MEDICAL IMAGING AND BREAST DISEASE HOW CAN WE HELP YOU?

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1 MEDICAL IMAGING AND BREAST DISEASE HOW CAN WE HELP YOU? Barbara M. Preston, M.D.

2 SCREENING MAMMOGRAPHY AVERAGE RISK PATIENTS KAISER RECOMMENDATION: ALL WOMEN (INCLUDING TRANSGENDER FEMALES) Every years age 40-74

3 SCREENING MAMMOGRAPHY HIGH RISK PATIENTS PERSONAL HISTORY OF BREAST CANCER OR HIGH RISK LESION ADH, ALH, LCIS (INCLUDING MALES WITH BREAST CANCER) FAMILY HISTORY OF FIRST DEGREE RELATIVE(MOTHER, DAUGHTER, SISTER, FATHER, BROTHER) BRCA 1/BRCA 2 GENE CARRIERS KAISER RECOMMENDATION: EVERY YEAR, age35-74

4 SCREENING MAMMOGRAPHY VERY HIGH RISK PATIENTS FAMILY HISTORY OF FIRST DEGREE RELATIVE WITH ONSET UNDER THE AGE OF 40: BEGIN YEARLY SCREENING YEARS BEFORE AGE OF RELATIVE S S CANCER (NO EARLIER THAN 25) MANTLE IRRADIATION AS CHILD OR YOUNG ADULT: BEGIN YEARLY SCREENING 25

5 SCREENING ULTRASOUND AS YET NOT EVIDENCE PROVED EFFICACY (ACRIN 6666 STILL ACCRUING) My patient is requesting a screening breast sonography,; what should I tell her? : : Berg, et al, Am J of Radiology: 180, , 1478, 2003 (

6 SCREENING MRI BRCA1 / BRCA2 GENE CARRIERS NO EVIDENCE PROVED EFFICACY FOR AVERAGE RISK PATIENTS Efficacy or MRI and Mammography for Breast Cancer screening in women w with familial or genetic predisposition, Kriege et al, New England J of Medicine: 351: , 437, (

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8 DIAGNOSTIC BREAST IMAGING SYMPTOMATIC PATIENTS: PALPABLE MASS AXILLARY LYMPHADENOPATHY (+CXR) SPONTANEOUS OR BLOODY DISCHARGE SKIN / NIPPLE RETRACTION / THICKENING PAIN ALONE IS NOT AN INDICATION FOR MAMMOGRAPHY

9 DIAGNOSTIC BREAST IMAGING SYMPTOMATIC PATIENTS MAMMOGRAPHY ULTRASOUND GALACTOGRAPHY MRI PET BIOPSY REMOVAL / ABLATION

10 DIAGNOSTIC BREAST IMAGING SYMPTOMATIC PATIENTS-MALES IN OUR CENTER, MAMMOGRAMS ARE NOT DONE IN MALES WITH BREAST MASSES UNLESS REQUESTED BY A SURGEON

11 BENIGN MAMMOGRAPHIC FINDINGS-CALCIFICATIONS CALCIFICATIONS- Alert code 2 SECRETORY CALCIFICATION MILK OF CALCIUM DYSTROPHIC VASCULAR CALCIFICATIONS <50 Consider: DM, premature vascular disease, Renal disease, Hyperparathyroid SKIN CALCIFICATION CALCIFIED FIBROADENOMA

12 BENIGN MAMMOGRAPHIC FINDINGS-Alert code 2 FAT CONTAINING MASSES (OIL CYSTS, LIPOMAS, HAMARTOMAS, GALACTOCELES) BENIGN INTRAMAMMARY LYMPH NODES SURGICAL SCARS

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14 PROBABLY BENIGN MAMMOGRAPHIC FINDINGS- Alert code 3A MASSES SMOOTH SHARP MARGINS AROUND AT LEAST 75% OF CIRCUMFERENCE ROUND OR OVAL ABSENCE OF MALIGNANT FEATURES ULTRASOUND

15 PROBABLY BENIGN FINDINGS- ALERT code 3 A MASSES OR CALCIFICATIONS: LESS THAN 2% CHANCE OF MALIGNANCY- 6 MONTH FOLLOWUP

16 INDETERMINATE MAMMOGRAPHIC FINDINGS- ALERT CODE 4 POWDERY CALCIFICATIONS Sclerosing adenosis vs Low Nuclear Grade DCIS GRANULAR CALCIFICATIONS Crushed stone Calcified fibroadenoma vs fibrocystic change vs High nuclear grade DCIS

17 INDETERMINATE CALCIFICAITONS DCIS can be stable for years; therefore biopsy is almost always recommended OCCASIONALLY 6 MONTH FOLLOWUP IS APPROPRIATE (suspect calcifying fibroadenoma,, fat necrosis)

18 MALIGNANT MAMMOGRAPHIC FINDINGS-- --Alert code 5 CALCIFICATIONS PLEOMORPHIC XYZ USUALLY HIGH NUCLEAR GRADE DCIS

19 MALIGNANT MAMMOGRAPHIC FINDINGS ARCHITECTURAL DISTORTION Nipple

20 ULTRASOUND NOT YOUR MAMA S ULTRASOUND

21 BENIGN ULTRASOUND FINDINGS CYST SMOOTH SHARP BORDERS THROUGH TRANSMISSION ROUND OR OVAL NO INTERNAL ECHOES ( OR MOBILE DEBRIS)

22 A CYST THAT S S NOT A CYST

23 BENIGN ULTRASOUND FINDINGS-Alert code 2 BENIGN SOLID MASSES SMOOTH SHARP MARGINS OVAL ONE/ TWO GENTLE LOBULATIONS NO MALIGNANT FEATURES

24 MALIGNANT ULTRASOUND FINDINGS-Alert code 5 SPICULATTIONS POOR THROUGH TRANSMISSION ANGULAR MARGINS SHADOWING ECHOGENIC FAT NON-COMPRESSIBLE

25 STAGING BREAST CANCER WITH ULTRASOUND DUCT EXTENSION SATELLITE LESIONS

26 STAGING BREAST CANCER WITH ULTRASOUND AXILLARY ADENOPATHY LOOKING FOR INVASION WITHIN DCIS

27 SPECIAL PROBLEMS IMPLANT INTEGRITY MAMMOGRAPHY ULTRASOUND MRI

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29 SPECIAL PROBLEMS - INFLAMMATORY BREAST CANCER -

30 SPECIAL PROBLEMS AXILLARY LYMPHADENOPATHY WITH A NEGATIVE MAMMOGRAM ULTRASOUND MRI

31 SPECIAL PROBLEMS PAGET S S DISEASE OF THE NIPPLE MAMMOGRAPHY MRI

32 GALACTOGRAPHY FILLING DEFECTS DUCT OBSTRUCTIONS DUCT DISTORTION EXTRAVASATION

33 GALACTOGRAPHY EXCISE ALL LESIONS EXCISE EXTRAVASATION

34 GALACTOGRAPHY MULTIPLE LESIONS LESIONS MAY REQUIRE 2 WIRE NEEDLE LOCALIZATION PERIPHERAL LESIONS MAY REQUIRE NEEDLE LOCALIZATION

35 GALACTOGRAPHY FAILED GALACTOGRAM: TRY ULTRASOUND (MRI?)