Basic Mammography

DARUNEE BUNJUNWETWAT MD.

Breast imaging
Mammography Ultrasonography MRI Scintimammography

Mammography
Food and Drug Administration ( FDA ) June 2, 1993 Most effective for early breast cancer detection Screening mammography Screening interval

Screening mammography Diagnostic mammography

Screening mammography
Women > 40 years Yearly, annual check up Early cancer detection

Early stage

Cure Small size < 1 cm Free of metastases Non-palpable

High risks
Early menarch Late menopause Nulliparity Late age at full term pregnancy (> 30 yrs ) Biopsy proof atypical epithelial proliferation Biopsy proof lobular carcinoma in situ
(Kopans DB. Breast imaging Lippincott-Raven p45)

High risks
Genetic ( BRCA 1, BRCA 2 ) Environmental Gene-environmental interaction Affected first degree relative ( mother, sister, daughter ) Previous history of cancer ( breast , ovary )
Ronbidoux et al, AJR 166(1): 29-31, 1996 Foulkes et al, Clinical and intensive Medicine 18(6): 473-483, 1995

American cancer society ( ACS ) National cancer institution ( NCI )

Screening mammography 40-80 yrs High risks 35 yrs

Mammography
Technique : standard two views ( MLO , CC views) : additional views ( spot compression, magnification )

Standard views
1. 2.

Mediolateral oblique ( MLO ) Craniocaudal ( CC )

Supplement views
Spot compression Magnification True lateral Exaggerated medial or lateral CC Tangential Rolled Cleavage ( buttock ) Axillary views

Technique
Pulling Compression Angle Breath holding

MLO view
Length and contour of pectoralis muscle Nipple Inferior mammary angle

Pitfall
Inner quadrant

CC view
Visualized pectoralis muscle 30-40 % Retromammary fat Pectoralis-Nipple line ( PNL ) Stress on inner aspect

Mammography Risks
Low dose radiation ( 2mGy per view ) Compression effect Uncertainty in diagnosis of CA in situ

( Napol et al; Journal of National Cancer Institute Monograph (22):11-3, 1997 )

Anatomy of breast
1. 2. 3. 4. 5. 6.

Mammary gland Ducts Collagenous connective tissue Fatty tissue Cooper ligament Vessels and lymphatic

Breast evolution and involution

Individual Age Hormonal Menstrual cycles Pregnancy Lactation Menopausal

Menarchal development
15 yrs 25 yrs Lobular structure, duct system
( hypoplasia, inverted nipple, juvenile hypertrophy, fibroadenoma )

Cyclical change
Premenstrual phase ( endocrine
stimulation )

Epithelial and stromal activity, regression Breast enlarge, patchy density

( fibrosis, adenosis, lymphoid proliferation, mastalgia, nodularity )

Pregnancy, Lactation
Pronounced glandular activity Superimposed cyclical change Patchy

Post Lactation
Some areas of regression Fibrosis

Involution
30yrs - 40yrs till menopause Lobular regression ( involution of epithelium ) Replacement of fibrous tissue in interlobular regression sclerosis, microcyst formation

Breast patterns
Fatty breast Ductal Dense breast

Wolfe Classification
Ducts, lobules, fibrosis Linear and nodular opacities

N1 = Parenchymal chiefly fat P1 = Duct pattern in anterior portion

< of breast volume

P2 = Duct pattern > of breast volume DY = Confluence densities or dysplasia

( AJR 126: 1130-1139, 1976 )

Histologic appearance of P1, P2

connective tissue hyperplasia surrounding duct periductal collagenosis

Histologic appearance of DY
severe mammary dysplasia adenosis, microcyst formation

Wolfes study
Parenchymal patterns and cancer risk

DY + P2 > P1 + N1 6 times

Thai women 444 cases Negative mammograms Technique MLO, CC views

DY P2

60.6% 46.8% 30.7%

40 50 yrs 40 50 yrs 50 60 yrs 50 60 yrs 60 70 yrs

P1 N1

47.8% 50%

DY + P2 80% of Thai women

Breast parenchymal density

ACR BIRADS 4 level systems Fatty Scattered fibroglandular densities Heterogeneously dense Extremely dense

Classification of breast lesion

ACR BIRADS 1. Negative 2. Benign 3. Probable benign 4. Probably malignant 5. Highly suspicious malignant 6. Known case malignant

ASSESSMENT CATEGORIES
Mammographic assessment is incomplete
Category 0
Need Additional Imaging Evaluation and/or Prior Mammograms For Comparison

ASSESSMENT CATEGORIES Mammographic Assessment Is CompleteFinal Categories

Category 1
Negative

Category 2
Benign Finding(s)

Category 3
Probably Benign FindingInitial ShortInterval Follow-Up Suggested

ASSESSMENT CATEGORIES
Category 4
Suspicious AbnormalityBiopsy Should Be Considered

Category 5
Highly Suggestive of MalignancyAppropriate Action Should Be Taken (Almost certainly malignant.)

ASSESSMENT CATEGORIES
Category 6
Known Biopsy Proven Malignancy Appropriate Action Should Be Taken

Category 0
almost always used in a screening situation. additional imaging evaluation may include, but is not limited to the use of spot compression, magnification, special mammographic views and ultrasound. should only be used for old film comparison when such comparison is required to make a final assessment.

Category 1
The breasts are symmetric and no masses, architectural distortion or suspicious calcifications are present.

Category 2
Involuting, calcified fibroadenomas, multiple secretory calcifications, fat-containing lesions such as oil cysts, lipomas, galactoceles and mixed-density hamartomas all have characteristically benign appearances Intramammary lymph nodes, vascular calcifications, implants or architectural distortion clearly related to prior surgery while still concluding that there is no mammographic evidence of malignancy

Both Category 1 and Category 2 assessments indicate that there is no mammographic evidence of malignancy. The difference is that Category 2 should be used when describing one or more specific benign mammographic findings in the report, whereas Category 1 should be used when no such findings are described.

Category 3
Less than a 2% risk of malignancy Three specific findings are described as being probably benign
noncalcified circumscribed solid mass focal asymmetry cluster of round [punctate] calcifications

exclude palpable lesions

an initial short-term follow-up (6 months) examination (usually unilateral mammogram) followed by additional examinations (bilateral F/U in another 6 months and then bilateral 12-month F/U) until longer-term (2 years or longer) stability is demonstrated may be changed to Category 2 occasional biopsy when patient wishes or clinical concerns

Category 4
For findings that do not have the classic appearance of malignancy but have a wide range of probability of malignancy that is greater than those in Category 3. Most recommendations of breast interventional procedures will be placed within this category.

Subdivided to account for the vast range of lesions subjected to interventional procedures and corresponding broad range of risk of malignancy
Category 4A, 4B and 4C

Category 4A
need intervention but with a low suspicion for malignancy palpable, partially circumscribed solid mass with ultrasound features suggestive of a fibroadenoma, a palpable complicated cyst or probable abscess

Category 4B
Intermediate suspicion of malignancy warrant close radiologic and pathologic correlation partially circumscribed, partially indistinctly marginated mass yielding fibroadenoma or fat necrosis is acceptable, but a result of papilloma might warrant excisional biopsy

Category 4C
Moderate concern, but not classic (as in Category 5) for malignancy ill-defined, irregular solid mass or new cluster of fine pleomorphic calcifications malignant result in this category is expected

Category 5
High probability (> 95%) of being cancer Example,
spiculated, irregular high-density mass, segmental or linear arrangement of fine linear calcifications or irregular spiculated mass with associated pleomorphic calcifications

Category 6
For lesions identified on the imaging study with biopsy proof of malignancy prior to definitive therapies No associated intervention required to confirm malignancy Appropriated for second opinions or for monitoring of responses to neoadjuvant chemotherapy prior to surgical excision

Not appropriate following excision of a malignancy (lumpectomy ) A major rationale for adding Category 6 is that examinations meriting this assessment should be excluded from auditing
If include inappropriately indicate inflated cancer detection rates, positive predictive values, and other outcomes parameters

Fibrocystic change

Popcorn calcifications

Popcorn calcifications

Fibroadenoma

Hamartoma

Hamartoma

Lipoma Galactocele Oil cyst (fat necrosis)

Case 1

Sclerosing adenosis

Case 1 Case

guide

Case 2

Fibroadenosis

Case 2

Case 2

Case 2

Thank you