BREAST

IMAGING
 TIMELINE OF BREAST
IMAGING
• 1950’s – Breast Self Examination
• 1960’s – BSE + Mammography
• 1970’s – BSE + Mammography + Thermography* +
Ultrasound
• 1980’s – BSE + Mammography + Better US
• 1990’s – BSE + Mammo + US + MRI
• 2000’s – Digital Mammo + US + MRI
• 2020?? – Digital Mammo + US + MRI + MR spectroscopy +
Tomosynthesis
*Thermography is a test that uses an infrared camera to detect heat patterns and blood flow in
 MAMMOGRAPHY :
HISTORY
1913 - Albert Salomon
• Laid the foundations of mammography
• 3000 mastectomy specimen
• Collaboration of macroscopic anatomy with
microscopic examinations.
1963 - 1966: Health Insurance Plan (HIP) of New York
• First RCT- periodic screening with
physical examination & mammography.
• 1/3rd reduction in mortality at 5 yrs f/u &
sustained benefit till 18 yrs of f/u
In 1965: 1st mammography unit the “Sénographe”
was built by Compagnie Générale de Radiologie”
headed by Charles Gros
 MAMMOGRAPHY
• Mammography is a special type
of X -ray imaging - to create X-ray tube
detailed image of the breast.

• Permit earlier detection

of abnormality Compression device

• High contrast resolution is

required Image detector
- attenuation diff. between normal
& diseased breast tissue is so
small
 FILM/SCREEN
MAMMOGRAPHY
• Old method
• The image is created directly on a
film- Non modifiable

• Less sensitive for women with

dense breasts

• 10 - 20 % of breast cancers that are

detected by physical examination
are not visible on film
mammography

• A major limitation of film

mammography is the film itself
 DIGITAL MAMMOGRAPHY
• Electronic (digitised) image of the
breast - stores it directly in a
computer

• Can be manipulated

• Less radiation exposure than

film mammography

• Improvement in image storage

and transmission

• Cost 1.5 to 4 times more than

 ADVANTAGES OF DIGITAL MAMMOGRAPHY
• Exposure can be tailored to enhance tissue contrast
• Faster image acquisition
• Shorter examination time
• Improved contrast
• Better delineation of parenchyma & subcutaneous
tissue
• Reproducibility
• Electronic transmission ( Tele-mammography)
• Less storage space
New advances
• CAD- Computer Aided Detection
• Dual energy subtraction
DIGITAL MAMMOGRAPHY
 BASIC POSITIONING – CRANIOCAUDAL VIEW
• From above a
horizontally-compressed
breast
• Will show as much as
possible of glandular
tissue surrounded by
fatty tissue and the
outermost edge of chest
muscle
• Nipple will be
shown in profile.
• Can't capture much of
armpit and upper
chest
 MEDIO-LATERAL OBLIQUE
VIEW
• From the side and at an
angle of a diagonally-
compressed breast

• The angle allows more of

breast tissue to be
imaged including tissue
in armpit.

• It will show glandular as

well as
fatty tissue

• Gives a larger area than a

 VIEWS:
• Standard
• CC - From above a horizontally-compressed breast
• MLO - From the side and at an angle of a diagonally-compressed breast
• Supplementary
• Latero-medial (LO) - from the outside towards the center
• Medio-lateral (ML) - from the center towards the outside
• Spot compression - compression on only a small area, to get more detail
• Cleavage view - both breast compressed, to see tissue near the center of
the chest
• Magnification - to see borders of structures and calcifications
WHY USE SO MUCH COMPRESSION?
• Holding breast away from chest wall permits projection of most tissue &
decreases noise from chest wall structure
• less motion results in clearer edges (less blurring)
• Decrease in dose due to reducing thickness thro’ which radiation has to
pass
• Separates overlapping structure
• Pressing close to detector minimizes geometric unsharpness
• More uniform thickness and uniform exposure
• Accurate registration of image for computer reconstruction algorithm

The compression force should be firm but should not cause pain;
preferably should not be more than 20 N
 MAMMOGRAPHY

SENSITIVITY 67% (60-78%)

SPECIFICITY 94% (93-96)

MAMMOGRAPHIC APPEARANCE OF NORMAL
BREAST
 Fatty tissue absorbs a small amount of x-rays and appears black or dark gray.
 Normal fibrous and glandular tissues (milk glands, lymph nodes) contain water fluid and
absorb a moderate amount of x-rays, and appear light gray.
 Fibrous and glandular tissues may contain calcium and appear nearly white or white.
FIBRO-GLANDULAR BREAST

• Dense with very little fat

• Females 15-30 years of
age or 30 years or older
without children
• Pregnant or lactating

17
FIBRO-FATTY
BREAST

• Average density
• 50% fat & 50%
fibro- glandular
• Women 30-50 years
of age or women
with 3 or more
children

18
FATTY
BREAST

• Minimal density
• Women 50 and
older
(postmenopausal),
men and children

19
MAMMOGRAPHIC FINDINGS

 If a malignancy is present, it appears as a distortion of normal ductal and connective tissue patterns.
 Approximately 80% of breast cancer is ductal and may have associated deposits of micro
calcifications that appear as small grains of varying size.
 In terms of detecting breast cancer, micro calcifications smaller than approximately 500 μm are of
interest.
 The breast tissue most sensitive to cancer by radiation is glandular tissue.
 The incidence of breast cancer is highest in the upper lateral quadrant of the breast
 Assessment: BI-RAD on basis of criteria defined
MAMMOGRAPHIC FINDINGS - MASSES
SPICULATED/STELLATE
MASS
• central soft-tissue tumour mass
from the surface of which
spicules extend into the
surrounding breast tissue
• Approximately 95% of spiculate
masses seen on mammography
are due to invasive breast
cancers
• typical ultrasound features are
of an echo-poor mass, with
poorly defined margins and
posterior acoustic shadowing
ARCHITECTURAL
DISTORTION
• seen mammographically as
numerous straight lines
usually measuring from I to
• 4 cm in length radiating toward
a central area
 TYPES OF CALCIFICATION
BENIGN MALIGNANT MICROCALCIFICATIONS
MICROCALCIFICATIONS
 5 or more in number
• Smooth & round
• Calcification with  Each equal to or less than 0.5mm in
lucent center size
• Dermal calcification
• Vascular cal.
 Pleomorp
• Large rod like cal. hic Size
• Popcorn cal. Shape
Density
 Fine linear
branching
 Dot and
BIRADS (BREAST IMAGING-REPORTING AND DATA
SYSTEM)
was established by the
American College of
Radiology. BI-RADS is a
scheme for putting the
findings from
mammogram screening
(for breast cancer
diagnosis) into a small
number of well-defined
categories.
 MAMMOGRAPHY LIMITATIONS
• As many as 20% of breast cancers will be missed by mammography.

• Approximately 10% of women are recalled for additional workup and

a significant portion prove to have no abnormality, resulting in
unnecessary anxiety and cost.

• Tissue superimposition that is created by the overlap of normal breast

structures in a two-dimensional mammographic projection can
obscure a lesion making it more difficult to perceive or rendering it
mammographically occult
 BREAST ULTRASOUND
Diagnostic test for evaluation of mammographic and
palpable abnormalities
• Used as a 'second-look' procedure
• Can differentiate cystic from solid mass
• Characterize solid masses
• Evaluate axilla for metastatic disease
• First examination in young women <35 yrs and is valuable in
the assessment of mammographically `dense' breast
• Being the only `real-time' imaging modality it can be used
to accurately localise or biopsy breast lesions
INDICATIONS
•Symptomatic breast lumps in women <35 years
• Breast lump developing during pregnancy or lactation
•Assessment of mammographic abnormality (± further
mammographic views)
• Assessment of MRI detected lesions
• Clinical breast mass with negative mammograms
• Breast inflammation
• The augmented breast (together with MRI)
• Breast lump in a male (together with mammography)
• Guidance of needle biopsy or localisation
• Follow-up of breast cancer treated with adjuvant
BREAST ULTRASOUND -
PROCEDURE
• 7.5-10 MHz linear array probe
• patient is examined in the supine
oblique position
• The side being examined is raised and
the arm placed above the head to
ensure that the breast tissue is evenly
distributed over the chest wall
 BREAST ULTRASOUND

Screening ultrasound
• No radiation, no compression
• 28% increase cancer detection when combined with mammography
compared to mammography alone

Not ready for widespread use

• Low specificity, higher cost, lack of availability
• Low sensitivity for calcifications
 BREAST
MRI

Technical Requirements:

•High-field breast MRI (1.5T or >)

• Gadolinium-DTPA injection
• Dedicated bilateral breast coil
• Good fat suppression
techniques
•High-resolution 3D gradient echo
pulse sequence
BREAST MRI:
INDICATIONS
• Screening of High-Risk Women
• Contralateral Breast Cancer in Newly Diagnosed Breast Cancer
• Lobular Cancer
• Occult Breast Cancer (It is defined as carcinoma that has. metastasized to
the axilla or other sites of the body)
• Close or Positive Surgical Margins
• Post-operative Scar vs. Tumor Recurrence
• Implants and Known or Suspected Cancer
• Problematic Mammogram
CLINICAL INDICATIONS
Detection of Contralateral Breast Cancer in Newly Diagnosed
Breast Cancer
• 10% of women with breast cancer will develop a new tumor in the
opposite breast with a negative mammogram and physical exam at
the initial time of diagnosis
• Finding cancers earlier may help women make treatment decision,
potentially sparing additional surgery, radiation therapy and
chemotherapy later
• Contralateral breast cancers more often identified when index cancer
was infiltrating lobular carcinoma
BENEFITS OF BREAST
MRI
• Can image breast implants and ruptures
• Highly sensitive to small abnormalities
• Used effectively in dense breasts
• Can evaluate inverted nipples for evidence of cancer
• May detect breast cancer recurrences and residual tumors
after lumpectomy
• Can locate primary tumor in women whose cancer has spread
to axillary (armpit) lymph nodes
• Can spot or characterize small abnormalities missed
by mammography
• May be useful in screening women at high risk for breast
cancer, according to recent studies
LIMITATIONS OF BREAST
MRI
• MRI takes 30-60 minutes compared to 10-20 minutes for
screening mammography

• The cost of MRI is several times the cost of mammography

• MRI requires the use of a contrast agent

• MRI patients must tolerate any claustrophobia

• MRI can be non-specific; often cannot distinguish

between cancerous and non-cancerous tumors
 Sensitivity Specificity

Mammogram 82% 99%

SENSITIVITY
Ultrasound 86%& SPECIFICITY
98%
MAMMOGRAM VS ULTRASOUND VS
MRI 3T 100% 94%
MRI
SCINTIMAMMOGRAPHY/ BREAST NUCLEAR
IMAGING

 Scintimammography: a non-invasive diagnostic tool that produces planar and tomographic

images and gives general information on tumour cell viability and cellularity.
CLINICAL INDICATIONS

 detection of breast cancer when mammography is doubtful, inadequate or indeterminate, may serve as
a complementary procedure in patients with doubtful microcalcifications or parenchymal distortions,
in the presence of scar tissue in the breast following surgery or biopsy, in mammographically dense
breast tissue, and in breasts with implants
 assistance in identifying multicentric, multifocal or bilateral breast cancer in patients with a diagnosis
of breast cancer
 study of multidrug resistance
 evaluation and prediction of tumour response to chemotherapy for breast carcinoma.
TECHNIQUE

 Tracer Injection: SestaMIBI or Tetrofosmin activity required for good imaging should range between
740 and 1110 MBq (20-30 mCi).
 Gamma Camera: A single- or multiple-head gamma camera is needed to acquire planar and/or
tomographic (SPECT) images. - The gamma camera should be equipped with a low-energy, high-
resolution collimator.
 An imaging table (mattress) with specially designed breast cutouts to allow the breast to be fully
dependent or with a foam cushion with a lateral semicircular aperture is required.
 Views: Planar images should be acquired 5-10 minutes after injection for 10 minutes
1. prone lateral scintigraphy of the breast with the suspected lesion;
2. prone lateral scintigraphy of the contralateral breast
3. supine (or upright) anterior scintigraphy.