Breast Imaging PDF - Ebook for Undergraduate Radiology Education

Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline CHAPTER: Breast Imaging ...

Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline CHAPTER: Breast Imaging  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Preface Breast Anatomy Undergraduate teaching of radiology in Europe is provided according to national schemes and may vary considerably from one academic institution to another. Sometimes, the field of radiology is considered as a “cross- Anatomical Variants cutting discipline” or taught within the context of other clinical disciplines, e.g., internal medicine or surgery. Pregnancy and Lactation This e-book has been created in order to serve medical students and academic teachers throughout Europe to Diagnostic Imaging Techniques understand and teach radiology as a whole coherent discipline, respectively. Its contents are based on the Disease of the Breast: Benign Undergraduate Level of the ESR European Training Curriculum for Radiology and summarize the so-called core elements that may be considered as the basics that every medical student should be familiar with. Although Disease of the Breast: Malignant specific radiologic diagnostic skills for image interpretation cannot be acquired by all students and rather belong to Axilla the learning objectives of the Postgraduate Levels of the ESR Training Curricula, the present e-book also contains some further insights related to modern imaging in the form of examples of key pathologies, as seen by the Interventional Procedures different imaging modalities. These are intended to give the interested undergraduate student an understanding of Screening modern radiology, reflecting its multidisciplinary character as an organ-based specialty. High Risk Women We would like to extend our special thanks to the authors and members of the ESR Education Committee who Communication have contributed to this eBook, to Carlo Catalano, Andrea Laghi and András Palkó who initiated this project, and to the ESR Office, in particular Bettina Leimberger and Danijel Lepir, for all their support in realising this project. Multidisciplinary Team Meeting Take-Home Messages We hope that this ebook may fulfil its purpose as a useful tool for undergraduate academic radiology teaching. References Minerva Becker Vicky Goh Test Your Knowledge ESR Education Committee Chair ESR Undergraduate Education Subcommittee Chair  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Copyright and Terms of Use Breast Anatomy This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Anatomical Variants License. Pregnancy and Lactation You are free to: Diagnostic Imaging Techniques Share – copy and redistribute the material in any medium or format Disease of the Breast: Benign Under the following terms: Disease of the Breast: Malignant Axilla Attribution – You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses Interventional Procedures you or your use. Screening NonCommercial – You may not use the material for commercial purposes. NoDerivatives – If you remix, transform, or build upon the material, you may not distribute the modified High Risk Women material. Communication How to cite this work: Multidisciplinary Team Meeting European Society of Radiology, Federica Pediconi, Fiona J. Gilbert, Francesca Galati, Filipe Barros Alves, Pascal Take-Home Messages A.T. Baltzer, Melis Baykara Ulusan, Paola Clauser, Francesca Ferrara, Elisabetta Giannotti, Fleur Kilburn-Toppin, References Maria Adele Marino, Jessica Muscat, Simone Schiaffino, Rubina Manuela Trimboli, Chantal Van Ongeval, Thiemo J.A. van Nijnatten, Giulia Vatteroni, Mirjam Wielema (2023) eBook for Undergraduate Education in Radiology: Test Your Knowledge Breast Imaging. DOI 10.26044/esr-undergraduate-ebook-14  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy Anatomical Variants Pregnancy and Lactation Hyperlinks Compare Diagnostic Imaging Techniques Disease of the Breast: Benign Disease of the Breast: Malignant Core Knowledge Questions Axilla Interventional Procedures Screening High Risk Women Further Knowledge References Communication Multidisciplinary Team Meeting Take-Home Messages Attention References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline eBook for Undergraduate Education in Radiology Breast Anatomy Based on the ESR Curriculum for Undergraduate Radiological Education Anatomical Variants Chapter: Breast Imaging Pregnancy and Lactation Diagnostic Imaging Techniques Authors Disease of the Breast: Benign Editors: Authors: Filipe Barros Alves Elisabetta Giannotti Simone Schiaffino Disease of the Breast: Malignant Federica Pediconi Pascal A.T. Baltzer Fiona J. Gilbert Rubina Manuela Trimboli Axilla Fiona J. Gilbert Melis Baykara Ulusan Fleur Kilburn- Chantal Van Ongeval Toppin Interventional Procedures Paola Clauser Thiemo J.A. van Maria Adele Marino Nijnatten Screening Assistant Editor: Francesca Ferrara Jessica Muscat Giulia Vatteroni Francesca Galati Francesca Galati High Risk Women Federica Pediconi Mirjam Wielema Communication Affiliation Multidisciplinary Team Meeting Take-Home Messages European Society of Breast Imaging (EUSOBI) References Test Your Knowledge [email protected]  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline (1) Chapter Outline Breast Anatomy Breast Anatomy Diagnostic Imaging Techniques Anatomical Variants ▪ Introduction ▪ Mammography Pregnancy and Lactation ▪ Nipple-areola complex ▪ DBT Diagnostic Imaging Techniques ▪ Breast density ▪ US ▪ Quadrant anatomy ▪ MRI Disease of the Breast: Benign ▪ Structure: lobes and lobules ▪ CEM Disease of the Breast: Malignant Breast anatomy during pregnancy and lactation Diseases of the Breast: Benign ▪ Axilla ▪ Male breast: Anatomy and gynaecomastia ▪ Cysts Interventional Procedures Anatomical Variants ▪ Fibrocystic change Screening ▪ Normal Variations in Development ▪ Fibroadenoma High Risk Women ▪ Gynecomastia ▪ Phylloides tumour Communication ▪ Congenital and development abnormalities ▪ Hamartoma ▪ Acquired development abnormalities ▪ Lipoma and Angiolipoma Multidisciplinary Team Meeting Mastitis/Abscess Take-Home Messages Pregnancy and Lactation ▪ ▪ Hematoma References ▪ Pregnancy ▪ Fat Necrosis ▪ Partum Test Your Knowledge ▪ Lactation  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline (2) Chapter Outline Breast Anatomy Anatomical Variants Disease of the Breast: Malignant Screening Pregnancy and Lactation ▪ What is screening? ▪ Aim of breast screening Diagnostic Imaging Techniques Axilla ▪ Risk factors Disease of the Breast: Benign ▪ Anatomy ▪ How to screen Disease of the Breast: Malignant ▪ Appearance on ultrasound ▪ Limitations of screening Axilla ▪ Intervention Interventional Procedures High Risk Women Screening Interventional Procedures ▪ Introduction High Risk Women ▪ Fine-needle aspiration cytology (FNAC) ▪ Average risk Communication ▪ Core needle biopsy (CNB) ▪ Intermediate risk Multidisciplinary Team Meeting ▪ Vacuum assisted biopsy (VAB) ▪ History Take-Home Messages ▪ Vacuum assisted excision (VAE) ▪ Density ▪ Pre-operative localization ▪ High risk References ▪ Minimal invasive therapy Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline (3) Chapter Outline Breast Anatomy Anatomical Variants Communication Take-Home Messages Pregnancy and Lactation ▪ Mammography – indications and Recommendations Diagnostic Imaging Techniques ▪ Ultrasound – Indications Disease of the Breast: Benign ▪ Triple assessment References Disease of the Breast: Malignant ▪ Breast imaging scenarios ▪ Basic considerations in communicating with patients Axilla Test Your Knowledge Interventional Procedures Screening Multidisciplinary Team Meeting High Risk Women ▪ Considerations in communicating with health professionals Communication ▪ Multidisciplinary Team Meeting Multidisciplinary Team Meeting Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Introduction Pectoralis Breast Anatomy major Introduction Female breasts are skin annexes, equal and symmetrical, Anatomical Variants with breastfeeding as their main function. Pregnancy and Lactation Glandular The breast is covered with skin, and at the apex it has a Diagnostic Imaging Techniques tissue rounded pigmented area, the areola, in the center of which the nipple protrudes, resulting in the nipple areola Disease of the Breast: Benign Nipple complex (NAC). Disease of the Breast: Malignant areola Until puberty, the appearance and volume of the breasts Axilla complex are similar in both sexes. In women, when the breast develops, there can be notable variation in volume. Interventional Procedures Breast volume and texture are under the influence of Screening genetic and endocrine stimuli. After puberty, in the male, the glandular part does not develop and, High Risk Women therefore, the breasts remain structurally in the prepubertal state for lifetime. In the female, at puberty, Communication Fatty the breasts develop, with growth occurring by Multidisciplinary Team Meeting proliferation of all the components of the organ tissue (parenchymal tissue, periductal stroma and interstitial Take-Home Messages connective tissue). References Inframammary fold Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Nipple-Areola Complex Breast Anatomy Nipple-Areola Complex Ultrasound (US) anatomy of the confluence of the ducts in the nipple areola complex in a normal breast. The ducts are identifiable as anechoic tubular structures that are oriented towards the nipple. Anatomical Variants Pregnancy and Lactation Nipple Diagnostic Imaging Techniques Disease of the Breast: Benign Disease of the Breast: Malignant Ducts Axilla Interventional Procedures Screening High Risk Women Communication Multidisciplinary Team Meeting Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Density Breast Anatomy Breast Density Breast density is due to fibroglandular tissue. This Anatomical Variants varies during the menstrual cycle due to proliferation of the epithelial cells and increased vascularity. Pregnancy and Lactation Diagnostic Imaging Techniques There is an increase in volume in pregnancy due to the development of the alveoli and related ducts. Disease of the Breast: Benign At menopause, the glandular component of the Disease of the Breast: Malignant breasts undergoes atrophy, while the connective Axilla support structures tend to relax. Hormone replacement therapy can increase breast density or Interventional Procedures prevent involution of breast glandular tissue. Screening The quantity of glandular and connective High Risk Women components is classified on mammography Communication by the ACR BI-RADS1 into 4 categories: Multidisciplinary Team Meeting a: almost entirely fatty, b: scattered areas of fibroglandular density, Take-Home Messages c: heterogeneously dense, and References Extremely dense Almost entirely fatty d: extremely dense. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Quadrant Anatomy Breast Anatomy Quadrant Anatomy Anatomical Variants Pregnancy and Lactation Two perpendicular axes passing through the nipple divide the breast into four quadrants. Diagnostic Imaging Techniques Disease of the Breast: Benign The axillary tail is added adjacent to the Disease of the Breast: Malignant upper-external quadrant. Furthermore, the hours of the clock can be used to locate any Axilla focal lesion, adding the distance to the Interventional Procedures nipple, as shown in the figure. Screening High Risk Women The upper-outer quadrant is the one with Communication the largest amount of glandular tissue and, Multidisciplinary Team Meeting therefore, is more frequent site of breast Take-Home Messages cancer. References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Structure: Lobes and Lobules Breast Anatomy Structure: Lobes and Lobules The breast contains glandular, fatty and connective tissue. Anatomical Variants The glandular tissue (a modified apocrine gland) is divided Pregnancy and Lactation in lobules, and produces the milk, which is drained by the mammary ducts to the nipple. The nipple areola complex Diagnostic Imaging Techniques (NAC) is part of the visible breast. Disease of the Breast: Benign Connective bundles (retinacles) divide the glandular tissue Disease of the Breast: Malignant into lobes and lobules. Axilla Each breast has 12-20 lobes drained by a separate main Interventional Procedures duct per lobe. Screening Each lobe includes several lobules of glandular tissue, also High Risk Women referred as terminal ductal lobular units (TDLU) and Communication Multidisciplinary mammary ducts carrying milk from lobules to the nipple. Team Meeting Take-Home TDLUs are epithelial structures that produces milk during Messages References lactation and are the main source of breast neoplasms precursors and cancers. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy During Pregnancy and Lactation Breast Anatomy Breast Anatomy During Pregnancy and Lactation During the second month of gestation the breasts grow due to lobular enlargement of the TDLUs and new TDLUs are formed. During the 3rd and 4th month of gestation the lobular glands Anatomical Variants distend even more due to accumulation of secretions. Early lactation is accompanied by a further Pregnancy and Lactation increase in the volume of the breasts, especially in the glandular component. Diagnostic Imaging Techniques Disease of the Breast: Benign Disease of the Breast: Malignant Axilla Interventional Procedures Screening High Risk Women Communication glandular tissue glandular tissue Multidisciplinary Team Meeting Take-Home Messages T1-weighted sequences before and during pregnancy in the same patient. There is an evident References increase in volume and in the glandular tissue bilaterally. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Male Breast: Anatomy and Gynaecomastia Breast Anatomy Male Breast: Anatomy and Gynaecomastia In the male, the breast appear as a small, even and Anatomical Variants symmetrically located on the mid-clavicular line, at Pregnancy and Lactation the level of the 4th intercostal space. Diagnostic Imaging Techniques Structurally, the male breast is comparable to the Disease of the Breast: Benign female one before puberty. The glandular body is Disease of the Breast: Malignant atrophic, in which the connective stromal tissue is Axilla dominant over the epithelial parenchyma. Interventional Procedures At puberty, the male breast can undergo a Screening temporary hypertrophy (gynecomastia), mostly High Risk Women unilateral, due to transient hormonal imbalance, with a prevalence of estrogen over androgens. Communication Multidisciplinary Team Meeting At older age gynaecomastia can develop due to the Take-Home Messages use of several drugs. References Normal male breast Gynecomastia Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Normal Variations in Development Breast Anatomy Anatomical Variants PREMATURE THELARCHE: breast development excessive development of the breast tissue in male: Gynecomastia Pregnancy and Lactation Physiologic: Diagnostic Imaging Techniques In 90% of neonates transient breast hypertrophy due Disease of the Breast: Benign to maternal hormone 1 year after puberty and for 1-2 years (75% healthy Disease of the Breast: Malignant boys) Axilla Interventional Procedures Further causes: Anabolic steroids, digitalis, isoniazid, tricyclic Screening antidepressants, marijuana High Risk Women General obesity: pseudo gynecomastia Communication Klinefelter syndrome, anarchism, acquired testicular failure androgen receptor defects Multidisciplinary Team Meeting Take-Home Messages References Ultrasound shows typical US Test Your Knowledge appearance of gynecomastia  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Congenital and Developmental Abnormalities Breast Anatomy Anatomical Variants Congenital and Developmental Abnormalities = anomalous nipple and breast development Pregnancy and Lactation ▪ Polythelia => accessory nipples, most common Diagnostic Imaging Techniques ▪ Polymastia => accessory tissue incomplete involution of mammary ridge, usually enlarged during pregnancy Disease of the Breast: Benign and lactation Disease of the Breast: Malignant ▪ Amastia => absence of breast development Axilla ▪ Hyperplasia and Hypoplasia => unilateral or bilateral Interventional Procedures ▪ Congenital inversion of nipple (3%) associated with duct ectasia, periductal mastitis Screening ▪ Ectopic breast tissue: along the mammary ridge or milk line. Incomplete involution of ectodermal mammary High Risk Women ridge. Most common in the axilla (2-6% women). Communication ▪ Poland syndrome => child born with missing or underdeveloped pectoralis muscle, breast hypoplasia or Multidisciplinary Team Meeting aplasia, rib and chest wall deformities, and ipsilateral limb abnormalities [rare 1/36.000-50.000] Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Congenital and Developmental Abnormalities Breast Anatomy Anatomical Variants Congenital and Developmental Abnormalities Pregnancy and Lactation Diagnostic Imaging Techniques Disease of the Breast: Benign Sternalis muscle: Disease of the Breast: Malignant Axilla Uncommon anatomic variant of the Interventional Procedures chest wall musculature. Screening Often cause of false positives in High Risk Women mammography Communication Multidisciplinary Team Meeting Take-Home Messages References Mammogram and MRI images of sternalis muscle Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Pregnancy Breast Anatomy Physiological changes in the architecture of the breast to prepare for breast feeding (increased Anatomical Variants serum level of oestrogen, progesterone and prolactin) Pregnancy and Lactation Pregnancy ▪ Marked ductal and lobular proliferation in early weeks of pregnancy Diagnostic Imaging Techniques ▪ Weeks 5-9 generalised breast enlargement and progressive increase in nipple-areolar complex Disease of the Breast: Benign pigmentation Disease of the Breast: Malignant ▪ First trimester Under the influence of oestrogen, ductal proliferation and growth, alveolar-lobular Axilla growth. Expansion of the glandular tissue results in invasion of adipose tissue, which progresses Interventional Procedures gradually, occurring simultaneous to increased vascularity and blood flow Screening ▪ Second half of pregnancy hyperplasia, as well as the continuous involution of the fibrofatty stroma, High Risk Women colostrum accumulates in alveoli Communication As a result of these changes, the typical image of the breast at ultrasonography Multidisciplinary Team Meeting (US) is diffusely hypoechoic during pregnancy due to the increase in glandular Take-Home Messages tissue. References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Post Partum Breast Anatomy Anatomical Variants Pregnancy and Lactation ▪ At the end of the pregnancy high levels of oestrogens and progesterone counteract prolactin, Partum Diagnostic Imaging Techniques this inhibiting milk production, although colostrum production occurs in the alveolar cells Disease of the Breast: Benign Disease of the Breast: Malignant ▪ After delivery: The reduction in oestrogen and progesterone levels results in the continuous Axilla release of prolactin, by hypothalamus, and the physical stimulation of the nipple by the new-born Interventional Procedures suction promotes the release of oxytocin by the anterior pituitary gland, in order to stimulate and Screening maintain lactation High Risk Women Communication Multidisciplinary Team Meeting Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Partum Breast Anatomy Lactogenesis => Conversion from a proliferative state during pregnancy to a secretory state during Anatomical Variants lactation. Pregnancy and Lactation Partum ▪ The amount of milk produced does not correlate with the amount of glandular tissue, the number Diagnostic Imaging Techniques of ducts, or the mean duct diameter. Disease of the Breast: Benign ▪ Immediate post-partum enlargement due to colostrum accumulation Disease of the Breast: Malignant ▪ 3-7 days post partum milk secreted into alveoli Axilla Interventional Procedures ▪ Post-lactational changes: periductal perivascular stromal connective tissue increases Screening ▪ Alveolar cells and ductal branches regress High Risk Women Communication Multidisciplinary Team Meeting As a result of these changes, in ultrasonography (US) the typical image of the breast becomes diffusely hyperechoic during lactation, as a function of increased Take-Home Messages vascularity and prominence of the ducts. References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Lactation Breast Anatomy Anatomical Variants Mammographic findings (for Pregnancy and Lactation Lactation screening wait 3 months after discontinuing lactation): Diagnostic Imaging Techniques ▪ Diffuse increase in size and density Disease of the Breast: Benign ▪ Little to no Disease of the Breast: Malignant change to breast density Axilla Interventional Procedures US Findings: Screening ▪ Increase in High Risk Women parenchymal echogenicity Communication ▪ Ductal ectasia Multidisciplinary Team Meeting ▪ Increased vascularity Take-Home Messages Ultrasound of breastfeeding woman. The B-mode US shows increased References echogenicity pattern of the fibroglandular tissue, with bilateral dilated ducts (black Test Your Knowledge arrow). Some of them are filled with echogenic material (white arrow).  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Diagnostic Imaging Techniques Breast Anatomy Anatomical Variants Pregnancy and Lactation The most important diagnostic imaging techniques used in breast Diagnostic Imaging Techniques radiology/imaging are: Disease of the Breast: Benign Disease of the Breast: Malignant ◦ Mammography; Axilla ◦ Digital Breast Tomosynthesis (DBT); Interventional Procedures Screening ◦ Ultrasound (US); High Risk Women ◦ Magnetic Resonance Imaging (MRI); Communication Multidisciplinary Team Meeting ◦ Contrast-enhanced Mammography (CEM). Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Mammography Breast Anatomy Anatomical Variants Mammography is a radiographic Pregnancy and Lactation technique specifically designed Diagnostic Imaging Techniques for breast imaging. Mammography For the acquisition of Disease of the Breast: Benign mammograms – the images Disease of the Breast: Malignant produced by Mammography –, Axilla the breast is compressed in order to allow the dispersion of Interventional Procedures its components and facilitate Screening their visualization. High Risk Women The standard mammographic Communication views are the craniocaudal (CC) and mediolateral oblique (MLO) Multidisciplinary Team Meeting views. Take-Home Messages CC view MLO view References Orientation of the acquisition of the craniocaudal (CC) and mediolateral oblique (MLO) view. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy CC views MLO views Anatomical Variants Fibroglandular tissue Pregnancy and Lactation Fat Diagnostic Imaging Techniques Mammography Cooper ligaments Disease of the Breast: Benign Nipple Disease of the Breast: Malignant Skin Axilla Interventional Procedures Vessel Screening Lymph nodes High Risk Women Pectoral muscle Communication Posterior nipple line Multidisciplinary Team Meeting Right breast Left breast Right breast Left breast Take-Home Messages References Breast anatomy as seen at normal mammography. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Mammography Breast Anatomy Principles Anatomical Variants Pregnancy and Lactation Quality criteria of adequate positioning for Mammography include: Diagnostic Imaging Techniques Mammography ◦ CC views: ◦ MLO views: Disease of the Breast: Benign ▪ Well-visualized posterior medial breast; ▪ Pectoralis muscle extends inferior Disease of the Breast: Malignant ▪ Pectoralis muscle should be demonstrated to the PNL; Axilla when possible; ▪ Convex anterior border of the Interventional Procedures ▪ If the pectoralis muscle is not included, the pectoralis muscle; length of the posterior nipple line (PNL) – an Screening ▪ Pectoralis muscle is wider imaginary line extending posteriorly and superiorly and narrows inferiorly; High Risk Women perpendicularly from the nipple to the ▪ Open inframammary fold; Communication pectoralis muscle – on CC and MLO views should be within 1 cm of each other; ▪ Fat is seen posterior to the Multidisciplinary Team Meeting fibroglandular tissue; ▪ Fat is seen posterior to the fibroglandular Take-Home Messages tissue; ▪ Nipple in profile. References ▪ Nipple in profile. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Mammography Breast Anatomy Anatomical Variants Pregnancy and Lactation  The Average Glandular Dose (AGD) = estimate of the average absorbed dose by the Diagnostic Imaging Techniques glandular breast tissue during Mammography measured in Gray (Gy): Mammography Disease of the Breast: Benign AGD = K x g x c x s Disease of the Breast: Malignant K: entrant surface air kerma Axilla g: conversion factor for 50% glandular breast based on thickness and half-value layer Interventional Procedures c: correction factor based on non-standard glandularity/thickness s: correction factor based on non-molybdenum anode/filter combination Screening High Risk Women Communication  AGD levels in Mammography are between 0,8 and 2,5 mGy for 4,5 cm PMMA Multidisciplinary Team Meeting (Polymethyl methacrylate) phantoms in clinical settings. Take-Home Messages  AGD levels in Mammography increase with increased breast thickness References  Limiting AGD: 3-4 mGy. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Mammography Breast Anatomy Anatomical Variants Pregnancy and Lactation Main Indications Diagnostic Imaging Techniques Mammography Screening Mammography: Disease of the Breast: Benign ◦ Applied on asymptomatic women to identify breast cancer at an early/ potentially Disease of the Breast: Malignant curable stage; Axilla ◦ Starting from the age of 45-50 to the age of 70-74 depending on the country. Interventional Procedures Diagnostic Mammography: Screening ◦ Applied on symptomatic patients or to work-up an abnormality found on Screening High Risk Women Mammography. Communication ◦ The standard mammographic views are supplemented with additional views (eg. Multidisciplinary Team Meeting lateral view, spot compression etc.) to further assess the screening-detected Take-Home Messages abnormality. References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Digital Breast Tomosynthesis (DBT) Breast Anatomy Principles/ Relative Diagnostic Value/ Main Indications Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques DBT produces quasi-3D images of the breast based DBT on the reconstruction of several low-dose 2D- projections acquired in a limited range of X-ray Disease of the Breast: Benign tube angles. Disease of the Breast: Malignant It reduces the burden of overlapping tissues in the Axilla evaluation of standard mammography and Interventional Procedures improves the detection and the delineation of findings, increasing the sensitivity and the Screening specificity/ decreasing the false negatives and the High Risk Women false positives Communication It is particularly useful in the detection and delineation of masses and architectural distortions Multidisciplinary Team Meeting and in the further evaluation of asymmetries. Take-Home Messages References The X-ray source rotates around the compressed breast within a limited range (green dashed line). Projection images are formed on the detector. These are Test Your Knowledge then reconstructed through the breast volume along the Z direction.  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Digital Breast Tomosynthesis (DBT) Breast Anatomy Anatomical Variants Pregnancy and Lactation Principles/ Relative Diagnostic Value Diagnostic Imaging Techniques DBT DBT allows the production of synthetic mammograms – images similar in appearance to Digital Disease of the Breast: Benign Mammography (DM) that are generated based on the data acquired with DBT, without the need to further expose the breasts to additional radiation. Disease of the Breast: Malignant DBT radiation dose depends on whether it includes additional Digital Mammography (DM) or Axilla synthetic mammograms. Interventional Procedures The radiation dose from DBT alone is currently similar or only slightly higher to that of DM Screening High Risk Women Communication Multidisciplinary Team Meeting Take-Home Messages DBT allows improved detection of architectural distortion in comparison to DM ! References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques DBT Disease of the Breast: Benign Disease of the Breast: Malignant Axilla Interventional Procedures Screening High Risk Women Communication Mammography vs DBT – CC views: Multidisciplinary Team Meeting Take-Home Messages Improved detection and delineation of an architectural distortion in the upper outer quadrant of the right breast (Circle in DBT). References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Digital Breast Tomosynthesis (DBT) Breast Anatomy Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques DBT Relative Diagnostic Value Disease of the Breast: Benign Main disadvantages compared to Mammography: Disease of the Breast: Malignant Axilla ◦ Longer evaluation time – approximately 2 times more; Interventional Procedures ◦ Artifacts: Screening ▪ Blurring (continuous image acquisition); High Risk Women ▪ Motion (longer scanning time). Communication Multidisciplinary Team Meeting Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Mammography and Digital Breast Tomosynthesis (DBT) Breast Anatomy Anatomical Variants Pregnancy and Lactation Principles Diagnostic Imaging Techniques DBT Breast density refers to the relative amount of fibroglandular tissue comparing to fat Disease of the Breast: Benign in the breast. Disease of the Breast: Malignant The 5th edition of BI-RADS (Breast imaging-reporting and data system) classifies Axilla breast density according to four descriptors (see also page 11): Interventional Procedures ◦ a: The breasts are almost entirely fatty; Screening High Risk Women ◦ b: There are scattered areas of fibroglandular density; Communication ◦ c: The breasts are heterogeneously dense, which may obscure small masses; Multidisciplinary Team Meeting ◦ d: The breasts are extremely dense, which lowers the sensitivity of Take-Home Messages Mammography. References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques DBT Disease of the Breast: Benign Disease of the Breast: Malignant Axilla Interventional Procedures Screening High Risk Women Communication a b c d Multidisciplinary Team Meeting The breasts are almost There are scattered areas The breasts are The breasts are extremely Take-Home Messages entirely fatty of fibroglandular density heterogeneously dense, dense, which lowers the which may obscure small sensitivity of Mammography References masses Breast density – Digital mammograms. Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Breast Anatomy Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques DBT Disease of the Breast: Benign Disease of the Breast: Malignant Axilla Interventional Procedures Screening High Risk Women Communication Multidisciplinary Team Meeting a b c d The breasts are almost There are scattered areas The breasts are The breasts are extremely Take-Home Messages entirely fatty of fibroglandular density heterogeneously dense, dense, which lowers the which may obscure small sensitivity of Mammography References masses Breast density – Synthetic mammograms Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Ultrasound (US) Breast Anatomy Anatomical Variants Pregnancy and Lactation Diagnostic Imaging Techniques US Breast US is an imaging technique that uses sound waves to visualize breast tissue: Disease of the Breast: Benign Disease of the Breast: Malignant ◦ The US transducer sends ultrasound pulses and receives echoes that contain spatial and contrast information regarding the tissues that are being scanned. Axilla Interventional Procedures ◦ It is recommended using high-frequency transducers, with a broad bandwidth Screening operating at a centre frequency of at least 12 MHz and preferably higher. High Risk Women Communication Multidisciplinary Team Meeting ◦ See also e book chapter on ultrasound technique. Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Ultrasound (US) Breast Anatomy Breast US modalities include: Anatomical Variants ◦ B-mode (Grey-scale) – the standard modality; Pregnancy and Lactation ◦ Doppler – allows the evaluation of vascularization (e.g., simple cysts – absent vascularity vs solid lesions –present vascularity); Diagnostic Imaging Techniques US ◦ Elastography – allows the evaluation of stiffness (benign tumours – tend to be softer vs. Disease of the Breast: Benign malignant tumours – tend to be harder). Disease of the Breast: Malignant B-mode Doppler Elastography Axilla Interventional Procedures Screening High Risk Women Communication Multidisciplinary Team Meeting A B C Take-Home Messages References Breast US: B mode, Doppler and Elastography modalities revealing a biopsy-proven invasive breast cancer presenting as an irregular lesion (with microlobulated and angular margins, red arrow, A) heterogeneous hard mass exhibiting internal vascularity (white arrow, B) located in the inner Test Your Knowledge quadrants of the left breast. Increased stiffness at elastography (C).  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline Ultrasound (US) Breast Anatomy Anatomical Variants Pregnancy and Lactation Relative Diagnostic Value Diagnostic Imaging Techniques US Disease of the Breast: Benign Disease of the Breast: Malignant Main advantages: Main disadvantages: Axilla ◦ Non-ionizing radiation; ◦ “Operator dependence”; Interventional Procedures ◦ More available; ◦ Longer scanning time. Screening ◦ Less expensive. High Risk Women Communication Multidisciplinary Team Meeting Take-Home Messages References Test Your Knowledge  Chapter: eBook for Undergraduate Education in Radiology Breast Imaging Chapter Outline