Breast Imaging E-Book

Susanne Luftner-Nagel

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 166

Veröffentlichungsjahr: 2007

Beschreibung

Dx-Direct is a series of eleven Thieme books covering the main subspecialties in radiology. It includes all the cases you are most likely to see in your typical working day as a radiologist. For each condition or disease you will find the information you need -- with just the right level of detail. Dx-Direct gets to the point: - Definitions, Epidemiology, Etiology, and Imaging Signs - Typical Presentation, Treatment Options, Course and Prognosis - Differential Diagnosis, Tips and Pitfalls, and Key References ...all combined with high-quality diagnostic images. Whether you are a resident or a trainee, preparing for board examinations or just looking for a superbly organized reference: Dx-Direct is the high-yield choice for you! The series covers the full spectrum of radiology subspecialties including: Brain Gastrointestinal Cardiac Breast Urogenital Spinal Head and Neck Musculoskeletal Pediatric Thoracic Vascular

Leseprobe

Direct Diagnosis in Radiology

 Breast Imaging

Uwe Fischer, MD

 Associate Professor Women’s Health Care Center Göttingen, Germany

Friedemann Baum, MD

 Women’s Health Care Center Göttingen, Germany

Susanne Luftner-Nagel, MD

 Women’s Health Care Center Göttingen, Germany

379 Illustrations

Thieme

Stuttgart • New York

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized and revised translation of the German edition published and copyrighted 2007 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Pareto-Reihe Radiologie: Mamma.

Translator: Susanne Luftner-Nagel, MD, Göttingen, Germany

Illustrator: EmilWolfgang Hanns, Schriesheim, Germany

© 2008 Georg Thieme Verlag KG

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ISBN 978-3-13-145121-7

(TPS, Rest ofWorld)

ISBN 978-1-60406-041-6

(TPN, The Americas)              1 2 3 4 5 6

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Contents   

1   Methods

Ultrasonography

Radiation Exposure

Mammography: Craniocaudal Projection

Mammography: Mediolateral Oblique Projection

Mammography: Spot Compression

Mammography: Magnification Mammography

Mammography: Galactography

Digital Mammography

MR Mammography

Fine Needle Aspiration Biopsy (FNAB)

Core Biopsy

Vacuum Biopsy

Preoperative Localization Techniques

Sentinel Lymph Node (SLN)

2   Nomenclature and Findings

Diagnostic Criteria in Ultrasonography

Diagnostic Criteria in Mammography

Diagnostic Criteria in MR Mammography

PGMI (Perfect, Good, Moderate, Inadequate) Criteria

Breast Composition

BI-RADS (Breast Imaging Reporting And Data System)

Normal Findings

Asymmetry

Architectural Distortion

Skin Changes

Changes in the Nipple

Non-Sanguineous Nipple Discharge

Bloody Nipple Discharge

Mass: Shape

Mass: Margins

Mass: Density (Attenuation)

Distribution of Microcalcifications

Monomorphic Microcalcifications

Pleomorphic Microcalcifications

Amorphous Microcalcifications

Benign Calcifications

3   Benign Changes

Axillary and Intramammary Lymph Nodes

Skin Lesions

Mondor Disease

Abscess

Adenoma

Adenosis

Atypical Lobular Hyperplasia (ALH)

Hyalinizing Fibroadenoma

Myxoid Fibroadenoma

Giant Fibroadenoma

Focal Fibrosis

Hamartoma (Fibroadenolipoma)

Hemangioma

Lipoma

Mastitis

Papilloma

Multiple Peripheral Papillomas

Plasma Cell Mastitis

Radial Scar

Tubular Adenoma

Simple Breast Cyst

Complex Cyst

Gynecomastia

Pseudogynecomastia

Breast Changes During Pregnancy

4   Borderline Lesions

Atypical Ductal Hyperplasia (ADH)

Lobular Carcinoma In Situ (LCIS)

5   Breast Carcinoma

Risk Factors

Surrogate Factors 5 for Screening

Early Detection

Breast Cancer Genes (BRCA)

Ductal Carcinoma In Situ (DCIS, Low Grade)

Ductal Carcinoma In Situ (DCIS, Intermediate Grade)

Ductal Carcinoma In Situ (DCIS, High Grade)

Invasive Ductal Carcinoma (IDC)

Invasive Lobular Carcinoma, Nodular Form

Invasive Lobular Carcinoma, Diffuse Form

Invasive Papillary Carcinoma

Medullary Carcinoma

Mucinous Carcinoma

Tubular Carcinoma

Inflammatory Breast Cancer

Male Breast Cancer

Paget Disease of the Nipple

Local Recurrence

Extensive Intraductal Component (EIC)

Multifocality

Multicentricity

6   Other Potentiolly Malignant and Malignant Lesions

Phyllodes Tumor

CUP Syndrome

Sarcoma

Lymphoma

Intramammary Metastases

7 Post-Traumatic Changes

Seroma

Early Fat Necrosis

Late Fat Necrosis

Oil Cyst

Postoperative Changes

Post-Radiation Changes

Reduction Mammaplasty

8   Prosthesis

Breast Prosthesis

Gel Bleeding

Capsular Contracture

Intracapsular Rupture

Extracapsular Rupture

Index

Abbreviations   

 ACRAmerican College of RadiologyADHAtypical ductal hyperplasiaALHAtypical lobular hyperplasiaBI-RADSBreast imaging and reporting data systemBRCABreast cancer geneCRComputed radiographyCUPCancer of unknown primaryDCISDuctal carcinoma in situDDDifferential diagnosisEICExtensive intraductal componentFNABFine needle aspiration biopsyFOVField of viewGEGradient echoHRTHormone replacement therapyIDCinvasive ductal carcinomaILCInvasive lobular carcinomaIRInversion recoveryLCISLobular carcinoma in situMIPMaximum intensity projectionMLOMediolateral oblique projectionMRIMagnetic resonance imagingPGMIPerfect, good, moderate, inadequate. Quality assurance categorization of mammograms used in the British screening system.PNLPosterior nipple lineROIRegion of interestSESpin echoSLNSentinel lymph nodeTSETurbo spin echoWHOWorld Health Organization

1 Methods

Ultrasonography   

 

Brief Description

Imaging modality using sound waves • Tissue-specific wave reflection.

Indications

Evaluation of palpable breast nodules • Evaluation of clinically occult mammographic findings • Complementary assessment of dense breast tissue • Assessment of breast tissue after reconstruction surgery or augmentation with silicone implants • Supplementary examination of women with a high risk for breast cancer • Guidance during interventional techniques.

Device-related Prerequisites

Calibration to 1540 m/s sound velocity • B-mode with automatic scanning • Matrix memory with more than 16 gray scales • Adjustable transmitting power • Measurement error < 3% • Image documentation with measurement scale • Display of rated frequency • Display of signal processing.

Technical Requirements

Digital or hard-copy documentation • Transducer frequency of > 5 MHz or multifrequency transducer • Image rate > 12 images/s • 128 gray scales • Field of view width of at least 5 cm at 1.5 cm depth • Variable focus • Monitor screen must display—patient name, date of examination, transducer identifier, measurement scale, body marker, capacity, depth adjustment, preset, depth scale • Symmetric imaging (right/left) • Depiction of wall irregularities in tumors • Depiction of cysts ≥ 4 mm diameter (better: 2 mm) • Penetration depth ≥ 4 cm.

Evaluation Criteria

Echogenicity of lesion compared with surrounding tissue. Presence of hyperechogenic lesion wall. Shape (round, oval, lobular, irregular). Margins (circumscribed, microlobulated, obscured, ill-defined, spiculated). Surrounding tissue (disruption of continuous structures, e.g., Cooper ligaments). Transmission of ultrasound waves (i.e., posterior acoustic enhancement or shadowing). Compressibility. Internal structure (homogeneous/inhomogeneous). Lesion axis in relation to the skin. Mobility. Architectural distortion.

Fig. 1.1 a–d Ultrasound.

a Complicated cyst with intraluminal hyperechoic mass at the upper margin.

b Fibroadenoma. Well-circumscribed, hypoechoic lesion. Slight posterior acoustic enhancement and bilateral edge refraction.

Conclusion

Ultrasonography can be selectively performed in the diagnostic workup of palpable breast findings • In addition, ultrasonography is an important supplementary procedure in the diagnostic workup of ambiguous mammographic lesions, as well as in the assessment of dense breast tissue, where the detection of breast cancer on mammography is limited (ACR 3 and 4).

c Papilloma. Well-circumscribed, hypoechoic lesion. Posterior acoustic enhancement.

d Carcinoma. Ill-defined hypoechoic lesion. Posterior acoustic shadowing.

Irregular echogenic rim.

 

   Radiation Exposure

Brief Description

Terminology in mammography:

Skin dose (with backscatter): 110% Entrance surface dose (without backscatter): 100% Average glandular dose: 20% Image receptor dose: 1%

Guidelines for Radiation Protection and Quality Assurance

Justification requirement: The indication for mammography must be declared by a physician (except when performed in the context of a quality-assured mammography screening program). Optimization requirement: The applied patient radiation dose must be the lowest possible with which the required image quality can be achieved. Breast compression: Maximized within safety limits. Radiation quality: Correct anode and filter materials. Correct exposure: Automatic exposure control. Correct screen–film combination. Correct film processing: Verified by phantom imaging and analysis. Regular system testing by a radiation protection officer: Dosimetry, image quality, and consistency.

Radiation Exposure

Average glandular dose: 2 mGy per exposure • Reduced in digital mammography by 30% • Bilateral mammography (two views) increases the risk for breast cancer in a 45-year-old woman by 0.0055% • One additional radiation-induced breast cancer is expected to occur in 100 000 women undergoing regular screening mammography • Lifetime risk of breast cancer is increased from 10% to 10.06% after 20 years of biennial screening mammography beginning at 40 years of age • For 1 breast cancer induced by screening mammography, 300 breast cancers are detected through screening.

The risk of developing radiation-induced breast cancer decreases with age. Risk coefficient:

10–19 years: 2.95% Sv–1 20–29 years: 0.52% Sv–1 30–39 years: 0.43% Sv–1 40–49 years: 0.20% Sv–1 50–59 years: 0.06% Sv–1 60–69 years: 0.00% Sv–1

Conclusion

The benefits of mammography are realized immediately, the potential side effects after 20–30 years.

Fig. 1.2 Terminology for radiation dose in mammography.

 

   Mammography: Craniocaudal Projection

Brief Description

Standard mammographic view positioning the breast in the craniocaudal x-ray beam path • Best method to visualize the medial aspect of breast tissue.

Indications

Screening. Diagnostic workup. Follow-up.

Positioning Technique

C-arm in neutral position • Patient position: Feet forward, 5 cm back from positioning platform, leaning forward from the waist (pendent position), rotate patient slightly medially • Image receptor adjusted to meet elevated inframammary fold •Breast positioning: Lift and pull breast forward with flat hands onto image receptor • Apply compression while smoothing skin wrinkles toward the nipple • Continue compression until firm • Place AEC detector under glandular tissue • Exposure in breath-hold technique.

Quality Assessment Criteria

Adequate visualization of glandular tissue: Pectoral muscle presents at the posterior medial aspect of the craniocaudal projection • Nipple visualized in profile • Visualization of a maximum amount of lateral breast tissue without compromising medial tissue visualization.– Correct labeling: Patient data • Specification of side and examination date. Correct exposure: Optical density 0.4–2.5. Firm compression. No motion blurring. Correct film processing. No developing or handling artifacts. No skin folds. Symmetry of right and left mammograms.

Radiation Exposure

The average glandular dose is 2 mGy per exposure • The increased risk for developing breast cancer due to bilateral mammography (two views) in a 45-year-old woman is 0.0055% • Potential side effects do not occur before 20–30 years.

Selected References

Roth-Gander G. Mammographie-Handbuch f¨r die tägliche Praxis. Stuttgart: Thieme; 2002

Fig. 1.3a–d Craniocaudal mammography.

a Lean thoracic wall against positioning platform.

b Lift and pull breast forward with flat hands.

c Right craniocaudal mammogram. Nipple is not visualized in profile and is slanting laterally. PGMI category: Inadequate.

d Right craniocaudal mammogram. PGMI category: Perfect.

Mammography: Mediolateral Oblique Projection   

 

Brief Description

Standard mammographic view positioning the breast in the mediolateral oblique xray beam path (MLO projection) • Maximum visualization of breast tissue in its entirety, including the axillary tail • Limited visualization of the inner breast quadrants.

Indications

Screening. Diagnostic workup. Follow-up.

Positioning Technique

X-ray projection plane: Varies depending on patient habitus. Adjust C-arm angle to obliquity of pectoral muscle (45–60°) • Patient position: Patient should first stand with her hips sideways and slightly anterior to the lower end of image receptor, then turn toward the unit approximately 45° • Rest the relaxed upper portion of the ipsilateral humerus on the image receptor at right angles to the body • Lift and pull breast upward and forward, bringing the lateral aspect of the breast onto image receptor and placing the upper corner of the image receptor slightly posterior to the axilla • Pull breast upward and outward with a flat hand bringing the inframammary fold into the open position with the thumb • Apply compression, keeping paddleedge as close to the chest wall as possible • Compression paddle should rest against the middle of the clavicle and sternum.

Quality Assessment Criteria

Adequate visualization of glandular tissue: Pectoral muscle visualization to the posterior nipple line • Pectoral muscle angle > 20° to the vertical film edge • Nipple visualized in profile • Open inframammary fold. Correct labeling: Patient data • Specification of side and examination date. Correct exposure: Optical density 0.4–2.5. Firm compression. No motion blurring. Correct film processing. No developing or handling artifacts. No skin folds. Symmetry of right and left mammograms.

Fig. 1.4a–d Mediolateral oblique (MLO) mammography.

a Position of the right axilla.

b Position of the right inframammary fold.

c Right MLO mammogram. Nipple is not visualized in profile, abdominal skin fold. PGMI category: Moderate.

d Right MLO mammogram. PGMI category: Perfect.

Radiation Exposure

The average glandular dose is 2 mGy per exposure • The increased risk for developing breast cancer due to bilateral mammography (two views) in a 45-year-old woman is 0.0055% • The benefits of mammography are seen immediately, the potential side effects after 20–30 years.

Selected References

Roth-Gander G. Mammographie-Handbuch für die tägliche Praxis. Stuttgart: Thieme; 2002

 

   Mammography: Spot Compression

Brief Description

Localized compression over an area of interest (spot compression) using a small compression paddle • In techniques with structural overlap, such as mammography, superimposition can result in pseudo lesions • Increased compression allows more effective and even spreading of glandular tissues, thus reducing structural overlap • Spot compression can resolve dubious mammographic densities by spreading apart the superimposed areas.

Positioning Technique

Use spot compression paddle and collimator • Calculate position of the area of interest in relation to the nipple • Position spot compression paddle on the area of interest and in the central ray.

Indications

Differentiation between a true abnormality and superimposition of normal breast structures—increased focal compression reduces the summation effect of normal structures. More precise assessment of questionable findings—lesion border definition is improved by reducing superimposition, geometric blurring, and radiation scatter. Diagnostic workup of densities seen only in one projection.

Examination Results

A spot compression study can have the following effects:

The finding is no longer identifiable: Summation, benign. The finding appears changed and can be assessed more easily: Benign/malignant. The finding appears unchanged but can be better assessed (less overlap and blurring): Benign/malignant.

Tips and Pitfalls

Missed lesion (spot compression paddle is misplaced).

Conclusion

A spot compression view can be useful in the diagnostic workup of questionable lesions (masses, densities, or architectural distortions).

Selected References

Roth-Gander G. Mammographie-Handbuch für die tägliche Praxis. Stuttgart: Thieme; 2002

Fig. 1.5a–d Spot compression study.

a Left MLO mammogram. Architectural distortion in the central aspect of the left breast.

b Spot compression study, left MLO projection. Architectural distortion is seen more clearly than in a.

c Left craniocaudal mammogram. Questionable mass in the lateral aspect of the left breast.

d Spot compression study, left craniocaudal projection. The spiculated mass is seen more clearly than in c.

 

   Mammography: Magnification Mammography

Brief Description

Geometric magnification achieved by increasing object–film, i.e., object–detector distance • Visualization of the finding of interest is optimized by its magnification.

Positioning Technique

Mammography unit must be adapted for magnification view by adding positioning table that increases object–film distance • Use spot compression paddle and collimation blade • Calculate position of the area of interest in relation to the nipple • Position spot compression paddle on the area of interest and in the central ray • Magnification factor: 1.8.

Indications

To characterize microcalcifications by improving visualization of their:

Morphology. Number. Distribution.

To better assess a mass or density with regard to:

Reproducibility. Form alteration. Better delineation of mass borders.

Technical Requirements

Mammography units with a high frequency/constant potential generator to allow short exposure times • Focal spot size of 0.1 mm to reduce geometric blurring resulting from the increased object–film distance • High intensifying film–screen combinations to reduce exposure time • No grid is used to maintain acceptable doses and exposure times.

Tips and Pitfalls

Magnification mammography with its increased radiation dose can often be avoided with digital mammography. Use of the zoom function during monitor evaluation often allows adequate visualization and analysis of detected microcalcifications.

Selected References

Roth-Gander G. Mammographie-Handbuch für die tägliche Praxis. Stuttgart: Thieme; 2002

Fig. 1.6a–d Digital mammography.

a Right craniocaudal mammogram. Fine, linear branching microcalcifications at the posterior glandular border.

b Magnification mammography of a. Better visualization of microcalcifications (invasive lobular carcinoma).

c Clustered pleomorphic microcalcifications in left upper outer quadrant. Enlarged detail view (MLO).

d Magnification mammography of c. Better visualization of microcalcifications (sclerosing adenosis).

Mammography: Galactography   

 

Brief Description

Contrast-assisted depiction of ductal structures after selective cannulation of one or more discharging ducts. Synonym: Ductography.

Indication: Bloody duct nipple discharge (positive hemo-test or cytologic proof).

Histology: Papilloma (approximately 97%), intraductal carcinoma (approximately 3%).

Examination Technique

Cleanse and disinfect nipple • Elicit nipple discharge using gentle pressure to identify discharging duct orifice (magnifying glasses) • Cannulate discharging duct with blunt-tipped sialography needle attached to contrast-filled flexible tubing • Slowly inject 0.1–0.5 mL iodinated, water soluble contrast material, being careful to avoid air bubbles • Spray nipple with liquid bandage • Mammography in craniocaudal and medio-lateral views • Carefully manually express contrast material from mammary duct.

Findings

Normal findings: Smooth-walled mammary duct with increasing branching and decreasing caliber toward the base of the breast.

Pathologic findings: Filling defect (caution: air bubbles?) • Abrupt termination of dilated, contrast-filled duct.

Consequences

When a lesion is detected within a duct, surgery is usually recommended (ductectomy).

Conclusion

Galactography allows the detection and localization of intraductal lesions. It does not, however, permit differentiating between benign and malignant lesions.

Selected References

Gregl A. Atlas der Galaktographie. Stuttgart: Schattauer; 1985

 

   Digital Mammography

Fig. 1.7a–d Galactography.

a Normal findings.

b Galactography depicting dilated ducts.

c Galactography depicting microcystic changes in duct segment.

d Galactography depicting abrupt termination of contrast filled duct and filling defect (carcinoma).

Brief Description

X-ray mammography using a digital detector to form an image • There are two ways of digital acquisition:

Computed radiography (indirect technique, “off-line”): Primary exposure of a photostimulable phosphor plate in the CR cassette using a conventional mammography machine • Secondary digital image formation in a CR reader. Digital full-field mammography (direct technique, “on-line”): Primary exposure of large-format detectors • Direct digital image production.

Advantages

Radiation exposure is 25–30% less than in conventional mammography • Consistent optimal exposure • Improved diagnostic potential in younger women • Improved diagnostic potential in women with dense breast tissue • “Soft-copy” image reading and post-processing on a computer workstation • Digital archiving • Teleradiology.

Post-processing

Alteration of image brightness and contrast • Zooming • Image inversion • Tumor measurement • CAD system: Computer-aided diagnosis, analyzes digital mammograms for evidence of suspicious findings, can act as second reader.

Future Possibilities

Fusion systems (combination of digital mammography and ultrasonography) • Contrast-assisted tomosynthesis • Contrast-assisted dual-energy technique.

Conclusion

Digital full-field mammography is the method of choice for radiographic examination of the breast • Conventional screen–film mammography is increasingly losing importance.

Selected References

Fischer U et al. Digital mammography: current state and future aspects. Eur Radiol 2006; 16: 38–44

Pisano ED et al. Diagnostic performance of digital versus film mammography for breastcancer screening. N Engl J Med 2005; 353: 1773–1783

Fig. 1.8a–d Digital mammography.

a Digital full-field mammography system.

b Computer workstation for “soft-copy” image reading.

c Digital mammogram.

d CAD markings on digital mammogram.

MR Mammography   

 

Brief Description

Contrast-enhanced MRI of the breast • High sensitivity and specificity for invasive breast cancer due to its neoangiogenesis • Goal sensitivity for in situ carcinomas.

Indications

Preoperative local staging Differentiation between postoperative scar and recurrence or carcinoma CUP syndrome High-risk constellation, BRCA Prosthesis Problem cases

Examination: Requirements, Technique, and External Influences

Technique: Field strength: 1–3 (usually 1.5) Tesla • Bilateral breast surface coil • Immobilization of breasts to reduce motion artifacts (compression device, pads). Optimal time of examination: Second (or third) week of the menstrual cycle. Influence of HRT: If the evaluation of the examination is limited, a repeat examination should be carried out after 4–6 weeks without HRT Time interval between open surgery and MRI of the breast: ≥ 6 months. Time interval between radiation therapy and MRI of the breast: ≥ 12 months. Slice orientation: Transverse, coronal, sagittal.