Mammographic imaging of nonpalpable breast lesions. Malai Muttarak, MD Department of Radiology Chiang Mai University Chiang Mai, Thailand

Transcription

1 Mammographic imaging of nonpalpable breast lesions Malai Muttarak, MD Department of Radiology Chiang Mai University Chiang Mai, Thailand

2 Introduction Contents Mammographic signs of nonpalpable breast cancer Digital breast tomosynthesis (DBT) Additional imaging eg. US, MRI Conclusion

3 Introduction Breast cancer is the most common cancer in women worldwide and is one leading causes of cancer death 2002 ~ 1.15 mil new cases/yr 2012 ~ 1.67 mil new cases/yr 2050 ~ 3.2 mil new cases/yr Early detection & treatment can save life and breast (small tumor BCT)

4 Introduction Mammography is the best imaging method to detect early breast carcinoma that is nonpalpable RCTs: screening mammography BC mortality 30 % in women yrs, and more BCT Familiarity of early sign of breast cancer can help early detection

5 Mammographic signs of breast cancer Microcalcifications Mass Architectural distortion Developing density (Axillary adenopathy)

6 BIRADS 2013 Suspicious microcalcifications Group of amorphous and coarse heterogenous microcalcifications Pleomorphic microcalcifications Fine linear, branching microcalcifications

7 Can mammographic appearance of nonpalpable breast cancer reflect pathology? Microcalcification is likely to be DCIS Mass and architectural distortion are likely to be invasive carcinoma Mass with microcalcifications is likely to be invasive carcinoma with extensive intraductal component Annals of Surgery 2002;235: Radiology 2002;222: , AJR 1992;159:483-5

8 Microcalcifications Microcalcifications usually represent DCIS <5% before screening Now 22-45% detect from screening More breast conservative treatment

9 Microcalcifications Fine linear, branching microcalcifications = comedo DCIS Comedo DCIS = high nuclear invasive cancer and more recurrence wide excision Pleomorphic microcalcifications = mixed comedo & noncomedo (FCC, fibroadenoma, fat necrosis) Noncomedo DCIS = low to intermediate grade

10 Fine linear branching microcalcifications DCIS comedo type

11 55 years, screening Group of pleomorphic microcalcifications DCIS: noncomedo Cribriform pattern

12 50 yrs, screening Pleomorphic & fine linear microcalcifications = mixed comedo & non comedo DCIS

13 67 yrs, left MRM 14 yrs ago. This is 12 nd screening mammograms Mixed comedo and noncomedo DCIS

14 41 yrs, screening Group of pleomorphic microcalcifications DCIS mixed comedo and noncomedo

15 Density = fatty mass is benign Evaluation of breast mass Circumscribe Round Microlobulated Oval Obscured Irregular Indistinct Spiculated

16 Mass suggestive of malignancy

17 54 yrs, screening Invasive ductal carcinoma

18 62 yrs, screening

19 Invasive ductal carcinoma

20 56 yrs, screening 1.2 cm Invasive ductal carcinoma N2, H2

21 65 yrs, screening mammography

22 FNA under US guided and lumpectomy = mucinous carcinoma

23 58 yrs:bleeding tendency, search for occult BC Invasive lobular carcinoma

24 Mass with microcalcifications Invasive ductal carcinoma with extensive intraductal component

25 60 yrs, screening Invasive ductal carcinoma with EIC

26 51 yrs, screening Invasive ductal carcinoma with EIC

27 Architectural distortion Carcinoma (invasive) Radial scar Surgical scar

28 50 yrs, screening

29 Spot compression Mild distortion RUOQ Invasive ductal carcinoma N 2

30 65 yrs, screening Distortion RUOQ, invasive lobular carcinoma

31 45 yrs, screening Invasive ductal carcinoma

32 42 yrs, screening

33 Radial scar

34 Developing density Be mindful of any developing solid mass in post menopausal women, particulary if they are not on HRT.

35 46 yrs, left MRM 2 yrs ago, suspected recurrent carcinoma left chest wall. This is 2 nd screening mammography

36 Compare to previous film Developing density

37 Biopsy was performed by US guided Histopathology= invasive ductal carcinoma

38 60 yrs, left MRM 5 yrs ago 4 th screening 3 rd screening

39 US shows an irregular hypoechoic mass. Biopsy by US guided = invasive ductal carcinoma Specimen radiograph

40 58 yrs, 2 nd screening

41 Axillary adenopathy Occasionally patients with breast cancer may present with axillary adenopathy from occult breast carcinoma Stage IIB

42 Normal and abnormal axillary nodes

43 41 yrs, excision mass at rt axilla= metastaic carcinoma

44 1.2 cm irregular hypoechoic mass Pathology = invasive ductal carcinoma

45 54 yo, presented with right axillary mass. Biopsy = ductal carcinoma Invasive ductal carcinoma with axillary node metastases

46 83 yrs, screening mammography

47 Excision = metastaic tumor from breast cancer FNA node = malignant cells suggestive from breast

48 Mammography Although mammography is the best imaging method to detect breast cancer Accuracy of conventional mammography is limited by super imposition of breast tissue and dense parenchymal tissue which may obscured cancer or create suspicious lesion

49 Digital breast tomosynthesis (DBT) DBT might help to overcome these limitations Many studies: DBT cancer detection and diagnostic accuracy and recall rate

50 2D Imaging RX Breast Normal Detector Abnormal Overlapping structures

51 Digital breast tomosynthesis 3-D mammographic technique Tissue overlapping effect Improved cancer detection Faster interpretation Lower recall rate radiation Unnecessary biopsy

52 53 yrs, screening mammography

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54 Ultrasound

55 Pathology LCIS IDC

56 Additional imaging Decreased sensitivity of mammogram in dense breast Additional US and MRI increased detection

57 Ultrasonography Though US is less sensitive than mammogram to detect microcalcifications Improvement of current US detect microcalcifications corresponding to mammographically detected microcalcifications biopsy by US guidance US detect occult BC in dense breast

58 50 yrs, screening

59 DCIS

60 US: detect occult lesion Synchronous bilateral breast carcinoma 54 yrs, left breast mass

61 53 yrs, screening 0.5 cm, rt subareola IDC

62 55 yrs screening mammogram

63 Additional US FNA Mucinous carcinoma 1cm

64 MR mammography Detect cancer in dense breast More sensitive in evaluation of tumor size, multicfocality, multicentricity for BCT Search for occult carcinoma in case with axillary metastasis Evaluation of contralateral breast in patients with newly diagnosed breast cancer Radiology 2007;243:670 N E J Med 2007;356:1295

65 MRI in detection and diagnosis of DCIS Better to detect high grade DCIS with sensitivity 98% compared with mammography only 52% Appear as nonmass-like enhancement with clumped internal enhancement in a segmental, linear or regional distribution Variety of kinetic curve shapes False negative 40% because of poor vascularization, partial volume effects, diffuse parenchymal enhancement Semin Ultrasound CT MRI 2011;32:306

66 43 yrs, presented with a palpable breast mass

67 Both lesions = invasive ductal ca

68 MR breast Enhancement of 2 masses and segmental clumped Enhancement in the rt breast IDC with extensive intraductal component

69 45 yrs, palpable left axillary mass Invasive ductal carcinoma with axillary node metastases Courtesy of Dr. Wittaya Padungchaichote Lopburi Cancer Center

70 Conclusion Signs of nonpalpable breast lesions: microcalcifications, mass, architectural distortion, developing density and axillary adenoapthy Microcalcifications: DCIS: fine linear branching high grade, more invasive and recurrence Mass and architectural distortion: invasive carcinoma Mass with microcalcifications: invasive carcinoma & EIC Additional imaging eg US, MR are helpful in more detection of cancer and proper management

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