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Breast imaging
Mammography Ultrasonography MRI Scintimammography
Mammography
Food and Drug Administration ( FDA ) June 2, 1993 Most effective for early breast cancer detection Screening mammography Screening interval
Screening mammography
Women > 40 years Yearly, annual check up Early cancer detection
Early stage
High risks
Early menarch Late menopause Nulliparity Late age at full term pregnancy (> 30 yrs ) Biopsy proof atypical epithelial proliferation Biopsy proof lobular carcinoma in situ
(Kopans DB. Breast imaging Lippincott-Raven p45)
High risks
Genetic ( BRCA 1, BRCA 2 ) Environmental Gene-environmental interaction Affected first degree relative ( mother, sister, daughter ) Previous history of cancer ( breast , ovary )
Ronbidoux et al, AJR 166(1): 29-31, 1996 Foulkes et al, Clinical and intensive Medicine 18(6): 473-483, 1995
Mammography
Technique : standard two views ( MLO , CC views) : additional views ( spot compression, magnification )
Standard views
1. 2.
Supplement views
Spot compression Magnification True lateral Exaggerated medial or lateral CC Tangential Rolled Cleavage ( buttock ) Axillary views
Technique
Pulling Compression Angle Breath holding
MLO view
Length and contour of pectoralis muscle Nipple Inferior mammary angle
Pitfall
Inner quadrant
CC view
Visualized pectoralis muscle 30-40 % Retromammary fat Pectoralis-Nipple line ( PNL ) Stress on inner aspect
Mammography Risks
Low dose radiation ( 2mGy per view ) Compression effect Uncertainty in diagnosis of CA in situ
Anatomy of breast
1. 2. 3. 4. 5. 6.
Mammary gland Ducts Collagenous connective tissue Fatty tissue Cooper ligament Vessels and lymphatic
Menarchal development
15 yrs 25 yrs Lobular structure, duct system
( hypoplasia, inverted nipple, juvenile hypertrophy, fibroadenoma )
Cyclical change
Premenstrual phase ( endocrine
stimulation )
Pregnancy, Lactation
Pronounced glandular activity Superimposed cyclical change Patchy
Post Lactation
Some areas of regression Fibrosis
Involution
30yrs - 40yrs till menopause Lobular regression ( involution of epithelium ) Replacement of fibrous tissue in interlobular regression sclerosis, microcyst formation
Breast patterns
Fatty breast Ductal Dense breast
Wolfe Classification
Ducts, lobules, fibrosis Linear and nodular opacities
Histologic appearance of DY
severe mammary dysplasia adenosis, microcyst formation
Wolfes study
Parenchymal patterns and cancer risk
DY + P2 > P1 + N1 6 times
DY P2
P1 N1
47.8% 50%
ASSESSMENT CATEGORIES
Mammographic assessment is incomplete
Category 0
Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison
Category 2
Benign Finding(s)
Category 3
Probably Benign FindingInitial ShortInterval Follow-Up Suggested
ASSESSMENT CATEGORIES
Category 4
Suspicious AbnormalityBiopsy Should Be Considered
Category 5
Highly Suggestive of MalignancyAppropriate Action Should Be Taken (Almost certainly malignant.)
ASSESSMENT CATEGORIES
Category 6
Known Biopsy Proven Malignancy Appropriate Action Should Be Taken
Category 0
almost always used in a screening situation. additional imaging evaluation may include, but is not limited to the use of spot compression, magnification, special mammographic views and ultrasound. should only be used for old film comparison when such comparison is required to make a final assessment.
Category 1
The breasts are symmetric and no masses, architectural distortion or suspicious calcifications are present.
Category 2
Involuting, calcified fibroadenomas, multiple secretory calcifications, fat-containing lesions such as oil cysts, lipomas, galactoceles and mixed-density hamartomas all have characteristically benign appearances Intramammary lymph nodes, vascular calcifications, implants or architectural distortion clearly related to prior surgery while still concluding that there is no mammographic evidence of malignancy
Both Category 1 and Category 2 assessments indicate that there is no mammographic evidence of malignancy. The difference is that Category 2 should be used when describing one or more specific benign mammographic findings in the report, whereas Category 1 should be used when no such findings are described.
Category 3
Less than a 2% risk of malignancy Three specific findings are described as being probably benign
noncalcified circumscribed solid mass focal asymmetry cluster of round [punctate] calcifications
an initial short-term follow-up (6 months) examination (usually unilateral mammogram) followed by additional examinations (bilateral F/U in another 6 months and then bilateral 12-month F/U) until longer-term (2 years or longer) stability is demonstrated may be changed to Category 2 occasional biopsy when patient wishes or clinical concerns
Category 4
For findings that do not have the classic appearance of malignancy but have a wide range of probability of malignancy that is greater than those in Category 3. Most recommendations of breast interventional procedures will be placed within this category.
Subdivided to account for the vast range of lesions subjected to interventional procedures and corresponding broad range of risk of malignancy
Category 4A, 4B and 4C
Category 4A
need intervention but with a low suspicion for malignancy palpable, partially circumscribed solid mass with ultrasound features suggestive of a fibroadenoma, a palpable complicated cyst or probable abscess
Category 4B
Intermediate suspicion of malignancy warrant close radiologic and pathologic correlation partially circumscribed, partially indistinctly marginated mass yielding fibroadenoma or fat necrosis is acceptable, but a result of papilloma might warrant excisional biopsy
Category 4C
Moderate concern, but not classic (as in Category 5) for malignancy ill-defined, irregular solid mass or new cluster of fine pleomorphic calcifications malignant result in this category is expected
Category 5
High probability (> 95%) of being cancer Example,
spiculated, irregular high-density mass, segmental or linear arrangement of fine linear calcifications or irregular spiculated mass with associated pleomorphic calcifications
Category 6
For lesions identified on the imaging study with biopsy proof of malignancy prior to definitive therapies No associated intervention required to confirm malignancy Appropriated for second opinions or for monitoring of responses to neoadjuvant chemotherapy prior to surgical excision
Not appropriate following excision of a malignancy (lumpectomy ) A major rationale for adding Category 6 is that examinations meriting this assessment should be excluded from auditing
If include inappropriately indicate inflated cancer detection rates, positive predictive values, and other outcomes parameters
Fibrocystic change
Popcorn calcifications
Popcorn calcifications
Fibroadenoma
Hamartoma
Hamartoma
Case 1
Sclerosing adenosis
Case 1 Case
guide
Case 2
Fibroadenosis
Case 2
Case 2
Case 2
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