modalities

1. Screening Guidelines And Tools
Of Screening In Carcinoma
Breast And Its Impact On
Survival
By
Dr. Gedela Lakshmi Deepthi

2.  screening refers to a test or examination performed on
an asymptomatic individual.
 Goal : prevent death and suffering from the disease in
question through early therapeutic intervention.
 Screening may be either
opportunistic.
Programmatic

3. ACS 2012 – Breast Cancer
 worldwide breast cancer is the most commonly
diagnosed cancer in women—23% of total cases.
 Worldwide leading cause of cancer death in women ----
-14% of cancer deaths.
 most frequent cause --less developed regions
 second cause --more developed regions
 Since 1990 there has been decrease in death rate by
24% attributable to screening mammography and thus
early intervention.

4. GLOBOCAN Indian Scenario :

5. GLOBOCAN Indian Scenario :

6. Components Of A Breast Screening
Evaluation :
I. breast awareness (ie, patient familiarity with her
breasts),
II. physical examination,
III. risk assessment
IV. screening mammography
V. screening breast magnetic resonance imaging (MRI).
Although there is preliminary evidence that breast ultrasonography
can be a useful screening adjunct to mammography in the evaluation
of high-risk women with dense breasts, its use as a screening test is
not recommended at this time.

7. I . Breast Self Examination :
STEP 1

9. STEP 2

10. STEP 3

12. STEP 4 :

13. Impact :
 To date, no study has shown that BSEs decrease
mortality.
 BSEs have been studied in two large
randomized trials
 The UK Trialists study, a nonrandomized study
with 16 years of follow-up, showed no
significant difference in breast cancer mortality
between the BSE and control groups

14. Cochrane review
RUSSIAN : CHINESE/SHANGHAI:
 124,000
 monthly BSEs versus no
BSEs
 There was no difference in
mortality rates, despite the
BSE group having a higher
proportion of early stage
tumors and a significant
increase in the proportion
of cancer patients surviving
15 years after diagnosis.
 266,000
 10 years of follow-up
 there was no difference in
mortality, but the
intervention arm had a
significantly higher
incidence of benign breast
lesions diagnosed and
breast biopsies preformed.

15. BSE guidelines :
 no screening organization now recommends routine
instruction of women in BSE
 The ACS, the NCCN, and ACOG all promote teaching
patients about breast self-awareness, the concept that a
woman should be familiar with her own breasts and
bring any changes to the attention of her health
provider
 Breast Cancer Detection Demonstration Project, the
estimated overall sensitivity of breast self-examination
in detecting breast cancer was 26%

16. II . Clinical Breast Examination :
 A clinical breast exam (CBE) is systemic palpation
and visual inspection of entire breast by a health
professional such as a doctor, nurse practitioner,
nurse, or physician assistant.(ACS)
 national breast and cervical cancer early detection
program (UK) :
sensitivity –58.8%
specificity—93.4%

17. INSPECTION :
Patient must be stripped to the waist
Majority of the examination in the sitting position

18. 1.BREASTS
– position
size and shape
any puckering or dimpling
swelling or ulcer—
size, shape, surface
2.SKIN OVER THE BREAST— colour and texture
engorged veins
dimple, retraction or puckering
peau de orange
nodules
ulceration and fungation

19. 3.NIPPLE : presence
position
number
size and shape
surface
discharge
4. AREOLA :
colour
size
surface and texture

20. 5.Arm And Thorax :
6.Axilla And Supraclavicular Fossa
7.On Raising Arms Above The Head :
last part of inspection.
change in shape of breast reveals lumps , puckering
distortion .
it also reveals lower surface of breasts—if not lift up the
breast.
 Examine axilla
 Movements of shoulder

21. PALPATION :
 sitting position semi recumbent  recumbent position.
 Palpate normal breast first .
 Palpate with palmar surface of the fingers with hand flat
 Normal breast –firm lobulated impression with nodularity.
 4 quadrants to be palpated systemically
axillary tail
just behind the nipple
look for discharge

22. If Lump Is Detected :
 local temperature and
tenderness
 situation
 number
 size and shape
 Surface
 margin
 Consistency
 Fluctuation
 Transillumination
 fixity– skin,
breast tissue,
underlying fascia &
muscles
chest wall
 palpation of nipple

23. Examination Of Lymph Nodes :

24. Pectoral Group : Brachial Group :

25. Subscapular Group : Central Group:

26. SupraclavicularApical Group

27.  No randomized-controlled trials have been
conducted of CBE in women not receiving other
types of screening, and so the evidence for this
modality remains uncertain.
 A meta-analysis of clinical trials revealed a
pooled data sensitivity of 54% and specificity of
94%.

28. Guidelines For CBE :
• ACS - Every 3 y from ages 20 to 39, then annually
• ACOG
every 1-3yrs from ages 30-39yrs ,then annually
• NCCN
• USPSTF – insufficient evidence
• CANADIAN TASK FORCE - Every 1–2 y starting at
age 40

29. III . Risk Assessment :
Negative physical
examination
Risk stratification
Average risk Increased risk

30. Average risk :
According to ACS guidelines, this includes women
who:
 find out they have a lifetime risk of breast cancer of
15-20%, according to risk assessment tools based
mainly on family history
 have a personal history of DCIS, LCIS, or
abnormal breast cell changes such as atypical ductal
hyperplasia or atypical lobular hyperplasia
 have extremely dense breasts or unevenly dense
breasts when viewed by mammograms

31. Increased Risk :
A. Prior history of breast cancer
B. 5-year risk of invasive breast cancer ≥1.7% in
women≥35 yrs (per Gail Model)
C. Women who have a lifetime risk >20% as defined by
models that are largely dependent on family history.
D. Women who have a lifetime risk >20% based on history
of LCIS or ADH/ALH
E. Prior thoracic RT for patients younger than 30 y (eg,
mantle irradiation)
F. Pedigree suggestive of or known genetic predisposition.

32. Guidelines -Average risk :
 For women between ages 25 and under 40 years,
the NCCN Panel recommends CBE every 1 to 3
years and breast awareness encouraged.
 For women aged 40 years and older,
-- annual CBE and screening
mammography, and encourages breast awareness.

33. High risk :
A. prior history of breast cancer
 History and physical examination 1-4 times per year as
clinically appropriate for 5 yrs. and then annually.
 Mammography every 12 months.
 Women on tamoxifen : annual gynecological
assessment every 12 months if uterus is present.
 If no clinical symptoms or signs of recurrent disease –
no need of metastasis screening.
 Women on aromatase inhibitor – bone health
monitoring.

34. B . 5-year Risk Of Invasive Breast
Cancer ≥1.7% In Women≥35 Yrs (
As Per GAIL Model ) :
MODIFIED GAIL model …
 Current age
 Age at menarche
 Age at first live birth or nulliparity
 Number of first-degree relatives with breast cancer
 Number of previous benign breast biopsies
 Atypical hyperplasia in a previous breast biopsy
 Race*

35. B . NCCN Recommendations :
 encourages breast awareness and recommends
CBE every 6 to 12 months and annual
mammography .
 women in these groups should be asked to
consider risk reduction strategies

36. C. Women with a Lifetime Risk of
Breast Cancer >20% based on models
largely dependent on family history:
 MODELS – Claus, Tyrer-Cuzick, and other
models.
 BRCA risk patients -- BRCAPRO and Breast
and Ovarian Analysis of Disease Incidence and
Carrier Estimation Algorithm (BOADICEA)

37. Tyrer Cuzick model :
 includes family history and other inputs such as the
individual’s age, family history of breast and ovarian
cancer, age at menarche, parity, age at first childbirth,
age at menopause, use of HRT , Ashkenazi Jewish
heritage, history of breast biopsy and atypical
hyperplasia, LCIS, height, and body mass index.
 The model is a statistical model based on the Mayo
Clinic Benign Breast Disease cohort.

38. Claus model :
 no of first and second-degree relatives with breast cancer
and the age of cancer onset.
 The Claus model was developed from
the cancer and steroid hormone (CASH) population based,
case–control study .
 This model is based on the premise
that breast cancer risk is transmitted as an autosomal
dominant trait and bases the statistical calculation on the
genetic relationships between affected relatives and women
in question.

39. BRCAPRO :
 The BRCAPRO model requires a family pedigree as
the only input, including age of the individual, ages of
relatives, age of onset for particular cancers, and ethnic
heritage.
 This model is designed to predict who is a
BRCA-1 or BRCA-2 gene mutation carrier and who is at
the risk of developing breast and ovarian cancer.
 The BRCAPRO model is based on a Mendelian approach
that assumes an autosomal dominant pattern of inheritance.

40. Screening – special populations :

41. • Breast awareness - >18yrs
• CBE – every 6-12 months starting at age 25yrs
• Breast screening:
25-29yrs – annual MRI or Mammogram
30-75yrs – annual mammogram and breast MRI
>75yrs – individual basis
• Risk reduction mastectectomy and counselling
• Risk reduction salpingo oopherectomy –35 – 40yrs
• If not elected risk reducing salpngo oopherectomy then
Concurrent TVS and CA-125 every 6 months starting at
30yrs or 5-10yrs before earliest age at first ovarian cancer
diagnosis in family.
• Chemoprevention.

42. BRCA Positive Men :

43. Li Fraumeni Syndrome :
 For women with a TP53 mutation who are treated for
breast cancer, screening of remaining breast tissue with
annual mammography and breast MRI should
continue.
 Discuss option of risk-reducing mastectomy and
counsel regarding degree of protection, degree of cancer
risk, and reconstruction options.
 Address psychosocial, social, and quality-of-life aspects
of undergoing risk-reducing mastectomy.

44. Cowden Syndrome :
 Breast awareness >18yrs
 CBE every 6-12 months >25yrs or 5-10yrs
before
Earliest known breast cancer in family
 Annual mammogram and MRI >30-35yrs
 Endometrial cancer – annual endometrial
biopsies and/or USG >30-35yrs
 Option of risk reducing mastectomy

47. D . Women with a Pedigree
Suggestive Of or With a Known
Genetic Predisposition:
 encouraging breast awareness and CBE every 6-12
months starting at age 25 years.
 annual mammograms and breast MRI as an adjunct to
mammogram starting at age 25 years or on an
individualized timetable based on the earliest age of
cancer onset in family members.
 offer risk reduction counseling and strategies.

48. Risk Reduction Strategies :
 Lifestyle Modifications
 Bilateral Total Mastectomy
 Bilateral Salpingo-oophorectomy
 Risk-reduction agents (i.e., tamoxifen, raloxifene,
anastrozole, exemestane) are recommended for women
≥35 years of age only.

49. Bilateral Prophylactic Mastectomy-high
Risk Women :
AUTHOR POPULATIO
N
NO OF
WOMEN
FOLLOW UP
(yrs)
RISK
REDUCTION
(%)
Hartmann et
al
Women with
family history
of breast
cancer
639 14 (median) 90-94
Meijers-
Heijboer et al
BRCA 1 / 2
mutation
carriers
139 3 (mean) 100
Rebbeck et al BRCA 1 / 2
mutation
carriers
105 6.4 (mean ) 90-95

51. Clin Breast Cancer. 2007 Dec;7(11):875-82. doi:
10.3816/CBC.2007.n.053.
Bilateral prophylactic oophorectomy and bilateral
prophylactic mastectomy in a prospective cohort of
unaffected BRCA1 and BRCA2 mutation carriers.
Friebel TM1, Domchek SM, Neuhausen SL, Wagner T, Evans DG,
Isaacs C, Garber JE, Daly MB, Eeles R, Matloff E, Tomlinson G, Lynch
HT, Tung N, Blum JL, Weitzel J, Rubinstein WS, Ganz PA, Couch F,
Rebbeck TR.

52. Role of tamoxifen chemoprevention :
• the NSABP P1 trial, a 49% risk reduction was seen with
tamoxifen, with 43.4 cancers per 1,000 women occurring in
the placebo arm compared with 22.0 per 1,000 in the
tamoxifen arm.
• A particular benefit was seen in those at risk because of
atypical hyperplasia, with an 84% reduction in cancer
incidence in this group.

53. IV . Screening Mammography :
 Mammography is the process of using low-energy X-rays
to examine the human breast, which is used as a
diagnostic and screening
tool.
 goal –
early detection of
breast cancer.
 Only screening modality to
have shown decrease in mortality.

54.  Screening mammography has resulted in a shift in both
the Incidence & stage of patients presenting with
breast cancer.
 Advantages—
low cost
low radiation Dose
high sensitivity
 poor performance - women younger than 50 years is
related to lower breast cancer incidence, faster-growing
tumors, and reduced mammographic sensitivity caused
by breast density

55. Interpretation :
• Fatty – lease dense, appear dark on image
• Glandular tissue – dense, appear bright on image
• Pectoral muscle, axillary lymph nodes, calcifications
(calcium deposits), fluid filled cysts, tumors – dense,
appear bright on image

57. • reduces overlapping anatomy and decreases tissue thickness of
the breast • less scatter, less geometric blurring of the anatomic
structures, less motion and lower radiation dose to the tissues
Craniocaudal view : Mediolateral oblique
/lundgren’s :

58. Mediolateral Oblique View :
• pectoral shadow seen
down to level of nipple or
lower
• inframammary fold well
seen
• nipple in profile
• length of posterior nipple
line (PNL) within one 1cm
in size c.f PNL on CC
• images symmetric

59. Craniocaudal View :
 all glandular tissue
identified
 nipple in profile
 nipple in midline of
image
 length of posterior
nipple line (PNL)
within one 1cm in size
c.f PNL on MLO
 images symmetric

60. Standard Reporting :

61. 2. Breast Composition :
b. There are scattered areas
of fibroglandular density
a. The breasts are almost
entirely fatty

62. d. The breasts are extremely
dense, which lowers the
sensitivity of
mammography
c. The breasts are
heterogeneously dense,
which may obscure small
masses

63. 3 : Important Findings :
 Mass
 Calcification
 Architectural Distortion:
 Asymmetries (asymmetry, global asymmetry,
focal asymmetry, developing asymmetry)
 Intramammary lymph node
 Skin lesion
 Solitary dilated duct

64. Mass :
 'Mass' is a space occupying 3D lesion seen in two
different projections
Shape
Margins
Density
 If a potential mass is seen in only a single projection it
should be called a 'asymmetry' until its three-
dimensionality is confirmed.

65. The most significant features that indicate whether a mass
is benign or malignant are its shape and margins.
Evaluation Of A Mass : Shape

66. Evaluation Of A Mass : margins

67. Density of mass :
 The density of a mass can be designated as low,
intermediate or high by comparing it with an area of
normal breast tissue on the mammogram.
 benign masses are lower in density than carcinomas
 density is frequently not a reliable sign.

68. Calcifications :

69. Typically benign :

70. Suspicious morphology
Amorphous (BIRADS 4B)
So small and/or hazy in appearance
that a more specific particle
shape cannot be determined.
Coarse heterogeneous (BIRADS 4B) :
Irregular, conspicuous calcifications
that are generally between 0.5 mm
and 1 mm and tend to coalesce
but are smaller than
dystrophic calcifications.

71.  Fine pleomorphic (BIRADS
4C) Usually more conspicuous
than amorphous forms and are
seen to have discrete shapes,
without fine linear and linear
branching forms, usually < 0.5
mm.
 Fine linear or fine linear
branching (BIRADS 4C)
Thin, linear irregular
calcifications, may be
discontinuous, occasionally
branching forms can be seen,
usually < 0.5 mm

72. Distribution of calcifications :
• Diffuse: distributed randomly throughout the breast.
• Regional: occupying a large portion of breast tissue > 2 cm
greatest dimension

73. Grouped (historically cluster) : few calcifications
occupying a small portion of breast tissue (2cm).
Linear: arranged in a line, which suggests deposits in a
duct.
Segmental: suggests deposits in a duct or ducts and their
branches.

74. Associated features :


75. Architectural distortion
Differential diagnosis
includes --includes scarring
from previous surgery, radial
scar,and carcinoma.
It is the appearance on a mammogram of
spicules without an associated mass

76. Mammographic features characteristic of
breast cancer :
Mass with spiculated
margins
Microcalcification Architectural
distortion

77. 4.BIRADS
Breast Imaging Reporting and Database
System
 The American College of Radiology (ACR) has established a
uniform way for radiologists to describe mammogram
findings.
 The system, called BI-RADS, includes seven standardized
categories, or levels.
 Each BI-RADS category has a follow-up plan associated
with it to help radiologists and other physicians
appropriately manage a patient’s care.

78. Category 0 : Incomplete
 Need additional imaging evaluation
 Additional imaging needed before a category can be
assigned such as compression, magnification, special
mammographic views, ultrasound.
 This is also used when requesting previous images not
available at the time of reading
 Management :Recall for additional imaging and/or
comparison with prior examination(s).

79. Category 1 : Negative
 symmetrical and no masses, architectural
disturbances or suspicious calcifications present
 Management : Continue regular screening
mammograms (for women over age 40)
 Likelihood of cancer : 0 %

80. Category 2 : Benign
 this is a normal assessment
 Interpreter may wish to describe a benign-appearing
finding, e.g.
• calcified fibroadenomas
• multiple secretory calcifications
• fat containing lesions such as oil cysts
breast lipomas
fibroadenolipoma or mixed density hamartomas
galactoceles
simple breast cysts
• intramammary lymph nodes
 Management : Routine mammography Screening
 Likelihood of cancer : 0%

81. Calcified Fibroadenoma Vascular Calcification
Intramammary Lymph
Node

82. Category 3 : Probably benign
 noncalcified circumscribed solid mass,
 focal asymmetry which becomes less dense on spot
compression view
 solitary group of punctate calcifications
Management – short interval follow up(6 month) or
continued surveillance
Likelihood of cancer - >0% but <2%.

83. Category 4 : Suspicious
Category 4a in findings as:
 - Partially circumscribed mass, suggestive of (atypical)
fibroadenoma
 - Palpable, solitary, complex cystic and solid cyst
 - Probable abscess
Category 4b in findings as:
 - Group amorphous or fine pleomorphic calcifications
 - Nondescript solid mass with indistinct margins
Category 4c in findings as:
 - New group of fine linear calcifications
 - New indistinct, irregular solitary mass

84. Likelihood of cancer :
4a - >2% to <10%
4b - >10% to <50%
4c - >50% to <95%
Management : tissue diagnosis

85. Category 5 : Highly Suggestive of
Malignancy
• Spiculated,
irregular mass +
high-density.
• Fine linear
calcifications +
segmental or
linear
arrangement .
• Irregular
spiculated mass +
associated
pleomorphic
calcifications.
Use if a combination of highly
suspicious
findings are present:

86.  Management : tissue biopsy
 Likelihood of malignancy : >95%

87. Category 6 :
 performed after biopsy proof of malignancy (imaging
performed after percutaneous biopsy but prior to
complete surgical excision) in which there are no
mammographic abnormalities other than the known
cancer that might need additional evaluation.
 Management : Surgical excision when
clinically appropriate

88. Evolution of mammography :

89. Digital vs screen film :
 Digital mammography uses a special detector capable of
transforming x-ray images into electronic digital image.
 Advantages Of Digital :
no film processing
faster image acquisition
less call backs (due to ability to manage image
digitally)
 ACRIN trial—digital = screen film mammography
overall
superior in young women and those with
dense breasts.

90. Limitations:
 The compression of the breast is uncomfortable.
 Compression causes overlapping of the breast tissue.
 Mammograms take only one picture, across the entire
breast, in two directions: top to bottom and side to
side.

91. CAD :
 draws attention to areas of focal density or possible
micro calcifications potentially reducing the rate of
missed cancers.
 Computer algorithms process the digital
information in a given plane of view while
suppressing overlapping density from other planes.
 The advantage is improved sensitivity for cancer
detection and also improved specificity by reducing
false positives

92. Tomosynthesis :
• Digital tomosynthesis creates a 3-dimensional picture of the
breast using X-rays.
• Overcomes problems of standard mammogram
• It takes multiple X-ray pictures of each breast from many
angles. The breast is positioned the same way it is in a
conventional mammogram, but only a little pressure is
applied — just enough to keep the breast in a stable
position during the procedure.

93.  Tomosynthesis, also known as 3-dimensional
(3D) mammography, was patented in 1999 and
approved by the Food and Drug Administration
(FDA) in 2012.

94. Procedure :
Then the information
is sent to a computer,
where it is assembled
to produce clear,
highly focused 3-
dimensional images
throughout the breast
The X-ray tube moves in an arc around the breast while 11
images are taken during a 7-second examination.

96.  The cancer detection rate is increased for invasive but not
in situ cancers reflecting enhanced sensitivity for masses,
asymmetries, and distortions rather than calcifications.
 The radiation exposure for tomosynthesis remains a
potential limitation as the MGD varies from approximately
1.5-4 mGy per acquisition.
 limitation of tomosynthesis - decreased sensitivity for
detection of micro calcifications.
 Tomosynthesis is currently FDA approved as an adjunct to
standard mammography, and does not replace it.

97. Impact Of mammographic screening :
 first advocated in the 1950s.
 The Health Insurance Plan (HIP) Study –1963
61,000 women
 MMG + CBE vs. no screening
 mammography reduced breast cancer mortality
by 30% at about 10 years after study entry.
 18 years FU - 25% lower breast cancer
mortality rate in screening arm.

98. 9 PROSPECTIVE RANDOMISED
TRIALS :
 that screening women 40 to 75 years of age does
reduce the relative risk of breast cancer death by
10% to 25%.
 The 10 studies demonstrate that the risk–benefit
ratio is more favorable for women over 50 years
of age .

100.  The Canadian screening trial suggests mammographies
and clinical breast examinations do not decrease risk of
death for woman aged 40 to 49 and that
mammographies add nothing to CBEs for women age
50 to 59 years
 the Kopparberg Sweden study suggests that
mammographies are associated with a 32% reduction in
the risk of death for women aged 40 to 74 years

101. Guidelines - screening mammography:
• ACOG
• ACS
Annually beginning at age 40
• NCCN
• ACR
• CANADIAN TASK FORCE - Annually for women ages 50
to 74
 USPSTF - Every 2 y for women ages 50 to 74

102. V . SCREENING MRI
 The sensitivity of MRI for breast cancer detection is
estimated at 71% to 100%
 breast MRI vs mammography
sensitivity >mammography
specificity <mammography
resulting in a higher rate of false-positive findings
 micro calcifications are not detectable with MRI,
 whether breast MRI screening impacts survival has not
been addressed in randomized clinical trials

103.  MRI of the breast is not a replacement for
mammography or ultrasound imaging but rather a
supplemental tool.
 Breast MRI has never been directly compared with
mammography in the general population,

104. Indications :
Annual MRI as an adjunct to mammography starting at
age 30 is recommended for women:
 With a known BRCA mutation.
 Who are untested but have a first-degree relative with
a BRCA mutation.
 Who had been treated with radiation to the chest for
Hodgkin disease
 Who have an approximately 20% to 25% or greater
lifetime risk of breast cancer based on specialized breast
cancer risk estimation models.

105. Interpretation :
Enhancing lesions are divided into three main
categories :
focus
mass
non mass like enhancement

106. Focus :
 Focus (or when
multiple, foci) is an area
of enhancement
measuring less than 5
mm in diameter which is
too small to
characterize.

107. MASS :
 Shape
 Margins
 T1
 T 2
 Enhancement
pattern
 kinetics

108. T 1 characterstics :
 In T1 precontrast images
Fat appears bright (high signal)
fat necrosis
intramammary lymph nodes
hamartoma containing fat
 All are benign

109. T2 fat suppressed –characteristics :
 High signal is seen with water or fluid containing
lesions such as
cysts
lymph nodes
hamartoma
 All are benign except
high signal
malignant ---
colloid carcinoma

110. T2 fat suppressed –characteristics :
Moderate signal
 Invasive lobular Ca
 DCIS
 Fibrocystic change
Low signal
 Invasive ductal Ca
 Sclerotic fibroadenoma
 scar

111. Enhancement pattern :
 Homogenous enhancement
 Heterogenous
 Rim –high grade invasive ductal cancer,fat necrosis &
inflammatory cysts.
 Dark internal septations—fibroadenoma.
 Enhancing internal septations - malignancy
 Central enhancement – high grade ductal cancer

112. Enhancement patterns :
Homogenous
Heterogenous
Rim :

113. Kinetics : Type 1
 There is a slow rise and a continued rise with time.
 6 % chance of being malignant.

114. Type 2 :
• a slow or rapid initial rise followed by a plateau in
the delayed phase, which is allowed a variance of
10% up or down.
• The chance of a lesion with a type 2 curve being
malignant –BN type 1 nd 3

115. Type 3 :
 The type 3 curve shows a rapid initial rise, followed by a
drop-off with time (washout) in the delayed phase.
 A lesion with this type of curve is malignant in 29-77%.

116. Non mass enhancement :
 Non-mass enhancement is enhancement without three-
dimensional characteristics.
 distribution,
 enhancement pattern
 symmetry or asymmetry.

117. Distribution :
 Focal –<25% .
 Ductal involvement – 60% of cases.
 Linear enhancement – not ductal & 31% of cases.
 Segmental enhancement – multiple ducts & 78% chance
 Regional enhancement -- is not ductal or segmental &
21% chance.
 Diffuse non-mass enhancement –
is typically benign

118. Enhancement pattern :
 Homogenous
 Heterogenous
 Punctate – 25% chance
 Clumped – 60% chance

119. NCCN :
 MRI is more sensitive but less specific than
mammography, leading to a high FP rate and
more unnecessary biopsies, especially among
young women.
 The impact of MRI breast screening on breast
cancer mortality has not yet been determined.

120. Screening sonography :
 The American College of Radiology and the Society of
Breast Imaging recommend screening sonography as an
adjunct to mammography in high-risk women who
cannot have an MRI.
 Sonography is also recognized as a possible screening
supplement in intermediate-risk women with
mammographically dense breast tissue
 cancer detection rate generally associated with
screening mammography is 6 per 1000.

121. Interpretation :
Benign lesions
Well crcumscribed
with uniform
hyperechogenicity
Ellipsoid
capsule and
thick echogenic
capsule
2 o3 gentle
lobulations and
thich echogenic
capsule

122. Malignant features :
 Spiculations
 Angular margins
 Hypoechogenicity
 microlobulation

123. Malignant features :
 Shadowing
 Calcification
• Duct extension
• Branch pattern

124. BIRADS – USG :
BIRADS 2

125. BIRADS 5BIRADS 3

126. Elastography :
 Adding elastography to ultrasound screening may also
help us pick out those few lesions categorized as BI-
RADS 3 that turn out to be cancer.
 the sensitivity and specificity of elastography is 100%
and 90%
 Basis : compressibility
usually benign lesions compress with transducer pressure
and malignant lesions displace the breast tissue without
changing in height.

127. ACRIN 6666 trial
 In this trial, radiologists performing the sonography
were blinded to the results of mammography.
 Additional cancers were identified in 0.42% of women,
but sonography disproportionately increased the
number of biopsies
 Annual screening over a 3-year period continued to
return cancers in about 0.4% each year, but the biopsy
rate remained disproportionately high.

128. GUIDELINES :
 there is no recommendation for performing
ultrasound as part of routine breast cancer
screening.

129. NEW FRONTIERS :
 Molecular Imaging :
 Positron emission mammography (PEM)
 breast-specific gamma imaging (BSGI)
increase specificity in cancer detection by
demonstrating increased metabolic activity.
Both of these techniques have high positive predictive
values and low negative predictive values.
 Two-dimensional AWBUS :is a promising technology
that aims to standardize the screening examination and
produce a consistently high-quality examination to
improve the conspicuity of cancers

130. Problems of screening :
 Pain and discomfort
 Radiation exposure - 2 to 4 mGy (200–400
mrad) per standard 2-view examination .
 Anxiety
 False negatives
 False positives
 Cost
 Over diagnosis– 7-50%

131. Developing countries -- screening

132. Global Summit Early Detection Panel
and the Breast Health Global Initiative
 promote the empowerment of women to obtain health care
 develop the infrastructure to diagnose and treat breast
cancer
 begin early detection efforts through breast-cancer
education and awareness.
 when resources permit, expand early detection efforts to
include mammographic screening.
These recommendations for early detection and screening
are in line with World Health Organization guidelines

133.  The World Health Organization does not advocate
breast-cancer screening in countries with low- or
medium-level resources, because developing adequate
breast cancer therapy centres is more likely to affect
breast cancer mortality than screening alone .
 The Global Summit Early Detection Panel goes further
than this, and suggests that screening can be
implemented in countries with limited resources within
centralised cancer facilities at which breast cancer
treatment is available.

134. CONCLUSION :
 mammography is the only screening modality proven to
have decreased mortality.
 CBE is one of the most important methods for breast cancer
detection, especially in countries that lack screening
mammography.
 MRI and USG are used only as an adjunct to screening
mammography in high risk populations.
 Acc to NRHM & “health for all” – breast self examination
& breast awareness are the first step towards creating
nationwide screening program.