The Role of Imaging and

Interventional Radiology in
Breast Diseases
Sanjay Sharma
MD, DNB, FRCR (Lon)
Associate Professor
Radio-diagnosis
AIIMS, New Delhi
Breast Cancer

# 1 female cancer in world

 # 1 female cancer in Indian metros

Mammography is the only standard and proved cancer

screening technique
Reduces mortality by 20-35%*

*JAMA2005;293:1245-56 (Meta analysis)

Breast Imaging Modalities

 Mammography is the primary modality

 Complimentary modalities
– Ultrasound
– MRI
– Scintimammography, PET
Mammography

 Radiography of breast
 Modified to evaluate low density soft tissues
with high contrast and spatial resolution
– Low energy x-rays
– High resolution films
Resolution of mammography is several times better
than any other imaging modality
BIRADS Grades
Grade Interpretation Managemant

0 Incomplete evaluation Complete it

1 Normal None

2 Benign None

3 Probably benign (<2%) Short follow-up

4 Suspicious/ indeterminate Biopsy

5 Highly suspicious (>95%) Biopsy

BIRADS Grades: Masses

2 3

4 5
BIRADS Grades: Calcifications

2 3

4 5
Digital Mammography
Digital Mammography:
Requirements

 Highresolution flat panel detectors

 Powerful workstation
– Up to 27 mega pixels per image!
 High resolution, high brightness monitors
Digital Mammography:
Advantages

 Post processing
– e.g. zoom, pan, windowing, contrast, edge
 No artifacts
 No under/ overexposed images
 Digital storage and communication
– PACS/ Teleradiology
Digital Mammography:
Disadvantages

 High cost
 Inferior spatial resolution

-5-10 lp/mm with FFDM

-(versus 12-15 lp/mm with conventional FSM)
 Films display more gray shades than monitor
Digital Mammography
 Should we go digital??
-Digital mammography is still in infancy
– Accuracy is comparable to film-screen mammography*
 Potentials of new applications are already
demonstrated (not possible with FSM)

*N Engl J Med 2005;353:1773-83

Computer Aided Detection (CAD)

 Help inexperienced radiologists

 Inexpensive alternative to second radiologist
for ‘double reading’
– Sensitivity for missed cancers: CAD 95%*
– Vs ‘double reading’ by radiologists 64%
*AJR 2007;188:377-84
 Cancer detection rate increased by > 20%#
#
AJR 2003;181:687-93
Tomosynthesis
 Low dose exposures at
different angles
 Produces tomograms
 Useful in dense breasts
Ductography
 Single duct discharge
 Uncommonly performed
 US and MRI are also
useful
Breast US: Indications
 Evaluation of clinical or mammographic
abnormalities
– Differentiation of cystic Vs solid mass
– Asymmetric densities
– Dense breasts
 Young, lactating, pregnant women
 Implants
 Interventions
Cysts
 Simple cysts
 Complex cysts

US diagnosis of simple
cyst is important as it
does not require biopsy,
treatment or follow-up
Masses
 Benign
– Round, oval
– Well defined walls
– Distal enhancement
 Malignant
– Irregular
– Poorly defined walls
– Distal shadowing
Breast MRI
 Recently in focus
– Dedicated breast coils
– Standardized protocols and ACR reporting lexicon
– MR compatible needles
– Enough literature
 Sensitivity
90-100%, Specificity 50-70%* for
breast cancer detection
*Radiol Clin N Am 2004;42:919-34
Breast MRI: Indications
 Before diagnosis
– Equivocal mammogram
– Screening modality in high risk women
 After diagnosis
– Preoperative staging
– Assess response to chemotherapy
 After treatment
– FU
– Scar Vs recurrence
Not to be used as an alternative to mammography/ biopsy
Breast MRI: Cancers
 Morphology similar to
mammography
 Dynamic CE MRI of Breast

plain

0
min
1 min
2 min
5 min
delaye
d
Breast MRI: High PPV for cancer

Ring Heterogeneous Ductal

Enhancement internal enhancement distribution
MR Screening

 BRCA 1, BRCA 2 mutations

 MRI is the only screening tool in these women*
– MRI sensitivity 94%#
– (CBE 50%, mammography 59%, USG 65%)

*Lancet 2005;365:1769-78
#
Radiology 2007: epub
PET
 Most accurate*
– Sensitivity 88% (25% for <1cm tumors)
– Specificity 80%
 Single stop shop for both local and complete body
assessment
 Dedicated PET mammography units# are being
developed
– Detection of small tumors

*Acad Radiol 2002;9:773-83 (meta analysis)

#
Radiology 2005;234:527-34
Molecular Imaging With PET

 16 alpha fluoro estradiol

– In vivo ER receptor analysis
 F18 tamoxifen
– Detection & response assessment of ER+
metastases
 Cu64 monoclonal antibodies
– Tumor grade and malignant potential
Image Guided Breast Biopsy
 Guidance
– US
– Stereotactic (mammography)
– MRI
 Core biopsy more accurate than FNAC*
– FNAC sensitivity 77%
– Core biopsy sensitivity 98%, no false +

*Acad Radiol 2004;11:293-308

US Guided Core Biopsy
Stereotactic Biopsy
 Preferred technique for
mammography detected
cancers
 Type of units
– Add-on erect unit
– Dedicated prone table
Directional Vacuum Assisted
Breast Biopsy (DVAB)

 Mammotome®

 Multiple, large cores

with single insertion
Mammotome® Biopsy
 8-11 G Needles Mammotome cores
 5 fold more tissue per core
(18 Vs 98 mg)*
 Better concordance (100%#)
with surgical biopsy than
FNAC/ trucut Bx

Tru cut cores

*Radiology 1997;205:203-08
#
AIIMS study, continuing
Hook Wire Localization

 Pre operative procedure for open surgical

biopsy or therapeutic lumpectomy
 Aim
– Guides surgeon to accurately reach and remove the
non-palpable lesion
– Accurate pathological sampling
– Minimize surrounding tissue removal
 Mammography, US or MR guidance
Planning of Breast Conservation
Surgery
 Imaging is required in a
diagnosed case
– Extent of the tumour
– Additional lesions
– Baseline
 Mammography is the
primary modality
Breast MRI: Preoperative Staging
 Accurate assessment of
size & local spread of
index tumor
 Detects additional foci in
41% patients*
 Changes management
in 26% patients#

*AJR 2005;184:868-77
#
Cancer 2003;98:468-73
Residual Tumor
 After lump excision
 Positive margins after
BCS

 Mammography and USG

are difficult to perform
and interpret
 MRI is most accurate*

AJR 2004;182:473-80
*
Follow up Imaging

 Seroma – round,
oval density
 USG most useful in
immediate post-op
Follow up Imaging

 Mammogram six
months after BCS
and annually
thereafter
 Post RT changes
– Increased breast density
– Skin thickening
– Thickening of trabeculi
Recurrence
 Mammography is usually
sufficient
– New opacity
– Increased density/ size of
scar
– New suspicious
calcification
 MRI/ PET in equivocal
cases
Recurrence

 PET: Highest sensitivity

– Sensitivity- local 90%, distant 100%

*J Cancer Res Clin Oncol 2003;129:147-53

Neo-adjuvant Chemotherapy

 Assess response
– Mammography/ MRI
– PET is most accurate
 Pre-op hook wire
localization, if lesion
becomes non
palpable
Radio-frequency Ablation

 Minimally invasive alternative to surgery in

small breast cancers
 Feasibility studies have shown complete tumor
ablation with adequate margins in 95-100%

Radiology 2004;231:215-24
J Surg Oncol 2006;93:120-28
AIIMS study (continuing,unpublished)
Radio-frequency Ablation
 Randomized trials have
been planned
 Combination of
RFA+SN mapping may
offer minimally invasive
alternative to
conventional surgery
In India

 Screening mammography is a distant dream

However,
 Diagnostic and interventional breast radiology
of symptomatic breast is no less important
 We must tailor our approach to new
developments in the breast radiology
Thank You