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Russian National Research Medical University Imaging Modalities for Diagnosis of Breast Cancer (MRI, Ultrasound, Mammography)

Name: Guan Yy Ling


Group: 34A Year: 2012

Breast Cancer What is it? Breast cancer is a cancer that starts in the tissues of the breast. There are two main types of breast cancer: Ductal carcinoma starts in the tubes (ducts) that move milk from the breast to the nipple. Most breast cancers are of this type. Lobular carcinoma starts in the parts of the breast, called lobules, which produce milk. In rare cases, breast cancer can start in other areas of the breast. Breast cancer may be invasive or non-invasive. Invasive means it has spread from the milk duct or lobule to other tissues in the breast. Non-invasive means it has not yet invaded other breast tissue. Non-invasive breast cancer is called "in situ." Ductal carcinoma in situ (DCIS), or intra-ductal carcinoma, is breast cancer in the lining of the milk ducts that has not yet invaded nearby tissues. It may progress to invasive cancer if untreated. Lobular carcinoma in situ (LCIS) is a marker for an increased risk of invasive cancer in the same or both breasts. Many breast cancers are sensitive to the hormone oestrogen. This means that oestrogen causes the breast cancer tumour to grow. Such cancers have oestrogen receptors on the surface of their cells. They are called oestrogen receptor-positive cancer or ER-positive cancer. Some women have what is called HER2-positive breast cancer. HER2 refers to a gene that helps cells grow, divide, and repair themselves. Diagnostic Tests Tests used to diagnose and monitor patients with breast cancer may include: Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram Breast ultrasound to show whether the lump is solid or fluid-filled Breast biopsy, using methods such as needle aspiration, ultrasound-guided, stereotactic, or open CT scan to see if the cancer has spread Mammography to screen for breast cancer or help identify the breast lump PET scan Sentinel lymph node biopsy to see if the cancer has spread

Breast MRI Magnetic Resonance Imaging- Breast A breast Magnetic resonance imaging (MRI) is a non-invasive medical test that helps physicians diagnose and treat medical conditions. MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. The images can then be examined on a computer monitor, transmitted electronically, printed or copied to a CD. MRI does not use ionizing radiation (x-rays). A breast MRI may be done in combination with mammography or ultrasound. However, it is not a replacement for mammography. Detailed MR images allow physicians to evaluate various parts of the body and determine the presence of certain diseases. MRI of the breast offers valuable information about many breast conditions that cannot be obtained by other imaging modalities, such as mammography or ultrasound. Common Uses of the Procedure MRI of the breast is not a replacement for mammography or ultrasound imaging but rather a tool that has many important uses, including: 1. Screening women at high risk for breast cancer 1. For women who has a strong family history (e.g. mother or sister who has breast cancer before age 50), MRI can be an appropriate tool to screen for breast cancer. 2. Determining the extent of cancer after a new diagnosis of breast cancer 2. After being diagnosed with breast cancer, a breast MRI can be performed to determine several things such as: 1. How large is the cancer and whether it involves the muscles below 2. If there are other cancers in the site of breast cancer and whether there is unsuspected cancer in the opposite breast 3. If there are any abnormally large lymph nodes in the armpit, a sign whether the cancer has spread to that region 3. Further evaluating hard-to-assess abnormalities seen on mammography 3. Sometimes an abnormality seen on a mammogram cannot be adequately evaluated by additional mammography and ultrasound alone. In these rare cases, MRI can be used to definitively determine if the abnormality needs biopsy or can safely be left alone.

Benefits vs. Risks Benefits 1. MRI is a non-invasive imaging technique that does not involve exposure to ionizing radiation. 2. MRI has proven valuable in diagnosing a broad range of conditions, including detecting and staging breast cancer, particularly when other imaging studies (mammography, ultrasound, etc.) fails to provide adequate information. 3. MRI enables the discovery of abnormalities that might be obscured by bone with other imaging methods. 4. The contrast material used in MRI exams is less likely to produce an allergic reaction than the iodine-based contrast materials used for conventional x-rays and CT scanning. 5. MRI is growing in popularity as an addition to traditional x-ray mammography in the early diagnosis of breast cancer. 6. MRI has been shown to detect small breast lesions that are sometimes missed by mammography. 7. MRI can successfully image the dense breast common in younger women, as well as breast implants, both of which are difficult to image using traditional mammography. 8. MRI as an addition to mammography has been shown to be useful in evaluating women at high risk for breast cancer. 9. If a suspicious lesion is seen with MRI only, MRI can provide guidance for biopsy. Risks 1. The MRI examination poses almost no risk to the average patient when appropriate safety guidelines are followed. 2. If sedation is used, there are risks of excessive sedation. The technologist or nurse monitors your vital signs to minimize this risk. 3. Although the strong magnetic field is not harmful in itself, implanted medical devices that contain metal may malfunction or cause problems during an MRI exam. 4. There is a very slight risk of an allergic reaction if contrast material is injected. Such reactions usually are mild and easily controlled by medication. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance. 5. Nephrogenic systemic fibrosis is currently a recognized, but rare, complication of MRI believed to be caused by the injection of high doses of gadolinium contrast material in patients with very poor kidney function. 6. Manufacturers of intravenous contrast indicate mothers should not breastfeed their babies for 24-48 hours after contrast medium is given. However, the available data suggest that it is safe to continue breastfeeding after receiving intravenous contrast.

Limitations of MRI 1. High-quality images are assured only if you are able to remain perfectly still while the images are being recorded. If you are anxious, confused or in severe pain, you may find it difficult to lie still during imaging. 2. A person who is very large may not fit into the opening of certain types of MRI machines. 3. The presence of an implant or other metallic object sometimes makes it difficult to obtain clear images. Patient movement can have the same effect. 4. Although there is no reason to believe that magnetic resonance imaging harms the foetus, pregnant women usually are advised not to have an MRI exam unless medically necessary. 5. MRI may not always distinguish between cancer tissue and fluid, known as oedema. 6. MRI typically costs more and may take more time to perform than other imaging modalities. 7. Sometimes a benign (non-cancerous) piece of tissue in the breast can take up the contrast material and show up as a bright spot on the image. Often, the radiologist can tell by the appearance of the tissue whether it is cancer or not. When it is not possible, other testing such as ultrasound of that specific spot or a biopsy may be needed. If additional testing or biopsy shows no cancer, it is called a false-positive test result.

Ultrasound Imaging of the Breast Ultrasound imaging, also called ultrasound scanning or sonography, involves the use of a small transducer (probe) and ultrasound gel to expose the body to high-frequency sound waves. Ultrasound is safe and painless, and produces pictures of the inside of the body using sound waves. Ultrasound examinations do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels. Ultrasound imaging is a non-invasive medical test that helps physicians diagnose and treat medical conditions. Ultrasound imaging of the breast produces a picture of the internal structures of the breast. Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck. During a breast ultrasound examination the sonographer or physician performing the test may use Doppler techniques to evaluate blood flow or lack of flow in any breast mass. In some cases this may provide additional information as to the cause of the mass.

Common Uses of the Procedure 1. Determining the Nature of a Breast Abnormality The primary use of breast ultrasound today is to help diagnose breast abnormalities detected by a physician during a physical exam (such as a lump or bloody or spontaneous clear nipple discharge) and to characterize potential abnormalities seen on mammography or breast magnetic resonance imaging (MRI). Ultrasound imaging can help to determine if an abnormality is solid (which may be a non-cancerous lump of tissue or a cancerous tumor) or fluid-filled (such as a benign cyst) or both cystic and solid. Ultrasound can also help show additional features of the abnormal area. Doppler ultrasound is used to assess blood supply in breast lesions.

2. Supplemental Breast Cancer Screening Many studies have shown that ultrasound and magnetic resonance imaging (MRI) can help supplement mammography by detecting breast cancers that may not be visible with mammography.

Ultrasound may be used to characterize and biopsy abnormalities seen on MRI. When ultrasound is used for screening, many more abnormalities that may require biopsy are seen than are seen with mammography or MRI. These abnormalities usually are not cancer (false positives), and this limits its usefulness. 3. Ultrasound can be offered as a screening tool for women who: Are at high risk for breast cancer and unable to undergo an MRI examination Are pregnant or should not be exposed to x-rays (which is necessary for mammogram) Benefits vs. Risks Benefits Most ultrasound scanning is non-invasive (no needles or injections). Occasionally, an ultrasound exam may be temporarily uncomfortable, but it is almost never painful. Ultrasound is widely available, easy-to-use and less expensive than other imaging methods. Ultrasound imaging is extremely safe and does not use any ionizing radiation. Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-ray images. Ultrasound provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and needle aspiration. Ultrasound imaging can help detect lesions in women with dense breasts. Ultrasound may help detect and classify a breast lesion that cannot be interpreted adequately through mammography alone. Using ultrasound, physicians are able to determine that many areas of clinical concern are due to normal tissue (such as fat lobules) or benign cysts. For most women 30 years of age and older, a mammogram will be used together with ultrasound. For women under age 30, ultrasound alone is often sufficient to determine whether an area of concern needs a biopsy or not.

Risks For standard diagnostic ultrasound, there are no known harmful effects on humans. Interpretation of a breast ultrasound examination may lead to additional procedures such as follow-up ultrasound and/or aspiration or biopsy. Many of the areas thought to be of concern only on ultrasound turn out to be non-cancerous.

Limitations of Ultrasound Imaging of the Breast Ultrasound is one of the tools used in breast imaging, but it does not replace annual mammography and careful clinical breast examination. Many cancers are not visible on ultrasound. Biopsy may be recommended to determine if a suspicious abnormality is cancer or not. Most suspicious findings on ultrasound that require biopsy are not cancers. Many calcifications seen on mammography cannot be seen on ultrasound. Some early breast cancers only show up as calcifications on mammography. MRI findings that are due to cancer are not always seen with ultrasound. Many facilities do not offer ultrasound screening, and the procedure may not be covered by some insurance plans.

It is important to choose a facility with expertise in breast ultrasound, preferably one where the radiologists specialize in breast imaging. Ultrasound depends on the abnormality being recognized at the time of the scan as it is a "real-time" examination. This requires experience and good equipment.

Ultrasound of benign fibroadenoma. Unlike a cyst, a fibroadenoma (solid benign tumor of the breast) has internal echoes or dots on ultrasound. Unfortunately, ultrasound is not 100% accurate in telling a fibroadenoma from breast cancer, so a biopsy may be necessary.

Mammography Mammography is a specific type of imaging that uses a low-dose x-ray system to examine breasts. A mammography exam, called a mammogram, is used to aid in the early detection and diagnosis of breast diseases in women. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. Three recent advances in mammography include digital mammography, computer-aided detection and breast tomosynthesis. 1. Digital Mammography / Full field digital mammography (FFDM) Mammography system in which the x-ray film is replaced by solid state detectors that convert x-rays into electrical signals. The electrical signals are used to produce images of the breast that can be seen on a computer screen or printed on special film similar to conventional mammograms. 2. Computer-aided detection (CAD) system Digitized mammographic image that can be obtained from either a conventional film mammogram or a digitally acquired mammogram. The computer software then searches for abnormal areas of density, mass, or calcification that may indicate the presence of cancer. The CAD system highlights these areas on the images, alerting the radiologist to the need for further analysis. 3. Breast tomosynthesis (3D breast imaging) Mammography system where the x-ray tube and imaging plate move during the exposure. It creates a series of thin slices through the breast that allow for improved detection of cancer and fewer patients recalled for additional imaging. Common Uses of the Procedure Mammograms are used as a screening tool to detect early breast cancer in women experiencing no symptoms. It can also be used to detect and diagnose breast disease in women experiencing symptoms such as a lump, pain or nipple discharge. 1. Screening Mammography Plays an essential part in early detection of breast cancers because it can show changes in the breast up to 2 years before a patient or physician can feel them.

Research has shown that annual mammograms lead to early detection of breast cancers, when they are most curable and breast-conservation therapies are available. 2. Diagnostic Mammography Used to evaluate a patient with abnormal clinical findings such as breast lumps or lumps that have been detected Diagnostic mammography may also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening exam. Benefits vs. Risks Benefits Imaging of the breast improves a physician's ability to detect small tumours. When cancers are small, the woman has more treatment options and a cure is more likely. The use of screening mammography increases the detection of small abnormal tissue growths confined to the milk ducts in the breast, called ductal carcinoma in situ (DCIS). These early tumors cannot harm patients if they are removed at this stage and mammography is the only proven method to reliably detect these tumors. It is also useful for detecting all types of breast cancer, including invasive ductal and invasive lobular cancer. No radiation remains in a patient's body after an x-ray examination. X-rays usually have no side effects in the typical diagnostic range for this exam.

Risks

There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose for this procedure varies. False Positive Mammograms.

It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period. Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.

Limitations of Mammography 1. Initial mammographic images themselves are not usually enough to determine the existence of a benign or malignant disease with certainty. If a finding or spot seems suspicious, radiologist may recommend further diagnostic studies. 2. Interpretations of mammograms can be difficult because a normal breast can appear differently for each woman. Also, the appearance of an image may be compromised if there is powder or salve on the breasts or if you have undergone breast surgery. Because some breast cancers are hard to visualize, a radiologist have to compare the image to views from previous examinations. Not all breast cancers can be seen on mammography. 3. Breast implants can also impede accurate mammogram readings because both silicone and saline implants are not transparent on x-rays and can block a clear view of the tissues behind them, especially if the implant has been placed in front of, rather than beneath, the chest muscles Experienced technologists and radiologists know how to carefully compress the breasts to improve the view without rupturing the implant. 4. When making an appointment for a mammogram, women with implants should ask if the facility uses special techniques designed to accommodate them. Before the mammogram is taken, they should make sure the technologist is experienced in performing mammography on patients with breast implants. 5. While mammography is the best screening tool for breast cancer available today, mammograms do not detect all breast cancers. Also, a small portion of mammograms indicate that a cancer could possibly be present when it is not (called a false-positive result).

Normal Mammogram of the Breast

Conclusion Mammography alone, and also mammography combined with breast ultrasound, seems insufcient for early diagnosis of breast cancer in women who are at increased familial risk. If MRI is used for surveillance, diagnosis of intra ductal and invasive familial or hereditary cancer is achieved with a signicantly higher sensitivity and at a more favourable stage. Reference http://www.radiologyinfo.org/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003858/ http://jco.ascopubs.org/content/23/33/8469.full.pdf http://www.cancerquest.org/breast-mriintroduction.html?gclid=CPPr85PVirQCFRJ7cAodTlQAWA http://breastcancer.about.com/od/newlydiagnosed/a/mri_decisions.htm http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004609/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003859/