SEMMELWEIS UNIVERSITY

BREAST IMAGING

ANATOMY OF THE HUMAN BREAST

Normal variations: : prepubertal, pubertal, premenstrual, gestational, during lactation,

menopausal

Male breast

EXAMINING TECHNIQUES

1. Medical history

Family: Breast, gynecological, prostate, colon cancer

Hormonal treatment: Postmenopausal hormon supplement, test-tube baby program

2. Physical examination - Teaching how to performa a breast self-exam

3. Mammography

2 basic views from both breast, CC, MLO

+ additional views: spot, magnification, lat-lat, etc.

CAD: computer aided diagnosis

MAMMOGRAPHY

Standard MLO és CC settings

IMAGING MODALITIES

Tomosynthesis

IMAGING MODALITIES

Mammography and tomosynthesis can be done with administration of

contrast material – better evaluation of dens breasts, extensions of tumors.

IMAGING MODALITIES

5. Ultrasound

Linear transducer probe : 7,5 – 13 MHz, elastography can be useful too

Cyst Fibroadenoma Tumor

IMAGING MODALITIES

ABUS - Automated Breast Ultrasound

IMAGING MODALITIES6. MR

Unenhanced – evaluation of the implant

Enhanced – Tumor – borders, multifocality, scar vs. reoccurance, therapetuic response, BRCA

positive young adult, postiton to chest wall

ítélése

Tumor Implant ruptureMinimum 1,5 T

Dedicated breast coil

IMAGING MODALITIES

7. PET – CT

In breast diseases it is mostly used for staging

8. Isotope diagnostics

Sentinel lymh node marking and mapping

ROLL marking - Radio Guided Occult Laesion Localisation - peroperatív marking of non-

palpable tumors

INTERVENTIONS

1. Galactography (ductography)

discharging nipple

Common causes: Hormonal, papilloma

Lack of contrast filling

2. Paget disease susp.: scraping cells with a slide

3. Pneumocystography

It was used for cysts with intacystic solid component

Nowadays can be well visualised with US,

biopsy can be done as well

INTERVENTIONS

4. Cysts, haematomas, seromas drainage

5. Sampling

based on the thicknes of the needle and the technik: FNAB (20-22 G), core (14-16 G),

vacuum- core (8-11G)

Guidance: what gives the best visualization (UH, sztereotaxia, MR)

! Vacuum core: in some cases can be a definitive solution instead of surgery

INTERVENTIONS

FNAB

Core biopsy

Vacuum coreStereotactic

6. Preoperative marking/mapping (wire localization, ROLL)

7. Marker placement for neuadjuvant treatment

INTERVENTIONS

BREAST EXAMINATIONS

There are „special” kinds of mammography techniques that are advertised as painless and not using ionizig radiaton:

CT-laser mammography, Electrical impedance mammography, Termographic mammography.

According to current studies they are not suitable for screening!!!

1. Diagnostic

if symptomps are present

under 30 years: first modality: US

above 35 years : mammography (+UH)

between 30- 35 years : based on individual

needs

2. Screening

Organized or opportunistic

Oranized by ÁNTSZ – National Public

Health and Medical Officers’s Service

Hungary: between 45-65 years in every 2

years

BREAST DISEASES

1. Benign conditions

Developmental anomalies

Benign tumors: fibroadenoma, lipoma, hamartoma, phylloid,

Papilloma

2. Pseudotumors – dystrophies

3. Mastopathies

4. Other conditions

galactocele, retroareolar cysts, epidermoid cysts, Mondor-disease

(superficial thromophlebitis), etc.

BREAST DISEASES

5. Inflammation

acute – infection, postpartum, lymphangitis, abscess

chronic – tbc, syphilis, sarcoidosis

traumatic

plasma cell mastitis (secreting ductectasia)

granulomatosus mastitis – autoimmun causes

BREAST DISEASES

6. malignant tumors

carcinomas:

lobular in situ: 1 %

lobular infiltrative: 5 %

ductal in situ: 2 %

ductal invasive: 75 %

sarcomas: phylloid tumor, fibrosarcoma, liposarcoma, great cell, leiomyosarcoma

metastases: melanoma, lymphoma, genital cc, lung, GI cancers,

INTERPRETATION OF MAMMOGRAPHY

Asymmetric density:

round or oval laesion

star shaped laesion

not specific asymmetric density

Microcalcification with tumor shadow

Microcalcification without tumor shadow

Retromamillar variances

FEATURES OF BENIGN CONDITIONS

SHAPE: Round or rounded, oval

MARGIN: Smooth, macrolobulated

BORDERS: Sharp

Capsule

Halo sign

Partially or totally ill-defined

DENSITY: Radiolucent

Mixed

Low

Dens

CALCIFICATIONS: Common, mostly benign-like

BENIGN CONDITIONS

Fibroadenoma Cyst Fat necrosis

FEATURES OF MALIGNANT CONDITIONS

SHAPE: Irregular, Star-shaped, rarely round

MARGINS: Irregular, spiculated, microlobulated

BORDERS: Partially or fully ill-defined

DENSITY: Usually high

CALCIFICATAIONS: Malignant-like

CALCIFICATIONS

OCCURANCE:

intraductal

intralobular

extraglandular

SIZE:

micro and macrocalcifications

DISTRIBUTION: grouped (soliter, multiplex), diffuse

TYPES: benign malignant

FEATURES: monomorf or polymorf

Calcifications can not be evaluated well with other modalities

Cluster Branching Powder-like

CALCIFICATIONS

TREATING BREAST CANCER

ONCOLOGICAL TEAM:

oncologist

surgeron – with oncoplastic fellowship!!!

pathologist

radiation oncologist

radiologist

INTERDISCIPLINARY WORK IS CRUCIAL!

TYPES OF BREAST SURGERIES

breast cosmetic surgery (reduction, mastopexia, breast augmentation with implants)

tumor

lumpectomy

sector resection

quadrantectomy

mastectomy

+ SNB = sentinel lymph node biopsy

if necessary ABD : axillary block dissection

reconstructive – primer or elective

with implant or with own flap (TRAM, LD)

Reconstructive surgey with TRAM flap

Tatto after mestectomy

POSTOPERATIVE OPTIONS

POSTOPERATIVE OPTIONS

Reconstruction with silicon implant

MALE BREAST

Breast cancer - examination, treatment, just as in case of the female breast

Gynecomasty

Most common age: Teenagers and middle aged men

Background: Mostly hormonal

Urological conditions: Testis, prostate

Internal medicine: endocrine és hepatic diseases

Drugs: digitalis, anabolic drugs

Tumors: Testis and lung

Mammography and US: retromamillar gland tissue is visible

CLINICAL CASES

EXTRACAPSULAR RUPTURE

Free silicon, silicon in the lymph nodes as well, US is

sufficient

INTRACAPSULAR RUPTURE

linguini sign , keyhole sign, salad-oil sign

TUMOR

LEFT CC LEFT MLO US

CYST

Right CC Right MLO US

FIBROADENOMA

Left CC Left MLO US

PRACTICE

Inspecting the mammography machine, setting the

correct image postitons

Inspecting the tomosynthesis (DBT) on a phantom

Intervencional tools (Cameco, core biopsy pistol,

localisation wire, tumor marker)

SUMMARY

Importance of breast self-exam!

Not every lump is a tumor!

Look for calcifications!

Males have breasts too!

EXAM PICTURES

SELECTED PICTURES FROM THE WEBSITE:

Number: 49, 50, 51

Thank you for your attention!