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optimizing RadPath Conference for
residents and medical students
Breast Imaging Division 2018
Views You Can Use:
R2P2 week 2(Resident RadPath Powerpoint)
R2P2 weekly .pptx aka educational modules
• wk1 basics of radpath-high risk lesions-risk factors amplified
• wk2 basics of radpath amplified-screening mammography-medical audit basics-common cancer histology
• wk3 cancer histologies-breast cancer staging and survival-common benign breast dx
• wk4 molecular subtypes-breast MRI
Today’s R2P2
• Week 2 .pptx to supplement the imaging during discussion
• Amplify Bassett article homework week 1 (follow-up, false negative, underestimation of disease tenets)
• The abnormal screening mammogram
• The medical audit
• Case-based learning histology of breast cancer
Radiology Pathology Concordance
• Concordant (choose one of)
- Clinical follow-up
- 6-month follow-up
- 1-year follow-up
• Discordant (choose one of)
- Re-biopsy same modality
- Re-biopsy different method
- Surgically excise
Radiology Pathology Concordance
• Concordant (choose one of)
- Clinical follow-up: if high risk, malignant, <40 benign
- 6-month follow-up: 14 gauge US CNB
- 1-year follow-up: 9 gauge CNB, FA
• Discordant (choose one of)
- Re-biopsy same modality
- Re-biopsy different method
- Surgically excise
Follow-up for Benign CNB
• Follow-up crucial
• Established schedule and clear recommendations communicated to MD and pt
• ALC 14g (US) benign concordant = 6 month
• VACB 9g (Stereo) benign concordant = 12 month
• 1 year followup adequate for ‘definite benign’ cases 14g (FA)
False negative CNB
• Defined: CNB benign on pathology but with cancer detected on interval followup in same quadrant
• Does not include discordant or underestimation of disease
• False negative rate for CNB 2%
• Equal to excisional biopsy false negative rate
• Follow-up crucial
CNB underestimation of malignancy
• Occurs when CNB of calcs indicates atypia or DCIS but IDC is identified at surgery
• Atypia and DCIS more likely at final pathology if 1-10mm, granular calcs, 8-11 g VACB
• Invasive cancer foci more likely at final pathology if:
a. calcs extended 11 mm or more
b. fine linear branching calcifications
c. 14g ALC device
Bassett LW, Mahoney MC, Apple SK. Interventional Breast Imaging: Current Procedures and Assessing Concordance for Pathology. Radiol Clin N Am 45 (2007) 881–894
Recommend Further Tissue Sampling due to:
• ADH
• ALH and LCIS = lobular neoplasia
• Other high risk lesions per next slides (‘atypia’)
• Radial scar and Complex sclerosing lesion
• Discordance
• Insufficient tissue
• Locally aggressive benign diagnosis per later slide
Today’s R2P2
• Week 2 .pptx to supplement the imaging during discussion
• Amplify Bassett article homework week 1
• The abnormal screening mammogram
• The medical audit
• Case-based learning histology of breast cancer
Remember: At-Risk Population
• Female
• Age > 50
• Mammographically dense breasts
• BRCA1 and BRCA2 - 80% risk
• Syndromes - Li-Fraumeni, Cowden, Peutz- Jeghers, Ataxia Telangiectasis
• Personal history of breast, ovarian, colon cancer
• Personal history of high risk benign biopsy
• Positive family history first degree relative
• Personal history of mantle radiation for Hodgkin Ds
Screening Mammography
• Standard projections MLO and CC
• If Baseline risk pt: Begin age 40 and annual thereafter
• High risk screening pt: test(s) determined by her specific risk parameters ie mammo+US/MR
• SEARCH! Screening mammogram hallmarks of malignancy: suspicious mass, calcifications, site of architectural distortion, asymmetry
Architectural Distortion
• Normal breast architecture is distorted with no definite mass
• Thin straight lines of spiculations radiating from a point; focal retraction, distortion, straightening at the anterior or posterior edge of the parenchyma
• May also be seen in association with asymmetry or calcifications
• Determine if concordant history of trauma or surgery
• DDx = Cancer, Radial scar, Posttraumatic/Surgical scar, Infx
Asymmetries
• Unilateral deposits of fibroglandular tissue not conforming to the definition of a radiodense mass. Four types:
• 1. ASYMMETRY - visible in only one mammographic projection. Typically summation artefact
• 2. GLOBAL ASYMMETRY - large amount of fibroglandular-density tissue over a substantial portion of breast (at least a quadrant) compared to contralateral breast. Usually normal variant
• 3. FOCAL ASYMMETRY - relatively small amount of fibroglandular-density tissue over a confined portion of breast (< a quadrant). Concave borders and interspersed fat distinguish from mass. DDxSuperimposition of two normal structures, Mass
• 4. DEVELOPING ASYMMETRY - focal asymmetry that is new, larger, or more conspicuous than previously. 15% are CA
The Abnormal Screening Mammogram
Abnormal screening mammogram is assigned BI-RADS® CATEGORY 0 and is called back for a Diagnostic breast imaging workup
• For mass/asymmetry: compression magnification views in MLO and CC possibly followed by targeted ultrasound
• For architectural distortion: compression magnification views in MLO and CC possibly followed by targeted ultrasound
• For calcifications: compression magnification views in TL 90 and CC
• PPV1 based on abnormal screening exam 3-8%
• PPV2 when biopsy (surgical, FNA, or core) recommended 20-40%
Case-based learning #3Asymmetry patient
69 yoF abnormal left screening mammogram
LT CC 2016 LT CC 2013
20132016
Case-based learning #3 Asymmetry patient
69 yoF abnormal left screening mammogram
LT CC 2014
Case-based learning #3Asymmetry patient
69 yoF abnormal left screening mammogram
US CNB + Clip Critical to place/confirm clip
Case-based learning #4CA presenting as an asymmetry
69yoF right breast mass
Current RT MLO and CC Prior RT MLO and CC
Case-based learning #4CA presenting as an asymmetry
69yoF right breast mass
Current RT MLO comp mag RT CC comp mag
Screening Mammography
ACR BI-RADS® 5th ed Desirable Medical Audit #s for interpreting radiologists
• Cancer detection rate (per 1000 exams) >2%
• Abnormal interpretation (recall) rate 5-12%
• Sensitivity >75%
• Specificity 88%-95%
• PPV1 based on abnormal screening exam 3-8%
• PPV2 when biopsy (surgical, FNA, or core) recommended 20-40%
ACR BI-RADS® Breast Imaging Audit
ACR BI-RADS® 5th ed now includes auditing procedures for all three modalities Mammography Ultrasound MR• Positive exam defined as further imaging or short interval
surveillance (BI-RADS® 0 and 3) on screening OR tissue diagnosis recommended (BI-RADS® 4 and 5) on diagnostic study
• Negative exam defined as tissue diagnosis not recommended (BI-RADS® 1 and 2 on screening OR BI-RADS® 1, 2 and 3 on diagnostic study)
• True positive TP defined as tissue diagnosis of cancer within 1 year of a positive exam
• True negative TN defined as no tissue diagnosis of cancer within 1 year of a negative exam
• False negative FN defined as tissue diagnosis of cancer within 1 year after the negative exam
• False positive FP has 3 separate definitions (see next slide)
ACR BI-RADS® Breast Imaging Audit
False positive FP has 3 separate definitions:
• FP1 = No known tissue diagnosis of cancer within 1 year of a positive screening examination
• FP2 = No known tissue diagnosis of cancer within 1 year of a tissue diagnosis recommendation
• FP3 = Concordant benign tissue diagnosis or discordant benign tissue diagnosis and no known diagnosis of cancer within 1 year of a tissue diagnosis recommendation
TP + TN + FN + FP = total number of examinations
Today’s R2P2
• Week 2 .pptx to supplement the imaging during discussion
• Amplify Bassett article homework week 1
• The abnormal screening mammogram
• The medical audit
• Case-based learning histology of breast cancer
Ductal carcinoma in situ
• Accounts for 20-25% CA
• Confined to the ducts
• Increased risk in pts with family history, elevated BMI postmenopausal, dense breasts
• Mortality is extremely low and related to IDC 8-10 years post diagnosis of DCIS
• Mammographically detected
• May also present with mass, nipple discharge, Paget’s disease
DCIS on Imaging
• Mammographically detected
• Fine linear and fine linear branching calcifications, pleomorphic calcifications - high grade DCIS
• Amorphous and coarse heterogeneous - low to intermediate grade DCIS
• On MRI - nonmass enhancement with delayed peak enhancement kinetics
• Path DDx UDH, ADH, IDC
Incidence of Histological Types of Invasive Breast Cancer
• Invasive Ductal Carcinoma NST (No special type) 70-80%
• Invasive Lobular Carcinoma 10-15%
Special Type (Rare) Carcinomas each <1-5%• Mucinous• Medullary• Tubular• Papillary • Metaplastic• Anaplastic
Case-based learning #5CA patient
71 yoF right breast mass
MLO CC
Case-based learning #5CA patient
71 yoF right breast mass
MLO CC
Case-based learning #5CA patient
71 yoF right breast mass
MLO CC
Illustrates typical breast imaging care algorithm
• Diagnostic workup to include full field, compression magnification views and ultrasound of mass and axilla
• USCNB + clip for index mass and USCNB (or FNA) of axillary LN
• RadPath review (at UNC, we have RadPathintradepartmental conference)
• Oncologic referral (at UNC, MDC referral and conference discussion)
• Mammographic grid- or US-guided needle localization if breast conservation
• Sentinel node injection unless pt has biopsy proven LN and will undergo axillary node dissection
Infiltrating Ductal Carcinoma NST
• Accounts for 50-75% invasive cancers
• Heterogeneous group of tumors without sufficient histologic features to be classified more specifically
• Ductal origin
• Present as mass, size varies
• Mammogram, US, and MR evident
(Recall pt #4) Infiltrating Lobular Carcinoma
• Accounts for 10% CA• Lobule rather than duct origin• Women in early 60s slightly
older than IDC• Present as thickening• Multifocal, multicentric,
bilateral• Asymmetry, architectural
distortion or occult on mammogram
• Indistinct mass on US• MRI has important role
One final slideCore Foundation RadPath2
DCIS presents as calcs, rarely as Paget, mass.
Accounts for ~25% breast cancer, Stage 0 disease, no
LN spread hence no sentinel node. 100% 5 year survival
Most common invasive cancer is Invasive mammary
of no special type 75%. Special types include ILC 10-
15%, all others <5%
15% developing asymmetries are CA. If subtle asymmetry and architectural distortion, think ILC
Medical Audit desired: Recall rate 5-12%, PPV2 20-40%, Sensitivity
>75% and Specificity 88-95%
One final slideCore Foundation RadPath1
RadPath DIScordancyrequires rebiopsy: often (but not always) needle localization followed by
excision
RadPath CONcordancyrequires followup
recommendation: follow up imaging, clinical
followup, surgical referral
AT RISK Patients include: BRCA gene mutations, other hereditary, prior/family history breast, ovarian colon, prior mantle radiation
HIGH RISK Pathologies include: ADH, FEA, Lobular neoplasia,
Papilloma with atypia, Radial scar CSL
R2P2 weekly .pptx aka educational modules
• wk1 basics of radpath-high risk lesions-risk factors amplified
• wk2 basics of radpath amplified-screening mammography-medical audit basics-common cancer histology
• wk3 cancer histologies-breast cancer staging and survival-common benign breast dx
• wk4 histologies-breast MRI