Screening &

Diagnostic
Mammography

Julie Lyons MS3

December 2004
Screening and Diagnostic Mammography
 To screen or not to screen?
Click here for current recommendations
 I’m not going to get breast cancer!
Click here to learn about risk factors
 What the heck is that white speck?
Click here to learn how to read mammograms
 Ouch!! That hurts!
Click here to learn about adverse effects
 Yikes, the doc called me back!
Click here to learn about diagnostic imaging
 Are they ever going to stop squishing my breasts?
Click here to learn about new/experimental breast imaging methods
 References and practice cases
 No good screening test comes
without…

CONTROVERSY!!!
Although the recommendations are clear…

The story is not.

 U.S. Preventive Services Task
Force
(B) Screening mammography (+/- clinical breast exam)
reccomended every 1-2 years for women > 40 years
old

(I) Insufficient evidence to reccommend for/against:

- routine CBE alone
- teaching or performing routine breast self exam
(BSE)

B= The USPSTF found at least fair evidence that [the service] improves
important health outcomes and concludes that benefits outweigh harms.
 American Cancer Society
“Women age 40 and older should have a screening
mammogram every year, and should continue to do
so for as long as they are in good health.”

“Women at increased risk should talk with their doctor

about the benefits and limitations of starting
mammograms when they are younger, having
additional tests, or having more frequent exams.”
 American College of Radiology
“Annual screening mammography is indicated for
asymptomatic women 40 years of age or older.”

“It is reasonable to institute screening mammography at an

earlier age for women with high risk factors.”

“Decisions when to stop routine mammography screening

should be made on an individual basis by each woman
and her physician.”

ACR PRACTICE GUIDELINE FOR THE PERFORMANCE OF SCREENING

MAMMOGRAPHY, 2004
 What do the data say?
 Recommendations on screening mammography
are derived from 7 long-term international
studies

 Multiple meta-analyses have since been done

 The validity of some of these RCTs has been

questioned which has lead to different
conclusions about the efficacy of screening
 If you like numbers…
One study says*…
 Protective benefit of screening
mammography, ages 50-74 = 0.66
 Meaning 34% reduction in breast cancer mortality

Another study says**…

 Protective benefit of screening
mammography, ages 50-74 = 0.97
 Meaning 3% reduction in breast cancer mortality
*Tabar et.al., 1995
**Olsen & Gotzsche, 2004
Does screening save lives?

Out of
1000

Fletcher, SW and JG Elmore. N Eng J Med 2003, UpTpDate

Image
 More numbers…
One-time mammography in women >50:

 Sensitivity: 71%- 96%

 Specificity: 94%- 97%*
 + predictive value: 2%- 22%
(women who will require further evaluation)
 + predictive value: 12%- 78%
(women who will require biopsy)

USPSTF: Screening for Breast Cancer, February 2002

 Hmmm….
What do they say about
DOGMA?

The Bottom Line:

Women, clinicians, & policy makers should think critically

about the benefits and risks of any screening test,
especially mammography.

Click Here to Return 

 FACTS:
 Breast cancer is the most common non-skin
malignancy among women…

 Breast cancer is the 2nd most common cause of

cancer-related death among women

 The probability of developing breast cancer in

the next 10 years is 1.5%- 3.9% in women
between the ages 50-70
 Breast Cancer: Epidemiologic Risk Factors

Risk Factors Relative Risk

Age > 50 6.5

Family History
1st degree relative 1.4-13.6

2nd degree relative 1.5-1.8

Age at Menarche (<12) 1.5-2.0

Age at Menopause (>55) 1.5-2.0

Age at first live birth (>30) 1.3-2.2

Benign Breast Disease

Breast biopsy 1.5-1.8

Atypical hyperplasia 4.0-4.4

Hormone Replacement Therapy 1.0-1.5

Armstrong, K, et. al.. NEJM. 2000(342): 564-571.

 Other risk factors
 BRCA1 and BRCA2 mutation

 60-80% lifetime risk of breast cancer

 15-40% lifetime risk of ovarian cancer

 Increased likelihood of having mutation if:

 Early onset breast cancer
 Breast AND ovarian cancer

 Ashkenazi Jewish ancestry

 Male breast cancer

 Calculating Risk In Women
Knowing risk may help guide medical decision-making:

 Whether to use HRT or not

 Age to begin mammographic screening
 Whether to use tamoxifen to prevent breast cancer
 Whether to perform prophylactic mastectomy

 Risk-predication can be calculated by

clinicians!
 This may someday be important in deciding who to
screen Click here to go to the NCI
web risk calculator based
on the Gale model Click here to
return to menu
 Adverse Effects of Screening
Mammography
 Anxiety
 Usually diminishes when cancer is ruled out
 Does not seem to dissuade women from
undergoing screen
 May even improve compliance

 Discomfort
 Costs associated with false
positives
 Exposure to radiation
 How Much Radiation?
 Amount of exposure to radiation in
mammography is called average glandular dose

 Single breast cranial/caudal view has b/w

1-3 mGy (remember, each patient has 4 images)
 Total dose is about equal to a KUB (5 mGy), and
much more than a CXR (0.14 mGy)*

 Literature says:
Women with an inherited susceptibility to ionizing radiation damage
may have higher risk for radiogenic breast cancer, but no studies
have proved this.
Click here to return to menu
Parry, R et.al. 1999
How screening mams are
done:
2 views of each breast are obtained:

Pectoralis major

CC View MLO View

 Screening Mammograms
CC Views MLO Views
“cranial caudal” “mediolateral oblique”

 Pectoral muscle seen  Pectoral muscle

in 20%-40% of views
visible to nipple
 If not seen, look for
retroglandular fat to  Small amount of
ensure all lateral abdomen at base of
tissue has been view
imaged
Images are compared to existing
previous studies:
 Normal Breast Anatomy

Most cancers arise in the interlobular duct unit

 Where do you look?

EVERYWHERE!!
In particular, examine:

 The subareolar area (CC, MLO)

 The glandular-fat interface (CC, MLO)
 The fatty area between pectoral muscle and
glandular tissue (MLO)
 The medial portion of breast (CC)
 What do you look for?
Microcalcifications
1. Size
  0.5 mm  think malignancy
  2.0 mm  think benign
2. Shape
 Round, oval, uniform  benign
 Irregular, pleomorphic,
“fragmented glass” think malignancy
 Popcorn-like  think fibroadenoma
3. Number “popcorn” calcification

 Usually need 4-6/mm³ to think malignancy

 What do you look for?
Masses
1. Assess if mass is a variation of
“normal breast pattern”
 There is a very wide range of normal!
 Knowing normal comes with time

2. If you do not think so, then assess for:

 Asymmetric density
 Nodularity
 Distortion of normal breast architecture
 Areas of calcification
**One or more of the above indicates a “suspicious” lesion**
 What do you look for?
Asymmetric Densities

1. Is it positioning and/or compression?

 Superposition of breast tissue
 Usually only seen in 1 view

2. 3-D asymmetries may be a mass

 Seen in both MLO and CC
 Large, diffuse, appearing similar to
contralateral breast  benign
 New appearing density, absence of fat
Large, diffuse asymmetry
streaks  malignancy
There is a wide range of
normal…

Dense --------------------------------------------- Fatty

Most mammograms are in fact normal.

The most difficult mammograms to read are those from
women with fibrous breasts; specificity is much lower.
 Less than 1 out of 200 screening mammograms may
have abnormalities…

In short:
 Soft tissue mass, ill-defined  BAD
 Spiculated mass is most specific

for cancer (90%)

 Only 1/3 of cancers are spiculated

 Clusters of microcalcifications  BAD

 Only 1/3 of cancers have

 microcalcifications

Click here to return to menu

 What is the differential dx for a mass?

 Fibroadenoma
 Cyst
 Abscess
 Cytosarcoma phylloides
 Intramammary lymph node
 Intraductal papilloma
 Hematoma
 Circumscribed breast cancer
If an abnormality is detected it is given a number…
 BI-RADS
Breast Imaging Reporting & Data Systems
Up To Date Patient-ease

BIRADS What it means

0 More information is needed to give a final mammogram

report.

1 Your mammogram is normal.

2 Your mammogram shows only minor abnormalities that

are not suspicious for cancer. No additional
testing is needed.

3 Your mammogram shows minor abnormalities that are

probably benign. The radiologist may recommend
follow-up testing in six months to make sure the
suspicious area has not changed.

4 Your mammogram shows a suspicious change, and a

biopsy should probably be performed. However,
less than half of women with category 4
mammograms will end up having cancer.

5 Your mammogram shows a worrisome change. A biopsy

is strongly recommended. Up to 80 percent of
women with a category 5 mammogram will end up
having cancer.

Mammographic findings are summarized into a

BI-RADS category
 Management Algorithm for Patients with Abnormal Mams

Abnormal screening
mammogram

Obtain supplemental views

•Spot compression
•Magnification
•Varied angle
Consider Ultrasound

Stage Mass according to BI-RADS

BI-RADS 1,2 BI-RADS 3 BI-RADS 4 BI-RADS 5

NL or benign Probably benign Image-guided biopsy Percutaneous core
F/U annual F/U 6 mo or FNA
 First: Consider Obtaining
Other Views
 Exaggerated Cranialcaudal Views (XCCL)
 10% of women will need this
 Used to evaluate lateral tissue
 Prominent axillary tail of Spence visualized
 Some of the pectoral muscle is seen (unlike CC)
 Other Views, cont.
 Spot Compression Views
 Used to (dis)confirm the presence of a lesion
 Used to further evaluate areas of increased density
 Often done when a woman receives assessment
category 0 (“incomplete study”)
 Other Views
 Magnification views
 Used when there is a mass
or calcifications on screening
 Provides more info on:
 Margins, morphology,
distribution
 Presence of satellite lesions

 Presence of associated

microcalcifications

Spot compression magnification mammography

 Ultrasound
Indications:
 To characterize mass as cystic or solid
 To characterize solid masses as intermediate
or high probability benign or malignant
 To evaluate nonspecific findings, asymmetric
densities
 To evaluate masses in women who are
pregnant, lactating, or <30
 To guide interventional procedures
Malignant characteristics on US
 Marked hypoechogenicity (darkness)
 Spiculation
 Angular margins
 Taller than wide
 Shadowing
 Branch pattern
 Duct extension
 Microcalcification This US shows an oval, hypoechoic and
homogeneous mass, therefore suggesting a
benign lesion. It was rated a BIRADS 4, and
was found to be a fibroadenoma on biopsy.
 Ultrasound Imaging

Q: Is this a solid or cystic mass?

A: Solid mass
On a sonogram, most simple cysts have smooth walls, sharp anterior and
posterior borders, no internal echoes and usually posterior enhancement. Most
solid masses will be hypoechoic, relative to the surrounding tissue, with
posterior acoustic shadowing.
So, the US indicates BIRADS 4…
What next?
Types of image-guided needle biopsies:

1. Ultrasound
Allows biopsy of the breast from
almost any orientation
Quicker and easier on patient
 Types of image-guided needle
biopsies:
2. Prone stereotactic

 
 Biopsy path is imaged from two slightly angled
directions
 Good for patients with microcalcifications

                             

                                            
 Types of image-guided needle
biopsies:
3. Upright stereotactic
 Also uses two slightly angled
directions to determine biopsy path
 Best method for guiding a biopsy
of the axilla

4. MRI guided biopsy

 Refer to next section for details
 Biopsy Techniques
Depending                                                                                                                                             
on mammogram results various biopsy tactics are
chosen
 Is there a difference?
 FNA
 Sensitivity =98%, specificity = 97%
 Rates are dependent on clinician
experience
 False negative rates up to 32%
 Often inadequate samples are
obtained
US FNA
 Core needle biopsy
 May have better diagnostic
outcomes in non-palpable masses
 Concern for seeding needle tract
with tumor cells
 Is there a difference?
 Vacuum- assisted
 Can remove abnormalities up to 1 cm
 Small clips may be deployed at site for future ID
 Also has risk of seeding

 Wire localization and excision

 Goal may be to diagnose or excise suspicious
lesions on core biopsy-proven tumors
 Up to 20% of excisions may have positive
histologic margins
 Radiologist puts wire(s) in; surgeon excises

Click here to return to menu

Wire Localization
 New & Experimental
 Computer-aided detection (CAD)
 Prompts reader to suspicious regions
 FDA has approved the use of several models
 Insurance reimbursement $17 per case
 Few studies supporting CAD exist
 No studies have shown that single reader + CAD is better
than double reading
 Inaccurate prompting may act against any potential benefit
 Readers may have up to 100 false prompts for every true prompt
 Ultimate goal is to help solve problem of national
shortage of readers
 CAD
Computer algorithm is
designed to recognize:
• Calcifications
• Masses
• Architectural distortion

“Double reading” has been

shown to increase the
detection rate of cancers by
5% to 15%.
 New & Experimental:
Uses of MR Mammography
1. Evaluation of extent of tumor invasion in biopsy-proven
malignancy prior to surgery
 Staging and determination of surgical plan
 Hook wire placement in small lesions (<12mm)

2. Diagnosis
 Dynamic contrast-enhanced (DCE) MRI may be
as sensitive and more specific than the combined traditional
triple assessment for diagnosis of malignancy*
 Ductal carcinoma-in-situ is identifiable on MR images in only
50% of patients

3. Evaluation of metastatic disease to search for unknown

primary
Kneeshaw et.al. 2003.
 Uses of MR Mammography
4. Evaluation of breast implants & ruptures
5. Response to chemotherapy
 Initial studies show improved differentiation of fibrotic tissue from
remaining tumor verses other imaging techniques

6. Screening
 High sensitivity (99.2%)
 May be useful in high risk patients, dense breasts

7. Evaluation and diagnosis of axillary disease

8. Evaluation and diagnosis of nipple discharge

Staging of Breast Cancer Using MRI
MRI Evaluation of Implants

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New & Experimental:

Scintimammography
• A nuclear medicine study that
involves the injection of the
radionuclide technetium 99m
sestamibi (miraluma)
• It is currently undergoing studies
to evaluate its ability to
distinguish between benign and
malignant lesions.

Click here to return to menu

 Practice Cases
Want to test your knowledge?

Click here for some examples posted by the

University of Wisconsin Radiology Department
on MRI mammography…

Click here for some examples of screening and

diagnostic mammography from University of
Washington Radiology department

To return, close the web windows

Normal or abnormal?

A: Normal
 References
 Barton MB, Harris R, Fletcher SW. Does this patient have breast cancer? The screening clinical
breast examination: should it be done? How? JAMA 1999;282(13):1270-80.
 Humphrey LL, Helfand M, Chan BKS, Woolf SH. Breast cancer screening: summary of the
evidence. Ann Intern Med 2002;137:344-6.
 ACR PRACTICE GUIDELINE FOR THE PERFORMANCE OF SCREENING MAMMOGRAPHY,
2004
 Green, B. and S. Taplin. Breast Cancer Screening Controversies. J Am Board Fam Pract
2003;16:233-41.
 Olsen, O and P Gotzsche. Screening for breast cancer with mammography. Cochrane
Database of Systematic Reviews 2004;4:1-68.
 Astley, S and F Gilbert. Computer-aided detection in mammography. Clinical Radiology
2004;59:390-399.
 Kneeshaw, P et.al. Current applications and future direction of MR mammography. British
Journal of Cancer 2003;88:4-10.
 Parry, R. et.al. Typical patient radiation doses in diagnostic radiology. Radiographics
1999;19:1289-1302.
 Jackson VP. Screening mammography: controversies and headlines. [Editorial] Radiology.
2002:225(2):323-6.
 Tabar L, Fagerberg G, Chen HH, et al. Efficacy of breast cancer screening by age: new results
from the Swedish Two-County Trial. Cancer 1995;75:2507-17.
 Cardenosa, G. The Breast Imaging Companion, 2nd Ed. Philadelphia:2001.