These slides will help medical students

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

7. Screening mammogram

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

22. Macrocalcification

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

24. Microcalcification

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

29. Normal breast U/S

30. Breast cysts U/S

31. Solid masses U/S

32. Malignant mass 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

36. Breast composition

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