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Radiological approach for malignant breast lesions
- 2. RADIOLOGICAL APPROACH FOR MALIGNANTBREAST LESIONS DR. ANJUM MEHDI MBBS, DMRD, FCPS (Radiology) Associate Professor Radiology Punjab Medical College, Faisalabad.
- 3. Breast Cancer • Incidence= 90 / 100 000. • 10 % of women will have a Breast Cancer • Treatment efficient for local disease • 5 % of Women will die
- 4. Risk Factors BeforeMenopause >>> Tall & Slim Border Line Lesions > 1 Abortion Long Study Contraceptive Pill > 5 years very early Short Menstrual Cycles (<26 days) Psychological Factors > > > > > ? ? ? ? >>> >>> Nulliparous < 25 years First menstruation <13 years Alcoholism Family History History of pulmonary TB
- 5. Risk Factors afterMenopause Nulliparous < 25 years >>> Menopause > 52 years >>> First menstrual cycle < 13 years >>> Obesity >>> Alcoholism > High social class > Urban Habitat > Family History > History of pulmonary TB ? Celibate ?
- 6. Predisposing Genes ofBreast and Ovary cancer Breast Cancer Ovarian Cancer BRCA1 9 q 34 (Japan)BRCA 2 BRCA 3 (8p) Androgen-R
- 7. FNA Magnification Core Biopsy SurgeryFallow-up SpotUltrasound Decision Microcalcifications Stellate Lesions Mass Screening Mammography Diagnostic Stratégie
- 8.
- 9. TNM Classification Tumor • T0: No Clinical Sign •T is : Carcinoma in situ • T1 < 2 cm •T1a < 0,5 cm •T1b > 0,5 cm &< 1 cm •T1c > 0,5 cm &< 2 cm • T2 : 2 to 5 cm • T3 > 5 cm • T4 : Skin or Pectoral Adherence •T4a : extension to the Wall •T4b : Edema, ulceration •T4c : Inflammatory Carcinoma Nodes Non palpable : N0 Mobiles : N1 Fixed : N2 Ipsilateral or Susclavian : N3 Metastasis Absent : M0 Present : M1 p Nodes pN0 : No invasion •pN1 : Axillary extent mobile • pN1b: Metastasis >2 mm • pN1a: Micro metastasis •pN2 : Axillary extent fixed •pN3 : Internal Mammary Extent Pathologic Classification p TNM
- 10. STAGES 0 I IIIII IV T is N0 M0 T1 N0 M0 Tn Nn M1 T0 N1 M0 T1 N1 M0 T2 N0 M0 T2 N1 M0 T3 N0 M0 A B A B T0 N2 M0 T1 N2 M0 T2 N2 M0 T3N1&2M0 T4 Nn M0
- 11. Mortality of BreastCancer 0 20 40 Deathfor100000 Breast Uterus Lung Ovaries 1975 1995 2015 Women 35 - 64 years
- 12. BREAST ANATOMY Breast tissueis composed of 3 layers. 1. Premammary. 2. Mammary. 3. Retromammory. Breast contains 15-18 lobes, Each lobe contain 20-40 lobules. Cooper’s ligament are fibrous bands that course between the superficial fascia and the deep fascia.
- 13. BREAST ANATOMY Basicfunctional unit of breast is a TDLU/lobule. TDLU consist of 10 -100 acini that drain into the terminal duct. The terminal duct drains into larger ducts main duct of the lobe nipple. The terminal ductal lobular unit is an important structure because most invasive cancers arise from the TDLU. It also is the site of origin of ductal carcinoma in situ (DCIS), lobular carcinoma in situ, fibroadenoma and fibrocystic disease.
- 14. BENIGN VS MALIGNANT FeatureBenign Malignant Shape Round, wider than tall Taller than wide Margins Smooth Irregular, angular, spicular Lobulations None or up to 3 Multiple Capsule Encapsulated No capsule Halo Absent Echogenic halo Fixity None Fixed to surrounding issue and/or underlying muscles Shadowing or enhancement Enhancement, edge shadowing Shadowing behind lesion Substance echogenicity Anechoic (cystic), Hyperechoic Hypoechoic, calcification FEATURE BENIGN MALIGNANT Shape Round, wider than tall Taller than wide Margins Smooth Irregular, angular, spicular Lobulations None or up to 3 Multiple Capsule Encapsulated No capsule Halo Absent Echogenic halo Fixity None Fixed to surrounding issue and/or underlying muscles Shadowing or enhancement Enhancement, edge shadowing Shadowing behind lesion Substance echogenicity Anechoic (cystic), Hyperechoic Hypoechoic, calcification
- 15. ANGULAR MARGINS Indicativeof invasion. The angles of lesion margins can be acute, right angle or obtuse. A single angle of any type on the surface should be considered suspicious. Angles on the surface of the lesion occur in regions of low resistance to invasion(fatty tissue).
- 16. MARKEDLY HYPOECHOIC Marked hypoechogenicityof a solid nodule (compared with fat) is a suspicious sonographic finding for malignancy.
- 17. AXILLARY LYMPHADENOPATHY • √Normallymph nodes have a hypoechoic cortex with a thickness up to 2 mm, and a fatty hyperechoic central hilum. • Normal nodes can be very large but almost entirely made up of fat with a thin rim of hypoechoic cortex. • Measurement of nodal length is therefore useless in predicting nodal infiltration by tumour. • √ Normal nodes are typically oval in shape. Metastatic nodes are frequently round rather than oval (l:s axis ratio < 2),they show either concentric or eccentric cortical thickening of >2 mm with concomitant narrowing of the hilum. • √ Some of the proposed criteria for malignant lymph nodes have included size greater than 2 cm, round or irregular shape and absence of a fatty hilum.
- 18. AXILLARY LYMPHADENOPATHY Normal lymph node.On sonography, features include an ovoid shape and thin cortex (arrowhead), well-defined margins, and a preserved fatty hilum (arrow).
- 19. AXILLARY LYMPHADENOPATHY Suspicious sonographiccharacteristics of lymph nodes. Nodes A and B show cortical thickening with compression and displacement of the central fatty hilum. Nodes C and D demonstrate focal eccentric cortical thickening. Nodes E and F are completely replaced with loss of hilum. Note the rounded configuration of nodes B and F. The ratio of the long-to-short axis is less than 2. Node G is hypervascular with a nonhilar blood flow pattern.
- 20. BREAST IMAGING REPORTING ANDDATA SYSTEM (BIRADS) classification of breast lesions is an attempt to standardize the reading and reporting of mammograms
- 21. 0 Category additional evaluation(e.g., magnification or spot compression view, old films for comparison, or ultrasound ) needed
- 22. 1 Category breasts aresymmetric and normal, annual screening is recommended
- 24. 2 Category benign lesions(stable mass, simple cyst, calcified fibroadenoma, scattered benign calcifications, normal lymph node) annual screening is recommended
- 25. • 67 Yearold women with left cephalocaudal mammogram Simple Cyst
- 26. 3 Category probably benignlesion (multiple rounded densities, round calcifications, circumscribed mass on a first mammogram) short interval follow up suggested (6 months)
- 27.
- 28. 4 Category suspicious lesion(10-30%chance of malignancy) biopsy recommended
- 29. • 38 year-oldwoman with a palpable mass; Right MLO view (a) demonstrates a high density irregular mass with indistinct margins in the upper aspect of the right breast. Also present is adenopathy in the axilla. Ultrasound (b) demonstrates the palpable mass to be hypoechoic with irregular margins. Pathology: Invasive ductal carcinoma.
- 30. 5 Category malignant lesion(spiculated lesion- 90% chance of malignancy) appropriate action (e.g.,biopsy, excision)should be taken.
- 31. • 43 year-oldwoman for screening mammography. Right craniocaudal views show a classical appearing carcinoma, which is a high density mass with spiculated margins, and microcalcifications. Pathology: Invasive ductal and lobular carcinoma.
- 32. Infiltrating ductal carcinoma •71 year old women had a firm mass in the left breast • Cephalocaudal view of the left breast
- 33. Calcifications on mammography •Microcalcifications less than 0.5mm • Not specific to carcinoma • Is seen in 30-40% of carcinoma on mammography • Macrocalcifications more than 0.5mm • May be found in carcinoma
- 34. PROBABLY BENIGN • Widespread– all one/both breasts. • Macrocalcification of one size. • Symmetrical distribution. • Widely separated opacities. • Superficial distribution. • Normal parenchyma.
- 35. POSSIBLY MALIGNANT Biopsy indicated •Microcalcification – particularly segmental, cluster distribution (> 5 particles in 1.0 cm3 space; of these 30% will be malignant). • Mixture of sizes and shapes – linear, branching, punctate. • Associated suspicious soft-tissue opacity. • Microcalcification eccentrically located in soft- tissue mass. • Deterioration on serial mammography.
- 36.
- 37. DUCTOGRAPHY • Galactography, orductography, is a mammographic technique that involves injection of a contrast agent (dye) into a milk duct. This study may be useful in the evaluation of unilateral spontaneous nipple discharge that is bloody. (Nipple discharge that is milky, yellow, or green is rarely associated with breast cancers.)
- 39. Ninety-degree mediolateral ductogramshows a filling defect (arrows) within dilated ducts, which represents a papilloma.
- 40. Carcinoma. Craniocaudal ductogram showslarge filling defects near the nipple (arrow). Sanguineous spontaneous nipple discharge prompted acquisition of a diagnostic ductogram. The standard central duct excision would have resulted in excision of tissue within a cone limited by the white lines and the nipple. Note the filling defects outside the margin of the standard excision (arrowheads). Histologic analysis demonstrated extensive ductal carcinoma in situ (DCIS) involving much of the area opacified with ductography.
- 41. Where do westand today in breast imaging?
- 42.
- 43. Lymphoscintigraphy Pre-surgical marking ofsentinal lymph node • Performed for invasive cancers • Tc-99 SC injected at tumor site or peri-areolar • Static planner images or CT-SPECT to identify the sentinal lymph node – LN marked on skin – Surgeons explore with Gamma probe during surgery
- 44.
- 45.
- 46. Ultrasound Elastography • Usesassessing inherent tissue elasticity to find cancers • Cancers that are harder than breast tissues / benign lesions show different values • Cancers usually measures larger on elastograms compared to grey-scale Standardization is currently a real problem
- 47. Elasticity Scores Figure 1:Images present general appearance of lesions for elasticity scores of (a) 1, (b) 2, (c) 3, (d) 4, and (e) 5. Black circle indicates outline of hypoechoic lesion (ie, border between lesion and surrounding breast tissue) on B-mode images.
- 48. Elastography RADIOLOGY: VOLUME 239:NUMBER 2 2006
- 49. Breast specific gammaImaging (BSGI) • High sensitivity (>90%), specificity (>45%) • Intravenous Tc-99 Sestamibi scintigraphy • Comparable images to mammography • Not affected by breast density • High dose of radiation (20-30 X mammography) • Limitations with biopsy capabilities
- 50.
- 51. Positron Emission Mammography(PEM) – F-18 FDG • Sensitivity and specificity similar to MRI • > 90% sensitivity for DCIS • Is not affected by the breast density or hormonal status • Newer agents more specific to DNA synthesis • High dose of radiation • Current limitation for biopsy
- 53.
- 54.
- 55. Digital Tomosynthesis (3D-Mammography) • Digitalmammography and computed tomography • 3-D image slices through the breast • Initial research suggest lesser recall and finding more cancer • Hybrid units with Tomo + functional imaging • Time consuming (scanning and reading) • Not significantly better for calcifications
- 56.
- 57. Low dose breastCT scan • Still in early stages of research • Contrast enhanced CT improves detection of benign and malignant breast masses Prionas et al. ‘Radiology’Sept. 2010
- 58. Low dose breastCT scan
- 59. Low dose breastCT scan Calcifications Enhancing mass
- 60. Contrast enhanced ultrasound CEUS •Not FDA approved in USA for clinical use • Assesses enhancement suggesting neovascularity in cancer • Analysis of time-intensity curves or enhancement pattern (peak%, Time to peak, Mean transit time) • Significant overlap between benign and malignant • Peripheral enhancement seen with malignancy but low sensitivity (39.5%) and high specificity (98%)
- 61. Homogeneous and peripheralenhancement Invasive cancers
- 62.
- 63. INDICATIONS • High riskfor breast cancer: personal or strong family history (especially premenopausal cancer in first degree relative - mother, sister or daughter) • Breast cancer gene present • Prior to breast cancer conservation surgery to look for occult breast cancer in either breast • Problem-solving for breast diagnosis • Breast implants with a question of leak • Technique of choice in the differentiation between postoperative scarring and local recurrence • Differentiation of axillary recurrence and brachial plexopathy post radiotherapy
- 64. A: Fibroadenoma B: InvasiveLobular Carcinoma Five minutes after contrast injection: Subtracted images (only the cancer is visible): Controlled Movement means that Subtraction can be used.
- 65. MRI Spectroscopy • Informationon intracellular metabolites • Increased Choline peak between the water and lipid peaks in cancers • Has shown high sensitivity (83%) and specificity (85%) • Utility may improve with 3T MR RADIOGRAPHICS;27:1213-1229 2007
- 66. MRI Spectroscopy Image-localized magneticresonance spectroscopy (MRS) of a breast tumor. Left panel is an MRI image with tumor voxel (square) selected. Right panel is the corresponding 1H MRS spectrum with the tCho resonance at 3.2 ppm
- 67. Breast MRI enhancementcurves Following administration of Gadolinium there can be three possible enhancement kinetic curves for a lesion on breast MRI. • type I curve: progressive enhancement pattern – typically shows a continuous increase in signal intensity throughout time – usually considered benign with only a small proportion of (~9%) of malignant lesions having this pattern • type II curve: plateau pattern – initial uptake followed by the plateau phase towards the latter part of the study – considered concerning for malignancy • type III curve: washout pattern – has a relatively rapid uptake shows reduction in enhancement towards the latter part of the study – considered strongly suggestive of malignancy
- 68. Breast MRI enhancementcurves
- 69. RECOMMENDATIONS FOR SCREENING •AMERICAN CANCER SOCIETY • AMERICAN COLLEGE OF RADIOLOGY WOMEN AT NORMAL RISK SHOULD BEGIN ANNUAL BREAST CANCER SCREENING AT STARTING AT AGE 40
- 70.
- 72. Survival of InvasiveDuctal Carcinoma / Grade 0 1 2 3 4 5 6 7 8 9 10 11 12 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Grade 1 Grade 2 Grade 3
- 73. Survival of InvasiveDuctal Carcinoma Related to the Size 0 2 4 6 8 10 12 0 0.5 1 <0.9 mm 1-14 mm 15-19 mm 20-29 mm 30-49 mm > 50 mm
- 74. 0 1 2 3 45 6 7 8 9 10 11 12 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Grade 1 Grade 2 Grade 3 Survival of Invasive Ductal Carcinoma / Grade & Size 0 2 4 6 8 10 12 1 2 3 0 0.2 0.4 0.6 0.8 1 30-49 mm15-19 mm
- 75. BRCA-1 (chromosome 17),BRCA-2 (chromosome 13), BRCA3 (chromosome 11), and BRCA4 (chromosome 13) are tumor suppressor genes. Mutations in these genes are associated with an increased risk of hereditary (familial), early onset (pre- menopausal) bilateral breast or ovarian cancer. Hereditary breast cancer accounts for 5% of all breast cancer. The BRCA mutation confers a 50% - 85% lifetime risk of developing breast cancer, as compared to 10% for the general population. The mutation confers a 15% - 40% lifetime risk for ovarian cancer, as compared to 1.5% in the general population.