Breast Imaging

Breast imaging is a “catchall” term that encompasses many different imaging modalities. Any radiologic study that looks at the breast anatomy to evaluate it for disease is considered breast imaging. There are many different modalities including mammography, breast ultrasound, breast MRI, positron emission mammography, breast specific gamma imaging and thermography.

Each imaging study can give independent information to help your doctor determine whether or not your breast is healthy, needs to have a biopsy or needs to be watched closely for changes. There is no one imaging tool that finds 100 percent of cancers, therefore the imaging must be used in conjunction with your doctor’s assessment and clinical breast exam.

Screening Studies

Mammograms are the preferred screening tool around the world to detect breast cancers early. Digital imaging is the state-of-the-art imaging technique, which is rapidly replacing analogue, or film-screen mammography.

Breast MRI in high-risk women, those carrying the BRCA gene or those with a >20 percent lifetime risk of breast cancer, as calculated by their doctor, may obtain an annual MRI as part of their screening process.

To date, they are the only “screening” studies recommended.
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Mammography

Can early detection save your life?

Mammograms do not prevent breast cancer, they prevent death from breast cancer.

Studies have shown that mammography and the resultant early detection decreases the chance of dying from breast cancer by 40 percent. The smaller and earlier stage the tumor is at diagnosis, the better the chance of curing the disease.

Screening mammography can detect lesions in the breast often year’s earlier then clinical breast exam. The American Academy of Radiology, American Cancer Society and The American College of Surgeon’s all recommend annual mammograms for women over 40 and it is suggested you obtain a baseline at 35.

The Mammogram 
Mammography is the screening tool used for the early detection of breast cancer. We use two-dimensional pictures to evaluate a three-dimensional object—the female breast. The mammogram takes approximately 15 minutes to complete. Four views of the breast are obtained as a routine. Women with breast implants require four additional views to displace the implants for a better look. Occasionally, large-breasted women may require additional views to get all of their breast tissue on the film.

The breast is compressed from the top to the bottom in the cranial-caudal (cc) view (head to tail). The breast is then compressed from the medial aspect (the breast bone) to the lateral (armpit) in an angled fashion that allows the maximal view of the breast tissue in the MLO (mediolateral oblique view). If a mass or calcifications are seen on the screening mammogram, additional diagnostic views may be needed. Calcifications are evaluated by magnifying them (spot magnification view) and densities are evaluated by spot compressing (spot compression views). Additionally, a film may be performed called a true 90° view that allows the radiologist to know where in the breast a lesion is located within the breast tissue.

The compression of the breast is slightly uncomfortable, but is required to obtain the best pictures of your breast tissue to rule. The amount of radiation required for a low dose screening mammography is less then the radiation exposure from a plane flight at high altitudes repeatedly.
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Diagnostic Studies

Abnormal mammograms and palpable breast masses may lead to additional mammographic views (diagnostic mammography), breast ultrasound and occasionally breast MRI. If a suspicious lesion is identified, a breast surgeon should be seen for a comprehensive evaluation and a minimally invasive breast biopsy may be performed.

There are some new molecular breast imaging devices, PEM (Positron Emission Mammography) and BSGI (Breast Specific Gamma Imaging) that may play a role in the future work up of suspicious mammograms.

Breast MRI 

Magnetic resonance imaging (MRI) of the breast uses the energy of very strong magnets combined with an injection of gadolinium, a contrast medium used to enhance the images, to determine the nature of breast lesions. The scan should be performed between 7 to 14 days of the menstrual cycle to eliminate changes in the breast due to hormonal variations. The MRI requires placement of an intravenous line to inject the contrast. The MRI scanners are cylindrical chambers where the table moves into the cylinder order to complete the scan. Individuals who are claustrophobic may have difficulty with the scan. Some scanners can perform the scan on both breasts at the same time, where other scanners require a return on a different day to adequately evaluate the other breast. There is one breast MRI scanner that only scans breasts, and this scanner evaluates both breasts. To reduce claustrophobia, the scanner allows patients to go feet first, which provides a sense of relief for them who suffer from claustrophobia.

Positron Emission Mammography PEM

Breast Specific Gamma Imaging BSGI

Molecular imaging is in its infancy as a breast imaging technology. A nuclear tracer (sestamibi or FDG radio labeled glucose) is injected and after a variable time of waiting, images are taken. Images are obtained similar to mammography, but the time in compression is approximately 10 minutes per breast. The scanners are limited in their availability, but they will most likely become far more common in the next few years.
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Diagnostic Mammogram

A diagnostic mammography requires additional views of the breast in addition to the regular two views that are performed as a screening study. Diagnostic studies are performed to magnify to get a closer look at calcium deposits to determine if they need biopsy or if they can be watched. Spot compression views are ordered when there is a density or area of “thick” tissue that needs to be looked at with more intense compression of the mammography paddles. It is not necessarily more painful to compress the breast, it is just a focused compression to determine if a density in the breast is real and requires ultrasound and possibly biopsy, or if a region of thick tissue is just one piece of breast superimposed on another. Mammograms are two-dimensional pictures of a very three-dimensional object, therefore tissue can hide other tissue unless you push it out of the way.

If there is a question about whether or not a region of density is real or not, your doctors will almost always recommend a biopsy of the region or additional films.
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Breast Ultrasound

Ultrasonography (US) of the breast is a non-invasive diagnostic tool that is used to evaluate mammographic densities and palpable breast masses. Lying on your back with your arm over your head, warm gel is placed on the breast and a device called a transducer is used to create the image on the US machine. The transducer is gently moved over the breast to evaluate the areas of interest. Short pulses of electrical energy are transmitted through the breast and a signal is returned through the transducer, which creates a picture that is then interpreted by the radiologist or surgeon. The US is not painful or uncomfortable in any way.

US is often used to guide surgeons and radiologists when performing minimally invasive breast biopsies.
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Breast MRI

Magnetic Resonance Imaging (MRI) of the breast uses the energy of very strong magnets combined with an injection of gadolinium, a contrast medium used to enhance the images, to determine the nature of breast lesions. The scan should be performed between days 7 to 14 of the menstrual cycle to eliminate changes in the breast due to hormonal variations. The MRI requires placement of an intravenous line to inject the contrast. The MRI scanners are cylindrical chambers where the table moves into the cylinder order to complete the scan. Individuals who are chlaustrophobic may have difficulty with the scan. Most scanners can perform the scan on both breasts at the same time where other scanners require a return on a different day to adequately evaluate the other breast.

If you have trouble with clasutrophobia, you should alert you physician. Many centers now require you to have a pre-scan evaluation of your kidney function with a simple blood test.
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Positron Emission Mammography (PEM)

Molecular imaging is in it’s infancy as a breast imaging technology. A nuclear tracer FDG <fluorodeoxyglucose> radio labeled glucose, is injected into an arm vein and after a variable time of waiting, images of the breast are taken. Images are obtained similar to mammography, but the time in compression is approximately 10 minutes per breast. PEM scanners are limited in their availability, but they will most likely become far more common in the next few years.

The FDA has approved minimally invasive biopsy devices that can be used in conjunction with the PEM imaging. <Dr DuPree was one of the first physicians to perform a PEM biopsy in the country!>

Most insurance carriers will cover this imaging for women with a cancer diagnosis.

This scan is related to PET scans that are often performed to look for cancers that have spread to other areas of the bosy. The difference between the scans is the ability of the PEM scanner to find small areas in the breast that are less then 2mm in size that may be early non-invasive cancers. (The whole body scans are less sensitive and can only detect cancer regions that are larger then 7mm)
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Breast Specific Gamma Imaging (BSGI)

Molecular imaging is in its infancy as a breast imaging technology. A nuclear tracer (sestamibi) is injected and after a period of waiting, images are taken. Images are obtained similar to mammography, but the time in compression is approximately 10 minutes per breast. This technology has great promise in women who have very dense breast tissue and can be used as an adjunct to mammography.

The scanners are limited in their availability, but they will most likely become far more common in the next few years. It is hoped that they may become a standard tool for evaluation of dense breast tissue.
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Thermography

Thermography is an imaging modality that is a noninvasive method of imaging the breast that measures differences in heat distribution in the breast. We know that ingrowth of blood vessels, angiogenesis, is a very early sign of the development of a breast cancer. Thermography has not been proven to be effective in screening for breast cancer and is not covered by standard insurance companies.

Disclaimer: Breast thermography offers women information that no other procedure can provide. However, breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography is meant to be used in addition to mammography and other tests or procedures. Breast thermography and mammography are complementary procedures—one test does not replace the other. All thermography reports are meant to identify thermal emissions that suggest potential risk markers only and do not in any way suggest diagnosis and/or treatment. Studies show that the earliest detection is realized when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor.
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Abnormal Mammogram

Mammograms do not prevent breast cancer; they can prevent DEATH from breast cancer.

Mammography is the breast cancer screening tool that is used throughout the world as the standard method of early breast cancer detection. Countries vary in the interval between screenings and the age at which the screening begins. In the United States, the recommendation is for annual screening mammography from the age of 40 on with a baseline study between 35 and 40.

Ideally, we would like to be able to detect changes in the breast that are considered pre-cancerous therefore preventing a cancer from forming and by identifying women at high risk so that they can be followed more closely.

There are certain findings or changes that can be perceived or seen on the mammograms. The changes can fall into two main categories; microcalcifications and densities. If either is identified on the screening mammogram, additional views (spot compression, spot magnification and true lateral imaging) and occasionally a breast ultrasound may be recommended.
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Microcalcifications

Microcalcifications are small deposits of calcium that accumulate in the breast from a variety of sources. Calcium is a byproduct of cell metabolism. (In other words, the trash from the cells doing their job). Calcium can be formed in cancers and also in benign or noncancerous lesions.

The difficulty in this process is determining what the source of the calcium is. If we could tell just by looking at the mammogram whether or not the calcium is coming from a cancer, there would be no need to do 70-80 percent of the breast biopsies each year. Since we cannot determine this by looking alone, we need to biopsy enough of the calcium deposits so that we do not miss the cancers.

The breast is a living organ, and as such, changes occur monthly that are under the influence of hormone changes in the body. Our ultimate goal is to find a cancer as early as possible or better yet, identify tissue in the breast that is beginning to exhibit bad behavior otherwise known as “cellular atypia” (cells that are dividing faster than normal but not fast enough or bizarre enough to be called cancer).

Microcalcifications can be classified as clustered, pleomorphic, branching, snakeskin, crushed stone, vascular, dystrophic, scattered or any number of varieties of the former. Depending upon the specifics of the calcium deposit, a biopsy may be recommended. Most microcalcifications are able to be sampled via minimally invasive vacuum assisted stereotactic biopsy. If the breast is very small, calcium is close to the chest wall or under the nipple, or at the surgeon’s discretion, an open surgical biopsy using a needle localization technique may be warranted.
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Density

Densities are the second finding on a mammogram that warrants evaluation. A density is a region seen on the mammogram that stands out from the surrounding tissue. Prior mammograms, if available, are essential in completing the mammographic evaluation, as a subtle change in the density if the breast may only be perceived when the films are compared to previous studies.

Densities, once proven to be persistent even when the breast is compressed, should be evaluated by an ultrasound.

Densities can be anything from a simple cyst (a fluid filled sack that is not cancer) to a cancer invading into the breast tissue. Densities are often described as round, regular, oval, asymmetrical, speculated, irregular or any combination of these. In order to determine what is causing the mass, a biopsy may need to be performed. This may be as simple as placing a needle into the lesion to pull out fluid or as complex as going to the operating room to have the area removed.

The “Best Breast Practice” in 2010 is to have what is called a minimally invasive diagnostic biopsy. At your surgeon’s discretion, you may need to go to the operating room to have an open surgical biopsy through a standard incision.
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Breast Biopsy

You will be offered several options for diagnosis and treatment of your breast problem. The options are given to you, recommendations are made and you will be able to decide what works best for you.

When an abnormal mammogram, ultrasound, MRI or a palpable mass are found, a breast biopsy may be necessary to be sure that a cancer is not growing in the breast tissue. Minimally invasive breast biopsy is the method of choice to determine if a lesion is cancer, pre-cancerous or benign (not cancer). This means that samples of the tissue are extracted from the breast with guidance from a mammogram, ultrasound or MRI. If the mass can be felt, a minimally invasive biopsy can also be performed. Once the tissue is removed, it is sent to the pathologist to be evaluated.

What does the biopsy entail?
Obtaining an accurate diagnosis is the key to breast biopsy. The state-of-the-art method for the diagnosis of both cancer and noncancerous or benign lesions of the breast is through a minimally invasive biopsy technique (consensus statement 2009). The imaging method (mammogram, ultrasound, MRI) is chosen by how the lesion is best visualized and the type of biopsy, whether it is a core biopsy, vacuum assisted biopsy or excisional biopsy is chosen by the surgeon or radiologist to allow for the most effective method that will make an accurate diagnosis.

With a core biopsy, a small needle biopsy device is inserted into the breast multiple times to obtain tissue to send to the pathologist for evaluation. With a vacuum assisted biopsy, the device is inserted once and several samples are removed. An open surgical excisional biopsy requires a trip to the operating room.

With an incisional biopsy, a piece of breast tissue is removed. An excisional biopsy removes the entire lesion.

With a fine needle aspiration (FNA), your doctor will insert a skinny needle into a lesion or a lymph node in order to remove cells that can be evaluated under a microscope. An FNA may not be able to give your doctor all of the information they need to be certain that a breast lesion is not cancer. You may require an additional biopsy if the FNA is felt to be non-diagnostic. Your doctor should discuss all of these options with you before a biopsy is performed. FNA is often used to evaluate lymph nodes that are enlarged.
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Open Surgical Biopsy

Incisional Biopsy
Incisional biopsy is a procedure performed either in the office or operating room, where a piece of a breast mass is removed for the purpose of obtaining a diagnosis. It is an option used when a mass requires evaluation and the surgeon deems it is necessary to take a piece of skin, or just needs to have a larger sample of the mass to make a diagnosis. The surgeon will mark the area while you are awake and then begin the procedure.

Once the skin is cleansed and numbed with local anesthesia, an incision is made and the tissue is removed and the skin placed back together.

Open Surgical Biopsy
Open surgical biopsy is a procedure performed in the operating room or office that removes a palpable mass. It is always an option when you can feel the lesion. It is at times the recommended procedure if the mass is near the nipple or very close to the surface of the skin.

The surgeon will mark the area while you are awake and can confirm that the appropriate area is being removed. The skin is then cleansed with antiseptic solution. Then under local anesthesia, with or without drugs to sedate or relax, the area is removed through a small incision in the skin. Once the mass is removed, the skin is reapproximated to create the best cosmetic result possible.

Risks

Bleeding
Infection
Anesthesia
Defect in the breast
Scar formation

Needle Localization Biopsy
Needle localization biopsy is an open biopsy that uses the placement of a needle to guide the surgeon to the area of interest. It is placed under mammographic, ultrasound or even MRI guidance. It may be used as a primary procedure or as a follow up to a stereotactic or mammotome biopsy.

If you plan to undergo this procedure, you will take a trip to the radiology department before surgery and a series of mammograms, MRI or an ultrasound will be used to place a needle. The radiologist will place a needle in to the breast to guide the surgeon to the exact area of concern. An area of previous biopsy that is marked by a clip or marker may be the target or possibly the needle may be identifying an area of microcalcifications for excision. If you have a larger area of microcalcifications, the doctor may choose to place two needles to “bracket” the area in question.

Once the needle(s) are placed, a series of follow up mammograms are needed with the needles in place to guide the surgeon as to where to go in the operating room.

An X-ray of the specimen will confirm that the appropriate region has been removed.

Risks

Bleeding
Infection
Anesthesia
Defect in the breast
Inability to remove the lesion, clip or calcifications

Minimally Invasive Biopsy

Indications: To obtain a diagnosis of a breast lesion that is seen on mammogram, ultrasound, MRI or is palpable on breast exam (2009 Consensus Statement “Best Practice” for diagnosing breast lesions).

Benefits:

Can be performed in the doctors office or outpatient imaging facility
Local anesthesia
Choice of incision placement
Precise targeting of the lesion
No radiation exposure
Minimal disruption to normal tissue
More rapid pathology reporting
Less time away from work and play

Risks:

Bleeding, hematoma (blood collection)
Pain
Infection
Skin dimpling from the incision
Marker palpable after the procedure
Biopsy of the incorrect area
Neck stiffness
Loss of nipple sensation (if the lesion is near the nipple)
Mondor’s disease (thrombosis of a superficial vein in the breast)

Alternatives:

Open surgical biopsy
Short term radiologic follow up
Birads-3 lesions (lesions felt to be likely noncancerous)

Associated Factors: You are awake for the procedure and will be made as comfortable as possible.

Stereotactic Breast Biopsy – With this type of biopsy, the mammogram is used as our guide to obtain the specific tissue that we need to sample. You are placed face down on the table and by gravity, your breast hangs through a hole in the table. Your breast is then imaged with a low dose, digital X-ray to identify the density or area of calcifications. Once the area is identified, the computer helps to determine the appropriate placement of the biopsy device. Once images are confirmed, the breast is cleansed and local anesthesia (lidocaine) is placed. After a tiny nick is made in the skin, the device is positioned and a digital image checked. The area is further infiltrated with lidocaine to numb or deaden the area. The samples are then taken and an X-ray confirms the presence of the calcifications in the specimens. At the completion of the procedure, a radiologic marker is placed to mark the area for future reference. The marker may be made of titanium or surgical steel and often has a material that makes it visible under ultrasound as well.

Don’t worry—they will not set off the metal detectors in the airport! This marker allows us to know where to return to if further surgery is needed, and it also allows the radiologist in the future know that you did indeed have a biopsy of that area. When the procedure is completed, the technologist will initially hold pressure on the area and they apply steri-strips or surgical glue. An outer dressing is placed. Many times an ace wrap or tube top-type wrap is placed to add additional pressure over the biopsy site. You may have a regular mammogram immediately after the procedure if one is necessary to confirm that the appropriate area has been biopsied.

Ultrasound Guided Vacuum Assisted Biopsy – This procedure is performed when there is either an ultrasound abnormality or a palpable mass in the breast. You are placed on the table lying on your back and your arm is usually over your head. Once the breast is scanned with the ultrasound machine, the area for biopsy is marked with a surgical marker. The breast is then cleansed with an antiseptic and the area is made numb with lidocaine. The incision is made as a tiny nick in the skin. A larger needle is then used to assure the area is completely numb. Once the lidocaine is allowed to work, the biopsy devise is inserted under ultrasound guidance. Once position is checked, the area is sampled. If all image evidence of the lesion is to be removed, the procedure is continued until the ultrasound image of the density confirms the removal. A tiny marker is then placed for future reference. Pressure is held over the biopsy cavity and then steri-strips and sterile dressings are placed. A mammogram may be performed if confirmation of a mammographic lesion is necessary.

MRI Guided Biopsy – When an abnormality is identified on MRI and it is the only modality that identified the lesion, a biopsy may require MRI guidance. Your biopsy will be performed using a breast MRI scanner. After an initial scan, an injection of gadolinium (a contrast material that enhances the image) will allow our radiologist and/or surgeon to identify the abnormality; sophisticated software is then used to localize the lesion. Once the lesion is localized, you will have your breast cleansed, after which local anesthesia is administered. The biopsy device is placed, and an additional scan confirms that we are in the appropriate position. When the position is confirmed, the biopsy is performed, and a marker is placed to identify the biopsy site in the event that a cancer or atypical lesion is found. The final scan confirms the placement of the marker, and steri-strips are placed, as is an ace wrap, which helps prevent bleeding.

Core Needle Biopsy – A biopsy performed in the doctor’s office to make a diagnosis of a breast problem. When the patient and the doctor feel a lesion, a core biopsy can be used to confirm a diagnosis and/or to rule out a cancer. This procedure can be performed with or without ultrasound guidance. The procedure involves the cleansing and numbing of the skin. A small nick is then made in the skin and the core needle device is repeatedly placed in the breast, fired and removed, until adequate samples are obtained. With this biopsy technique the area is not removed, just sampled. A marker can be placed to mark the area or the physician may choose not to mark the lesion. No sutures are needed, just steri-strips to approximate the skin.

Fine Needle Aspiration – A procedure that is performed to sample cells from a solid lesion or to confirm that a mass is a fluid filled cyst. A skinny needle is inserted into the breast without anesthesia. This may be done with or without ultrasound guidance. If your pathologist is not specially trained in FNA cytology readings, then a core biopsy would be a better choice. The results of the cytology are only as good as the pathologist reading the slides. If fluid is obtained, it may be discarded or tested based upon its consistency. Further biopsies may be required if the mass is solid.
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Benign Breast Pathology

Benign is a category of breast lesions that do not need to be completely removed and do not increase a woman’s risk of developing breast cancer. Lesions that fall into this category are fibroadenomas, papillomas, fibrous mastopathy, sclerosing adenosis, PASH (pseudoangiomatous stromal hyperplasia) and various other noncancerous growths.

During the biopsy procedure, the surgeon or radiologist removes the suspicious tissue to see if it is benign or malignant. If it is malignant, the pathologist will try to identify the type of cancer cells present, how fast they reproduce, if the blood vessels or lymph systems contain cancer cells, and if the cancer’s growth is affected by hormones. This information allows your doctor to determine the best treatment for you.

There are two ways that a pathologist prepares the tissue for examination—a “frozen section,” which is a quick procedure that takes about 30 minutes, and a “permanent section,” which takes two to three days.

The frozen section is a quick way of determining whether or not cancer is present in the tissue and is often used when evaluating lymph nodes for spread of cancer while the patient is asleep in the operating room. The permanent section is the most accurate method and is the standard for diagnosis of breast lesions.

We encourage you to visit www.breastcancer.org and type in your pathology to obtain an understanding of your personal pathology report.
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Post Op Instructions

Ice area of surgical incision every three to four hours on night of surgery
You may remove outer bandage on day after surgery (If you have been placed in an ACE wrap, please leave it in place until the morning after your biopsy)
Leave steri-strips or dermabond in place until seen in office or it falls off
You may shower on day after surgery
No tub bath or swimming for 10 days after surgery
You may use your prescription pain medicine as prescribed or Tylenol 650 mg every four hours as needed for pain
You may use Ibuprofen 200 mg as prescribed on the bottle in addition or conjunction to the above pain meds.
You should be seen in the office in approximately 10-14 days after surgery for a check up
Please call if you develop fever, chills, worsening pain or redness/drainage at the incision site
Avoid heavy lifting or pushing
Please do not drive while taking prescription pain medications
Please call with any other problems or concerns.