Diagnostic Workup of Challenging Clinical

Scenarios of the Breast

Prof. Rasha M. Kamal

Prof. Maher Hassan
 The challenge in breast imaging…

• In breast imaging, it is challenging enough to be able to

diagnose the underlying cause behind breast symptoms.

• Yet, the BIGGEST CHALLENGE is how to apply the BEST

PRACTICE to do so:

Choose the most appropriate imaging modality

Correlate imaging findings with Findings in other imaging

clinical data modalities
 The breast imaging cycle…

Patient:
Symptomatic /
Asymptomatic

Radiologist Clinician
Report Order specific
Imaging/Intervention imaging

Radiologist
Approves or
disapproves
 The breast imaging cycle…

Patient:
Symptomatic /
Asymptomatic

Radiologist Clinician
Report miscommunication
Order specific
Imaging/Intervention imaging

Radiologist
Approves or
disapproves
 Only Mammography and Ultrasound in hand….

Asymptomatic Symptomatic
Regular screening Diagnostic work-up

<40-45y Pregnant Lactating <40 y

Mammography

> 40-45y High risk <40 y Ultrasound Mammography

YES EARLIER NO

+/- Ultrasound/ +/- Intervention

Intervention
 More and more imaging modalities….

Mammography Ultrasound DCE-MRI

• Tomosynthesis • Doppler • Diffusion

• CESM • Elastography • Spectroscopy

• Pet mammography • ABUS

The volume of breast imaging modalities have grown exponentially, and thus,

implementing sound practices has become a real challenge.

We will learn how we can incorporate the modern breast imaging

modalities in the diagnostic work-up of some challenging common

clinical scenarios…
 TECHNIQUE OF Mammography
Compression plate

BREAST

Detector

CC view MLO view

• Patients are imaged in the upright position.

• The breast is gently stabilized and compressed between compression

paddle and detector plate.

• The breast is imaged in 2 views: Craniocaudal and Mediolateral

oblique views.
Normal mammography anatomy
 BREAST DENSITY

Breast density is used to describe the proportion of the different tissues that make up
the breast namely:

Fatty Breast Dense Breast

FAT CT

GLAND.
TISSUE
 ACR Breast density classification
A: Fatty breast B: Scatter fibrogland. C: Heterogen. dense D: Extremely dense

Increased risk of breast caner development

Reduced contrast between lesions and surrounding normal breast parenchyma

Mammo
OLDER YOUNGER
Normal breast-tissue Superimposed breast –tissue

Obscure abnormality False abnormality

False-negative results False-positive results

Missed Breast Carcinoma in a dense breast

Multicentric carcinoma
The challenge with mammography interpretation increases with:

Younger Individuals

Dense Breast parenchyma

Heterogeneous Breast parenchyma

Non distorting and non calcified carcinomas

Radiologists’ bad perception and misinterpretation

 TECHNIQUE OF 3D DIGITAL TOMOSYNTHESIS
X-ray tube

Compression plate
Breast
Digital detector
 X-ray tube moves in an arc across the breast

 Series of low dose images are acquired at different angles

 Total dose similar to single view breast exam

 TECHNIQUE OF 3D DIGITAL TOMOSYNTHESIS

Reconstructed 3D image - viewed every 1mm like CT

We remove the problem of overlapping and superimposed tissues

 TECHNIQUE OF 3D DIGITAL TOMOSYNTHESIS

Breast with multiple

lesions

2D Images 3D Images
Overlapping structures The lesions are seen separately in the slice images

AMULET INNOVALITY – Fujifilm

LOOK AT ALL THE TOMOSYNTHESIS SLICES CAREFULY

IT IS NOT ONLY DIAGNOSIS BUT WE HAVE TO ASSESS THE TOMO EXTENSION

Has 3D Digital Tomosynthesis solved all the problems?

Best results

Morphology assessment
+ Functional information

Contrast Injection
CEM
Tomosynthesis MRI
 ANGIOGENESIS

Tumor cells secrete pro-angiogenic factors that stimulate the proliferation

of new blood vessels and new capillaries to supply the tumor cells with
oxygen and nutrients. These new blood vessels are not well formed and
allow for contrast leakage.

MRI CESM
 Both CESM and MRI have features in common

Contrast agent

MRI

Pre contrast image Post contrast images Subtraction images

CESM

LE images HE Images SUBT Images

35 year old female, with a palpable left breast mass lesion

Tiny right retro areolar lesion

 35 year old female, with a palpable left breast mass lesion

Right Breast: the lesion was better seen on Left Breast: Not a single but multifocal mass
CESM lesions
Screening
 The female population is classified into:

Average Risk Moderate Risk High Risk

No specific risk > 15-20% >20-25%

• General population • Breast Cancer

• BRCA mutation
• ADH/DCIS/LCIS • Irradiation to chest
• Heterogeneous dense
• Syndromes
breast
 Which modality should we use in screening??

Average Risk Moderate Risk High Risk

No specific risk > 15-20% >20-25%

Digital Mammography

2D Ultrasound

3D digital Tomosynthesis

Contrast Mammography

Dynamic Contrast MRI

 Which modality should we use in screening??

Average Risk Moderate Risk High Risk

Mammography +/- ultrasound Mammography +/- US + MRI

≥ 40 years ≥ 35 years

3D Digital Tomosynthesis
Less cancers will be missed
Less cases will be re-called

CESM
Primary screening modality
Instead of both mammography and MRI
 Asymptomatic woman
Annual screening mammography

Subtle microcalcifictions seen on

magnification views
Suspicious microcalcifications : parenchymal distortion
2D US: Irregular shaped indeterminate lesion

ABUS: Confirmed ultrasound findings

BIOPSY: IDC2
 DETECTION/SCREENING
Tomosynthesis detects more cancers
Breast Density: ACR D

BIRADS 0
Tomosynthesis detects more cancers

INVASIVE DUCT CARCINOMA

 DETECTION/SCREENING
Tomosynthesis detects more cancers
Breast Density: ACR C
Fibrocystic changes

fibroadenoma
 DETECTION/SCREENING
Tomosynthesis detects more cancers in dense breasts: ACR c

Spiculated mass

Tomosynthesis
INVASIVE LOBULAR CARCINOMA
 DETECTION/SCREENING
High risk patient with a strong family history

Bilateral
suspicious lesions

Multifocal IDC
 DETECTION/SCREENING
Screening mammogram, the participant was recalled because of
the heterogeneous dense parenchyma

US on recall: irregular hypoechoic

mass

We still cannot point it out!!!! IDC that was very evident on CESM
Screening Mammogram of a 50 year-old high risk individual

Newly developed grouped microcalcifications

 MRI was also performed

Subtraction Dynamic

Focal non-mass enhancement on MRI suggesting DCIS

Type 1 Curve

Biopsy: Atypical ductal hyperplasia

Pain (mastalgia)
 Modern diagnostic Imaging in mastalgia

Mastalgia
is a common symptom experienced by up to 80% of women at some point in
their lives.
The age at which the patient presents with mastalgia is of major concern!!!

Non-Cyclic Cyclic

Focal diffuse

Further imaging is appropriate to Further imaging other than

exclude underlying pathology regular screening is inappropriate
Modern diagnostic Imaging in mastalgia

 Mammography is often used to evaluate breast pain.

 In most cases, no imaging correlate is found to explain

the cause of breast pain.

 When clinicians insist on imaging evaluation of breast

pain in the presence of negative clinical examination,
this increases un necessary additional imaging studies.
 Unnecassary imaging
35 year –old female with cyclic mastalgia more on the left side. On examination nothing was palpable

Asymmetry
Enhancement

FOCAL ADENOSIS

Focal fibroglandular tissue Non specific LN

 Necessary imaging
28 year-old female with fibrocystic mammary changes and cyclic mastalgia .
She developed right focal mastalgia on top that was neglected for 6 months

Bilateral IDC; localy advanced on the right side

Palpable Mass lesion
 Palpble Mass lesion

A palpable breast mass is one of the most frequently

encountered clinical complaint and it is one of the
commonest presenting features of breast carcinoma.

In general, cancers presenting as palpable lumps tend to

be more aggressive than screen-detected cancers and
they usually carry a much worse prognosis.
 Palpable breast mass lesion

Below 40 years/
Above 40 years
pregnant/lactating

Mammography Ultrasound

US MRI/CESM BIOPSY Mammo MRI/CESM BIOPSY

Usually, no additional imaging is needed other

than sonomammography
 CESM:
Palpable much
left breast wider
mass extension
lesion

US: 2 adjacent mass lesions: Multifocal carcinoma

 Left breast palpable mass: Indeterminate asymmetry

3D Digital Tomosynthesis: confirmed the malignant nature

The carcinoma was more evident on the 2D ultrasound!!!

2D US
ABUS
A 45-year-old young female with multiple palpable breast
lesions

Pathological LN

Enhancing lesion

Non enhancing benign m

SHAPE: oval
MARGIN: non-circumscribed
Microcalcifications Enhancement pattern: homogeneous
Associations: Pathological LN + Microcalc

Malignant descriptors: IDC2

A 45 year-old young female with multiple palpable breast lesions
Pathological axillary LN

Enhancing malignant mass

Non enhancing fibroadenoma

Nipple Discharge
Nipple discharge is a common clinical complaint. It may
be…..

PHYSIOLOGIC PATHOLOGIC

 Bilateral  Unilateral

 Multi orificial  Uniorificial

 On squeezing the breast  Spontaneous

 Milk, green, yellow  Bloody

 May accompany duct ectasia,  Usually due to intra-ductal

mammary adenosis or some papilloma, sometimes peri-ductal
inflammatory lesions mastitis and malignant breast
lesions
 Examine the nipple discharge

PHYSIOLOGIC PATHOLOGIC

No specific imaging is
needed Sono mammography

Regular screening if Only if negative

applicable

MRI CESM CYTOLOGY

30 year-old female with history of duct excision. Now she is
complaining of bleeding per nipple

Left segmental malignant microcalcifications : DCIS

30 year-old female with history of left major duct excision due to focal duct ectasia

CESM was performed only to assess the extent of the DCIS

 Uniorificial bleeding per left nipple

Left breast
Ultrasound confirmed nodular
the ntra ductallesions
location of the lesions

Benign enhancing lesions taking a ductal distribution ?? Location

ULTRASOUND IS THE BEST IN PHYSIOLOGIC NIPPLE DISCHARGE!!!

Simple duct ectasia

Periductal mastitis
ULTRASOUND IS THE BEST IN PATHOLOGICAL NIPPLE DISCHARGE!!!

Intra-ductal papillomas with the Inspissated avascularlesions

Intra-ductal malignant secretions
with
typical vascular pedicle separateand
calcifications from the duct
irregular wall
vasculature
 Modern Imaging Diagnostic Work-up….

Asymptomatic Symptomatic
Regular screening Diagnostic work-up

Mammography Ultrasound Mammography

Usually are enough

3D tomosynthesis
Increase detection and decrease re-call
Ultrasound

Intraductal lesions and mastitis

Ultrasound
Dense breast and characterization CESM/MRI
CESM Multiplicity, Multifocality, extent and occult
lesions
In high risk individuals
In the last decade we have witnessed an intense increase in the volume of
breast imaging techniques with the development of new technologies and
the upgraded applications of already existing ones

These new breast imaging technologies are meant to enhance the

evaluation of patients with breast problem by ruling out the presence of
breast cancer and in the same time addressing the patient's symptoms.

Yet the challenge will always remain….

“How can we achieve this goal by using the right modality in the right
time and for the right person
Thank you