This document discusses various imaging modalities used for breast cancer screening and diagnosis, including mammography, ultrasound, MRI, CT, and PET scans. It provides details on mammography techniques for screening and diagnostic purposes. Key findings from studies on screening mammography for different age groups are summarized. Guidelines on screening from organizations like ACS, NCCN, and NCI are also outlined. The use of ultrasound and MRI as supplemental tools for diagnosis is discussed.

1. Dr Deepika Malik
J.R. II
Department of Radiotherapy

2.  Imaging modalities in breast cancer are used for
screening as well as diagnosis.
 -Mammography
 -Ultrasonography
 - MRI scan
 -CT scan
 -PET scan
 -Bone scan

3. Mammography
 Is used both as a screening as well as diagnostic tool in
breast cancer

4. Screening Mammogram
 Before 1977, no formal guidelines existed for
screening women for occult breast cancer.
 The publication of the Health Insurance Plan
(HIP) of Greater New York Screening Project, in
the 1960s, led the National Cancer Institute and
the American Cancer Society to support a breast
cancer screening project to evaluate further the
efficacy of screening by mammography and
physical examination.

5.  At 5 years, the HIP study found a 50% decrease in
mortality rate in women older than 50 years of
age, but only a 5% decrease in mortality rate in
women younger than 50 years of age.
 With follow-up, the mortality rate in women
younger than 50 years of age showed a 23.5%
 Women who refused screening had no reduction
in mortality rate.

6.  Screening Mammogram
 Although an active area of debate
 Several authors agree that screening mammography in
women 40-49 years of age may reduce mortality from
breast cancer
 Health insurance plan study, (1963-1969)
 Taber et al (1988-1996)
 {Canadian study- addition of annual mammography screening had no effect on breast cancer
mortality}

7.  National Organizations' Screening Guidelines for
Mammography
 ACS (American college of surgeons)
 For women for normal risk, yearly mammograms
are recommended starting at age 40.
 CBE suggested about every three years for women
in the 30′s and every year for women age 40 and
above.
 BSE is suggested for women starting in their 20s.

8.  NCCN
 Women at normal risk are recommended to have
CBE every 1–3 years;
 periodic SBE is encouraged.
 Beginning at age 40, annual CBE and
mammograms are recommended, and periodic
SBE is encouraged.

9.  NCI
 Women who are age 40 and above should be
screened with mammograms every 1–2 years.

10.  For age group <50 years
 The National Cancer Institute, American Cancer
Society, and the American College of Radiology
recommend a baseline mammogram at the age of 35
years (30 years in high-risk groups).
 Repeat examinations should be carried out every 2
years beginning at 40 years of age.
 In women older than 50 years, mammograms should
be performed annually.
 Frisell J, Lidbrink E. The Stockholm Mammographic Screening Trial: risks and benefits in age group 40-49
years. J Natl Cancer Inst Monogr 1997:49–51.
 UK Trial Group. 16-year mortality from breast cancer in the UK trial of early detection of breast cancer. Lancet
1999;353:1909–1914
 Kerlikowske K, Grady D, Rubin SM, et al. Efficacy of screening mammography. A meta-analysis. JAMA
1995;273:149–154.
 Feig SA. Estimation of currently attainable benefit from mammographic screening of women aged 40-49 years. Cancer
1995;75:2412–2419

11. Diagnostic mammogram
 most critical component of diagnostic imaging in
breast cancer patients
 bilateral mammograms should be performed routinely
in the work-up of the breast cancer patient

12.  Special x-ray machines
developed exclusively for
breast imaging
 produce mammography
films.
 use very low doses of
radiation and produce
high-quality x-rays

13.  The patient wears an
open wrap and
undress above the
waist

14.  Breast is briefly compressed
between 2 plates attached
to the mammogram
machine– an adjustable
plastic plate on top and a
fixed plate on bottom which
holds the x-ray film

15.  We should be familiar with the difference between
diagnostic and screening mammogram.
 Screening mammogram-
 Routine mammogram, done in asymptomatic women
 2 views- craniocaudal, mediolateral

16.  Diagnostic mammogram-
 To characterise abnormalities detected at screening or
in women with palpable masses
 Additional magnification views
 Done in presence of radiologist generally to determine
need for additional views or follow up studies
-lateromedial(from side towards center of chest)
- mediolateral(from the center of the chest out)
- Spot compression view

20. Mammographic abnormalities
Mammographic signs of cancer consist of two primary
findings:
 (1) a mass with ill-defined, irregular, or spiculated
edges and/or
 (2) irregular, pleomorphic calcifications

21. Benign cyst of breast

22. IDC- mass with illdefined ,
spiculated margins
Benign masses- well defined, with
sharp margins, and have little effect on
the surrounding breast architecture

23.  Calcifications
 Could be associated with benign or malignant
conditions of breast

24. Typical popcorn calcification
FIBROADENOMA

25.  In malignant
tumors– calcification
100 to 300
micrometeres, rod
like , tubular,
branching, punctate

26.  Vascular calcifications
 These are linear or form
parallel tracks, that are
usually clearly
associated with blood
vessels.

27. Micro-calcifications can
be very subtle
Biopsy of this area
showed 8mm DCIS

28. Biopsy = DCIS with focal micro-invasion

29. In ductal carcinoma in situ (DCIS), there is
normally no mass but just an area of
calcification

30. CC and MLO mammographic views
show a large and relatively
circumscribed ovalar lesion in the
upper outer quadrant.
On US scan it consists on a complex
cyst with a parietal ill-defined mass
(arrows).
US-guided core needle biopsy of the
intracystic mass revealed a
malignant phyllodes tumor

31.  The BIRADS ( Breast Imaging and Reporting Data
System) classification system is widely adopted in
classifying mammograms with respect to appropraite
follow up and intervention

32.  Nothing to comment on.
 Breasts are symmetric ; no masses,
architectural disturbances, or suspect
calcifications are present.
Category 1
Negative

33.  Negative mammogram, but the interpreter
may wish to describe a finding.
Involuting, calcified fibroadenomas,
multiple secretory calcifications, fat-
containing lesions such as oil cysts, lipomas,
galactoceles, and mixed-density
hamartomas all have characteristic
appearances, and may be labeled with
confidence.
 The interpreter might wish to describe
intramammary lymph nodes, implants, and
the like, while still concluding that there is
no mammographic evidence of malignancy
Category 2
Benign finding

34.  A finding placed in this category should
have a very high probability of being benign
 Not expected to change over the follow-up
interval, but the radiologist would prefer to
establish its stability.
(Data are becoming available that shed light
on the efficacy of short-interval follow-up.
At present, most approaches are intuitive.
These will likely undergo future
modification as more data accrue as to the
validity of an approach)
Category 3
Probably benign
finding ---short-interval
follow-up suggested

35.  lesions that do not have the
characteristic morphologies of
breast cancer but have a definite
probability of being malignant.
 The radiologist has concern to urge a
biopsy.
Category 4
Suspicious abnormality--
----biopsy should be
considered

36.  These lesions have a high
probability of being cancer
Category 5
Highly suggestive of
malignancy----appropriate
action should be taken

37.  Finding for which additional
imaging evaluation is needed.
 almost always used in a screening
situation and should rarely be used
after a full imaging workup.
 Perez , 6th edition , pg-1058
Category 0
Need additional
imaging evaluation

38. Ultrasonography
 Complementary tool to mammography for diagnosis
and screening of breast cancer
 Cannot replace mammography

39.  Screening USG
 In a randomised trial of USG and Mammography of
2809 women with dense breasts from ACRIN,
 Adding a single screening USG yielded and additional
1.1 to 7.2 additional cancers found in high risk women
 But a substantial increase in false positives
 Role of USG as a screening tool is therefore limited

40. Diagnostic USG
 But is a useful tool to complement physical
examination and mammography in diagnosis and
treatment of cancer.
 Sensitivity of 73%
 specificity of 95%

41.  USG Breast is most useful in
 differentiating cysts from
solid tumors
 Identification and
characterisation of palpable
and non palpable
abnormalities of breast
detected by physical
examination or
mammography.

42. USG breast---
 very accurate (>95%) in diagnosing breast cysts.
 Cysts have well-demarcated, smooth margins and
an echo-free center ; usually rounded and thin-
walled and produce distal shadowing.
 Clear cysts require no further evaluation.
 Complex cysts that contain evidence of tissue or
debris may be aspirated to clarify whether they are
simply cysts or represent cystic degeneration of a
tumor.

43.  USG as a guide
 in core biopsies
 FNA
 Cyst aspirations
 Presurgical localizations

44.  NCCN recommends- USG breast for patients with
- a dominant mass
- assymetric thickening
- nodularity

45. MRI
As supplemental tool for screening and diagnosis of
breast cancer.

46. Screening MRI
 Role of MRI screening is rapidly evolving
 But unlikely to replace mammography

47.  Its use in screening high risk populations has recently
been supported in several studies.
 Lehman et al ( MRI detected 4 contralateral breast
{MMG – none} cancers in 103 women with unilteral
breast cancer)
 Kriege et al ( MRI is more sensitive than
mammography in detecting tumors in women at high
risk for familial breast cancer)

48. Diagnostic MRI
 Routine use is controversial
 Use to supplement mammography in breast cancer
diagnosis is rapidly increasing.

49.  Upponi and Warren – MRI resulted in an increase in
confidence or change in clinical plan in 46% of
diagnostic group, 72 % of chemotherapy group, 80 %
of screening group.
In 44/283 of these MRI resulted in a beneficial change
in plan.
• Esserman etal – MRI detected cancer in 55/58 cases;
anatomic extent was correctly identified in 98%
,(MMG-55%)

50. In a woman with dense breasts, the mammogram was normal
but the MRI showed the cancer

51. NCCN recommends Breast MRI for women with
 With early stage disease whose breasts cannot be
imaged adequately with mammography and
ultrasound
 Who receive NACT in occult breast cancer to assess
response
 With genetic mutations leading to a higher risk of
bilateral or contralateral breast cancer

52.  Role of MRI in Occult Breast Cancer
 MRI has a clear role in evaluation of patients with
axillary metastasis with no evidence of primary tumor
in breast by physical examination or mammography.
 Buchanan et al – breast MRI detects mammographically occult cancer in half of women
with axillary metastasis and is a valuable tool for patients with occult primary breast
cancer.

53. Computed Tomography
 No established role for CT scans in routine staging in
patients of early breast cancer
 Its role in initial evaluation is minimal
 Need of iodine contrast material to differentaiate benign
from malignant lesions
 High radiation dose
 Cost per study
 Inability to detect small lesions

54.  NCCN recommends an abdominopelvic CT if
 Abnormal lab values
 Positive findings on physical examination
 For stage IIIA ( T3N1M0 ) or greater.

55. Bone Scan
 Not routinely used for initial evaluation of early stage
breast cancer.
 Koizumi et al reviewed records from 5538 patients of
breast cancer.
 The overall incidence of metastasis to bone was 2.13%
 In stage I– 0.08 %
 In stage II- 10.9%
 In stage III-9.96%
 In stage IV- 34.04%

56.  Therefore bone scans are more commonly
recommended in patients with
 Stage II large tumors (>3cm)
 Aggressive histopathological features
 Stage III or Stage IV cancer
 Perez 6th edition

57. PET scan
 Not a routine component of staging
 NCCN guidelines
 Recommend against routine PET scans in stage 0 to IIIA
disease
 May be useful in patients with locally advanced disease
or in situations where standard imaging results are
suspicious.

58.  Schirrmeister et al ---
 For interpreting results as being breast cancer , FDG
PET has sensitivity of 93%, specificity of 78%, accuracy
of 89%, PPV 92%, NPV- 96%
 For detecting multifocal lesions , FDG-PET was twice
as sensitive (63%) as combination of mammography
and ultrasonography
 High false-negative rate of 20% for detection of lymph
node metastases, this imaging method cannot replace
histologic evaluation of axillary nodes.

61. THANK YOU