Breast

Published on 12/06/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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17

Breast

Mammography

Indications

1. Focal signs in women aged >40 years in the context of triple (i.e. clinical, radiological and pathological) assessment at a specialist, multidisciplinary diagnostic breast clinic

2. Following diagnosis of breast cancer, to exclude multifocal/multicentric/bilateral disease

3. Breast cancer follow-up, no more frequently than annually or less frequently than biennially for at least 10 years

4. Population screening of asymptomatic women with screening interval of 3 years, in accordance with NHS Breast Screening Programme policy:

5. Screening of women with a moderate/high risk of familial breast cancer who have undergone genetic risk assessment in accordance with National Institute for Health and Clinical Excellence (NICE) guidance

6. Screening of a cohort of women who underwent the historical practice of mantle radiotherapy for treatment of Hodgkin’s disease when aged <30 years. These women have a breast cancer risk status comparable to the high-risk familial history group1

7. Investigation of metastatic malignancy of unknown origin.

Equipment

Conventional film-screen mammographic technology has largely been superseded by full-field digital mammography (FFDM) which has a higher sensitivity in:

Ongoing developments of FFDM include:

1. Tomosynthesis which creates a single three-dimensional image of the breast by combining data from a series of two-dimensional radiographs acquired during a single sweep of the X-ray tube. Ongoing studies suggest that this technique may improve diagnostic accuracy in screening of the order of 30%, reduce recall by an estimated 40% and has a radiation dose of approximately 50% of that of a single mammographic exposure

2. Contrast-enhanced digital mammography, i.e. angiomammography. Two approaches are being developed: temporal sequencing (in which images pre and post contrast are subtracted with a resultant angiomammogram) and dual energy imaging (in which imaging at low and high energies detailing, respectively, parenchyma and fat with and without iodine are obtained. The subsequent views can then be subtracted

3. Computer-aided detection (CAD) software can assist film reading by placing prompts over areas of potential mammographic concern. There is evidence that, even in the screening setting, single reading in association with CAD may offer sensitivities and specificities comparable to that of double reading.4

If conventional film-screen mammographic imaging is to be carried out, it should be performed on a dedicated unit which includes in its specification:

Technique

Standard mammographic examination comprises imaging of both breasts in two views, namely the mediolateral oblique (MLO) and craniocaudal (CC) positions. Screening methodology is bilateral, two-view (MLO and CC) mammography at all screening rounds.

Additional views may be required to provide adequate visualization of specific anatomical sites:

Compression of the breast is an integral part of mammographic imaging resulting in:

Adaptation of the technique can provide additional information:

Further Reading

Health Technology Assessment. The clinical effectiveness and cost-effectiveness of different surveillance mammography regimes after the treatment for primary breast cancer: systematic reviews registry database analyses and economic evaluation. Health Technology Assessment. 2011; 15(34):1–322.

NICE Clinical Guidelines. The Classification and Care of Women at Risk of Familial Breast Cancer in Primary, Secondary and Tertiary Care. http://www. nice. org. uk/nicemedia/live/10994/30244/30244. pdf, 2006.

Tucker, AK, Ng, YY. Textbook of Mammography. In: Tucker AK, Ng YY, eds. Textbook of Mammography. 2nd ed. Edinburgh: Churchill Livingstone; 2001:18–64.

Willet, AM, Michell, MJ, Lee, MJR. Association of Breast Surgery: Best Practice Diagnostic Guidelines for Patients Presenting with Breast Symptoms. www. associationofbreastsurgery. org. uk, 2010.

Ultrasound

Additional technique

Elastography is a non-invasive US technique, which provides a visual representation of the stiffness (elasticity) of both normal and abnormal tissue.2 US imaging is used to examine tissue, both before and after minimal compression. A colour-coded image is generated with dark tissue representing least compressible tissue, i.e. with a higher index of suspicion of malignancy.

Magnetic resonance imaging

Radionuclide imaging

Image-guided breast biopsy

Equipment

1. Require either:

(a) US guidance; using hand-held, high-frequency (8–18-MHz) probe. The avoidance of radiation combined with accessibility of the technique results in this approach being used wherever possible

    OR

(b) X-ray guidance; applying the principle of stereotaxis whereby imaging a static object from two known angles from a known zero point can provide data from which the x, y and z co-ordinates can be calculated. Small-field digital stereotactic equipment can be purchased as an add-on to conventional mammography machines, thus providing the most common approach to X-ray-guided biopsy, namely with the patient in the seated, upright position. Less commonly, the small-field digital stereotactic system is attached to a prone table (dedicated to biopsy use) with resultant increased accessibility for posteriorly sited lesions and reduction in syncopal episodes; advantages which can be reproduced by the use of an appropriate biopsy chair allowing the adoption of the lateral decubitus position in conjunction with an upright imaging system

2. Automated biopsy gun. Choice of needle depends on the nature of the mammographic abnormality. For US-guided biopsy of masses, 14G biopsy needle is adequate. For biopsy of clustered microcalcifications and parenchymal distortions, large-volume needles (up to 7G) in conjunction with vacuum-assisted techniques increase diagnostic accuracy.

Pre-operative localization

Pivotal to the success of this technique is close multidisciplinary team working at pre-operative discussion/planning, accurate communication between the imaging department and theatre, and postoperative confirmation of adequacy of surgery at the multidisciplinary team (MDT) meeting.

The technique involves the insertion of a thin metal wire (or several wires) through the skin with the wire tip positioned within the lesion itself. The position of the wire is secured and the wire is then used by the surgeon to guide excision of the lesion.

Equipment

1. Localizing wire

2. Non-allergenic adhesive to fix the wire to adjacent skin

3. Swabs – coloured to be easily identifiable as separate from those used in theatre

4. Image guidance: