Week 7 - E - Breast Imaging - Indications, Mammography (types/views/BIRADS Parenchymal pattern), Ultrasound & MRI

Question 1

Where does the bed of the female breast extend from? What is the extension of the breast towards the axilla known as?

Answer 1

The bed of the breast extends from ribs 2to6 form the lateral sternal border to the mid axillary line The extension towards the axilla is known as the axillary tail of spence

Question 2

What is the purpose of the breast?

Answer 2

The breast serves as a mammary gland in females - it is believed to be a modified sweat gland Mammary gland means milk producing gland

Question 3

Does everyone with a breast problem need a breast imaging test? Answer? No! When is imaging needed for a breast problem?

Answer 3

For either symptomatic patients - ie presenting with: * A lump * Unilateral or blood stained nipple discharge * Skin tethering or dimpling * Signs of inflammation * Axillary lumps And when screening is being carried out

Question 4

What symptoms would imaging not normally be carried out for?

Answer 4

NOT for pain; tenderness; symmetrical nodularity! in the absence of the other symptoms

Question 5

What is the key priniciple of examination used in patients presenting with a lump? What are the different aspects?

Answer 5

This would be to carry out a triple assessment of the breast Clinical - history and examination Imaging - Mammogram or Ultrasound Pathology - Histology (looks at tissues) or cytology (looks at cells)

Question 6

What are the different methods of obtaining cytology and histology samples?

Answer 6

Cytology

• 1. Fine needle aspiration - 3. Nipple discharge 2. Nipple scrapes -4. Fluid Histology -

Diagnostic

• * Needle core biopsy - Vacuum assisted biopsy
• * Skin biopsy - Incisional biopsy of mass

Therapeutic -

• * Excsiional biopsy of mass -
• * Resection of cancer - wide local excision or mastectomy

Question 7

When the samples of the breast are taken for histopathology or cytopathology, what is the grading given?

Answer 7

• Cytology -
  
  • C1 - unsatisfactory
  • * C2 - benign
  • * C3 - atypical, probably benign
  • * C4 - suspicious of malignancy
  • * C5 - malignant
• Histology -
  
  • B1 - unsatisfactory/normal
  • * B2 - benign
  • * B3 - atypia, probably benign
  • * B4 - suspicious of malignancy
  • * B5 - malignant

Question 8

The approach to imaging is age dependent and symptoms dependent Is imaging usually carried out for pain? If there is a mass which imaging modality is chosed?

Answer 8

If there is pain, imaging is not carried out unless focal/asymmetrical nodularity to exclude an underlying mass If the patient is below 35 years of age - ultrasound is carried out If the pattent is above 35 years of age - Mammogram is typically first line but ultrasound may also be used

Question 9

What are the three main imaging modalities used in breast cancer?

Answer 9

Mammorgraphy Ultrasound and Magnetic resonance imaging (MRI)

Question 10

What is the imaging technique that reliably visualises microcalcifications of <0.5mm? What is the only population based screening method shown to reduce mortality?

Answer 10

This would be mammography The only population based screening method shown to reduce mortality is mammorgraphy

Question 11

What is mammorgraphy?

Answer 11

This is a low dose xray designed specifically to maximise contrast between breast tissues whilst minimising ionising radiation dose

Question 12

Why is mammography used so often?

Answer 12

It is the most cost effective non-invasive breast examination that is reproducible and easy to document It also is the only technique to reliable visualise microcalcifications of less than o.5mm

Question 13

Define mamorgraphy again? What are the two different types of mammography?

Answer 13

Mammography is a low dose xray designed specifically to maximise contrast between breast tissues whilst minimising ionising radiation dose Two types Film/screen mammography (conventional) Digital mammography (Full field digitial mamography - FFDM)

Question 14

What are the advantages of digital mammography (full field digital mammography FFDM) over film/screen based mammography?

Answer 14

The digital mammograpy offers better contrast between dense and non-dense tissues and is therefore better in young woman It is also quicker at carrying out than conventional mamography and there are few repeats, films &easier image storage

Question 15

Can see the better contrast between dense and non dense tissues in the digital mammography than in the film/screen mammography What is the difference between screening and diagnosis when using mammorgaphy?

Answer 15

Screening is performed with asymptomatic individuals with women at regular intervals with the aim of detecting clinically occult breast cancer at an early stage Diagnosis - this is when symptomatic patients come and mammorgaphy is carried out to demonstrate IF any abnormality AND the nature of the abnormality

Question 16

What is the only population screening based method proven to reduce mortality? How sensitive is mamorgraphy for women greater than 50 years? What percentage of palpable cancers are not detectable on mammorgrams however?

Answer 16

The only population based screening method shown to reduce mortality in breast disease is mammography A mammography is 90% sensitive for women greater than 50years It does not however detect 10% of palpable cancers

Question 17

To whom is mammography offered? To whom is mammography not routinely indicated?

Answer 17

Mammography is offered to all women above 40 presenting with a palpable mass It is not routinely indicated for women below 40 years of age - (screening not indicated for this age range and if symptoms present, mammography still not indicated

Question 18

What does a normal mammogram show? What colour do calcifications appear?

Answer 18

Normal mammogram shows skin and pores Fat which is low density and blac Glandular is higher density and therefore appears light than black but not bright white Clcifications on xray appear as bright white

Question 19

What are the main views used in mammorgraphy?

Answer 19

The medialoteral oblique view and the craniocaudal view are the two most used views

Question 20

Where is the xray beam in relation to the breast in the mediolateral oblique view? (MLO) Why is the MLO view of the breast one of the two key mammorgaphy views?

Answer 20

The xray beam is perpendicular to the long axis of the breast in the mediolateral oblique view of the breast It is the most important projection as it allows to depict most breast tissue.

Question 21

The craniocaudal view is the other standard mammography views What tissue of the breast does this show?

Answer 21

This shows the medial and most of the lateral breast tissue but does not show the axillary tail of spence

Question 22

Where in the breast do most cancers statistically originate from?

Answer 22

Most cancers statistically originate from the upper outer quadrant of the breast

Question 23

Mediolateral oblique view - views almost the whole breast, xray beam is perpendicular to the long axis of the breast Craniocaudal view - table is horizontal with nipple in profile, shows medial and most of lateral tissue but axillary tail of spence is not in view BIRADS or ‘BI-RADS stands for Breast Imaging Reporting and Data System and was established by the American College of Radiology. What are the four categories for scoring the BI-RADS parenchymal breast patterns? (uses % of density)

Answer 23

* A - the breast is nearly all fat * B - there is scattered fibrogladular densities (25-50% glandular) * C - hetergenously dense breast tissue - 51-75% glandular tissue * D - extremely dense breasts >75%

Question 24

What is category D in the BI-RADS score for parenchymal pattern?

Answer 24

This would be extremely dense breasts where there is >75% breast density

Question 25

What are malignant calcification features on mammogram? (come under 4 headings - distrubution, cluster shape/size, individual particle shape, pleomoprhic nature)

Answer 25

• Distribution - cluster or segmental - suspicious
• Scattered or defuse (benign)
• Cluster shape/size - rhomboid forms Individual particle shape - linear/branching/Yshaped forms
• Pleomorphic nature - size and density

Question 26

State again malignant calcification characteristic features on mammogram? What are the indications of an ultrasound scan of the breast?

Answer 26

Malignant calcification characteristic features

• * Distribution - cluster/segmental
• * Cluster shape/size - rhomboid forms
• * Indivdual particle shape - linear/branching/Yshaped forms
• * Pleomorphic nature - size and density

Ultrasound scan can help differentiate between cystic and solid lesions

Used for palpable lesions in women <40 and women with nipple discharge

Question 27

How do cysts appear on ultrasounds? How are cysts treated?

Answer 27

Cysts appear as fluid collections on ultrasound and are therefore black There can be clustered and usually require aspiration

Question 28

How do solid nodules appear on ultrasound scan? (for benign and malignant) Circumscribed? Echoic Tall vs wide?

Answer 28

Benign nodules are

• * Usually wider than tall and
• * Can be hypo or hyperechoic
• * And are often multiple and well circumscribed

Malignant nodules are

• * Poorly circumscribed,
• * Hypoechoic,
• * Usually taller than wide

Question 29

What are the disdvantages of using ultrasound?

Answer 29

It is operator dependent and often time consuming and difficult to reproduce Can also miss calcifcations

Question 30

What is the advantage of using MRI scans? (these are usually used for staging)

Answer 30

There is excellent intrinsic tissue contrast And no ionising radiation Also accuracy independent of breast density

Question 31

How is the MRI interprated?

Answer 31

By if there was any enhancement during the procedure The morphology of the mass The rate of enhancement (ROIs)

Question 32

What are contraindications to MRI investigation for breast cancer?

Answer 32

Absolute contraindications - anything metal ie cardiac pacemakers, ferromagnetic aneurysm clips, cochlear implants And renal impairment Relative - the effect of gadolinium based contrast on pregnant and lactating women

Question 33

The screening for breast cancer is different in patients who are at high risk What are examples of high risk groups?

Answer 33

Those who have been exposed to previous irraiation Patients with BRCA1 (65% lifetime risk) and BRCA2 (45% lifetime risk) gene mutations Also patients who have TP 53 mutations (Ie Li Fraumeni syndrome)

Question 34

What is the inheritance of Li Fraumeni syndrome? What is the inheritance of the BRCA1and2 mutations?

Answer 34

Autosomal dominant for all the mutations (ie li fraumeni syndrome and BRCA)

Question 35

When is MRI characteristically used for screening tests?

Answer 35

Used for screening in very high risk patients - Women with a high risk have a 30% or greater chance of developing breast cancer in their lifetime.

Women aged 50 to 70 are offered mammograms every 3 years as part of the population screening programme[1]. If you have a family history of breast cancer you may have yearly mammograms or MRI scans after you reach 50, as shown in the table.