and interpretation of ultrasound elastography images. Evaluation of breast lesions and interpretation of different imaging findings are also discussed.

1. Breast Imaging Modalities
Dr. Y. Madhu Madhava Reddy

2. Mammography
• A mammogram can find breast cancer when it
is very small -- 2 to 3 years before patient can
feel it.
• No screening tool is 100% effective. Good
quality mammograms can find 85-90% of
cancers

3. Routine Images -
aka “screening mammo’’
• Positions
• CC - cranio caudal
• MLO – mediolateral oblique

6. Positioning of Breast for CC View

36. GALACTOGRAPHY / DUCTOGRAPHY
• Breast ductography is an imaging technique
which is used to evaluate lesions causing
nipple discharge. It helps in precisely locating
the mass within breast tissue and gives useful
information for surgical approach and
planning.

37. Indications and Contraindications
• The most common use of galactography is to evaluate
a woman who has a unilateral bloody or clear
discharge from her breast nipple and an otherwise
normal mammogram.
• Galactography is typically NOT called for in women
with the following conditions:
• A discharge that is milky, yellow, green, or gray is
usually not a cause for concern, especially if it comes
from multiple ducts in the breast.
• A discharge that is from both breasts in a woman who
has not had children may indicate a side effect from a
drug, or may be related to a pituitary etiology.

38. Technique
• A blunt-tipped sialogram needle (30-gauge) is
used for performing ductogram. The abnormal
duct is identified and cannulated.
Approximately 3 ml of contrast is injected into
the duct and canula is taped to the nipple.
• A standard two view mammography (or CC
and ML projections) are obtained.
• Ductal filling defects are generally caused by
papilloma or DCIS.

39. Filling defects d/t intraductal
Carcinoma

40. X ray guided Procedures
• Stereotactic guided FNAC:
• For lesions that are not seen or are poorly
visualised on ultrasound, mammographic
guidance is required for needle biopsy.
• The most common method currently in use is
an add-on stereotactic device which is used
with a conventional upright mammography
machine.

41. Technique
• The lesion is demonstrated on paired stereotactic
views obtained with the X-ray tube angled 15° either
side of the central tube position.
• Measurements defining the position of the lesion on
the stereotactic views are used to determine the
position of the needle guide in the X, Y and Z axes.
• When the needle, of specified length, has been
inserted through the guide into the breast, check
stereotactic views are obtained to ensure that the tip
of the needle is correctly positioned in relation to the
lesion. If the position is not correct, the needle can be
repositioned and further check films obtained.

42. Different parts of the lesion are sampled by moving the needle guide 2-3
mm in the X andY axes. Up to five aspirates are usually obtained.

43. Stereotactic guided Core biopsy
• Conventional mammography with add on
stereotactic equipment and analogue imaging
can be used for stereotactic core biopsy.
• More accurate results are obtained using
dedicated prone stereotactic biopsy
equipment with digital imaging.

44. Technique
• Using this equipment, the patient lies in the
prone or prone oblique position and the breast
passes through an aperture in the table.
• The direction of the X-ray beam is horizontal and
stereotactic views are obtained by rotating the
tube 15° either side of the central position. The
digital X-ray images obtained are displayed on a
computer screen within approximately 5 seconds
of exposure, and the computer offers rapid
contrast adjustment and zoom features.

45. Stereotactic guided core biopsy

46. Stereotactic guided core biopsy
• Target areas for biopsy are selected on the computer
screen and the position and angulation of the biopsy
needle/gun holder are adjusted automatically.
• A 14G needle is used; after insertion under local
anaesthetic, check films are taken to ensure correct
positioning .
• Check films can also be taken after firing the biopsy gun to
ensure that the lesion has been traversed by the needle.
Five or more core biopsies are usually obtained.
• Core biopsy specimen radiographs are taken when
sampling areas of microcalcification to ensure that
representative tissue has been obtained

47. Stereotactic guided core biopsy

48. Vaccum Assisted Core Biopsy
• This procedure allows a larger tissue sample to be
obtained.
• An I I G probe with a biopsy port attached to a
vacuum-producing device is inserted into the
breast under local anaesthetic and stereotactic
guidance.
• Tissue from the target area is sucked into the
biopsy port by the vacuum and is then separated
from the surrounding breast by a rotating cutting
cylinder which passes down within the probe.

49. Vaccum Assisted Core Biopsy
• The tissue sample is then delivered by
withdrawing the cutting cylinder-the probe is
left in position in the breast and is rotated so
that the biopsy port is aligned with the next
site for sampling and in this way multiple
samples are taken and small clusters of micro
calcification are usually completely removed.

51. Vaccum Assisted Core Biopsy
• If the mammographic marker is removed, a small
metal clip / gel pellets or combined gel-metal
(USG Sensitive) markers are deployed at the site
of the biopsy to allow accurate localisation should
subsequent surgical excision be necessary.
• Vacuum-assisted core biopsy has also been used
under ultrasound guidance for sampling of soft
tissue lesions, and under MRI guidance for lesions
which are not visible using either mammography
or ultrasound.

52. Core specimen radiography. A specimen radiograph showing a good yield of
microcalcifications in several vacuum-assisted mammotomy biopsy cores.

53. Preoperative localisation of Non
palpable lesions
• For the non palpable breast lesions the
position of the lesion is marked using a wire
with a hook or barb on the end to prevent
movement of the wire within the breast. The
wire is contained within a needle which is
inserted into the breast under local
anaesthetic, using either X-ray or ultrasound
guidance.

54. Preoperative localisation of Non
palpable lesions
• When the tip of the needle has been shown to
be satisfactorily positioned within 10 mm of the
lesion, the needle sheath is withdrawn leaving
the wire in situ.
• Check craniocaudal and lateral views are
obtained to show the final position of the wire in
relation to the lesion.
• Peroperative specimen radiography is mandatory
to ensure that the excised breast tissue contains
the mammographic abnormality.

56. DIGITAL TOMOSYNTHESIS

66. US Elastography
• Ultrasound (US) elastography is an imaging
technique that can visualize tissue elasticity
(stiffness) in vivo.
• Two types of Elastography
• Strain Elastography (SE)
• Shear wave elastography (SWE)

67. US elastography
• The most common type of strain elastography
(SE) displays relative tissue displacement
under compression, whereas SWE displays an
image of the shear-wave speed using acoustic
radiation force excitation.

68. Interpretation of US Elastography
• Strain Elastography
• When the breast tissue is pressed by the transducer, a
hard lesion undergoes less strain than does the
surrounding soft background.
• The relative strain in the tissue is displayed in a black-
and-white (bright, soft; dark, hard) or color-coded (red,
soft; blue, hard) image.
• In SE, the lesion size or area on the elastogram is
compared to the corresponding lesion on the B-mode
US image, as malignant lesions appear larger on
elastograms than on B-mode US images.

69. Strain Elastography
• Itoh et al. proposed the 5-point scale elasticity
score indicating an increasing probability of
malignancy that is most commonly used for SE.
• A cut-off point between the elasticity scores of 3
and 4 was initially suggested to differentiate
benign from malignant breast lesions.
• However, a cut-off point between the elasticity
scores of 1 and 2 or 2 and 3 was used in several
studies and achieved better diagnostic
performance with less interobserver variability.

70. Strain Elastography
• Recently, elasticity scores are classified into three
categories:
• score of 1 (even strain across the entire lesion) as
negative,
• scores of 2 and 3 (uneven strain in the lesion) as
equivocal, and
• scores of 4 and 5 (no strain across the entire lesion) as
positive results.
• A specific bull’s eye artifact on black-and-white images
or an aliasing artifact that appears as a blue-green-red
(BGR) pattern on colorcoded images can be observed
in simple cysts.

72. Shear-Wave Elastography
• Using SWE, transversely oriented shear waves are
generated by acoustic radiation force, and these waves
propagate faster in hard tissue than soft tissue.
• A color-coded image displaying the shear wave velocity
(m/sec) or elasticity (kilopascals, kPa) for each pixel in the
region of interest (ROI) is acquired.
• Generally, a color scale ranging from 0 (dark blue, soft) to
+180 kPa (red, hard) is used for breast lesions. A variety of
qualitative and quantitative parameters of SWE have been
studied so far , and the most useful SWE feature is the color
assessment of the maximum elasticity, which is correlated
with the maximum elasticity value (kPa).

73. Shear-Wave Elastography
• The positive predictive value for malignancy increases with
increasing elasticity, from 0.4% for dark blue to 81.8% for red colors.
• The maximum elasticity colors on SWE can be classified into three
categories:
• dark blue and light blue colors (representing soft elasticity) as
negative,
• green and orange colors (intermediate elasticity) as equivocal, and
red colors (hard elasticity) as positive.
• Signal-void areas that are not color-coded even in the penetration
mode can appear in simple cysts or in very hard masses with dense
collagen deposition, as shear waves cannot propagate through
them.

75. MRI of Breast

76. Standards for the performance of
breast MRI

77. MRI of Breast
• The fat have faster relaxation times (greater
interaction between molecules), so their T1
signal is shorter than pure water; thus, fat has
the shortest T1 relaxation time. By
convention, tissues with short T1 are
presented as bright signals on T1 images.

78. MRI of Breast
• 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.

79. 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).

80. FAT Suppression :
• Because of the high signal intensity of fat on
T1 images, it is often difficult to appreciate
enhancing lesions on gradient-echo images
from the high signal produced by fat on T1-
weighted images. Consequently, methods
have been devised that eliminate the high
signal from fat so that the tissues that
enhance following contrast administration are
more easily appreciated .

81. Fat suppression makes enhancing lesions easier to appreciate. Fat has low signal
intensity on this fat-saturated T1-weighted image (A) prior to the IV administration of
contrast. The cancer in the left breast is more evident on the first fat-saturated set of
images following contrast injection

82. Breast MRI indications
• 1-Preoperative evaluation of patients
with newly diagnosed breast cancer:
• when combined with mammography and
clinical breast exam, has been shown to
provide sensitivity of 99% for the
preoperative assessment of the local
extent of disease in patients with newly
diagnosed breast cancer.

83. • The purpose of MRI is to detect the presence
of multifocal and multicentric disease as well
as to detect bulky residual disease at the
lumpectomy site in order to allow directed re-
excision.
• malignancies may enhance at much more
rapid initial rates than benign lesions.

84. • Breast cancer staging is based on the extent of
local-regional disease in the breast and axilla, which
has predictive value regarding the patient's
prognosis and dictates treatment options.
• MRI sensitivity rates for the detection of
invasive breast cancer are estimated to be as
high as 95-100%.
•

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

86. • 2- evaluation of breast cancer patients treated
with neoadjuvant chemotherapy. MRI has
been used to monitor treatment response to
neoadjuvant chemotherapy in patients with
locally advanced cancer.
• Change in tumor vascularity/enhancement
appear to explain changes in functional
dynamic contrast assessment and can be seen
after only one cycle of chemotherapy.

87. • Neoadjuvant chemotherapy. Sagittal post contrast fat
suppressed T1W image prior to chemotherapy shows
an enhancing mass correlating to a biopsy-proven
invasive ductal carcinoma (A). Following
chemotherapy, a comparable image shows only a
small area of residual enhancement (B)

88. • 3- evaluation of patients with metastatic axillary
lymphadenopathy and an unknown primary
malignancy.
• 4- evaluation of breast cancer patients with
positive surgical margins following breast
conservation therapy.
• MRI can be useful in determining the extent of
residual disease when margins are positive and
the mammogram is not helpful.

89. Postsurgical MRI can demonstrate residual malignant
disease. The postoperative MRI shows the seroma cavity on
both the T2 images

90. (A) Retropectoral and (B) retroglandular placement of
implants on MRI. Sagittal T1-weighted images of two
different patients with silicone implants.
•5- determination of silicone breast implant integrity.

91. • 6-breast cancer screening in high risk
women.
• 7- use of breast MRI as a problem-solving
tool for equivocal mammographic findings
and for 3-dimensional localization of a
lesion seen.

92. • 8- Evaluation of occult breast cancer
• In patients with an occult primary presenting
with axillary lymphadenopathy or Paget's
disease, MRI has been shown to identify the
primary in many patients, thus allowing for
conservative surgery rather than
mastectomy.

93. Detection of occult malignancy. This patient had a
positive axillary lymph node with a negative clinical
examination

94. • 9-small breast (MRI) is well suited to the
investigation of breast cancer by virtue of its
noninvasive nature and its multiplanar imaging
abilities.
• 10-Post surgical scar vs. recurrent tumor
• In cases where mammography and ultrasound are
inconclusive in patient suspected of recurrent
disease, MRI can be helpful.
• Breast tissue can show enhancement for up to 18
months following radiation therapy.

95. Invasive breast cancer visible on T1-
weighted image because of the
surrounding fat.

96. Cysts are bright on T2. In this mammogram of the
right breast (A), the dense tissues obscure the cysts
that are easily seen on the T2-weighted MRI
examination (B).

97. Blood in the ducts can be bright on T1. This
patient had a bloody nipple discharge on the right
The blood in the duct is bright on the precontrast
T1 image.

98. • 11-Breast MRI has consistently been
found to detect additional unsuspected
malignancy within the ipsilateral breast(in
10% to 27% of patients).

99. 12-Pectoral muscle tumor invasion. .

100. • C. Inappropriate Use of Breast MRI
• 1. Screening of general population
• At present there is no data to support the
use of MRI as a screening tool.
• To date, there are no studies
demonstrating decreased mortality by
the use of MRI. Not all cancers seen on
mammography can be identified in MRI.

101. • 2. Differentiation of benign & malignant
lesions
• Because of an overlap between the
enhancement and morphological
characteristics of benign and malignant
lesions, MRI cannot be used as a substitute
for biopsy.

102. Scinti Mammography

103. Indications for scinti-mammography
• Indeterminate lesions
• Dense Breasts
• Implants
• Post Sx /RT
• Bone scan
• Sentinel node biopsy

104. Indication for molecular imaging
• Staging of patient with distant mets
• Loco regional extent
• Response to therapy
• Restaging of patient with loco regional
recurrence/mets
• Monitoring response to therapy
• Lymph node and mets
• Dense breast
• Implants
• Localize Primary in presence of mets
• Bone metastasis

106. PET Imaging

107. CAD
• Computer-aided detection (CAD) is a computer
software system that is designed to aid the film
reader by placing prompts over areas of concern, and
to try to reduce observational oversights. CAD
systems are highly sensitive for detecting cancers on
screening mammograms. CAD software will correctly
prompt around 90% of all cancers, with 86–88% of all
masses and 98% of microcalcifications correctly
marked. Specificity is much more of a problem with a
high rate of false-positive prompts. The number of
false prompts will vary according to the level of
sensitivity at which the system is set; typically there
are between two and four false prompts per study

108. CAD

109. Thank you