This document discusses various investigations used for breast cancer detection, staging, and treatment. For detection, modalities discussed include mammography, tomosynthesis, xeroradiography, thermography, ultrasound, aspiration, MRI, and mammoscintigraphy. Investigations for staging examine tumor size (T), lymph node involvement (N), and metastasis (M) using techniques like MRI, lymphoscintigraphy, chest x-ray, bone scans, and liver scans. Sentinel node biopsy and lymphoscintigraphy are discussed as investigations used for guiding treatment decisions.

1. Investigations OF
breast cancer
PT--2

2. Content;-
1.INVESTIGATIONS FOR DETECTION
2.INVESTIGATIONS FOR STAGING
3.INVESTIGATIONS FOR TREATMENT

3. INVESTIGATIONS FOR
DETECTION;-

4. MODALITIES;-
1. MAMMOGRAPHY
2. TOMOSYNTHESIS
3. XERORADIOGRAPHY
4. THERMOGRAPHY
5. ULTRASOUND
6. ASPIRATION
7. MRI
8. MAMMOSCINTIGRAPHY or POSITRON EMISSION MAMMOGRAPHY
9. BIOPSY

5. MAMMOGRAPHY
STATS;-
Sensitivity-55%
Size-changes by 15-20%
False+ves-5-15%
False-ves-10%

6. • Detection of breast cancer by using low energy x-rays(less
than which, is used for bone).
• Principle :- It identifies the areas of micro calcifications &
tissue densities.
• Procedure:…..x-ray of superior and medial
aspects,compression
• Malignant lesions show irregular densities and intra ductal
calcifications
• Benign lesions show well defined borders and peripheral
calcifications.
• Types
• BIRADS SCORE-0-6

7. PROCESSING OF MAMMOGRAM
PROCEDURE

8. NORMAL BREAST
BENIGN LESION
MALIGNANTLESION

9. TOMOSYNTHESIS
• Method of performing high resolution limited angle
tomography at mammography dosage levels.
• High increase in sensitivity with little increase in exposure.
• Unlike ct rotation is 40 degrees and exposure is very less.

10. XERORADIOGRAPHY
STATS;- nearly same as that of
mammography
Procedure;-it is same that of x-ray
except the screen which is made up
of selenium
It is useful for untrained eyes
It is outdated technique not used
now a days.

11. THERMOGRAPHY
• PRINCIPLE usually many malignant tumours are hot . so by
identifying these hot spots we can identify the tumour.
• FALSE+VES;-INFECTION
• FALSE-VES;-SOME MALIGNANT TUMOURS WHICH ARE
NOT HOT
• MAIN USE;-differ b/w benign and malignant.

12. ULTRASOUND
Principle:-
A non-invasive imaging technique that
uses sonic energy in the frequency
range of1-10MHz.
USG is non-ionizing form of energy
which is safe even in pregnants,children.
Echoes of USG beam gives info. about
size,shape&internal structure of
organs&masses.

13. USG IN BREAST CANCER
• APPEARANCE;-
1. Cysts-fluid filled lesions-no internal echo
2. Benign-Solid lesions-smooth and well defined borders
3. Malignant-jagged borders
Earlier the sensitivity of USG used to be very less but the
advent of advanced techniques like gray scale echography
has made it very useful

14. BENIGN CYST MALIGNANT LESION

15. ASPIRATION
Done in case of cystic lumps of breast.
Most of the times they are benign.but
if aspirateis,
1. Blood stained
2. Mass does not completely
disappear on aspiration
3. Recurrences are there,
send the fluid to FNAC
and the mass for BIOPSY,if +ve
results come mastectomy or
lumpectomy is done.

16. MRI

17. Principle
• It uses a pulsed radio
frequency beam in presence of
strong magnetic field to obtain
images of high quality.
•Nuclei of any atoms with odd
number of nucleons behave as
small magnets.
• in the diagram…….
•Hydrogen nuclei are used as
they-1.abundant in body
•2.Sensitive to phenomenon of
magnetic resonance

18. In breast cancer
contrast enhancement by
gladolinium chelate is used.
given i.v 0.1milli mol/kg.
Tumours are characterised by
a) Hypervascularity
b) Increased capilary permeability
c) Increased interstitial space
these are all due to
neovascularisation property of
tumours.it will lead to pooling
of contrast agent in that area.

19. • It used to have a high sensitivity but low specificity.
• But the problem has been overcome by new techniques
likedynamic imaging andhigh resolution static contrast enhanced
imaging
• Now the sensitivity is 95% and the specificity is 86%.
• Advantages;-
1. High sensitivity
2. Shows the exact size
3. Response to chemotheraphy can be known
4. Distinguish scar from recurrence
5. Useful for staging as it shows nipple areolar or pectoral or nodal
infiltration,detects multi-centered foci and tumuor size.

20. PRINCIPLE OF NUCLEAR MEDICINE
• It depends on the selective uptake of diff compounds by diff
orans of body.
• These compounds are labelled with radioactive substance of
sufficient energy level to detect it out side the body.
• Technitium99 is a near ideal isotope which is non toxic and
inexpensive.
• Mechanism for uptake;-
1. Blood pooling-cardiac scan
2. Phagocytosis –liver scan e.t.c.

21. POSITRON EMISSION TOMOGRAPHY
 Nuclear scan of breast is called mammoscintigraphy.
 X-rays and MRI identify anatomical changes,while PET helps in
identifying molecular changes even before the anatomical changes.
• It is of two types 1)single gamma and2)dual gamma
• Excellent sensitivity for tumours >1cm
• Poor sensitivity for tumours <1cm ,medially located and non
palpable tumours.
• Materials used are 99TCsestambi and 99TCtetrafosmin.
• If the scan is taken in different directions like CT it is called PET.

22. BIOPSY
•For definate diagnosis of
malignancy
•Types;-
1. Needle biopsy
2. Drill biopsy(>1cm)
3. X-ray guided biopsy(>3mm)
It helps in 1.search for
metastasis
2.Discussion for mastectomy

23. DRILL BIOPSY NEEDLE BIOPSY

24. INVESTIGATIONS FOR
STAGING;-

25. MODALITIES;-
1. FOR T—TECHNIQUES FOR DETECTION MAINLY MRI
2. FOR N- LYMPHO SCINTIGRAPHY,CT
3. FOR M-BONE XRAY,BONE SCAN,LIVER SCAN,CHEST X-
RAY, BIOCHEMICAL STUDIES.

26. CHEST X-RAY;-

27. • Simplest method for observing visceral metastasis.
• Lung involvement is of two types;-
• 1.blood borne-multiple nodular lesions ,late onset of
symptoms ,detect 1-2 cm
• 2.thru lymphatics-diffuse lesion,early onset of
symptoms,>2cm as they blend with other mediastinal
structures

28. LYMPHOSCINTIGRAPHY
• It is Nuclear scan of lymph nodes.
• It is done preoperatively to know the extent of invasion.
• Material is 10-15MBQ of 99TC labelled nanocoll
• 0.2 ml is injected subdermally on the lesion.
• Helps for identification of SLN and its differentiation from
other groups.

29. BONE XRAY

30. • Bones are the most common site of metastasis in breast cancer
• Most commonly involved are pelvis and spine.
• Lumbar >thoracic >sacrum >cervical.
• 4 types of changes in bone;-
• 1.osteolytic
• 2.osteoblastic.
• 3.Without any associated damage
• 4.combination

31. BONE SCAN

32. • PROCEDURE;-i.v injection of radioactive 99mTCphosphonate
and bisphosponate.overall body scan by rectilinear scanner.
• Routine skeletal survey is done by bone scan followed byx-
ray of the abnormal areas.
• Healing fractures,osteomyelitis,pagets disease show false+ve
hot spots .they have to be differentiated by x-ray .

33. LIVER SCAN
Sulphur colloid labelled
99mTECHNITIUM is injected i.v and
scan is done by rectilinear scanners.
It is taken up by the reticulo endothelial
system.Focal filling defects indicate
metastasis.
Lesions<2cm cannot be identified.but
they are found frequently

34. CT
For metastasis in
mediastinal and
retroperitoneal
lymph nodes.

35. BIOCHEMICAL STUDIES;-
1. ALKALINE PHOSPATASE for bone and liver.
2. GAMMA GLUTAMYL TRANSAMINASE for liver.
3. CARCINO EMBRYONIC ANTIGEN along with liver scan.
4. URINARY STEROIDS like aetiocholanolone in relation to 17-
hydroxy corticosteroids.
5. URINARY HYDROXYPROLINE-due to collagen destruction.

36. INVESTIGATIONS FOR
TREATMENT;-

37. MODALITIES;-
1. SENTINAL NODE BIOPSY
2. LYMPHOSCINTIGRAPHY

38. Sentinal node biopsy
• Sentinal node indicates first node encountered by the
tumour cells and its histological status predicts the status of
distant lymph nodes.
• ADVANTAGES;-
• 1.minimally invasive technique,morbidity and cost are very
low.
• 2.gives an idea of involvement of axillary lymph nodes
• 3.obviates the need for axillary node dissection in all breast
cancer cases without compromising staging information.

39. All good things come to an
end……
GRACIAS..///:-)
FOR UR PATIENCE ND ACCEPTANCE
- -- M.Uma sai (PT-2)