The Imaging Diagnostic Approach

to Breast Lesions
Mammografin Brstcentrum SS
Ariel Saracco, verlkare

Breast cancer in EU 2009

every 1.5 minute a woman in the EU develops a breast cancer

every 6.5 minutes results in a death in the EU due to breast cancer

yearly increase rate: 1.7% in the last 10 years

Breast cancer worldwide

heterogeneous, progressive disease that develops from within the
glandular tissue
spreads to the surrounding tissue
10% of all new cases of invasive cancer diagnosed in the world
25% of cancers diagnosed in women (most common among them)

1.4 millon new cases (2008)

460,000 deaths (2008)
second most common cause of death from cancer

Breast cancer in Sweden 2009

7,049 new cases per year (5-6/1000 from screening program)
1,500 patients die yearly from this disease
30% mortality reduction in the last 29 years due to:

early and better diagnosis

(improving the performance of screening programs, cyto/pathology)
prevents death in the medium to long term
reduces the incidence of advanced disease/node positive disease

improvement in treatments
(surgery, prompt delivery of high quality oncology adjuvant and neo-adjuvant
therapy)

Diagnostic imaging methods in breast

diseases
Mammography (Mx): sensitivity 74 - 95 %
specificity 89 - 97 %

Ultrasound (US): complementary method to mammography

Mx + US: sensitivity (98%)
Magnetic resonance (MRM): high sensitivity (99%), but low
specificity (70%)
5+2 specific indications
Nuclear medicine (NM): high sensitivity in detecting lymph
nodes (sentinel node metastases)
MBI (Molecular Breast Imaging)

Diagnostic imaging methods in breast

diseases
Mammography (Mx)

Ultrasound (US)

first image modality in screening

and clinical due to its high
sensitivity/specificity as a
method per se for breast
cancer detection

most important complementary

method to mammography

x-ray conventional or digital

mammography

no ionizing method
better assessment of the already
detected cancers - diagnosis
better assessment of palpable lesions not
seen on mammography (ex. dense
breasts)
lymph nodes investigation - staging

does not detect all malignancies

(limitation in dense breasts)

excelent for interventional procedures

fast, cheap and comfortable for the
patient

Screening M vs. Clinical M

Screening M

Clinical M

asymptomatic women invited

to have a mammogram

patients with symptoms or

control, sent (GP,
gynecologist, surgeon,
oncologist) for a
mammo/US + ev.biopsy

(77% attendance rate in Sweden)

detection tool

diagnostic tool

 Triple diagnosis
clinical examination
imaging methods (Mx/US)
biopsy (FNA, core biopsy,
vacuumbiopsy)

Diagnostic imaging methods in

breast diseases - ages
Mammography
Screening
40-49 years old/18 mth
50-74 years old/24 mth
Clinical
from 25 years old
whenever its needed
and if its possible to
perform...

Diagnostic imaging methods in

breast diseases - views
Mammography
Screening
2 views
(1) CC (craneo-caudal) 0
(2) MLO (mediolateraloblique) 45 to 60

Diagnostic imaging methods in

breast diseases - views
Mammography
Clinical
3 views
(1) CC
(2) MLO
(3) LM (latero-medial) 90

Diagnostic imaging methods in

breast diseases extra views
localizations (1, 2 and/or 3)
magnifications (1, 2 and/or 3)
rolled or rotated views (1, 2 and/or 3)

Cleopatra view (exagerated cc)

Eklund view (pushn pull technique for implants)

Diagnostic imaging methods in

breast diseases - scoring
ACR/BI-RADS

0 need additional imaging evaluation (or

comparison w/previous exams)
1 normal (or negative)
2 benign finding
3 probably benign finding, FN 2% (6-12-24
month follow up-no biopsy)
4 a,b,c suspicious of malignancy (biopsy?)
5 highly suggestive of malignancy (biopsy)
6 known biopsy-proven malignancy
(treatment)

Swedish score system

(Mx/US)
0 no exam performed (ex. mastectomy)

1 normal
2 benign finding
3 slightly suspicious of malignancy
(FN<3%, biopsy)
4 suspicious of malignancy (biopsy)
5

clear malignancy (biopsy)

Diagnostic imaging methods in

breast diseases Mx findings
masses (or densities)
calcifications

architectural distortions
asymmetries

Diagnostic imaging methods in

breast diseases masses
benign, indeterminate and malignant
localizations, roll views or
magnifications; in various views
looking for shapes, borders,
different densities, halo sign

Diagnostic imaging methods in

breast diseases masses, benign

Diagnostic imaging methods in

breast diseases masses, cancer

Diagnostic imaging methods in

breast diseases benign/cancer

Diagnostic imaging methods in

breast diseases calcifications
benign, indeterminate and malignant
magnifications in at least 2 views (1-3)
on the calcifications and surrounding
areas
looking for shapes, densities,
distribution and extention

Diagnostic imaging methods in

breast diseases calc., benign

Diagnostic imaging methods in

breast diseases calc., benign

Diagnostic imaging methods in

breast diseases calc., cancer

Diagnostic imaging methods in

breast diseases calc., cancer

Diagnostic imaging methods in

breast diseases ductography
bloody or clear secretion
from one pore of the
nipple
0,1-0,4 ml of Iodine CM
magnifications x3
cytology of the secretion

Diagnostic imaging methods in

breast diseases ductography

Diagnostic imaging methods in breast

diseases ultrasound
L17-5/L12-5 MHz transducer (Philips iU22)
correct gain and parameters for each
individual breast tissue
complete coverage of the breast
special attention in the subareolar region

at least 2 perpendicular views and

compression on + findings
doppler if needed

regional lymph nodes status if needed

Breast ultrasound (B-US) cancer

diagnosis

staging (TNM)

biopsies (IP)

Breast ultrasound (B-US)

diagnosis

better assessment of the tumor seen on the

mammogram (size)

better assessment of the tumor not-seen on

the mammogram (palpable, dense tissue)

better assessment of the disease process,

usually not well define on the
mammogram (dense tissue)

Breast ultrasound (B-US)

diagnosis
size

staging (TNM)

multifocality / multicentricity
regional lymph nodes status
axilla
FIC
FSC
IMC

Breast ultrasound (B-US)

diagnosis

staging (TNM)

FNAB (tumor and lymph nodes)

biopsies (IP)

Core biopsies (tumor, lymph nodes)

Vacuum-assisted biopsies (breast)

Diagnostic imaging methods in

breast diseases US findings
echogenicity
margins

RAP (retro-acustic phenomena)

Diagnostic imaging methods in

breast diseases (cyst)

Diagnostic imaging methods in

breast diseases (fibroadenom)

Diagnostic imaging methods in

breast diseases (fibroadenom)

Diagnostic imaging methods in

breast diseases (cancer)

Diagnostic imaging methods in

breast diseases (cancer)

Diagnostic imaging methods in

breast diseases (cancer)

Diagnostic imaging methods in

breast diseases US summary
US criteria for breast cancer ( 4 mm)
solid (almost anechoic)
wide and jagged borders (irregular)
lack of compressibility

vertical orientation (taller than wide)

Diagnostic imaging methods in

breast diseases US summary

Case 1 37 years old with a palpable lump caudalt in the

left breast. Mx score 5

Case 2 58 years old, palpable mass at 10 oclock, dense

breast tissue in mammography. MX score 5

Breast ultrasound - remarks

operator dependent
vast experience/ability required

previous knowledge of what we are looking for

required
proper interpretation of the image observed

Dynamic contrast-enhanced MRM

indications
clinical staging before breast conservation surgery
(multifocality/multicentricity), specially in ILC, DCIS HNG
screening of women with the risk of hereditary breast cancer (BRCA1-2)
detection of occult breast carcinoma (CUPS)
imaging after breast conservation surgery (scar? vs. recidiv tumour?)

evaluation of the patients with breast implants

monitoring the effect of neoadjuvant chemotherapy (?)

in vivo assessment of tumor aggressiveness and predicting prognosis (?)

Dynamic contrast-enhanced MRM

remarks
high sensitivity (99%) but low specificity (70%)

BI-RADS (scoring system: morphology and functional)

margin characteristics and time-to-peak are the most useful and

independant predictors of malignancy

no indication to evaluate the extention of the DCIS I-LNG, yet...

Dynamic contrast-enhanced MRM

remarks
False positives
proliferative changes (HRT, ADH, ALH, sclerosing
adenosis), FA, post-op hyperemia, fat necrosis,
infection, hormonal cycle (2nd week)
False negative
low/intermediate grade DCIS, low grade invasive
lobular, tubular or mucinous carcinoma, LCIS, recent
chemotherapy (suppresses enhancement)

Summary
There is no imaging method in the breast than can find 100% of
the malignancies

All three modalities-clinical examination, imaging methods and

cyto/pathology- give a very good approach (triple diagnosis)

This is a team work between surgeons, radiologists,

cyto/pathologists and oncologist

Thank you!