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BasicBasic
MammographyMammography
DARUNEE BUNJUNWETWAT MD.
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Breast imaging
MammographyUltrasonography
MRIScintimammography
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MammographyFood and Drug Administration ( FDA )
June 2, 1993
Most effective for early breast cancer
detection
Screening mammography
Screening interval
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Screening mammography
Diagnostic mammography
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Screening mammography
Women > 40 years
Yearly, annual check up
Early cancer detection
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Early stage Cure
Small size < 1 cm
Free of metastases
Non-palpable
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High risks
Early menarch
Late menopause
Nulliparity
Late age at full term pregnancy (> 30 yrs )
Biopsy proof atypical epithelial
proliferationBiopsy proof lobular carcinoma in situ
(Kopans DB. Breast imaging Lippincott-Raven p45)
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High risksGenetic ( BRCA 1, BRCA 2 )
Environmental
Gene-environmental interaction
Affected first degree relative( mother, sister, daughter )
Previous history of cancer
( breast , ovary )Ronbidoux et al, AJR 166(1): 29-31, 1996
Foulkes et al, Clinical and intensive Medicine 18(6):
473-483, 1995
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American cancer society ( ACS )
National cancer institution ( NCI )
Screening mammography 40-80 yrs
High risks 35 yrs
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Mammography
Technique : standard two views
( MLO , CC views)
: additional views
( spot compression,magnification )
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Standard views
1. Mediolateral oblique ( MLO )
2. Craniocaudal ( CC )
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Supplement viewsSpot compression
Magnification
True lateral
Exaggerated medial or lateral CCTangential
RolledCleavage ( buttock )
Axillary views
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Technique
Pulling
Compression
AngleBreath holding
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MLO view
Length and contour of pectoralismuscle
Nipple Inferior mammary angle
Pitfall Inner quadrant
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CC view
Visualized pectoralis muscle 30-40 %
Retromammary fat
Pectoralis-Nipple line ( PNL )
Stress on inner aspect
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Mammography RisksLow dose radiation ( 2mGy per view )
Compression effect
Uncertainty in diagnosis of CA in situ
( Napol et al; Journal of National CancerInstitute Monograph (22):11-3, 1997 )
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Anatomy of breastAnatomy of breast1. Mammary gland
2. Ducts
3. Collagenous connective tissue
4. Fatty tissue
5. Cooper ligament
6. Vessels and lymphatic
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Breast evolution and involution Individual
Age
Hormonal
Menstrual cyclesPregnancy
LactationMenopausal
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Menarchal development
15 yrs 25 yrs
Lobular structure, duct system
( hypoplasia, inverted nipple, juvenilehypertrophy, fibroadenoma )
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Cyclical change
Premenstrual phase ( endocrinestimulation )
Epithelial and stromal activity,
regressionBreast enlarge, patchy density
( fibrosis, adenosis, lymphoidproliferation, mastalgia, nodularity )
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Pregnancy, Lactation
Pronounced glandular activity
Superimposed cyclical change
Patchy
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Post Lactation
Some areas of regression
Fibrosis
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Involution30yrs - 40yrs till menopause
Lobular regression
( involution of epithelium )
Replacement of fibrous tissue in
interlobular regression sclerosis,
microcyst formation
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Breast patterns
Fatty breast
Ductal
Dense breast
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Wolfe Classification
Ducts, lobules, fibrosis
Linear and nodular opacities
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N1 = Parenchymal chiefly fat
P1 = Duct pattern in anterior portion
< of breast volume
P2 = Duct pattern > of breast volume
DY = Confluence densities or dysplasia
( AJR 126: 1130-1139, 1976 )
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Histologic appearance of P1, P2
connective tissue hyperplasia
surrounding duct
periductal collagenosis
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Histologic appearance of DY
severe mammary dysplasia
adenosis, microcyst formation
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Wolfes study
Parenchymal patterns and cancerrisk
DY + P2 > P1 + N1 6 times
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Thai women 444 cases
Negative mammograms
Technique MLO, CC views
DY 60 6% 40 50
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DY 60.6%
P2 46.8%
30.7%
P1 47.8%
N1 50%
40 50 yrs
40 50 yrs
50 60 yrs
50 60 yrs
60 70 yrs
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DY + P2 80% of Thai women
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Breast parenchymal density
ACR BIRADS 4 level systems
Fatty
Scattered fibroglandular densities
Heterogeneously dense
Extremely dense
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ASSESSMENT CATEGORIES
Mammographic assessment is
incompleteCategory 0
Need Additional Imaging Evaluation and/or Prior
Mammograms For Comparison
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ASSESSMENT CATEGORIES
Mammographic Assessment IsCompleteFinal CategoriesCategory 1
NegativeCategory 2
Benign Finding(s)
Category 3 Probably Benign FindingInitial Short-
Interval Follow-Up Suggested
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ASSESSMENT CATEGORIES
Category 4
Suspicious Abnormality
Biopsy Should BeConsidered
Category 5 Highly Suggestive of MalignancyAppropriate
Action Should Be Taken (Almost certainly malignant.)
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Category 0 almost always used in a screening situation.
additional imaging evaluation may include,but is not limited to the use of spot
compression, magnification, special
mammographic views and ultrasound. should only be used for old film comparison
when such comparison is required to make a
final assessment.
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Category 1 The breasts are symmetric and no masses,
architectural distortion or suspiciouscalcifications are present.
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Category 2
Involuting, calcified fibroadenomas, multiple
secretory calcifications, fat-containing lesionssuch as oil cysts, lipomas, galactoceles and
mixed-density hamartomas all have
characteristically benign appearances
Intramammary lymph nodes, vascular
calcifications, implants or architectural
distortion clearly related to prior surgery whilestill concluding that there is no
mammographic evidence of malignancy
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Both Category 1 and Category 2
assessments indicate that there is nomammographic evidence of malignancy.
The difference is that Category 2 should be
used when describing one or more specificbenign mammographic findings in the report,whereas Category 1 should be used when no
such findings are described.
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Category 3 Less than a 2% risk of malignancy
Three specific findings are described asbeing probably benign
noncalcified circumscribed solid mass
focal asymmetry cluster of round [punctate] calcifications
exclude palpable lesions
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an initial short-term follow-up (6 months)
examination (usually unilateral mammogram)followed by additional examinations (bilateral
F/U in another 6 months and then bilateral
12-month F/U) until longer-term (2 years orlonger) stability is demonstrated may be
changed to Category 2
occasional biopsy when patient wishes orclinical concerns
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Category 4 For findings that do not have the classic
appearance of malignancy but have a widerange of probability of malignancy that is
greater than those in Category 3.
Most recommendations of breastinterventional procedures will be placedwithin this category.
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Subdivided to account for the vast range of
lesions subjected to interventional proceduresand corresponding broad range of risk of
malignancy
Category 4A, 4B and 4C
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Category 4A
need intervention but with a low suspicion formalignancy
palpable, partially circumscribed solid mass withultrasound features suggestive of a fibroadenoma,
a palpable complicated cyst or probable abscess
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Category 4B Intermediate suspicion of malignancy
warrant close radiologic and pathologic
correlation
partially circumscribed, partially indistinctlymarginated mass yielding fibroadenoma or
fat necrosis is acceptable, but a result of
papilloma might warrant excisional biopsy
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Category 4C
Moderate concern, but not classic(as in Category5) for malignancy
ill-defined, irregular solid mass or new cluster offine pleomorphic calcifications
malignant result in this category is expected
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Category 5 High probability (> 95%) of being cancer
Example, spiculated, irregular high-density mass,
segmental or linear arrangement of fine linear
calcifications or irregular spiculated mass with associated
pleomorphic calcifications
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Category 6
For lesions identified on the imaging study
with biopsy proof of malignancy prior todefinitive therapies
No associated intervention required to
confirm malignancy
Appropriated for second opinions or formonitoring of responses to neoadjuvant
chemotherapy prior to surgical excision
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Not appropriate following excision of a
malignancy (lumpectomy )
A major rationale for adding Category 6 is
that examinations meriting this assessmentshould be excluded from auditing
If include inappropriately indicate inflated cancer
detection rates, positive predictive values, and otheroutcomes parameters
Fibrocystic change
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y g
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Popcorn calcifications
Popcorn calcifications
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Hamartoma
Hamartoma
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Lipoma
Galactocele
Oil cyst (fat necrosis)
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CaseCase 1
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guide
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Case 2
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Fibroadenosis
Case 2
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Case 2
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Case 2
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Thank you