Detailed Program of the second BREAST IMAGING AND INTERVENTIONS PROGRAM am am : Clinician s requirements from breast imaging

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1 Detailed Program of the second BREAST IMAGING AND INTERVENTIONS PROGRAM 2012 Day one, 2 nd November BREAST IMAGING AND INTERVENTIONS PROGRAM AM 9.10 am Introduction 9.10 am am : Clinician s requirements from breast imaging This lecture addresses the important information required by the operating surgeon / Medical / Radiation Oncologist to decide and plan treatment 1. Multicentricity 2. Extent of disease 3. Axillary nodal involvement 4. Opposite breast 5. Metastatic work up This information will help to decide Choice of surgery - Breast conservation / Mastectomy - Sentinel lymphnode biopsy or Axillary Clearance - BRCA testing - Bilateral surgery etc., 9.30 am am Anatomy: The basis of breast imaging As is the anatomy, so is the imaging.understanding the anatomy is crucial to appreciate the normal radiological features in breast imaging (Mammogram / US / MRI). When normal is clear then the pathology is perceived early. This lecture addresses 1. Normal building blocks of breast i. Terminal ductal lobular units ii. Fibrosis tissue iii. Fat 2. Distribution and possible variation in relation to age and hormonal status. 3. Normal patterns of breast 4. Correlating MRI/US/Mammographic appearance. 5. Understand the origin of the cancer and where to look for it in imaging. 6. Understand the pathway s of spread.

2 10.00 am am Understanding breast cancer Breast cancer is very heterogeneous. Therefore the appearance on mammography / ultrasound and MRI vary from being circumscribed to spiculated lesions. This presentation elucidates the heterogeneity in terms of cellularity, Extra cellular matrix, host reaction to tumor and water content. Staging, pathological classification, the newer molecular classification and biomarkers will be discussed am Question time am am Tea time am am Technical adequacy, positioning different views in mammogram A good mammogram is crucial for good interpretation. Understanding the KV, MAS and the density of the breast and positioning techniques, are important to acquire a good image. Processing, fixing and drying is equally important in an analog set up to avoid browning, degradation and artifacts. In a CR/Digital set up it is important use appropriate monitors to read the image. Understanding blind spots in mammography is essential to optimize the standard veiws and incorporate additional veins wherever required. Hanging protocols should be standardized for methodical viewing am noon Step by step reading of a mammogram Methodology in the approach to reading a mammogram is a very important. This lecture addresses the importance of history / clinical exam / hanging protocol, assessing adequacy, understanding normal patterns and follow a step by step approach to look for specific areas in a specific order to detect breast cancer early pm Strategies for detection of breast cancer early This lecture reinforces the previously addressed topics and presents an algorithmic approach to detect breast cancer early PM 1.00 PM Workflow for asymmetric density, architectural distortion and breast masses

3 Presents workflow for asymmetric density, architectural distortion and breast masses. This lecture shows a series of common findings like asymmetric density, architectural distortion, breast masses. a) To define and characterize lesions. b) Workflow for additional views, breast ultrasound and MRI, and tissue biopsy whenever required pm to 1.15 pm Question time 1.15 pm 2.00 pm - Lunch 2.00 pm to 2.30 pm All about Calcifications There are whole ranges of calcification that occur in the breast and not all of them are malignant. It is important to understand the pathophysiology of how calcifications are formed. 1. Morphology Size, shape and numbers 2. Distribution and its clinical significance will be discussed The entire range of calcification will be discussed with images and workflow with additional views, significance will be discussed. Following this a clear understanding of calcifications ( ie) 1. Which ones to leave alone? 2 Which ones to follow up? 3. Which ones to biopsy? 2.30 pm pm Reporting standards in mammogram BIRADS nomenclature This lecture will deliver the standard Birads reporting format with examples. 3.00pm to 3.15pm : Question time 3.15 pm to 3.30 pm : Tea time 3.30pm -4.00pm Newer technologies : Tomosynthesis

4 This talk addresses the newer technologies with full field digital mammogram, Tomosynthesis in the armamentarium of breast imaging and the relevance of newer technologies in the early detection of breast cancer pm 4.30pm Stereotactic Biopsy Lesions that are non palpable and not seen on ultrasound, need stereotactic guidance to biopsy This lecture addresses the 1. Principles of stereotaxy 2. Available methods 3. Techniques 4. Placement of markers pm 5.30 pm Case Discussions Panelists ( Dr. Bagyam, Dr. Sumodh Koshy, Dr. Deepa Chegu, Dr. Sasi G) Worked up images of mammogram to review the 1. Normal pattern 2. Asymmetric densities 3. Architectural distortion 4. Analysis of breast masses 5. Calcifications DAY 2, 3 rd November BREAST IMAGING AND INTERVENTIONS PROGRAM 2012

5 7.30 am to 8.00 am : Meet the expert s session ( Please book in advance) 8.00 am to 8.30 am Technique and machine requirements. This lecture addresses 1. Machine and probe requirements. 1. Understanding the knobology. Optimizing the settings. Focus / gain (etc) depth, frequency, harmonics and spatial compounding. 2. Scanning techniques 3. Ergonomics of the operator am to 9.00 am Characterization of benign lesions Characterization of solid nodules into Birads, II, III, IV & V is discussed in detail based on US findings. The indication for biopsy, follow up and excision are discussed am am A look at complex cystic lesions Cyst with intra cystic growth, mural nodule, septations (thin/thick) fat/ fluid levels, debris, are discussed. The NPV and PPV of various findings and the indication for biopsy /excision and follow up are discussed am Characterisation of malignant lesions Ultrasound features of malignant lesions are discussed in details with images.

6 10.00 am am : Elastography in breast, ABUS This talk discusses the newer modalities in ultrasound for breast imaging. Strain and sheer wave elastography Can it reliably distinguish between benign and malignant lesions Automated breast ultrasound Can ABUS play a role in breast cancer screening pro s and con s am to 10.45am Question time am to am Tea time am am Axillary nodal assessment Assessment of axillary nodal involvement is important in treatment planning ( ie) to do sentinel lymph node biopsy or axillary clearance. I. Levels of Axillary lymphnode II. Normal Lymphnode III. Pathological features in lymphnode Role of cytology and histopathology of lymph nodes will be discussed am Noon Breast ultrasound Birads This lecture will deliver the standard BIRADS reporting format with example. 12 noon pm Newer technologies: Elastography and automated breast ultrasound Newer technologies in breast ultrasound including strain and shearwave ealstography and automated breast ultrasound will be discussed with images pm to pm- Question time

7 12.30 pm 1.15 pm - Panel discussion Moderator: Dr. Selvi Radhakrishna Panelists : Dr. Sasi Govindarajulu, Dr. Sumodh Koshy, Dr. Deepa Chegu Worked up images of ultrasound (with correlating) mammogram to review the I. Normal lesions II. III. IV. Solid nodules / masses Cysts / simple / complex Infections V. Malignant lesion pm to 2.00 pm -Lunch 2.00 pm pm MRI Basic techniques of image acquisition Basic principles of magnetic resonance imaging, surface coils, time of examination, patient positioning, breast compression, field strength, T1 and T2 sequences, temporal, spatial resolution and slice orientation will be discussed pm pm Basics of MR interpretation Assessment of T1 wieghted precontrast examination, T2 weighted examination, assessment of the contrast enhanced T1 weighted examination, masses, non mass like enhancement, kinetics and evaluation protocols will be discussed pm 3.15 pm Question time 3.15 pm pm Tea break 3.30 pm 4.00 pm Clinical application of breast MRI Indications for breast MRI with examples will be discussed. Post op recurrence, Carcinoma of unknown primary Pre op staging Monitoring neoadjuvant chemotherapy Implants

8 High risk screening. Problem solving after mammogram or ultrasound 4.00 pm to 4.30 pm Imaging of the treated breast Imaging in patients who have had breast conservation and radiotherapy can be very challenging. The changes that occur after surgery and radiotherapy are discussed. Features of recurrence and workflow to approach a suspicious recurrent lesion will be discussed in this lecture pm pm Interventional breast biopsies Skills in doing interventional breast biopsies are crucial to arrive at a diagnosis. This lecture will address the step by step approach to perform an image guided breast biopsy and other procedures including breast abscess drainage, wire localization and vacuum assisted excision biopsies pm Case discussions Panelists ( Dr. Sasi.G, Dr. Deepa Chegu, Dr. Sumodh Koshy) Worked up images with histopathology correlation will be discussed with attention to features of benign and malignant lesions. Day Three, 4 th November BREAST IMAGING AND INTERVENTIONS PROGRAM 2012

9 Day -3 (4/1//2012) Workshop 100 participants will be split into groups. The two groups will be further subdivided into A1and A2, B1 and B2. The interventional biopsy session and the workstation will go paralleled with the groups switching over in 2 hours time. Interventional breast procedures Ultrasound guided FNAC, Cyst aspiration, core needle biopsy and vacuum assisted biopsy will be taught with hands on practice with phantom breasts. Workstations Worked up images of mammograms and ultrasound will be kept for interpretation in small groups as in real time imaging. Results will be discussed by faculty latter in the afternoon. This gives the opportunity to self assess skills learnt in the course and refresh am to 10.00am : ( Work Shop 1 and 2 parallel sessions) am to 10.30am : Tea Time am to pm: ( Work Shop 1 and 2 parallel sessions) 12.30pm to 1.30pm : Lunch 1.30 pm to 3.00pm : Review of images from ultrasound and discussion. mammogram workstations, 3.00 pm : Vote of thanks and close.

ANNEX 1 OBJECTIVES. At the completion of the training period, the fellow should be able to:

ANNEX 1 OBJECTIVES. At the completion of the training period, the fellow should be able to: 1 ANNEX 1 OBJECTIVES At the completion of the training period, the fellow should be able to: 1. Breast Surgery Evaluate and manage common benign and malignant breast conditions. Assess the indications