Criteria for suggesting mammogram or ultrasound screening
- 1. Criteria for suggesting mammogram or ultrasound screening Dr. Ahmed A. Kandil, MD.,PhD. Consultant Surgeon Ahli Arab Hospital 2018
- 2. Background • Although various radiographic modalities are available to identify lesions that are suspicious of breast cancer (BC) • Mammography remains the mainstay of BC screening • Role of breast ultrasound is confined mainly to the diagnostic follow up of a mammographic abnormality because it may help to clarify features of a potential lesion
- 3. Background • The life time risk of being diagnosed with BC is 12.3%, or 1 in 8 women • BC is the second leading cause of death after lung cancer in women • Overall BC death rate decreased because of both improvement in early detection and treatment
- 4. Introduction • Reduction of mortality from breast cancer is the goal of health providers allover the world • Different modalities for this purpose tried likes:- Breast self examination Clinical exam by doctors Screening mammography Screening ultrasonography
- 5. Risk factor for breast cancer • History of chest radiation • History of breast cancer • Extremely dense breasts compared with fatty breasts • History of biopsy with atypical hyperplasia • Two first degree relative with cancer breast • Menopause > 55y compared with ≤ 45y • Nulliparity or first full term pregnancy ≥ 30y
- 6. Risk factor for breast cancer • Menarche before 12y • History of begin breast biopsy • Post menopausal obesity • Currant use of combination menopausal hormone therapy • Genetic factor
- 8. Screening mammogram • Is performed in an asymptomatic patient to search for possible occult (hidden) BC • But, diagnostic mammogram is performed in a symptomatic patient most commonly with pain or a lump to evaluate for possible BC or other cause of the patient symptoms
- 9. mammography
- 10. Indications Quoted from the ACS Women with an average risk of breast cancer should undergo regular screening mammography starting at 40 y Women 45-54 y should be screened annually Women > 55 y should be screened every 2 y or every year Women should have the opportunity to begin annual screening between the ages of 40-45 y Women should continue screening mammography as long as their overall health is good and they have life expectancy >10y The ACS - does not recommend clinical breast exam for breast cancer screening among average-risk women at any age
- 11. Earlier screening Screening mammogram can be done earlier in: • Women who have had breast cancer or a biopsy diagnosis of LCIS • Women with 1st degree relative (mother or sister) who developed BC • Women who received irradiation to chest • For women with +ve genetic testing BRCA1 or BRCA2 screening mammogram can be done 10y earlier than 40y
- 12. Mammographic examination • Mammogram use low x-ray dose • Routine mammogram compromises of CC & MLO views to adequately image whole breast • Adequate degree of breast compression is applied before shooting the x-ray • Compression helps in increasing the image contrast by reducing motion artifact and by enhancing the x-ray penetration • The radiation dose absorbed by the breast depends on breast tissue thickness
- 13. Mammographic examination • Digital mammography use less x-ray and give better quality images • Digital image can either electronically sent to a viewing station or copied on CD • A film screen system does not offer such facilities and tends to suffer artifact during storage
- 14. Mammography
- 15. Mammography
- 16. Mammography
- 17. Benefits of screening mammography Early detection of BC, before clinical presentation Screening mammography reduces breast cancer mortality. This reduction may reach 20%
- 18. Harm of screening mammography False positive results: • Unnecessary follow up tests and biopsy • Anxiety and psychological distress • False negative results: • Here breast tissues obscure the BC Over diagnosis: • Cancer that would never have progressed to clinical importance in absence of screening • Harm of treatment without any benefit • Once cancer is diagnosed, no way to determine whether it is a case of over diagnosis Radiation exposure: ( may be small risk )
- 19. Technique of screening mammography • The standard screening mammogram consist of 2 view of each breast: • The cranio caudal view (CC), the view from the top • The mediolateral oblique view, the view from the side • Performance of both views is essential to locate the lesion • The posterior tissues of the breast should be included in the films • The breast is compressed to eliminate motion that could cause blurring of image, to create uniform thickness of breast tissues for better image quality and to minimize radiation dose
- 20. Main mammographic findings Calcification: • Calcifications are tiny Calcium deposits within the breast tissues • Looks like white spots on mammogram • They may or may be not caused by cancer • There are 2 types of calcification
- 21. Macrocalcification • Are large calcium deposits most likely due to changes cased by aging of the breast arterioles • Old injuries of breast • Old inflammation of breast • Typically related to non cancerous conditions
- 23. Microcalcification • Microcalcifications becomes common as women becomes older (>50y) • They are tinny specks of calcium in the breast tissues • Most cases of Microcalcifications are benign • They are more of concern than macro calcifications • If they are suspicious biopsy is recommended A mass Brest density
- 25. Ultrasound Role of ultrasound in breast cancer screening
- 26. U/S screening • Screening ultrasound (U/S) may also be performed in high risk patients or patients with dense breasts • Diagnostic ultrasound; perform to further evaluate a mammographic finding or to evaluate an area of pain or lump
- 27. Application • Though U/S is successfully used to aid assessment of abnormalities detected by mammography, it should not be used as a sole modality for screening as U/S does not always detect cancers that are visualized by mammography • With new high frequency transducers, the sensitivity increased
- 28. Ultrasound interpretation • The subcutaneous fat layer is demonstrated superficially as hypo echoic tissue compared to the glandular tissue from which it is separated by a well defined scalloped margin • Normal ducts are often visible, particularly in the subareolar region, as anechoic structures • Deep to the glandular tissue, a retromammary fat layers usually visible and behind this the structures of chest wall
- 30. Breast cysts U/S
- 31. Solid masses U/S
- 33. BI-RADS • Breast Imaging-Reporting And Data System used by medical professional to standardized reporting of breast images specially mammography • It categorize the reports in to numbers 0-6 e.g. 0 - Incomplete 1 - Negative 2- Benign 3 - Probably benign 4 - Suspicious 5 - Highly suggestive malignant 6 – Known biopsy – proved malignant
- 34. BI- RADS
- 35. BI- RADS
- 37. Breast Cancer genes • Two BC gens are known BRCA1 & BRCA2 • Every one normally has these gens and known as “tumor suppressors” • BRCA1 identified in 1990 on chromosome 17 • BRCA2 identified in 1994 on chromosome 13 • Normally mutation occurs on these gens and repair occurs by DNA • When harmful mutations occurs, the risk of BC increase from 1-8 to becomes 3-5
- 38. Breast Cancer genes • Harmful mutations of the 2 copies of BRCA1 or BRCA2 increase the possibility of BC up to 60% • Mutation of one copy of each gene does not increase the possibility of BC • But if the other copy altered later in her life BC can occur • For this reason about 5-10% of cancer breast is hereditary
- 39. Breast Cancer genes • Testing of these gens easily done in laboratories • The importance for testing of these gens is to discover high risky cases for possibility of prophylactic mastectomy
- 40. Thank You