Breast Imaging

Basic Course For Medical College StudentBasic Course For Medical College Student

WANG Deng-bin MD,Ph.D

Dept. of Radiology,RuiJin Hospital

WANG Deng-bin MD,Ph.D

Dept. of Radiology,RuiJin Hospital

IntroductionIntroduction

“Breast cancer is one of the best studied

human tumors, but it remains poorly

understood”

“ As in all medical endeavors, the practitioner

should, whenever possible, use the results of

scientific studies to guide clinical decision”

“Breast cancer is one of the best studied

human tumors, but it remains poorly

understood”

“ As in all medical endeavors, the practitioner

should, whenever possible, use the results of

scientific studies to guide clinical decision”

And the imaging modalities implemented

in clinical practice for breast care must

be served as the tools for detection and

characterization of breast lesions. As we

expect, they are very important for

diagnosis and treatment.

And the imaging modalities implemented

in clinical practice for breast care must

be served as the tools for detection and

characterization of breast lesions. As we

expect, they are very important for

diagnosis and treatment.

Imaging ModalitiesImaging Modalities

1.5T MRI1.5T MRI GE signa gemsowGE signa gemsow

0.5T MRI0.5T MRI GE signa GE signa Sys#MRSSys#MRS

Shanghai 2Shanghai 2ndnd Medical University Medical University

Rui Jin HospitalRui Jin Hospital

X-ray Examination MammograpyX-ray Examination Mammograpy

X-ray radiography (molybdenum X rays, rh

odium X rays):MLO,CC,etc.

Galactography --demonstrates the ducts a

nd ductule or their abnormalities.

X-ray radiography (molybdenum X rays, rh

odium X rays):MLO,CC,etc.

Galactography --demonstrates the ducts a

nd ductule or their abnormalities.

galactography

USGUSG

Ultrasonography (ultrasound)

B-mode US

Doppler US

Ultrasonography (ultrasound)

B-mode US

Doppler US

CTCT

Computed tomography

plain scan,

enhanced scan (iodine)

Computed tomography

plain scan,

enhanced scan (iodine)

MRIMRI

Magnetic Resonance Imaging

high resolution for soft tissue

different tissue, different signal

enhanced scan

Magnetic Resonance Imaging

high resolution for soft tissue

different tissue, different signal

enhanced scan

The othersThe others

Infrared thermal imaging

Computer diaphanography imaging,etc.

Infrared thermal imaging

Computer diaphanography imaging,etc.

Imaging-Guided Percutaneous Biopsy

supply specimens for pathologic examination

Imaging-Guided Percutaneous Biopsy

supply specimens for pathologic examination

Fine needle aspiration biopsy (FNAB)

Needle core biopsy (NCB)

Fine needle aspiration biopsy (FNAB)

Needle core biopsy (NCB)

Interventional TherapyInterventional Therapy Laser

Radiofrequency

Embolization

and so on

Laser

Radiofrequency

Embolization

and so on

Accessory Breast TissueAccessory Breast Tissue

The most common site is axilla The most common site is axilla

Basic Imaging Signs of Breast Lesion

Basic Imaging Signs of Breast Lesion

Mass/Lump

Calcification

Thickening and retraction of regional skin

Retraction of nipple

Enlargement or abnormality of blood vessels

Lymph nodes

Enhanced manifestations

Mass/Lump

Calcification

Thickening and retraction of regional skin

Retraction of nipple

Enlargement or abnormality of blood vessels

Lymph nodes

Enhanced manifestations

Mass/LumpMass/Lump

shape: round, oval, regular/irregular

margin: clear or ambiguous, spiculation or smooth

density or signal intensity: high/low/intermediate w

ith or without calcification

site: upper-outer quadrant breast, upper-inner quadrant

breast, lower outer quadrant breast, lower-inner quadrant

breast, nipple, central portion breast, axillary tail breast.

Number: solitary or multiple

shape: round, oval, regular/irregular

margin: clear or ambiguous, spiculation or smooth

density or signal intensity: high/low/intermediate w

ith or without calcification

site: upper-outer quadrant breast, upper-inner quadrant

breast, lower outer quadrant breast, lower-inner quadrant

breast, nipple, central portion breast, axillary tail breast.

Number: solitary or multiple

CalcificationCalcification

Size: large or micro

Shape: ring-like, nodular or salt-like, branching

Distribution: scattered or clustered with or

without mass

benign / malignant

Size: large or micro

Shape: ring-like, nodular or salt-like, branching

Distribution: scattered or clustered with or

without mass

benign / malignant

Thickening and Retraction of Regional Skin

Thickening and Retraction of Regional Skin

Frequently found in malignant tumors

Sometimes due to postsurgical scars.

Frequently found in malignant tumors

Sometimes due to postsurgical scars.

Retraction of NippleRetraction of Nipple

Congenital-dysplasia

Acquired-malignant tumor

Congenital-dysplasia

Acquired-malignant tumor

Enlargement or Abnormality of Blood

Vessel

Enlargement or Abnormality of Blood

Vessel

Mostly in malignant tumor due to

increase of blood supply

Mostly in malignant tumor due to

increase of blood supply

Enlargement of Lymph NodesEnlargement of Lymph Nodes

Axillary or intramammary lymph nodes Axillary or intramammary lymph nodes

Administration of Contrast Agents for

Breast Lesions

Administration of Contrast Agents for

Breast Lesions

Implication of the lesion’s hemodynamics

washout type--malignant

linear--benign

plateau--malignant/benign

Implication of the lesion’s hemodynamics

washout type--malignant

linear--benign

plateau--malignant/benign

Common Diseases in BreastCommon Diseases in Breast

Fibroadenoma

Cyst

Lobular hyperplasia

Cancer

Fibroadenoma

Cyst

Lobular hyperplasia

Cancer

Fibroadenoma overviewFibroadenoma overview

Frequency: most common tumor of breast (benign)

Age: below 30 yrs

Distribution: unilateral or bilateral

Source tissue: connective tissue and glandular tissue

Site: upper-outer quadrant

Size: < 5cm

Surface: smooth, movable

Frequency: most common tumor of breast (benign)

Age: below 30 yrs

Distribution: unilateral or bilateral

Source tissue: connective tissue and glandular tissue

Site: upper-outer quadrant

Size: < 5cm

Surface: smooth, movable

Imaging Findings of FibroadenomaImaging Findings of Fibroadenoma

X-ray

CT

MRI

X-ray

CT

MRI

X-ray FindingsX-ray Findings

Round, lobular or oval mass or nodule ,smooth

nodule in high density with thin ring/ halo in

low density

Compression of surrounding tissue

Large calcification:always dominated at the

center of tumor

Round, lobular or oval mass or nodule ,smooth

nodule in high density with thin ring/ halo in

low density

Compression of surrounding tissue

Large calcification:always dominated at the

center of tumor

CT FindingsCT Findings

Round smooth mass/nodule

Value of CT similar to normal glandular tissue

Calcification

Intermediate enhancement, linear type or

plateau,relatively long duration of enhancement

Round smooth mass/nodule

Value of CT similar to normal glandular tissue

Calcification

Intermediate enhancement, linear type or

plateau,relatively long duration of enhancement

Breast Cancer overviewBreast Cancer overview

most frequent malignancy in women

1% in adult women in China

34.4/100 thousand in 1989

39.7/100 thousand in 1993

46/100 thousand in 1997

52.98/100 thousand in women of Shanghai in 2001

over 100/100 thousand in women in Europe and USA

most frequent malignancy in women

1% in adult women in China

34.4/100 thousand in 1989

39.7/100 thousand in 1993

46/100 thousand in 1997

52.98/100 thousand in women of Shanghai in 2001

over 100/100 thousand in women in Europe and USA

Breast Cancer overviewBreast Cancer overviewAge: 40-60yrs, in China 1/5 are <35yrs

Gender: female (male)

Clinicalmass: unmovable mass, skin,orange-peel-like,retractionachingretraction/discharge of nippleenlargement of blood vesselsstiffness of breastlymph nodes

Age: 40-60yrs, in China 1/5 are <35yrs

Gender: female (male)

Clinicalmass: unmovable mass, skin,orange-peel-like,retractionachingretraction/discharge of nippleenlargement of blood vesselsstiffness of breastlymph nodes

Breast Cancer overviewBreast Cancer overview

Pathology

Invasive ductal carcinoma 65-80%

Intraductal carcinoma 15%

Lobular carcinoma(invasive/in situ) 5%

Special types 10%

Pathology

Invasive ductal carcinoma 65-80%

Intraductal carcinoma 15%

Lobular carcinoma(invasive/in situ) 5%

Special types 10%

X-ray Findings of Breast Cancer(1)

X-ray Findings of Breast Cancer(1)

Irregular/regular mass

Ambiguous border

Spiculations

Heterogeneous density, mostly higher than

the Surrounding tissue

Site: over 50% at upper-outer quadrant

Irregular/regular mass

Ambiguous border

Spiculations

Heterogeneous density, mostly higher than

the Surrounding tissue

Site: over 50% at upper-outer quadrant

X-ray findings of breast cancer(2)X-ray findings of breast cancer(2)

Calcification: clustered salt-like microcalcificatio

n in 1/3 cases inside/outside the mass, sometim

es only the microcalcifications observed

Retraction of nipple

Thickening of skin

Abnormal blood vessel

Large patchy region in high density

Calcification: clustered salt-like microcalcificatio

n in 1/3 cases inside/outside the mass, sometim

es only the microcalcifications observed

Retraction of nipple

Thickening of skin

Abnormal blood vessel

Large patchy region in high density

CT Findings of Breast Cancer(1)

CT Findings of Breast Cancer(1)

Mass: irregular/ill-shaped, coarse margin, s

piculation, CT value: 25-56HU, higher than t

he normal breast, necrosis at the center of t

he large mass(mostly >= 5cm)

Skin, nipple

Infiltration into the pectoralis major muscle

Mass: irregular/ill-shaped, coarse margin, s

piculation, CT value: 25-56HU, higher than t

he normal breast, necrosis at the center of t

he large mass(mostly >= 5cm)

Skin, nipple

Infiltration into the pectoralis major muscle

CT Findings of Breast Cancer(2)CT Findings of Breast Cancer(2)

Occupying of retromammary space

Enlargement of lymph nodes, axillary/retromammary

Administration of contrast agents

quick enhancement (wash in) at early phase

the peak of enhancement occur within 50s ~1min

quick washout

time-signal intensity curve——washout type

Occupying of retromammary space

Enlargement of lymph nodes, axillary/retromammary

Administration of contrast agents

quick enhancement (wash in) at early phase

the peak of enhancement occur within 50s ~1min

quick washout

time-signal intensity curve——washout type

MRI Findings of Breast CancerMRI Findings of Breast Cancer

Signal intensity:T1WI SE,low;T2WI FSE,low,

intermediate,inhomogeneous;STIR, interme

diate

Spiculation: irregular mass (lobular)

Enhancement: time-signal intensity curve

Signal intensity:T1WI SE,low;T2WI FSE,low,

intermediate,inhomogeneous;STIR, interme

diate

Spiculation: irregular mass (lobular)

Enhancement: time-signal intensity curve

Comparison of Different Imaging Modalities for

Detection and Characterization of Breast

Cancer

Comparison of Different Imaging Modalities for

Detection and Characterization of Breast

Cancer

Molybdenum X-ray radiography:

most important,widest used,most useful—not

very sensitive to the small lesion at very early

stage in dense breast;but digital mammography

can solve the problem to great extent

Molybdenum X-ray radiography:

most important,widest used,most useful—not

very sensitive to the small lesion at very early

stage in dense breast;but digital mammography

can solve the problem to great extent

USGUSG

Cystic or solid

Low spatial resolution

Limited ability to Differentiate

benign/malignant

Cystic or solid

Low spatial resolution

Limited ability to Differentiate

benign/malignant

CTCT Wide coverage for viewing ,sensitive to cystic

change,hemorrhage and calcification

Very useful for detection and characterization

of masses ,especially in the enhanced scan,

but can’t definitely view the microcalcification

Much more radiation,expensive

Wide coverage for viewing ,sensitive to cystic

change,hemorrhage and calcification

Very useful for detection and characterization

of masses ,especially in the enhanced scan,

but can’t definitely view the microcalcification

Much more radiation,expensive

MRIMRI High soft resolution

Better differentiation for benign/malignant

Wider coverage

Without radiation

High cost

Not sensitive to calcification

High soft resolution

Better differentiation for benign/malignant

Wider coverage

Without radiation

High cost

Not sensitive to calcification

CT C- CT C+

MR C+

Combination of Varying Imaging Modalities

Combination of Varying Imaging Modalities

Acquire the richest information

Appropriateness in application

Cost-effectiveness

Best diagnosis, timely correct therapy,

better health

Acquire the richest information

Appropriateness in application

Cost-effectiveness

Best diagnosis, timely correct therapy,

better health

To the women of the world, may

breast cancer soon be eliminated

as a source of dread and death

To breast cancer researchers and

breast health caregivers, may our

efforts soon be unnecessary

To the women of the world, may

breast cancer soon be eliminated

as a source of dread and death

To breast cancer researchers and

breast health caregivers, may our

efforts soon be unnecessary

Thank

YouThank

You