Breast Imaging

Olga Hatsiopoulou
Consultant Radiologist
Royal Hallamshire Hospital
Sheffield Breast Screening Unit
Sheffield Teaching Hospitals

Screening
Breast assessment in symptomatic FT
clinics
Case studies

Five-Year Breast Cancer Suvival Rates According to the

Size of the Tumor and Axillary Node Involvement
5 Year Survival, %
0 Positive

1-3 Positive

4 or More Positive

Nodes

Nodes

Nodes

< 0.5

99.2

95.3

59.0

0.5-0.9

98.3

94.0

54.2

1.0-1.9

95.8

86.6

67.2

2.0-2.9

92.3

83.4

63.4

3.0-3.9

86.2

79.0

56.9

4.0-4.9

84.6

69.8

52.6

? 5.0

82.2

73.0

45.4

Tumor Size, cm

Breast Cancer: Why Screen?

Improved outcome by treatment
during the asymptomatic period
Significant impact on public health

Mortality Reduction
50-69 y.o.: mortality reduction 16-35%
40-49 y.o.: mortality reduction 15-20%
Lower incidence
Rapidly growing tumors
Dense breasts

Mortality Reduction
Due to detection of cancers at smaller
size/earlier stage
Mammographically visible 3-5 years before
palpable
Increased detection of DCIS

Early stage disease is curable

Diagnostic Accuracy of Screening

Mammography
Sensitivity in women > 50 y.o.
98% fatty breast
84% dense breasts

Specificity

82-98%

On the positive side, screening confers a

reduction in the risk of mortality of breast
cancer because of early detection and
treatment.
On the negative side is the knowledge that
she has perhaps a one per cent chance of
having a cancer diagnosed and treated that
would never have caused problems if she
had not been screened.
Professor Sir Michael Marmot,
UCL Epidemiology & Public Health

Symptomatic clinic / fast track clinic

Triple assessment
Multidisciplinary team approach
Concordance

Concordance of triple assesment

P
M
U
B
Need for repeat biopsy or clinical core?

Digital mammography
Quicker to do mammo almost instant
output on monitor
Better penetration of dense breast
Digital manipulation of image

Digital mammography
Proven to be better for younger/denser
breasts
Almost eliminates the need for
magnification views can magnify digitally
and still have full resolution

Standard view mammography

Cranio-caudal projection (CC)

Medio-lateral oblique projection

(MLO)

Calcification
Most are benign and can be dismissed
The goal is to identify new or increasing
calcifications or those with suspicious
morphology

Benign Calcifications

Malignant microcalcification
Linear, branching casts comedo
Granular/ irregular crushed stone
Punctate - powdery

Architectural Distortion

Core biopsy
All solid lumps and M3 MC get a biopsy
Replaces fine needle aspiration in most
cases
14g spring-loaded needle gun
Well tolerated
Main complication is haemorrhage

Core biopsy - histology

Can give grade of cancers and presence of

invasion
Can give definitive diagnosis of benign lesions avoid surgery

Ultrasound vs /stereo biopsy

Ultrasound is used for all lesions visible on
ultrasound quick and accurate
Stereo biopsy is used for lesions not seen
on ultrasound mainly microcalcification
(mostly screening women)
Same principle as stereoscopic vision
two slightly different mammographic views
allow calculation of depth

Prone biopsy table

Woman lies prone on elevated table with
breast dependent through a hope in the
table
Biopsy is done from underneath
Access is 360 degrees

VAB
Used with either ultrasound or stereo
guidance
Vacuum-assisted biopsy, single needle
insertion, larger sample
Allows better non-operative diagnosis,
improved calc retrieval, more invasive
cancer detection in DCIS

VAB biopsy
11g, compared with 14g for core biopsy
8g can be used to remove benign lumps
Slightly greater risk of bleeding
Well tolerated
Can insert clip to mark site in case lesion
is totally removed

Why use such a large bore?

A larger sample is more likely to obtain a
definitive diagnosis:
DCIS may be upgraded to invasive cancer
ADH may be upgraded to DCIS
Small/difficult lesions are more likely to be
adequately sampled
- Therapeutic excision of B3 lesions

Wire localisation
Use U/S or stereo depending on how it is
best seen
Aim to get hook through the lesion
Specimen x-ray after excision to confirm
lesion remove

LIMITATIONS OF
MAMMOGRAPHY
As many as 5 15% of breast cancers
are not detected mammographically
A negative mammogram should not
deter work-up of a clinically suspicious
abnormality

FALSE NEGATIVES
Causes
Occult on mammogram (lobular CA)
Finding obscured by dense tissue
Technical
Error of interpretation

RISK OF MAMMOGRAPHY
Average glandular dose from a
screening mammogram is extremely
low
Comparable risks are:
Traveling 4000 miles by air
Traveling 600 miles by car
15 minutes of mountain climbing
Smoking 8 cigarettes

Breast MRI
Magnetic resonance imaging is used :
For problem solving
For assessing the extent of lobular or extensive cancers
For screening high risk women - high risk family history
and women who have had mantle radiotherapy for
Hodgkins disease
Pre and post neoadjuvant chemotherapy
For women with implants, to assess integrity

Detecting cancers on MRI

Dynamic scan bolus injection of
Gadolinium and rapid sequence of images
Benign lesions can enhance
Need to create a graph showing pattern of
uptake over time
Cancers show rapid uptake and washout

The axilla
Ultrasound
Level one nodes can be very low down
Level three nodes may be best seen from an
anterior approach through the pectoralis
major muscle

Axillary node levels

Level one:
lateral to lat margin of pectoralis major

Level two:
under pectoralis minor

Level three:
medial and superior to pectoralis minor, up to
clavicle

Why scan/ biopsy the axilla?

A pre-operative diagnosis of lymph node
metastases will prompt the surgeon to go
straight to an axillary node CLEARANCE
A negative axilla on imaging will mean the
woman has either:
Sentinel node biopsy
Axillary sampling (four nodes)

Advantages of axillary biopsy

Avoids two operations in women with
positive nodes
Alternative is axillary sample at time of
WLE, then second operation for clearance

What about PET

Indicated for the complex axilla/ brachial
plexus problem
May prove useful for looking for distant
mets but not accepted primary method
Resolution and specificity not good
enough to look for nodes

Importance of triple assesment

MDT approach
Concordance
Challenges around breast screening
A well informed patient