DR. VIBHAY PAREEKRADIATION ONCOLOGY

JUPITER HOSPITAL

BREAST MAMMOGRAPHY

ANATOMY OF THE BREAST

• Vary In Shape & Size• Cone Shaped With The Post Surface

(Base) Overlying The Pectoralis & Serratus Muscles

• Axillaries Tail Extends From Lat. Base Of The Breasts To Axillaries Fossa

• Tapers Ant. From The Base Ending In Nipple, Surrounded By Areola

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• Consists Of 15-20 Lobes• Divide Into Several Lobules• Lobules Contain Acini, Draining Ducts And

Interlobular Connective Tissue.• By Teenage Years Each Breast Contains

Hundreds Of Lobules

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• Breast Profile:• A Ducts• B Lobules• C Dilated Section Of Duct To Hold Milk• D Nipple• E Fat• F Pectoralis Major Muscle• G Chest Wall/Rib Cage•

Enlargement:• A Normal Duct Cells• B Basement Membrane• C Lumen (Center Of Duct)

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• Lymph Node Areas Adjacent To Breast Area.• A Pectoralis Major Muscle• B Axillary Lymph Nodes: Levels • C Axillary Lymph Nodes: Levels • D Axillary Lymph Nodes: Levels • E Supraclavicular Lymph Nodes• F Internal Mammary Lymph Nodes

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LYMPH NODES

Lymphatic Vessels Of The Breast Drain Laterally And Medially

• Laterally Into The Axillary Lymph Nodes (C & D)

• 75& Drain Toward Axilla• Medially Into The Mammary Lymph

Nodes• 25% Toward Mammary Chain (F)

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QUADRANTS OF THE BREAST

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Types Of Breast Tissue

Glandular• Ducts• Lobes• Lobules• TDLU

Stromal

• Fatty Tissue

• Connective Tissue

• (Cooper’s Ligaments – Suspensatory Ligaments

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3 Tissue Types

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EQUIPMENT

• CC - CRANIO CAUDAD• MLO – MEDIOLATERAL OBLIQUE

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POSITIONING

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Compression Important:

Evens Density of Breast

Reduces Motion

AEC choice depends of size and composition of breast

CC

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MLO – RT BREAST

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TRUE LAT CONE-MAG

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MAGNIFICATION = INCREASE OID

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BREAST CHANGES WITH AGE

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Breast Classifications

FIBRO-GLANDULAR BREAST

• Fibro-glandular• Dense With Very Little Fat• Females 15-30 Years Of Age

• Or 30 Years Or Older Without Children• Pregnant Or Lactating

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FIBRO-FATTY BREAST

• Fibro-fatty• Average Density

• 50% Fat & 50% Fibro-glandular• Women 30-50 Years Of Age

• Or Women With 3 Or More Children

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FATTY BREAST

• Fatty• Minimal Density• Women 50 And Older

(Postmenopausal), Men And Children

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THE MALE BREAST

38Male Mammography and Cancer

GYNECOMASTIA

• Benign Excessive Development Of Male Mammary Gland

• Occurs In 40% Of Male Cancer Pt’s

• Survival Rates With Treatment Are 97% For 5 Years

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• Most Common Causes :

• Puberty (Hormonal Growth And Changes During Adolescence)

• Estrogen Exposure (Female Hormone Present In The Body And The Environment)

• Androgen Exposure (Body-building Hormones) • Marijuana Use • Medication Side Effects (Older Men)• Klinefelter's Syndrome

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GYNECOMASTIA

• Is A Benign Male Breast (Non-cancerous) Condition

• Some Men Who Have Prominent Breasts, Or Uneven Breasts, Often Feel Some Embarrassment About Their Body Image.

• This Condition Can Also Cause Emotional Conflict Over Sexual Identity.

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MALE BREAST

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MALE MAMMOGRAPHY

• 1300 MEN GET BREAST CANCER PER YEAR• 1/3 DIE

• MOST ARE 60 YEARS OR OLDER• NEARLY ALL ARE PRIMARY TUMORS• SYMPTOMS INCLUDE:

• NIPPLE RETRACTION• CRUSTING• DISCHARGE• ULCERATION

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MALE MASTECTOMY

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BREAST IMPLANTSIS IT WORTH THE RISK?

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COMPLICATION WITH BREAST AUGMENTATION

• mammography has a 80-90% true positive rate for detecting breast cancer in those women without implants

• decreases to 60% with implants• because 85% of breast tissue is obscured

• more images are needed than the standard two projections• there is a risk of rupturing the implant• loss of sensation from surgical scars

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ELKLAND METHOD FOR IMAGING WITH BREAST IMPLANTS

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“PUSH BACK” TECHNIQUE

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ULTRASOUND OF BREAST

APPLICATIONS

• Not Always Detect Cancers That Are Visualised Mammographically. • Ultrasound Can Detect Clinically And Mammographically Occult Cancers

Particularly When There Is A Higher Possibility Of Cancer.• New High-frequency Transducers• Irregular Masses, Abnormal Dilated Ducts Or Clustered Foci Of Increased

Echogenicity With Increased Doppler Vascularity.

Patient PositionPatient Position

Medial LesionsMedial Lesions

• Patient Is Supine

• Ipsilateral Arm Is Placed Over The Patient’s Head.

Lateral LesionsLateral Lesions

• Patient Is Opposite.

Superior LesionsSuperior Lesions

• Patient Is SITTING

Apply Gentle Uniform Pressure With The Ultrasound Apply Gentle Uniform Pressure With The Ultrasound TransducerTransducer

Increase Transducer Pressure For:

– Greater Penetration

– Scanning The Subareolar Region.

Scanning Is Done In Three Directions.

1. Radial

2. Transverse

3. Longitudinal

• Localization Is By The Clock Face.12

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Lymph Node

• Solid nodule• Ovoid• Echogenic fatty hilum

• The Subcutaneous Fat LayerSubcutaneous Fat Layer Is Demonstrated Superficially As Hypoechoic Tissue Compared To The Glandular Tissue From Which It Is Separated By A Well-defined Scalloped Margin.

• Normal Ducts Ducts Are Often Visible, Particularly In The Subareolar Region, As Anechoic Tubular Structures.

• Deep To The Glandular Tissue, A Retromammary Fat LayerA Retromammary Fat Layer Is Usually Visible And, Behind This, The Structures Of The Chest WallChest Wall.

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• Symptomatic Breast Lumps In Women Aged Less Than 35 Years.• Breast Lump Developing During Pregnancy Or Lactation.• Assessment Of Mammographic Abnormality (± Further Mammographic Views)• Assessment Of MRI Or Scintimammography Detected Lesions.• Clinical Breast Mass With Negative Mammograms.• Breast Inflammation.• The Augmented Breast (Together With MRI).• Breast Lump In A Male (Together With Mammography).• Guidance Of Needle Biopsy Or Localisation.• Follow-up Of Breast Cancer Treated With Adjuvant Chemotherapy.

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Benign CharacteristicsBenign Characteristics

• Ellipsoid Shape

• Thin Definable Capsule

• Two Or Three Lobulations

• Hyperechogenicity.

SOLID MASS - MALIGNANT

• Irregular Shape• Irregular/Ill-defined Borders• Almost Anechoic• Angular Margin• Taller Than Wide

Irregular shape• Irregular/ill-defined borders• Almost anechoic• Thick echogenic rim• Posterior shadowing

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Simple Cysts– Anechoic– Smooth, Thin Margins– Posterior Acoustic Enhancement

Benign Malignant

Shape Oval/ellipsoid Variable

Alignment Wider than deep; aligned parallel to tissue planes

Deeper than wide

Margins Smooth/thinechogenic pseudocapsule with2-3 gentle lobulations

Irregular or spiculated; echogenic 'halo'

Echotexture Variable to intense hyperechogenicity Low-levelMarked hypoechogenicity

Homogeneity of internal echoes

Uniform Non-uniform

Lateral shadowing

Present Absent

Posterior effect Minimum attenuation/posterior enhancement

Attenuation with obscured posterior margin

Other signs -------------- CalcificationMicrolobulationIntraductal extensionInfiltration across tissue planes and increasedechogenicity of surrounding fat

• The sonographic pattern varies with age and individually, and depends on the amount and type of contents, i.e. fat, fibrous and glandular tissues.

• The fibrous and glandular components are variably echogenic, while fat is hypoechoic.

BI-RADS

• BIRADS Stands For Breast Imaging- Reporting And Data System Which Is A Widely Accepted Risk Assessment And Quality Assurance Tool In Mammography, Ultrasound And MRI.

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BI-RADS ASSESSMENT CATEGORIES

MAMMOGRAPHY AND ULTRASOUND LEXICON

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MASS

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A 'Mass' is a space occupying 3D lesion seen in two different projections.If a potential mass is seen in only a single projection it should be called a 'asymmetry' until its three-dimensionality is confirmed.Shape: oval (may include 2 or 3 lobulations), round or irregularMargins: circumscribed, obscured, microlobulated, indistinct, spiculatedDensity: high, equal, low or fat-containing.

SHAPE

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