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BREAST MAMMOGRAM

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Mammography
Mammography is a specific type of imaging that uses a High resolution

low-dose x-ray system to examine breasts.

A mammography exam, called a mammogram, is used to aid in the early

detection and diagnosis of breast diseases in women.

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Uses of mammography:

Screening mammography,

Diagnostic mammography,

Mammographic intervention,

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Types mammography,

xero mammography,

Conventional Film-screen mammography,

Computed mammography,

digital mammography,
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Screening Mammography:

Mammography plays a central part in early detection of breast cancers

because it can show changes in the breast up to two years before a

patient or physician can feel them.

Research has shown that annual mammograms lead to early

detection of breast cancers, when they are most curable and breastconservation therapies are available. show a relative mortality reduction between 28% and 45%.

Long-term follow-up of several randomized controlled trials (RCTs)

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Screening Policies Across North America and Europe

Country Starting Age United States 40 (ACS, ACR) 50 (USPSTF)50 (shared decision making 40 50) Canada 50 United 47 (from Kingdom 2012) 4/14/12

Ending Age Frequency All >40 (ACS)Q1 yr (USPSTF) Q2 yr US(USPSTF) preventive service task force 69 74 (from 2012) Q2 yr Q3 yr

The National Comprehensive Cancer Network (NCCN) screening guidelines

Average Risk Group

screening guidelines for women who have an

asymptomatic physical exam and who are not found to be at increased risk based on family and personal medical history:

Women between the ages of 20 and 40 years:

Clinical breast exam every 1-3 years Periodic breast self-exam encouraged

Women over the age of 40 years:

4/14/12 Annual clinical breast exam

Familial Breast Cancer

provides the following screening guidelines for women

with a strong family history of breast cancer:

For women under 25 years:

Annual clinical breast exam Periodic breast self-exams encouraged

For women over 25 years:

Clinical breast exam every 6-12 months and annual

mammogram starting at 5-10 years prior to the earliest age of onset in family member

Consider risk reduction strategies 4/14/12

Hereditary Breast and Ovarian Cancer syndrome screening guidelines for individuals with known mutations in

BRCA1 or BRCA2:

For women:
Regular monthly breast self-exam starting at age 18 Semi-annual clinical breast exam starting at age 25 Annual mammogram and breast MRI screening starting at

age 25 or based on earliest age of onset in family

Consider chemoprevention options Consider other risk reduction options such as prophylactic

surgery

For 4/14/12 patients who have not elected risk reduction surgery, concurrent trans vaginal ultrasound and CA-125 is recommended

Screening guidelines for individuals with known mutations in BRCA1 or BRCA2

For men:
Monthly breast self-exam Semi-annual clinical breast exam Consider baseline mammogram

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Diagnostic Mammography

Diagnostic mammography is used to evaluate a patient with abnormal clinical findings such as a breast lump, pain or nipple discharge. that have been found by the woman or her doctor.

Diagnostic mammography may also be done after an abnormal

screening mammogram in order to evaluate the area of concern on the screening exam.

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Mammographic interpretation
The American College of Radiology (ACR) has developed a

grading system,

Basic principals of mammographic interpretation, described

in the terms defined by ACR - BIRADS.

BI-RADS-

Breast Imaging Reporting and Data System . AJR 2002;179:1520

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MAMMOGRAPHIC INTERPRETATION
Category

Definition of BI-RADS Category

Need additional imaging evaluation

Recommendations
Additional imaging needed before a category can be assigned. Continue annual screening mammography (for

0 1 2 3 4 5 6

Negative . women over age 40). Continue annual screening mammography (for Benign (noncancerous) finding. women over age 40).

Probably benign.

Receive a 6-month follow-up mammogram.

Suspicious abnormality

May require biopsy.

Highly suggestive of malignancy (cancer)

Requires biopsy.

Known biopsy-proven malignancy (cancer) means that any findings on the

Biopsy confirms presence of cancer before treatment begins.

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mammogram have already proven to be cancer through a biopsy.

Mammographic Technique
Positioning:

The standard screen-film mammographic examination must

include a

Mediolateral oblique view (MLO) , craniocaudal view (CC)

However, other supplementary views may require in certain

conditions which help to reach to specific diagnosis.

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Radiation exposure from mammography

The modern mammography machine uses low radiation

dose.

Breast x-rays that are high in image quality

(usually about 0.1 to 0.2 rads)

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During the procedure, the breast is compressed,

Parallel-plate compression evens out the thickness of breast tissue

to increase image quality by reducing the thickness of tissue that x-rays must penetrate.

decreasing the amount of scattered radiation, reducing the required radiation dose holding the breast still (preventing motion blur).

Deodorant, talcum powder or lotion may show up on the X-ray as

calcium 4/14/12 spots, and women are discouraged from applying these on the day of their exam.

The MLO view:

X-ray beam directed from superomedial to inferolateral,

usually at an angle of 30-60 so that compression is applied perpendicular to the long axis of the pectoralis major muscle.

Since the pectoralis muscle will be parallel to the plane of

compression, the breast can be pulled away from the chest and on to the film.

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MEDIOLATERAL VIEW

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The CC view:

For the cranio caudal view,

the cassette is placed under the breast at the level of the

infra mammary fold and

then elevated as the breast is raised and pulled forward

until the skin of the infra mammary fold is taut.

The breast is then compressed from above.

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The X-ray beam is directed vertically from above.

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CRANIOCAUDAL VIEW

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Supplementary views:

1) Rotated (exaggerated) cranio caudal views Visualize either, more lateral (and less medial)

more medial (and less lateral) breast tissue than the

standard cranio caudal view,

2) Cone-down compression views

May be used to maximize diagnostic information about a

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localized area,

3) CLEOPATRA view To visualize lateral tissues with compression of axillary tail,

Patient semi reclining, gantry rotated parallel to tail of breast

4) CLEAVAGE view For tissues closer to sternum Both breasts pulled

on the cassette,

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Description of Breast Composition

The ACR-BIRAD system recognizes this limitation by reporting the background composition of the breast in categories:
1. 2. 3. 4.

Almost Entirely Fatty tissue: Mammography very effective, sensitive to even small tumors. Scattered Fibro glandular tissue: Minor decrease in sensitivity. Heterogeneously Dense tissue: moderate decrease in sensitivity. Extremely dense tissue: marked decrease in sensitivity.

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Description of findings
Evaluation of masses

Evaluation of calcification

Evaluation of associated structural changes

Location of the lesion

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Evaluation of masses
Characterization of mass

Size Shape Margin Density Location

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Shape: Typically benign:

round, oval, lobular.

Suspicious: irregular,

or architectural distortion

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Margins: benign:

circumscribed, obscured. indistinct,

Suspicious:

microlobulated, spiculated.

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Density: The density categories used are: High density: clearly higher than surrounding, suspicious, Equal density: density not appreciably different, neutral

significance.

Low density: density lower, but not fat containing, neutral

significance.
Fat containing (Radiolucent): This includes all lesions

containing fat such as cyst, lipoma, galactocele, hamartoma or fibrolipoma. 4/14/12

Calcifications

q Calcifications are tiny mineral deposits within the breast

tissue.

q They look like small white spots on a mammogram.

q The calcifications seen on a mammogram may or may not

be associated with breast cancer.

q There mainly are 2 types of calcifications. 4/14/12

Macro calcifications
q Macro calcifications are coarse (larger) calcium deposits,

q most likely associated with changes in the breasts caused

by - aging of the breast arteries, - old injuries, or - inflammation.

q These deposits are related to non-cancerous conditions and

usually do not require a biopsy.

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Micro calcifications
q Micro calcifications are tiny specks of calcium in the breast.

q They may show up alone or in clusters.

q The shape and layout of micro calcifications help the radiologist

judge how likely it is that cancer is present.

q But if the micro calcifications have a suspicious look and pattern,

a biopsy will be recommended.

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EVALUATION OF CALCIFICATION

q Micro calcification (< 0.5 mm)

q Macro calcification (> 0.5 mm)

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CALCIFICATION DESCRIPTIVE TERMS 4/14/12

Calcification with high probability of malignancy

High suspicion occur when any group of calcification within a

1 cm 3 volume comprising at least five discrete particles less than 0.5 mm

a) Pleomorphic or heterogeneous calcifications

(Granular):

They are irregular calcifications of varying size and shape, usually less than 0.5 mm. in size.
b) Fine and/or branching (casting) calcifications:
4/14/12 These are thin, irregular calcifications that appear linear,

Micro-calcificationq IDC or DCIS often presents as a areas of clustered micro-

calcification.

q Malignant calcification is

small(0.3-0.5mm), clustered (> 5 per mm), ductal or segmental in distribution and is likened to broken needles or crushed stone 4/14/12

Pleomorphic linear branching calcification

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Invasive ductal carcinoma

Mammographic abnormalities which may indicate Breast cancer

Spiculated mass lesionq breast cancers -commonly presents as mass lesion with an

irregular margin with long tentacle like linear opacities radiating to the surrounding tissue.

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Architectural distortionq This refers to changes in the normal regular pattern of breast tissue with or

without mass formation

q Architectural distortion with a mass ,

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Asymmetric densityq seen in lobular carcinoma.

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Evaluation of associated structural changes

1) Skin retraction: The skin appears to be pulled or tethered into an abnormality. In more advanced infiltrative cancers 2) Nipple retraction: The nipple is pulled in or inverted.

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3) Skin thickening: When localized, it may result from direct infiltration, or tumor blockage of

local lymphatic drainage.

4) Lymph adenopathy:

5) Architectural Distortion: Disturbance in the course and shape of the normal trabeculae architecture Possibility of infiltration

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Benign calcification
Lucen t centre Vascula r Popcor n Rod like

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Fibroaden oma

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Simple cyst

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Phyllodes tumor

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Lympho ma

ROLE OF MAMMOGRAPHIC INTERVENTION

Core biopsy,

mammographic stereotactic needle biopsy

Preoperative wire localization technique, Image guided procedure used to localize non palpable

lesions prior to surgery

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Preoperative wire localization

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Stereotactic needle biopsy

Digital mammography, also called full-field digital mammography

the x-ray film is replaced by solid-state detectors that convert x-rays into

electrical signals.
These detectors are similar to those found in digital cameras.

The electrical signals are used to produce images of the breast that can be

seen on a computer screen ,

From the patient's point of view, having a digital mammogram is essentially
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the same as having a conventional film mammogram.

Mammograms in special circumstances

Mammograms in younger women: Mammograms are harder to read in younger women, usually

because their breast tissue is dense and this can hide a tumor on an x-ray.

Mammograms after breast-conserving treatment: Radiation and chemotherapy both cause changes in the skin

and breast tissues. harder to read.

These changes show up on the mammogram, making it

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Mammograms in women with breast implants:

The x rays cannot go through silicone or saline implants well

enough to show the breast tissue that is over or under it.

the part of the breast tissue covered up by the implant will not be

seen on the mammogram

A ruptured (burst) implant can sometimes be diagnosed on a

mammogram, but a ruptured implant will often look normal.

mammograms can cause an implant to rupture. 4/14/12

USG BREAST

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Indications for breast US:

1.Differentiation between cyst and solid mass:
Characterization of masses as fluid-filled( i.e. simple cyst )

or

solid( i.e. tumor ) is the most important indication for breast

USG

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2.Evaluation of a palpable mass not visible in a radio graphically dense breast:

A palpable mass is occasionally not mammographically

visible in patients with dense breast parenchyma.

The role of USG is to confirm the presence of a mass, and to

determine if the mass is cystic or solid.

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3.Evaluation of a mass not completely evaluated with mammography:

extremely peripheral masses and masses in very deep position adjacent to the chest wall, USG is particularly helpful for evaluation of palpable masses

in patients with prosthesis ,

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4.Inflammation (Mastitis):
USG is an excellent method for detection of an abscess

cavity.

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5.Evaluation of a palpable mass in young women:

to limit the radiation exposure in young women.

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6.Guidance for interventional procedures:

USG has been successfully used to guide cyst aspiration,

needle biopsy, and preoperative needle or wire localization.

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7.Differentiation of benign from malignant solid masses:

Benign and malignant breast tumors may present with

characteristic USG features.

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8.Evaluation of node status:

USG shown to be more sensitive than physical examination

for the detection of positive axillary lymphnodes in women with breast cancer.

Its found that USG enabled detection of 72.7% of metastatic

nodes, while physical examination revealed only 45.4%.

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9.USG after augmentation Mammoplasty and breast conservation surgery:

These procedures may lead to difficulties with

mammographic techniques and interpretation.

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Sonographic findings suspicious for cancer

Spiculation or thick, echogenic halo Angular margin Micro lobulations Shape taller than wide Duct extension and branch pattern Acoustic shadowing Calcification Hypoechogenicity.

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A well-defined mass

with homogeneous mobile low-level internal echoes and posterior acoustic enhancement (arrows). Aspiration yielded inflammatory changes.

benign cyst with

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Thick-walled cystic

mass with thick septations, IDC.

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Intracystic mass,

intracystic papillary DCIS.

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Fat necrosis. The patient had a

palpable right breast mass.

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Smooth margins are commonly seen in benign tumors, but

can occasionally also be found in malignant breast tumor

Marginal irregularity is typical for breast cancer

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Comedo-type

DCIS.

the

microlobulated margin (large solid arrows), (open arrows), and (small solid arrows) of the mass.

ductal extension calcifications

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Both mammography and Sono mammography are

complementary and increase the sensitivity and specificity of malignant lesions when used simultaneously.

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BREAST MR IMAGING

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Indications for breast MRI

Search for occult breast cancer with known metastasis Monitoring response to chemotherapy To evaluate patients with positive margins-immediate post op-residual

lesion

Early detection of local recurrence- in breast conservative surgery Evaluate implant integrity and detect cancer

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Multifocal and multi centric lesion

Search for primary tumor

Demonstrate extent of existing lesion

Post op- scar , recurrence

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American cancer society screening guidelines

Recommend annual MRI screening (Based on evidence)

BRCA mutation Untested first-degree relative of BRCA carrier Life time breast cancer risk -20%-25%, depending on family history

Recommend annual MRI screening Radiation to chest between age 10 and 30 years (Based on expert consensus opinion) Li-Fraumani syndrome and first- degree relative Cowden syndrome and first- degree relative

Insufficient evidence to recommend Life time breast cancer risk -15%-20% as defined by models that for or against MRI screening are largely dependent on family history LCIS or atypical lobular hyperplasia ADH Heterogeneously or extremely dense breast on mammography Women with a personal history of breast cancer including DCIS

Recommend against MRI screening

Women at <15% life time risk.

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Irregular and spiculated border- malignant

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Rim-enhancing mass, representing an invasive carcinoma.

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Clumped enhancement in a segmental or ductal distribution, representing ductal carcinoma in situ

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Clumped cobblestone appearance of enhancing areas : extensive infiltrating 4/14/12 lobular carcinoma.

Multiple scattered small foci of enhancement. Benign parenchymal

The MR image demonstrated a large residual mass surrounding the lumpectomy bed, in addition to enhancing skin nodules and thickening and enlarged axillary nodes;

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Tumor recurrence at the lumpectomy site

Evaluation of the lumpectomy site by mammography is extremely limited

due to postoperative scarring

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Intracpsular rupture

8-1-08 4/14/12

Mohan

Implants and breast cancer

Implants may interfere with performance and interpretation of

mammography resulting in delayed detection of breast cancer

MR is useful to differentiate whether palpable abnormality is related to

implant or parenchymal breast mass

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Implants with breast cancer

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Mohan

Thank you

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