RADIOLOGIC EVALUATION OF BREAST CANCER
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1 RADIOLOGIC EVALUATION OF BREAST CANCER Orsolya Farkas, Gabriella Bodrogi and Gábor Szalai Department of Radiology, Pécs University
2 Complex evaluation of the breast Patient history Physical examination Mammography Ultrasound MRI Nuclear medicine (isotope infiltration for sentinel l.g.; PET) Cytology/Histology (Invasive methods - galactography, cyst punction, drainage, lesion localization)
3 Patient history & physical examination Any subjective complaint Gynecological surgeries, interventions Family history Previous brest surgeries or biopsies Any alteration in brest shape Palpable lesions Nipple discharge Skin thickening Skin retraction Birthmarks, moles
4 X-ray mammomgraphy Mammography is the main radiologic method to investigate the breast US and MRI mainly have only complementary roles Mammography is the only suitable method for breast cancer screening Mammograms must be evaluated only by trained and certified radiologists
5 Screening mammomgraphy Searching for cancer signs in females with no symptoms to find cancer in very early stage Hungary: y.o., every second year, by invitation High risk patients: familial, brca mutation: > 30y.o., annual
6 Screening mammography Standard views of each breast (CC + MLO) Mammograms can be evaluated later Does not provide definite diagnosis 20 % false negative (dense breast, non-calcified DCIS, lobular cc), 5 % false positive Double reading!!! If no consensus or if any alteration: complementary examinations: enlarged views, US, biopsy
7 Clinical mammography Complex diagnostics Mammograms are evaluated immediately and can be immediatelly completed by additional mammograms (e.g. enlarged views), US, biopsy Women w symptoms, follow up; asymptomatic women
8 Mammomgraphy technical considerations Requires the best image quality Most pathologies either have soft tissue density that is not very different from surrounding tissues or contain microcalcifications Soft x-rays to best differentiate between the soft tissues of the breast
9 Mammomgraphy technical considerations Low energy (25-32 kv) High mas Molybdenum (and rhodium) anode (characteristic x- ray production) Molybdenum filter Two, small focal spots (improved resolution) Compression more uniform breast thickness reduced blurring from patient motion reduced scattered radiation reduced radiation dose better visualization of tissues near the chest wall Grid: filter scattered radiation
10 Mammography
11 Mammography
12 Mammography standard views Craniocaudal (CC)
13 Mammography standard views Mediolateral oblique (MLO)
14 Left Craniocaudal Left Medio-lateral oblique Left craniocaudal
15 Left craniocaudal Left mediolateral oblique
16 Right craniocaudal Right mediolateral oblique
17 Mammography magnification views Mainly to evaluate microcalcifications
18 Ultrasound First method of choice under 30 year (+ pregnancy and breast feeding, implants) Complementary method for dense breasts (limitation of mammography!) Further characterization of pathologies found on mammograms Axilla!! - Always has to be scanned Differentiate between solid and cystic lesions Post surgical complications (hematoma) Guiding interventions (FNAB or core biopsy)
19 Ultrasound Technical considerations High frequency (10-12 MHz), linear probe Doppler: vascularization of lesions (high vascularization and high flow are suspicious for malignancy) Sonoelastography: compare and quantify tissue elasticity malignant lesions usually show higher stiffness relative to surrounding tissue
20 Fibroadenoma: wellcircumscribed, round to ovoid, or macrolobulated mass with generally uniform hypoechogenicity, pseudocapsule Cyst: anechoic, well circumscribed, acoustic enhancement
21 Breast cancer: echopoor, inhomogeneous, irregular border, poorly circumscribed, acoustic shadow, not compressible
22 Lesion analysis Ultrasound morphology Benign Anechoic or echopoor Round or oval Well circumscribed Homogeneous Acoustic enhancement Lateral shadow sign Compressible Not fixed No hypervascularity Malignant Echopoor Irregular Ill-defined border Inhomogeneous Acoustic shadow Non-compressible Fixed Hypervascularity and flow, irregular vessels
23 Ductal cc: stiff lesion Fibroadenoma: elastic lesion
24 MRI Suspected multifocal, bilateral lesions Occult primary tumor Exact extension of infiltrative lesions Suspected lobular cc. Chest wall infiltration To differentiate between recurrence and surgical scar Suspected implant rupture Screening in high risk populations (e.g. Brca mutation) Monitoring the effect of neoadjuvant chemotherapy
25 MRI technical considerations Min. 1.5 T (3T) Breast coils Native + contrast enhanced serials T1, T2, FatSat Dynamic MRI!!!: kinetics of contrast enhancement most important to differentiate between benign and malignant lesion
26 T1 FatSat CE, early phase, subtarction T2
27 Type I curve: Slow rise, continued rise with time. 6 % malignant. Type III curve: Rapid initial rise, followed by washout % malignant.
28 Anatomy Glandular ducts and lobules Connective tissue Fat Basic functional unit: Lobule or terminal ductal lobular unit (TDLU) Most invasive cancers rise from TDLU (+ DCIS, lobular cc in situ or infiltrating lobular cc, fibroadenoma, fibrocystic disease)
29 TDLU
30 How to interpret mammograms? Determine whether film is of diagnostic quality Find the lesion Analyze the lesion Circumscribed Stellate Structural distorsion Calcifications Thickened skin
31 Determine whether film is of diagnostic quality On MLO views, pectoral muscles should be visible at least above the level of the nipple On CC views, the edge of the pectoral muscle should be visible
32 Determine whether film is of diagnostic quality The line drawn from the nipple to the pectoral muscle should be the same length on both views (max. difference should be less than 1 cm) trained technitian! 129 mm
33 Determine whether film is of diagnostic quality Nipple should be in profil
34 Determine whether film is of diagnostic quality Image should not be blurred
35 Determine whether film is of diagnostic quality No artefacts! Bra strap Skin folds talcum ointment deodorant patch
36 Find the lesion Circumscribed easy to recognize; mostly benign Stellate difficult to recognize; most malignant lesions Certain breast types are not easy to evaluate on mammograms
37 Normal breast types (Tabar) Different types of breasts according to mammographic patterns (reflects composition) I: balanced proportion of all components of breast tissue with a slight predominance of fibrous tissue (Fibroglandular; young age) II: predominance of fat tissue (Fatty breast) III: predominance of fat tissue with retroareolar residual fibrous tissue IV: predominantly nodular densities (Adenotic) V: predominantly fibrous tissue (Fibrotic or dense breast) I-III. Can change e.g. with age or hormon therapy IV and V.: genetically coded; difficulte to evaluate on mammograms!!! US!
38 Normal breast types (Tabar) Fibroglandular
39 Normal breast types (Tabar) Involuted
40 Normal breast types (Tabar) Retroaleolar
41 Normal breast types (Tabar) Adenotic limitations of mammography!
42 Normal breast types (Tabar) Fibrotic - limitations of mammography!
43 Lesion analysis circumscribed lesions cyst, lipoma, fibroadenoma, papillary or mucinous cc, etc Easier to recognize Size Contour (sharp: usually benign feature) Halo, capsule: Benign features Density: radiolucent (lipoma, oil cyst, galactocele); radiolucent and radiopaque combined (l.g., hematoma, fibroadenolipoma); low density radiopaque (fibroadenoma, cyst, but: papillary cc, mucinous cc); high density radiopaque (cc, cyst, abscess, lg...)
44 Sharp contour - fibroadenoma
45 Sharp contour - Cyst
46 Ill defined contour - cc
47 Capsule Halo
48 High density radiopaque - cyst Lower density radiopaque - fibroadenoma Radiokucent and radiopaque combined - fibroadenolipoma
49 Lesion analysis stellate lesions = radiating structure w ill defined borders More difficult to recognize Center distinct mass - white star : invasive intraductal cc oval or circular radiolucent area - black star : radial scar, fat necrosis, invasive lobular cc Radiating structures sharp dense, fine lines radiating in all directions (invasive ductal cc) Many very fine spicules bunched together (radial scar, fat necrosis) Skin thickening: radial scar never associated w
50 Lesion analysis Radial scar = sclerosing ductal hyperplasia Benign but can be associated with DCIS or tubular cc Mimicker of scirrhous breast cc (invasive ductal cc) y.o. Not palpable Mammo: dark star stellate lesion with translucent, low density center w/o mass No associated skin thickening
51
52
53 Lesion analysis Invasive ductal cc Most frequent type of breast cc Peak: y.o. Can be palpable, immobile Mammo: white star stellate lesion with high density central mass w calcification (granular or casting); the larger the central mass, the longer the spicules; w/o localized skin thickening or retraction
54
55 Lesion analysis Structural distorsion Asymetric densities w architectural distortion Difficult to recognise Lobular carcinoma: often multifoca and bilateral MRI! Mammo: white star Structural distorsion dark star calcification uncommon
56
57 Lesion analysis Calcifications Localization: ductal (malignant) or lobular (benign), extraglandular Terms: cluster, scattered, casting, granular, punctuate Malignant type calcifications: Granular: tiny, dot-like, innumerable, irregularly grouped Casting: casts of ductal lumen, irregular outline, polymorph
58 Lesion analysis Calcifications Benign type calcifications: Egg shell Course or popcorn like Milk of calcium Skin, vascular, etc Large, rod like (plasma cell mastitis)
59 Lesion analysis DCIS Ductal carcinoma in situ % of breast cc on mammomgrams!!! (screening!!!!!) Mammo: 75 % Calcification!!!! Granular or casting
60
61 Lesion analysis Thickened skin sy Diffuse or localized Diffuse: Axillary lymphatic obstruction lg. met Breast cc Lymphoma Advanced gynecologic malignancies (ovarium, uterus) Advanced bronchus or esophagus cc Lymphangitic spread of breast cc Inflammation Right heart failure
62
63 Special type cancers DCIS, invasive ductal cc ~ 70 % Special types ~ 25 % Lobular: diffuse infiltration, structural distortion difficult to recognize Medullary, Mucinous, Papillary cc: usually well circumscribed, round lesions Metastasis: also circumscribed
64 Roentgen Mammography (RM) Benign morphology Sharp contour (but: high grade tumors, lymphomas, medullar and colloid are traps) Safety zone (halo or capsule; but: high grade tumors, lymphomas may show it as well) Shape (egg-like, spherical, ovoid, etc) but: mucinous cc, medullar cc, papillaris cc, invasive lobular Density: radiolucent (lipoma, oil cyst, galactocele); radiolucent and radiopaque combined; low density radiopaque (fibroadenoma, cyst, but: papillary cc, mucinus cc) Homogeneity Macro calcifications (but: every macro calcifications once developed from small ones, and malignant calcifications can contain several rough calcifications) Permanence (but: in situ carcinomas, low grade tumors, therapy may fool you!)
65
66 Roentgen Mammography (RM) Malignant morphology High density (but: not always) Indistinct border Spiculated contour (but: radial scar, hyperplasia, fibrosis, postoperative mixed changes /scar, haematoma, fat necrosis, granulomatosis/, sclerosing adenosis can be misleading) Irregular shape (but:...) Relation to the surrounding tissue (spiculae, appendix, Cooper-ligaments, skin, areolar-mamilla, chest wall) Microcalcifications (group, branching, casting, punctured, granular, bizarre, etc.; attention: is there any tumor body? What is it like? Since when?) Structural (parenchymal) torsion (very important to notice them!)
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71 COMMON CHANGES 1. Fibroadenoma Its sagittal axis parallel with the surface homogenous average intensity well rounded, sharp contour marginal rough calcifications low echogeneity
72 COMMON CHANGES 2. Fibroadenoma sometimes isoechoic fibrotic bundles small cystic parts polar vessel(s) age mobile and flexible in palpation
73 COMMON CHANGES 3. Fibroadenoma moderate sound amplification (marginal shadowing) care: medullar-, colloid cancer, high grade tumor, lymphoma, hyperplasia, granuloma, thick (oil) cyst
74 COMMON CHANGES 4. Ductectasia low echogeneity or with no echo mural calcification (inner precipitating crystals) tubular or cystic central or not homogenous discrete sound amplification or not
75 COMMON CHANGES 5. Cyst one - a few - several diluted - thick mural calcifications etc. care: lymphoma, high grade tumor, small colloidal cc.
76 COMMON CHANGES 6. Round hyperplasia like fibroadenoma Intramammary lymph nodes Papilloma intracystic or intraductal (excretion) mostly high echogeneity mostly cystic in other properties like fibroadenoma
77 COMMON CHANGES 7. Ductal and lobular carcinoma very well known morphology Mucinous cancer its characteristics: well rounded, lobulated, intensive, isoechoic, but: it can be micro cystic and micro calcificated
78 COMMON CHANGES 8. Papillary carcinoma intracystic or intraductal isoechoic or with low echogeneity irregularly hypervascularized microcystic micro calcificated
79 COMMON CHANGES 9. Medullar carcinoma, lymphoma, high grade tumor similar to FA often with lobular margins often with sound amplification
80
81 PUNCTURE, DRAINAGE cyst, abscess, seroma, hematoma US guidance! free hand technique for puncture G needle (18 G), 5-15 seconds for drainage 5-7 F set, in local analgesia, 3-10 minutes 10/24/2016
82 BIOPSY (FNAB or CORE) Fine Needle Aspiration Biopsy US-guidance (rarely stereotaxia) min. 1O MHz linear transducer without local analgesia 22-23G needle, free hand 5-15 seconds citology, histology
83 CORE BIOPSY US-guidance (rarely stereotaxia) local analgesia G 2-5 minutes histology
84 PREOP. LOCALISATION No-palpable mass! Palpable mass which can t exactly be determined US-guidance local analgesia 1 or more loop 18 G needle - 3 wire 2-5 minutes
85
86 ISOTOPE INFILTRATION sentinel lymph node peritumoral like puncture...
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