Imaging the Breast Flashcards by Aliya Hussain

Region of the breast?

Over the 2nd-6th ribs, midclavicular line

Extends towards the axilla (axillary tail of Spence)

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Does everyone with a breast problem require a breast imaging test?

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When is breast imaging required?

Symptomatic patients:
• Lumps
• Unilateral or blood-stained nipple discharge
• Skin tethering or dimpling
• Signs of inflammation
• Axillary lumps

Not indicated for pain, tenderness or for symmetrical nodularity

Imaging is also performed as part of screening

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What is triple assessment?

Clinical - history & examination
Imaging
Pathology - histology, cytology

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Grading of breast tissue biopsy?

Grade 1 - normal

Grade 2 - benign

3 - atypical, probably benign

4 - suspicious

5 - malignant

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When is imaging performed for breast pain and what does this involve?

Only is assoc. with focal or asymmetrical nodularity, in order to exclude an underlying mass

Perform mammography (XRM), USS or both

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How does age affect the choice of imaging?

If woman <40 years of age, USS

If woman >40 years, XRM +/- USS

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Modalities available for breast imaging?

Mammography:
• Film / screen (conventional)
• Full field digital mammography (FFDM)

USS

MRI

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What is mammography?

Low-dose X-ray designed specifically to maximise contact between the breast tissues, whilst minimising radiation dose

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Advantages of mammography?

Cost-effective

Non-invasive

Reproducible and easy to document

ONLY technique that reliably visualises micro-calcifications (<0.5mm)

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Significance of micro-calcifications?

Assoc. with ~30% of invasive cancers

Very sensitive for DCIS

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Advantages and disadvantages of digital mammography?

Advantages:
• Excellent contrast resolution, between dense and non-dense tissues
• Better in dense breasts, e.g: younger women
• Shorter exam time, fewer technical repeats and fewer films
• Easy image storage and transfer

Disadvantages:
• Compression of breasts causes discomfort

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Problems with imaging a woman who has breast implants?

Obstructs view of potentially significant breast findings

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Difference between mammography as part of screening and mammography in symptomatic patients?

For screening - mammography is performed on
asymptomatic women at regular intervals, with
the aim of detecting clinically occult breast
cancer at an early stage

In symptomatic patients - mammography used to
demonstrate if there is any abnormality and nature of the
abnormality

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Indications for mammography?

Screening - it is the only proven population-based method of reducing mortality
Problem-solving:
• For all women >40 years old with a palpable mass
• To exclude/confirm malignancy and assess the contralateral breast

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In which women is mammography not routinely indicated?

Women <40 years of age (either for screening or symptomatic patients)

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Options for breast imaging in women <40 years of age?

USS

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If breasts appear dense on mammography, what imaging options are available?

Follow the mammogram with an USS

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Structures visible on a normal mammogram?

Skin and pores

Fat (low-density)

Glandular tissue (higher density)

Trabeculae (thin & sharply defined)

Blood vessels +/- vascular calcifications

Lymph nodes (oval/horseshoe shape, visible fatty hilum)

Bright white calcifications - normal ones due to:
• Arterial
• Sebaceous (polo mint
• Oil cysts (eggshell curvilinear)

Views on a mammogram?

Main views:
• Mediolateral oblique (MLO)
• Craniocaudal (CC)

Extended CC

Other additional assessment views:
• Paddle (localised compression) views
• Magnification views
• Etc

Explain the mediolateral oblique (MLO) view on mammogram

Best single view, as it is the least foreshortening

Table at 45 degrees, off vertical, and the X-ray beam is perpendicular to the long axis of the breast

Explain the craniocaudal (CC) view on mammogram

Table is horizontal and nipple is in profile; it shows the medial and most of the lateral tissue and allows visualisation of the retromammary fat

Does not show the axillary tail

Explain the paddle view on mammogram

Apply very firm localised compression; this produces less scatter and more contrast and demonstrates the borders of a mass

Explain magnification views on mammogram

CC and lateral views with a magnification table (air gap); it is not just electronic zooming

How does breast density vary with age?

Breast involution after menopause Young women have dense breasts generally but a proportion have fatty breasts Similarly, a proportion of older women have dense breasts

Method of classifying breast density?

``` BIRADS parenchymal patterns: • a - nearly all fat • b - scattered fibroglandular tissues • c - heterogeneously dense • d - extremely dense ```

Types of calcification on breast mammogram?

Benign OR malignant

Features of malignant calcification?

Distribution: • Benign - scattered or diffuse • Suspicious - cluster or segmental Cluster shape / size - rhomboid forms suggestive of malignancy Individual particle shape - linear, branching, Y-shaped forms are suggestive of malignancy Pleomorphic nature - in both size and density

Newer methods of imaging breasts?

Digital breast tomosynthesis (DBT) - delineates lesion borders, showing any spiculation, and has increased cancer detection rates Contrast-enhanced spectral mammography (CESM) - shows neoangiogenesis; very good for dense breasts

Indications for USS?

Characterisation of mammographic findings - differentiation of cystic and solid lesions Palpable lesions in women <40 years of age Nipple discharge Women with breasts implants or augmentation For inflammatory conditions, e.g: abscess Evaluation of the response to chemo

If lesions are multiple, bilateral and well-defined, is this an indication or benign disease or malignancy?

Benign

Appearance of cystic lesion on breast USS?

Fluid collections (black) Can have clustered and complex cysts

Features of benign solid nodules?

Well-circumscribed and homogenous Can be hypoechoic / hyperechoic "Wider than they are tall" Peripheral/no vascularity Often multiple

Features of malignant solid nodules?

Poorly circumscribed and heterogeneous Hypoechoic "Taller than they are wide" Spiculate Have oedema / peri-tumoral fat

Types of USS-guided procedures?

Aspiration/drainage Cutting needle biopsy or vacuum-assisted biopsy (VAB) Radiofrequency interventions Sentinel lymph node analyses Vacuum-assisted removal of lesions

Why is another imaging modality required for imaging of breast disease?

XRM - low sensitivity in dense breasts, limited contrast, observer limitations, compression, irradiation USS - operator-dependent, time consuming, misses calcifications

Advantages of MRI?

Excellent intrinsic tissue contrast No compression and no ionising radiation Accuracy is independent of breast density

Types of MRI used to asses various features of the disease?

Morphology - high resolution T1 & T2 weighted scans Vascularity - dynamic contrast enhancement kinetics Cellularity - diffusion-weighted imaging (DWI) Metabolism - spectroscopy (MRS) Oxygenation - intrinsic susceptibility-weighted MRI

Method of assessing an MRI?

1. Any enhancement? Either mass (space-occupying effect) or non-mass 2. Morphology 3. Rate of enhancement (ROIs)

Types of enhancement curves?

Type 1 - benign Type 2 - suspicious Type 3 - malignancy (AKA washout curve) ADD IMAGE

Contraindications to an MRI?

``` Absolute: • Cardiac pacemakers • Ferromagnetic aneurysm clips • Cochlear implants • Renal impairment ``` Relative - due to effect of gadolinium-based contrast and also more difficult due to increased breast enhancement: • Pregnancy • Lactation

Indications for an MRI of the breasts?

Benign: • Implants • Characterisation of a lesion ``` Malignant: • Diagnosis • Staging and management plan • Residual disease post wide local excision • Assess response, e.g: chemo • Check for recurrent disease • Screening in high-risk groups ```

Examples of high-risk groups requiring breast MRI?

Previous irradiation (HL, mantle XRT), esp. if treated as children (lifetime risk of 30-50%) BRCA 1, 2 or TP53 mutations Personal Hx of breast cancer

Disadvantages of breast MRI?

Patient acceptability and tolerance Overdiagnosis Localisation/biopsy of lesions only seen on MRI Cost and access

What is the standard technique for evaluation of symptomatic breast disease in women >40 years of age?

Mammography

Technique for younger women and for evaluation of mammographic abnormalities?

USS