Investigation modalities

USG
Mammo graphy

MRI

FNAC

Tru-Cut Biopsy Nuclear medicine

Mammogram standard views

Cranio-caudal View (CC) Medial-lateral Oblique (MLO)

Mammography
Average-size lump found by woman practicing occasional breast selfexam (BSE) Average-size lump found by woman practicing regular breast self-exam (BSE) Average-size lump found by first mammogram Average-size lump found by getting regular mammograms

American Cancer Society Screening Recommendations

 Annual mammograms, starting

at age 40
 Clinical breast exams

every year starting at age 40 every 3 years for women age 20-39
 Self-breast exams monthly,

starting at age 20

 High quality mammography can demonstrate invasive lesions 10mm or smaller in size  Breast positioning during mammographic studies is critical. Natural breast mobility should be used to maximize the amount of tissues included in the images.

Digital Mammography
More inherent contrast than film-screen Post-processing will save on patient dose Telemammography option is an advantage Optical disc storage of images eliminates film loss At present time, resolution is better for film screen

Sensitivity of Mammography

85% - 90% in fatty replaced breasts 65% in dense breasts

Mammography Technique

Resolution is the important imaging parameter needed to detect microcalcifications Contrast is the important parameter needed to detect masses

Primary Signs of Cancer on Mammography

Mass Calcifications

Secondary Signs of Cancer on Mammography

Nipple Inversion Architectural Distortion Skin Thickening Axillary Adenopathy Skin Retraction Tissue Asymmetry Developing Neodensity

Spot compression

Indications:
To establish/ confirm the presence of a lesion evaluate masses more accurately evaluate sub areolar area evaluate areas of the breast that may otherwise be difficult to reach and include obtain better exposure of a particularly dense area of tissue

Indications:
To demonstrate dermal location of lesions Improves detection and evaluation of palpable masses Used to separate skin changes from possible underlying post lumpectomy changes since skin lesions can project and simulate breast lesions

Rolled spot compression view

y To help establish the presence of a lesion y To approximate the location y Used in old aged females

Mammography Dose Limit

y The FDA dose limit for a single view mammogram is

300mRAD

BI-RADS
BI-RADS BIClassification

Features Need additional imaging Negative routine in 1 yr Benign finding routine in 1 yr Probably benign, 6mo follow-up followSuspicious abnormality, biopsy recommended Highly suggestive of malignancy; appropriate action should be taken Known case of CA

0 1 2 3 4 5 6

USG is an adjunctive test and not a replacement for high quality mammography

Indications/ Uses:
Characterisation of masses as cystic or solid Characterisation of solid masses as low/ intermediate/high probability of malignancy Non specific mammo finding Palpable mass during pregnancy, lactation or under 30years of age Evaluation of women with nipple discharge To guide interventional procedures ..

Benign characteristics- solid masses

y Hyper echogenicity y Circumscribed margins y Oval shape y Pseudo capsule y Parallel orientation

FIGURE 7-1 Cyst. (A) Spot compression view of the left breast demonstrating a round mass with partially indistinct and obscured margins. A halo is seen outlining portions of the margin suggesting a benign etiology. The internal matrix of this mass cannot be established on physical examination or mammography alone. (B) On ultrasound, an anechoic mass with well-circumscribed margins and posterior acoustic enhancement diagnostic of a cyst is seen corresponding to the mammographic finding. Unless the patient is symptomatic, this does not require further intervention or short-interval follow-up.

FIGURE 7-2 Invasive ductal carcinoma. (A) Spot tangential view taken at site of lump described by the patient in the right breast. Dense glandular tissue is imaged. No underlying mass or distortion is apparent. Correlative physical examination and ultrasound are indicated for further evaluation. (B) On physical examination, a hard mass is palpated in the upper outer quadrant of the right breast corresponding to the area of concern to the patient. Sonographically, an irregular, vertically oriented, hypoechoic mass with spiculated and angular margins as well as associated shadowing is imaged at the 11:30 o'clock position, 3 cm from the right nipple.

FIGURE 7-18 Oval, hyperechoic mass (arrows) consistent with a benign finding.

FIGURE 7-19 Lipoma. Oval, circumscribed mass (arrows) with slightly increased echogenicity.

FIGURE 7-20 Fibroadenoma. Oval, hypoechoic mass with circumscribed margins and associated posterior acoustic enhancement.

Malignant chracteristics
y Marked hyper echogenicity/ mixed echogenicity y Spiculation y Non parallel orientation y Micro lobulation y Calcification

FIGURE 7-21 Invasive ductal carcinoma. Mass, portions of which are markedly hypoechoic, demonstrates a focal area of intense shadowing. The margins demonstrate lobulation and spiculation (arrows).

FIGURE 7-24 Invasive ductal carcinoma. Hypoechoic mass with microlobulated margins and a thick echogenic rim.

MRI, another adjunctive test MR images are reviewed in conjunction with recent mammogram and USG

Current indications:
Newly diagnosed breast cancer To evaluate extent of disease Evaluation of contra lateral breast Lymph node and chest wall involvement Response to neo adjuvant therapy To detect patients presenting with axillary metastatic disease and an otherwise undetected primary breast cancer

Contraindications
Cardiac pacemakers Artificial heart valves Aneurysmal clips Cochlear implants History of adverse reaction to gadolinium Patients with ESRD Claustrophobia not controllable with medication

Pre Gad

Post Gad

Color Overlay

FIGURE 8-19 Invasive ductal carcinoma. (A) T1-weighted axial image pre-contrast. (B) T1weighted axial immediately post-contrast bolus. Round mass with well-circumscribed margins. Low signal intensity pre-contrast. Rim enhancement post-contrast; rapid initial enhancement and wash out.

Magnetic resonance imaging scan of the breasts showing carcinoma of the left breast (arrows). (a) Pre-contrast; (b) Post gadolinium contrast; (c) subtraction image.

Tissue Acquisition Devices - Types

y FNA ( Fine needle aspiration) y Core biopsy y Vacuum assisted core biopsy y Fine needle localization devices

Minimally Invasive Procedures Types & Indications

FNA Core Needle Biopsy Drainage of collections Cysts, Lymph nodes Solid masses

Abscess and post surgical collections Fine Needle Localization Pre-Operative

Vacuum-Assisted Large Core Solid masses smaller than Needle Biopsy 5mm and calcifications

(Mammotome)

FINE NEEDLE ASPIRATION

Most popular technique of biopsy for breast palpable and nonpalpable lesions.
ADVANTAGES Virtually atraumatic Rare to even cause a hematoma Simple to perform DISADVANTAGES
Extremely dependent on level of cytological interpretation. High percentage of insufficient, material aspirates (34%-40%). Cytology doesnt differentiate between in situ from invasive disease

TECHNIQUE-EQUIPMENT
y 10-20-30 ml syringe y 21-23-25G needles y Needle length 3.6-7.8cm y Glass slides y 95% alcohol fixative y Anesthesia is optional

ASPIRATION TECHNIQUE
y After placement of needle, a syringe is connected. y Suction is applied by pulling the plunge of the

syringe. y Sampling needle should be moved back and forth rapidly within lesion. y Needle is angled in multiple directions.

TECHNIQUE FOR F.N.A.

y Vertical or oblique

needle insertion. y Needle should be oriented perpendicularly to ultrasonic beam. y Needle shaft and tip should be visualized during procedure.

FINE NEEDLE ASPIRATION

Pre-FNA

Post-FNA

CORE NEEDLE BIOPSY - CNB

y First described in 1982 by Perlinggren, Sweden. y Cutting needle fits in automated spring-loaded

biopsy gun. y Most accurate results with 14-gauge. y Needle consists of inner tissue sampling needle and outer cutting needle.

CORE NEEDLE BIOPSY - CNB

y Prebiopsy position , outer needle covers inner needle. y Inner needle is advanced forward, moving tissue slot within lesion. y Outer needle slides over inner needle, cutting a tissue sample and securing it in slot.

DISPOSABLE SEMIAUTOMATIC BIOPSY NEEDLE

Stylet

Hub

Main part

Plunger

CNB - TECHNIQUE
y Patient in supine position. y Skin disinfection with alcohol or polydine. y Probe is disinfected with alcohol y Probe may be covered with sterile plastic

sheath. y Sterile gel or alcohol should be used as coupling agent. y Local anesthesia. y Skin incision, 2-3mm.

Needle placement with ultrasound guidance TECHNIQUE

y Transducer is placed

on patients skin so both lesion and path of needle are visible. y Needle position is documented with longitudinal and transverse scans.

Ultrasound guidance-Technique

Core Sampling
y 5 or more cores require reinsertion and repositioning of

needle. y Visual inspection of samples.

CNB - TECHNIQUE
y Specimen placed in formalin and sent for histological diagnosis. y 5-10 minutes compression. y Bandaging applied.

High power view of core biopsy

duct containing a benign hyperplasia of epithelial cells

stroma

Stereotactic/US Core Biopsy

y Less invasive, more economical, more efficient than

excisional biopsy of the breast y 11 and 14 guage needle core samples obtained y As accurate as excisional biopsy

Core Biopsies
y Patient is supine for US core biopsies y Patient is prone for most stereotactic core biopsies y Stereo procedures usually are used to sample

calcifications; US cores are used to sample masses

Large-Core Needle Biopsy

y LCNB increasingly is the

diagnostic method of choice to histologically evaluate nonpalpable mammographic abnormalities. In experienced centers, it is considered the standard of care

Advantages of Core Biopsy

y 96%-100% concordance between CNB and surgery. y No insufficient samples. y Histological tissue diagnosis allows differentiation

of IDC from DCIS.

Disadvantages of Core Biopsy

y Multiple insertions and removal of the needle. y Later samples composed predominantly of

blood. y May be nondiagnostic in small lesions y Retrieval of calcifications is difficult y Incomplete characterization of DCIS

COMPLICATIONS AND RISKS

y Fainting. y Hematoma 6-30%. y Seeding of needle track by malignant cells.

Vacuum-Assisted

Mammotome

Histology Large, contiguous tissue samples Less precise targeting required because of vacuum assistance Ability to place a marker at the biopsy site Sutureless Single insertion

Vacuum-Assisted Biopsy: Advantages

y Suction of the blood out of the biopsy cavity. y Only one insertion of the needle. y Larger specimen- 11G or 8G.

Vacuum-Assisted Biopsy: Advantages



Significant improvement in the retrieval of calcifications

Vaccum assisted biopsy: Advantages

y Clip Placement

y More accurate characterization of DCIS and IDC. y Reduction in the underestimation of DCIS comparatively to core biopsy.

Core biopsy

Vacuum Assisted

NEEDLE LOCALIZATION FOR BREAST EXCISIONAL BIOPSY- F.N.L.

y Designed to direct the surgeon to appropriate site

within breast, insuring accurate removal of suspicious lesion. y Less commonly used for diagnostic purposes only when accurate needle sampling was not achieved

HOOKWIRE SYSTEMS

HOOKWIRE SYSTEMS

Guidance modalities
y Stereotactic mammographic guidance y Ultrasound guidance y MRI guidance

Mammographic Fine Needle Localization

Sonographic Fine Needle Localization

Excisional Biopsy
y Atypical lesions y LCIS y Radial scar y Atypical papillary lesions y Radiologic-pathologic discordance y Phyllodes y Inadequate tissue harvesting

Percutaneous core breast biopsy Advantages

y Since a few years ago most of the suspicious

clinical or mammographic lesions were diagnosed by surgical biopsy. y With time percutaneous core biopsy proved to be efficacy in the diagnosis of breast lesions. y Is faster, less expensive than surgical biopsy. y Less tissue is removed resulting in no deformity or scaring.

Minimally invasive technique in Breast Cancer Treatment: The Future

y Stereotactic excision with vaccum assisted core biopsy y Cryotherapy monitored by ultrasound y Laser ablation/focused ultrasound y Radiofrequency monitored by ultrasound

Nuclear medicine breast imaging

y Increased PPV as compared to x ray mammography y Obtains functional/metabolic information thus

reducing unnecessary biopsies y Also works for patients with radio dense breasts y Lymph scintimammography useful for pre op and intra op localistaion of non palpable breast tumors y Sentinel lymph node biopsy

Mammary ductoscopy
External diameter 1 mm with a working channel of 0.45 mm Diagnostic and therapeutic

Conclusions
y Minimal invasive procedures became 1/3 of the

diagnostic work in breast imaging. y Team work approach is essential for further management y The traditional approach to surgical margins may be replaced in the very near future by minimally invasive treatment techniques of the primary tumor.

References
y Breast imaging companion- Gilda Cardenosa- 3rd

edition y Breast ultrasound- Thomas Stavros y Schwartz s principles of surgery y World Wide Web

THANK YOU