Dr. Lina Choridah

8/11/2019 Dr. Lina Choridah

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Imaging Radiology in Breast Cancer and

Imaging-Pathology Correlation

Lina Choridah

Radiology Department

Faculty of Medicine UGM

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3 IMAGING MODALITY

1. Mammography

2. Ultrasonography

3. MRI

Mammograms dont

look fun

but they can save a life!

Malignant Lesion of the Breast

Ductal Carcinoma

Lobular Carcinoma

Ductal Carcinoma in situ

the most common type of in situ breast cancer,

accounting for about 83%

CALCIFICATIONS ARE MAMMOGRAPHIC HALLMARK.

Microcalcification typeDalarna County (W) Sweden

The first step in analyzing the calcifi cations is to

determine their site of origin:

1. Within the ducts: Casting type calcifications.

2. Within the terminal ductal lobular units (TDLUs):

a. Crushed stone-like calcifi cations.

b. Powdery/cotton ball-like calcifi cations.


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Casting type calcifi cations

Fine linear branching

The most important

Poor prognosis

Benign casting typeTabar

Malignancy Ratio Casting Type(Lazlo Tabar)

With and without tumor mass With tumor mass

Crushed Stone CalcificationLazlo Tabar

DCIS Right breast Subtle DCIS


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Invasive carcinoma

The prognosis is strongly influenced by the

stage of the disease

IDCThe mammographic signs of invasive

ductal carcinoma (IDC)

Primary

Secondary

Indirect signs.

IDC primary signs

a mass with irregular shape, ill defined or spiculated

margins

high radiographic density

microcalcifications (linear branching, clusters,

punctuate) either within the tumor or adjacent to it.

Tabar


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IDC secondary sign

Associated with advanced cancers.

Skin thickening or retraction

Nipple retraction

Axillary node enlargement.

IDC INDIRECT SIGN

a developing asymmetry

architectural distortion

focal asymmetry

Unilateral single dilated duct.

Invasive Lobular Carcinoma (ILC)

21Illustration Mary K. Bryson

Lobular cancercells breaking

through the wall

ILC

a mass with irregular shape, ill defined or spiculated

margins / architectural distortion

density equal to or less than that of normal

fibroglandular tissue

Microcalcifications are uncommonly seen

US HAS PROVEN TO BE A VALUABLE ADJUNCT IN THE

DETECTION AND WORK UP OF ILC

ILC Imaging


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ILC FEATURES

The most common mammographic feature of ILC was

architectural distortion

The most common US feature of ILC was irregular or

ill-defined hypoechoic mass with acoustic shadowing

PITFALL MAMMOGRAPHY

3 FACTORS

Patient

Technical

Interpretating

Ultrasound

(in Addition to Mammography)

Can be considered in high-risk women for

whom magnetic resonance imaging (MRI)

screening may be appropriate but who cannot

have MRI for any reason

Can be considered in women with dense

breast tissue as an adjunct to Mammography

Mammography vs Ultrasonography

Breast Cancer spectrum

mrozin,md

MAMMOGRAPHY

Frequency %

mammo (-) 8 15.7

architectural distortion 5 9.8

mass 18 35.3

mass + calcification 15 29.4

distorstion + calcification5 9.8

Total 51

(Choridah, et al 2014)


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Shape and Margin

64,7%

62,7%

ECHOSTRUCTURE AND ECHOGENISITY

94,1% 100%

SHADOW AND EDGE REFRACTION

54,9% 94,1%

MICROCALCIFICATION

47,1%

PATHOLOGY

Pathology Frequency Percent

Ductal Invasive 41 80.4

Lobular Invasive 3 5.9

Ductal + Lobular 2 3.9

Ductal + paget 1 2.0

Ductal + papilloma 1 2.0

Papillary 1 2.0

Musinosum 1 2.0

Phyllodes 1 2.0

Total 51

INVASIVE DUCTAL CARCINOMA


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LOW GRADE VS HIGH GRADE IDC

Classic Type, low grade High Grade

Ca Ductal Invasive

Low grade Ca ductal invasive

Desmoplasia >>>

Irregular shape

Spiculated

Posterior shadow

Low vascular

High grade Ca Ductal Invasive

Desmoplasia (-)

Oval / round

Ircumscribed

Enhancement

High vascular

IMAGING-PATHOLOGY

CORRELATION

5 possible

outcomes of imaging-pathology correlation

Category 1. Concordant Malignancy

Category 2. Discordant Malignancy

Category 3. Concordant Benign

Category 4. Discordant Benign Category 5. Borderline/High Risk

CONCORDANT MALIGNANCY

BI-RADS category 4 or 5- malignant on asubsequent core needle biopsy

DISCORDANT MALIGNANCY

BI-RADS category 2 or 3-malignant at coreneedle biopsy


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CONCORDANT BENIGN

BI-RADS category 2, 3-benign pathology at

core needle biopsy

follow-up sonography at 6 months after

biopsy and then annually for at least 2 years

FAM

DISCORDANT BENIGN

BI-RADS category 4-5-benign pathology at

core needle biopsy

Benign lesions with spiculated findings can

simulate malignant lesions

sclerosing adenosis,fat necrosis, postsurgical

scar, mastitis, granular cell tumor,diabeticmastopathy, and sarcoidosis

a substantial number of missed cancers at

core needle biopsy

For a sonography-guided 14-gauge core

needle biopsy,discordant lesions had cancer

rates of up to 50%.

Repeat biopsy A surgical biopsy

A the vacuum-assisted core needle biopsy.

Borderline or High Risk

A lesion in this category is not malignant but is considered to have an increased lifetime risk

for the

development of breast cancer (e.g., atypical

ductal

hyperplasia, lobular neoplasm, radial

sclerosing lesion,

papillary lesions, possible phyllodes tumors)

Thank you

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Dr. Lina Choridah