THE BREAST

ANCA CIUREA
Radiology Dept.
UMF I Hatieganu ClujCluj-Napoca

Breast examination WH
WHY
Y?

DIAGNOSTIC (symptoms
(symptoms))
- sub
subjjectiv - pain,
pain, tension , sindrom
sindrom premenstrual,
premenstrual, cancerophobia
cancerophobia
- ob
objjectiv lump (nodule)
(nodule),, breast discharge,
discharge, skin changes,
changes, nipple
retraction,, a
retraction
asymmetry
symmetry

NO SYMPTOMS
- SCREENING (screening programes
programes)
- high risk pacients
pacientst
- control of the breast treated conservatory/of the contralateral breast
- metastasis
metastasis of unknown origin

Breast examination HOW

HOW?
?
Mamogra
Mamography
phy

radiogra
radiography
phy,, X ra
rays
ys
elastography
phy))
Ultrasound 2D (Doppler, elastogra
MRI with contrast

Breast examination HOW

HOW?
?

NEVER!!!
NEVER!!!
CT
ermography
thermography
nuclear medicine (tr
(tre
eatment YES spearing breast surgery
with santinel node biopsy)
biopsy)

http://www.lasvegasthermography.com/services/

BREAST EXAMINATION MAM

MA
MMOGRA
MOGRAPHY
PHY

Analog or digital mam

mamm
mogra
ograhy
hy (2D
mamm
mam
mogra
ography
phy))
- two standard incidences
incidences : mediolateral oblic
(MLO) and cranio
cranio--caudal (CC)

BREAST EXAMINATION MAMM

MAM
MOGRA
OGRAPGY
PGY

Tomosintesis (3D digital mamm

Tomosintesis
mammogra
ography
phy))
- multiple sect
sections (one breast compresi
compresion
on),
),
diffferen
dif
erentt angles,
angles, one movement of the XX-ray
tube on an arch

BREAST EXAMINATION MAMM

MAM
MOGRA
OGRAPGY
PGY

Digital contrast enhenced mammography (CESM)

- iv contrast media (iodine)
- two exposures with different energies
- substraction of the images with visualization of the
CM only

Mammography Indica
Indicattions
sceening

(diagnosis of occult breast cc,

women over 40 years)
diagnosis
s (s
(sy
ymptomatic patients, over 35
diagnosi
years))
years
Follow--up patients
ients treated for a breast cc
Follow
tomosy
ynte
ntesis
sis sup
supp
plimentar
limentary
y (pa
(pattients
ients
tomos
with dense breast)
breast)
CESM could replace MRI (studies)
(pattients
(pa
ients with contraindica
contraindicattions for MRI)

Mammography Limit
Limitss
reduced

sensibilit
sensibility
y in the dense breast
reduced sensibilit
sensibility
y in the augmented
breast
dif
ifffic
icu
ult to perform in patients with acute
inflamation / breast trauma

BREAST EXAMINATION - ULTRASOUND

2D

US
Doppler US
Elastography

US - Indica
Indications
tions

palpable lumps or mammography anomalies

women under 30 years (first step examina
examination
tion))
dense breast (white mamm
mammogra
ography
phy))
peripheral lesions
guidance of interventional procedures (if visible
on US)
best method for axillary lymph nodes evaluation

US - Limit
Limitss
real

time and operator dependent

does not allow characterisation/detection
of microcalcifications associated with
breast cancer

BREAST EXAMINATION - MRM

highest sensitivity, low specificity
always with contrast
malignant lesions have an intense and early contrast
uptake and the contrast is rapidly washed out
T2, T1 pre and postcontrast

MRM - Indica
Indicattions
breast

cancer staging
diagnosis of multicentricity, multifocality or
bilaterality
diferenttial between recurrence and scar
diferen
after breast sparing surgery
etastasis
sis of unknown primary
metasta
augmented breast
screening for BRCA po
possitive

MRM - Indica
Indicattions
VASVARI

MARINELA
CICATRICE VS RECIDIV

MRM Limit
Limitss
multiple

fals pos
positive re
res
sult
ultss
fals negative res
resultate for comedo DCIS
(MRI does not depict the typical
microcalcifications))
microcalcifications
long waiting and examination time
expensive
expensive,, feromagnetism, claustrofobia
claustrofobia

ANATOMY
ANATOM
Y

Lobes consist of glandular tissue (lobular), ductal, fatty and fibrous tissue
fibrous tissue in and extralobule
Adipose tissue in and extralobule

Imaging normal appearance

Adipose tissue radiolucent / hipoechoic

Imaging normal appearance

glandular, ductal and fibros tissue
radiodense / hyperechoic

On Mx and US, these elements cannot be

differentiated

Correlation Mx US

cancer
opaque (WHITE) on mamo
hipoechoic (black) on US

Which is the difference?

difference?

NORMAL APPEARANCE

Variations from patient to patient

Variations due to physiological status and

age

ACR BIRADS (The American

College of Radiology Breast Imaging

Reporting and Data System)

Mammography normal appearance

BIRADS aa-d
Signification tells the clinician that in a dense breast,
mammography can miss a small cancer (low
sensitivity).

Mammographic semeiology
Asymmetrical

density (global/focal
(global/focal))
Nodular density (mass)
Architectural distorsion
Microcalcifications

Mammographic semeiology

Asymmetrical density
Causes:
Caus
- physiologic
physiological
al
- focal le
les
sion (mass)
- after surgery
- incor
ncorrrect technique

Mammographic semeiology

Nodular density
Analysis:
Analysis:
- localization clock
- dimension progresion
progresion indicator
- shape
- contour
- density
- associated lesions: architectural
distorsion, calcifications, skin/nipple
changes

Masses

Mammographic semeiology

Nodular density
Malignant

Benign

Shape

Irregular

Round, oval

Contour

Spiculated,
microlobulated or illdefined

Circumscribed

Density

Radioopaque

Radioopaque, radiolucent,
mixt

Surrounding
tissue

Architectural distorsion,
dilated ducts, edema,
skin changes (edema,
invasion, retraction)

Unchanged

Lesion with regula

regularr shape
shape,, circumscribed

Ill defined lesion (non

(non-circumscribed
circumscri
bed))

Lesion with microlobulated contour

Spiculated lesion

Les
Le
sion with mixt densities
densities

Mammographic semeiology

Architectural distorsion
the only finding
ociated
ed with cancer
associat
after surgery

Mammographic semeiology

Calcifications

bgn: large, round/oval, with similar size

and morphology

mgn: small (microcalcifications), irregular,

branching (intraductal)
(intraductal),, heterogeneous in
size/shape

Mammographic semeiology

Calcifications
bgn:

skin, vascular, pop

skin,
pop corn,
corn, rim,
calcified
calcifie
d sutures

mgn:

DCIS comedo, ass

associate
ociated
d
with IDC

Benign calcification

Benign calcification
Vascular calcifications

Benign calcification
pop-corn calcifications
- fibroadenomas
(menopause)

Benign calcification
Rim calcifications

Benign calcification
Calcification of the
sutures

Calcifications suggestive of malignancy

Calcifications suggestive of malignancy

Calcifications suggestive of malignancy

Calcifications suggestive of malignancy

Calcifications suggestive of malignancy

US normal appearance

skin
fatty superficial
glandular tissue
fatty profound
pectoral m.
ribs

US semeiology

shape regular
regular, irregu
egular
lar
cont
onto
our (margins) circumscribed
circumscribed
noncircumscribed
noncircumscri
bed
orientation
orienta
tion parall
parallel, perpendicular
ech
ec
hogenity
ogenity hypo, iso, h
hyyperecogen, anech
anechoic
ecostructure
ecostructu
re homogeneous
omogeneous,, inh
inhomogeneous
omogeneous
vascularissation pres
vasculari
present, absent
elasticity
elasticit
y elastic, stiff
associated changes: architectural distorsion,
distorsion,
skin changes etc

US semeiology

shape regular
regular, irregula
irregularr

US semeiology

contour
conto
- circumscribed
- non
non--circumscribed (ill defined, angulated,
microlobulated, spiculated,
spiculated, hy
hyperec
perech
hoic rim)

US semeiology

orientation
orienta
tion paralel/perpendicular

US semeiology

ech
ec
hogenity
ogenity hypo, iso, h
hyyperecogen, anech
anechoic

US semeiology

ech
ec
hostructure
ostructure homogeneous
omogeneous,, in
inh
homogeneous
omogeneous

US semeiology

Associated changes: architectural distorsion,

distorsion, skin
changes

US semeiology

Vascularissation pres
Vasculari
present/absent

US semeiology

Elasticity
Elasticit
y soft/
soft/stiff

Breast MRI

T2 for cystic lesions

T1 + SC for visualization and analysis of the

morphology and dynamic behaviour of the
lesions

MRI semeiology

findings:
findings:
- mass
mass
- hypers
persignal
ignal with no associated mass

MRI semeiology

Mass description:
Mass
description:
- shape:
shape: regular
regular (round or oval)
oval) or ir
irregula
regularr
- cont
conto
our: : circumscribed
circumscribed or noncircumsc
noncircumscibed
ibed (ill
defined,, lobulated
defined
lobulated or spicul
spiculated)
ated)
- internal signal morfology:
morfology: homogeneous
omogeneous,,
heterogeneous
heterogen
eous,, ring
- dynamic of the lesions (intensity
(intensity-tim
time
e curve
curve):
):
continuous,, in plat
continuous
platea
eau,
u, wash
wash--out

MRI semeiology

Mass
Mas
s (nodule
(nodule)
Malignant

Benign

Shape

Irregular

Round/oval

Contour

Spiculated/microlobulat
ed

Circumscribed

Caracterele
morfologice ale
hipersemnalului
intern

Omogen

Heterogen/n inel

Dynamic of the
postcontrast
hypersignal

Wash-out or plateau

Progressive or plateau

BI--RADS
BI
0

supplementary informations
needed
1 normal
2 benign lesion
3 probably benign lesion
4 possible malignant lesion
5 lesion highly suggestive for mgn
6 histological proven malignancy

BI--RADS
BI
0

supplementary ex.
1, 2 normal screening programme
(4-6 months)
3 control (4 4 biopsy
5 biopsy
6 therapy

Breast pathology

Benign lesions
- cyst
- fibroadeno
fibroadenom
mas

Malignant lesions
- ductal carcinom
carcinoma
a
- DCIS
- IDC
- lobular carcinom
carcinoma
a
- LIS
LISC
C high risk lesion!!!!
lesion!!!!
- ILC

Breast cysts

Mx circumscribed nodular density

density,, round/ovala, with rim calcifications
US anechoic lesions, circumscri
circumscribed
bed,, posterior enhancement
MRI T2 circumscribed lesion, in hypersignal

Fibroadenom
Fibroadeno
mas

Mx circumscribed nodular density,

density, oval, with pop corn calcifications
US hypoech
poechoic lesion
lesion,, homogen
omogeneous
eous,, circumscri
circumscribed
bed,, parallel to the skin
MRI circumscribed
circumscribed,, ho
homogen
mogeneous
eous / h
hyyposignal
posignal septa
septae, benign dynamic

DCIS

Mx branching intraductal microcalcifications

microcalcifications
US dilate
dilated
d ducts
ducts with microcalcifi
microcalcifications
cations//hypoechoic content
MRI low sensitivity (non
(non--mass hypersignal)
persignal)

DCIS

Mx branching intraductal microcalcifications

microcalcifications
US dilate
dilated
d ducts
ducts with microcalcifi
microcalcifications
cations//hypoechoic content
MRI low sensitivity (non
(non--mass hypersignal)
persignal)

IDC

Mx nodular density with malignant features

US hypoech
poechoic mass with malignant features
IRM mass
mass with hypersignal after CM
CM,, with morphology and
dynamic suggestive for malignancy
malignancy

IDC

Mx nodular density with malignant features

US hypoech
poechoic mass with malignant features
IRM mass
mass with hypersignal after CM
CM,, with morphology and
dynamic suggestive for malignancy
malignancy

(frequently
quently multicentric/multifocal, polimor
polimorf/multiform
f/multiform))
ILC (fre

Mx ocult/spiculated
ocult/spiculated mas
mass/
s/ar
arcchitectural distortion/focal
asimetry
US irregular mass with shadowing/aria of shadowing
IRM spiculated mass,
mass, with architectural distorsion

Interventional diagnosis
diagnosis and
therapeutical man
manoeuvres
oeuvres

Diagnostic
- FNAB
- breast microbiops
microbiopsy
y (tru
(tru--cut)
- vacuum assisted biopsy (m
(macrobiops
acrobiopsy)
y)

Treatment
Tre
- FNAB (cyst
(cyst aspira
aspiration
tion))
- vacuum assisted biopsy (le
(les
sions<
s<1,5
1,5 cm)
- placing
placing of tissue markers
- preoperative localisation (hook wires
wires))
- sentinel node biopsy

Guiding method
- rontgen (stereotax
(stereotaxyy)
- US
- MRI

Interventional man
manoeuvres
oeuvres US
guided

Interventional man
manoeuvres
oeuvres Rx
guided

Interventional man
manoeuvres
oeuvres hook
wire

Manopere intervenionale - harpon

Interventional man
manoeuvres
oeuvres
tissue marker

Sentinel node
preoperative limfoscintigraphy

gamma camera