Breast Imaging Flashcards
What makes up the triple assessment of a woman with suspected breast cancer?
Clinical
Radiology = mammography, US
Pathology = image guided core biopsy
How does breast density impact prognosis?
Women with 76-100% density have 4-5x increased risk compared to women with 1-10% density = dense area more predictive than percent dense area
What are the advantages of mammography?
Images whole of both breasts
High sensitivity for DCIS and invasive cancer
Only modality known to reduce population mortality
What are the disadvantages of mammography?
Uses ionising radiation
Can be uncomfortable
What is tomosynthesis?
3D mammography = multiple images from different angles, slices reconstructed, blurs overlapping tissues
What is contrast enhanced spectral mammography?
Identifies contrast enhancement in the breast after IV injection of iodinated contrast material = breast cancers have increased vascularity so enhance
What images can be taken using contrast enhanced spectral mammography?
Low energy image = equivalent to standard 2D DM
High energy image = sensitive to contrast
Subtraction image = only sees lesions that enhance
What is the most important adjunctive imaging modality for breast disease?
US
What are the indications for doing a breast US?
Palpable mass, image guided biopsy, breast inflammation, breast problems during pregnancy, work up of mammographically detected lesion
What are the advantages of US?
No ionising radiation and not uncomfortable for patient
Good sensitivity and specificity for invasive cancer
Can differentiate cystic from solid
Quick if examination tailored to specific area
Cheap and image guided biopsy very easy
What are the disadvantages of US?
Low specificity when used for screening
Low sensitivity for DCIS
What are some advanced US techniques?
Strain elastography, shear wave elastography, contrast enhanced US, 3D US
What are some features of contrast enhanced US?
Allows quantitative assessment of perfusion
2D or 3D
What are some uses of contrast enhanced US?
Assessing response to NACT
Axillary node characterisation
Improving BIRADS of solid breast masses
What does elastography measure?
Differences in tissue firmness
What kind of image does conventional elastography provide?
A colour map of stiffness superimposed on a grey scale image
How are invasive cancers viewed by elastography?
Stiffer than benign lesions = area of stiffness produced by a cancer is often larger than grey scale US abnormality
What are the appearances of lesions scored 1-3 by strain elastography?
1 = entire area and surrounding area is evenly shaded green 2 = lesion area has mosaic pattern of green, blue and red 3 = central part of area is blue and peripheral part green
What are the appearances of lesions scored 4 and 5 by strain elastography?
4 = entire area is blue (stiff) 5 = both entire area and its surrounding area are blue (stiff)
What are the disadvantages of strain elastography?
Non-quantitative
Poor reproducibility due to operator difference in producing strain
What are the advantages of shear wave elastography?
Quantitative and good reproducibility
Improved differentiation of benign from malignant when combined with US
What are the features of shear wave elastography?
Strain is produced by US probe
Ultrafast sequence catches in real time the propagation of shear waves
What is the most sensitive modality for detection of breast cancer?
MRI = dynamic contrast enhanced MRI has sensitivity of >95% for invasive cancer
What is the most accurate method for sizing and focality assessment of breast cancer?
MRI
What are the disadvantages of MRI?
Widespread use in women planned for wide local excision increases mastectomy rates
Doesn’t decrease positive margins, re-excision or local recurrence
What are some uses of MRI?
Lobular cancer, mammographically occult cancer, downsizing with neoadjuvant chemotherapy, Paget’s disease of the nipple, implant integrity, screening of very high risk women
What are some methods of breast biopsy?
FNA, core, vacuum
What can the EnCor biopsy equipment be used for?
Stereotactic, US and MRI guided biopsy
What are the commonest causes of breast lumps by age?
<30 = fibroadenoma 30-50 = cyst >50 = cancer
What is the best modality for assessing breast masses?
US
When would you do a mammogram for a breast mass?
If clinical or US is suspicious
Patient age >40
How are abnormal axillary nodes identified?
By cortical thickness and shape = usually seen on US
How sensitive are core biopsies of abnormal axillary nodes?
Identifies 40% of node-positive women pre-operatively
How is breast cancer staged?
Operable disease = local staging
Locally advanced or recurrent disease = CT chest/abdo/pelvis for metastases
What are some common sites for breast metastases?
Bones, lungs, pleura, liver, brain
Is unilateral nipple discharge from a single duct normal?
No = always a concerning symptom
What are some causes of single duct nipple discharge?
Invasive cancer, DCIS, duct ectasia, papilloma
What are some causes of breast abscess/infection?
Breast feeding and duct ectasia
How are most breast abscesses/infections managed?
US guided drainage and antibiotics
