In The Nam of God

Role of imaging in diagnosis

early breast cancer

Dr. Mehri Sirous

 * IMAGING *
The standard techniques used for breast
imaging are:
1. Screen film x-Ray mammography.
2. Real-Time ultrasound.
3. Other new techniques include:
MRI

Color Doppler

Contrast ultrasound

Digital Mammography

Scintimammography
Mammography can find abnormalities
between one and three years before
they can be felt.

Because the inherent attenuation differences

between normal & diseased breast tissues is so
small , high quality mammography required.
 Mammography

Although mammography is the most

sensitive exam available for detecting

small breast ca.

False Negative Rate is 5-10%

Breast cancers are most likely to develop in
dense tissue, where they are most difficult to
detect.

Mammograms can result in false negative

readings (particularly in younger women, who
have dense breast tissue) or false positive
readings
 False negative rate ↓
* Clinical history and examination
* Combination imaging
• Mammography standard views
• supplementary mammographic views
• Local compression views
• magnification views
• ultrasound
* Needle biopsy
* F.N.A.C
* Or core biopsy
 Review of old films :
If old films are available, comparison is

important to search for any changes.

It is a good idea to compare studies that are

of least 2 years apart.

 Mammography tests are not perfect.
Only the part of the breast that extends from the
body can be imaged. This makes it easier to
get an accurate picture of a larger breast than a
smaller breast !

It also may be difficult to detect abnormalities

that exist in the breast tissue adjacent to the
chest wall.
Up to 20 percent of breast cancers are
missed by mammograms, according
to the National Cancer Institute
Full-field digital
mammography (FFDM).

Recently approved by the U.S. Food and

Drug Administration (FDA), this technique
involves taking digital images of the breast.
Digital images are captured electronically
and can be viewed on a computer. Their
magnification, brightness and contrast can be
adjusted and enhanced to better reveal
abnormalities.
 Advantages to having digital
mammography

Elimination of process or artifacts

Contrast enhancement
Ability to perform invasive procedures faster
Potentially better resolution of breast tissue for women younger
than 50 years
Reduce examination time for patients
Increased production of examinations
Images are immediately available
 Digital Mammography Detected
up to 28% More Cancers in
Certain Groups:

• Women under the age of 50

• Women with heterogeneously
dense or extremely dense breast
• Women that are premenopausal
or perimenopausal
Greater Access

• The mammogram
can be
read where ever the
radiologist is located

• This also allows for

physicians
to consult with their
peers
Review of Prior Images
Before Procedure
 Incomplete assessment
Category 0:
Additional imaging evaluation and/or
comparison to prior mammograms needed.
Possible abnormality may not be completely
seen or defined and will need more tests, such
as use of spot compression, magnification
views, special mammogram views or
ultrasound.
 Complete assessment
Category 1:
Negative No significant abnormality to report.
Breasts appear the same (symmetrical) with no
masses, architectural distortion or suspicious
calcifications.
Category 2:
Benign (Noncancerous).Also a negative
mammogram, but with description of a finding
known to be benign, such as benign
calcifications, intramammary lymph nodes or
calcified fibroadenomas. This ensures others
viewing the mammogram will not misinterpret
benign finding as suspicious.
Category 3:
Probably benign - follow-up suggested, Findings have a
very high probability (greater than 98%) of being
benign. Findings are not expected to change. Follow-
up with repeat imaging usually done in six months
and regularly thereafter until finding is known to be
stable (usually at least two years). Procedure helps
avoid unnecessary biopsies while allowing for early
diagnosis of a cancer should suspicious area change.
Category 4:

Suspicious abnormality - biopsy suggested

Findings could be cancer, with sufficient
concern to recommend biopsy. Findings in this
category have a wide range of suspicion levels.
Some – though not all – physicians may divide
category further:

4A: finding with low suspicion of being cancerous

4B: finding with intermediate suspicion of being cancerous

4C: finding of moderate concern of being cancerous, but not as

high as Category 5
Category 5:
Highly suggestive of malignancy – appropriate
action necessary .Findings look like and have
high probability (at least 95%) of being cancer.
Biopsy is strongly recommended.

Category 6: Confirmed Malignancy – Appropriate Action Should

Be Taken .Used for findings on mammogram already
determined to be cancerous by a previous biopsy.
 Breast ultrasound
At the minimum, a 7.5 MHZ linear array probe
should be used
The original role of breast sonography is in the
differentiation of cystic and solid lesions
The role of ultrasound complements both clinical
examination and mammography
Ultrasound plays an important role in the triple
assessment of symptomatic lesions the dense breast
It is the examination of choice in young

women and is valuable in the assessment

of mammography ‘ dense’ breast

BIRADS 1 Sonographically normal tissue that cause
mammographic or clinical abnormality.

BIRADS 2 Benign entities (intramammary LN,

ectatic duct ,simple cyst ,definitively benign solid such
as lipoma)
BIRADS 3 Probably benign(<2% risk) complex cyst
,small intraductal papilloma ,fibroadenoma)
BIRADS 4a Mildly suspicious(3%-49% risk)
BIRADS 4b Moderately suspicious(50%-89% risk)
BIRADS 5 Highly suspicious( >90% risk )
 Management Rules
BIRADS 1 ,2 Routine screening

BIRADS 3 Three choices

short interval sonographic F.U
image guided needle biopsy
surgical biopsy

BIRADS 4a ,4b,5 Require biopsy

Imaging – guided practical procedures
The type of imaging chosen depends
principally on which method (ultrasound or
mamography) shows the lesion clearly.
Ultrasound is used for cysts and most soft –
tissue lesions
Mammography is used for microcarcification
and for soft – tissue lesions that are not seen or
are poorly visualized on ultrasound
particularly distortions
 Ultrasound – guided procedures
1. Cyst aspiration (simple cysts with symptoms)

2. Abscess aspiration (simple, unilocular abscess)

3. Ultrasound – guided FNAC (solid lesions)

4. Ultrasound guided core biopsy

(small solid lesions)

Mammography – guided procedures

Stereotactic – guided FNAC or core

biopsy
Preoperative localization of
non – palpable lesions.
 Indication for breast MRI
Breast MRI is the technique of choice in the
differentiation between postoperative scarring and
local recurrence
It has an important role in the assessment of the
indeterminate mass because of its very high
sensitivity for malignancy though at present, core
biopsy is a more cost – effective approach.
 Indication for breast MRI
It is very accurate in the local staging of breast cancer in
difficult cases (very dense breasts, mammographically
occult tumours, suspected multi- focality or
multicentricity and suspected chest wall involvement).
It is the technique of choice in the evaluation of implant
integrity and detection of cancer in the augmented breast.
It is also accurate in the differentiation of axillary
recurrence and brachial plexopathy post radiotherapy.
 Indication for breast MRI
Breast MRI appears highly accurate in the
assessment of response to neoadjuvant and
primary chemotherapy, predicting ulti- mate
response before changes in tumour volume and
differentiating between residual tumour and
fibrosis.
The place of breast MRI in screening high-risk
patients has yet to be established