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Imaging Radiology in Breast Cancer and
Imaging-Pathology Correlation
Lina Choridah
Radiology Department
Faculty of Medicine UGM
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3 IMAGING MODALITY
1. Mammography
2. Ultrasonography
3. MRI
Mammograms dont
look fun
but they can save a life!
Malignant Lesion of the Breast
Ductal Carcinoma
Lobular Carcinoma
Ductal Carcinoma in situ
the most common type of in situ breast cancer,
accounting for about 83%
CALCIFICATIONS ARE MAMMOGRAPHIC HALLMARK.
Microcalcification type
Dalarna County (W) Sweden
The first step in analyzing the calcifi cations is to
determine their site of origin:
1. Within the ducts: Casting type calcifications.
2. Within the terminal ductal lobular units (TDLUs):
a. Crushed stone-like calcifi cations.
b. Powdery/cotton ball-like calcifi cations.
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Casting type calcifi cations
Fine linear branching
The most important
Poor prognosis
Benign casting type
Tabar
Malignancy Ratio Casting Type
(Lazlo Tabar)
With and without tumor mass With tumor mass
Crushed Stone Calcification
Lazlo Tabar
DCIS Right breast Subtle DCIS
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Invasive carcinoma
The prognosis is strongly influenced by the
stage of the disease
IDC
The mammographic signs of invasive
ductal carcinoma (IDC)
Primary
Secondary
Indirect signs.
IDC primary signs
a mass with irregular shape, ill defined or spiculated
margins
high radiographic density
microcalcifications (linear branching, clusters,
punctuate) either within the tumor or adjacent to it.
Tabar
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IDC secondary sign
Associated with advanced cancers.
Skin thickening or retraction
Nipple retraction
Axillary node enlargement.
IDC INDIRECT SIGN
a developing asymmetry
architectural distortion
focal asymmetry
Unilateral single dilated duct.
Invasive Lobular Carcinoma (ILC)
21 Illustration Mary K. Bryson
Lobular cancer
cells breaking
through the wall
ILC
a mass with irregular shape, ill defined or spiculated
margins / architectural distortion
density equal to or less than that of normal
fibroglandular tissue
Microcalcifications are uncommonly seen
US HAS PROVEN TO BE A VALUABLE ADJUNCT IN THE
DETECTION AND WORK UP OF ILC
ILC Imaging
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ILC FEATURES
The most common mammographic feature of ILC was
architectural distortion
The most common US feature of ILC was irregular or
ill-defined hypoechoic mass with acoustic shadowing
PITFALL MAMMOGRAPHY
3 FACTORS
Patient
Technical
Interpretating
Ultrasound
(in Addition to Mammography)
Can be considered in high-risk women for
whom magnetic resonance imaging (MRI)
screening may be appropriate but who cannot
have MRI for any reason
Can be considered in women with dense
breast tissue as an adjunct to Mammography
Mammography vs Ultrasonography
Breast Cancer spectrum
mrozin,md
MAMMOGRAPHY
Frequency %
mammo (-) 8 15.7
architectural distortion 5 9.8
mass 18 35.3
mass + calcification 15 29.4
distorstion + calcification 5 9.8
Total 51
(Choridah, et al 2014)
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Shape and Margin
64,7%
62,7%
ECHOSTRUCTURE AND ECHOGENISITY
94,1%
100%
SHADOW AND EDGE REFRACTION
54,9%
94,1%
MICROCALCIFICATION
47,1%
PATHOLOGY
Pathology Frequency Percent
Ductal Invasive 41 80.4
Lobular Invasive 3 5.9
Ductal + Lobular 2 3.9
Ductal + paget 1 2.0
Ductal + papilloma 1 2.0
Papillary 1 2.0
Musinosum 1 2.0
Phyllodes 1 2.0
Total 51
INVASIVE DUCTAL CARCINOMA
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LOW GRADE VS HIGH GRADE IDC
Classic Type, low grade High Grade
Ca Ductal Invasive
Low grade Ca ductal invasive
Desmoplasia >>>
Irregular shape
Spiculated
Posterior shadow
Low vascular
High grade Ca Ductal Invasive
Desmoplasia (-)
Oval / round
Ircumscribed
Enhancement
High vascular
IMAGING-PATHOLOGY
CORRELATION
5 possible
outcomes of imaging-pathology correlation
Category 1. Concordant Malignancy
Category 2. Discordant Malignancy
Category 3. Concordant Benign
Category 4. Discordant Benign
Category 5. Borderline/High Risk
CONCORDANT MALIGNANCY
BI-RADS category 4 or 5- malignant on a
subsequent core needle biopsy
DISCORDANT MALIGNANCY
BI-RADS category 2 or 3-malignant at core
needle biopsy
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CONCORDANT BENIGN
BI-RADS category 2, 3-benign pathology at
core needle biopsy
follow-up sonography at 6 months after
biopsy and then annually for at least 2 years
FAM
DISCORDANT BENIGN
BI-RADS category 4-5-benign pathology at
core needle biopsy
Benign lesions with spiculated findings can
simulate malignant lesions
sclerosing adenosis,fat necrosis, postsurgical
scar, mastitis, granular cell tumor,diabetic
mastopathy, and sarcoidosis
a substantial number of missed cancers at
core needle biopsy
For a sonography-guided 14-gauge core
needle biopsy,discordant lesions had cancer
rates of up to 50%.
Repeat biopsy
A surgical biopsy
A the vacuum-assisted core needle biopsy.
Borderline or High Risk
A lesion in this category is not malignant but is
considered to have an increased lifetime risk
for the
development of breast cancer (e.g., atypical
ductal
hyperplasia, lobular neoplasm, radial
sclerosing lesion,
papillary lesions, possible phyllodes tumors)
Thank you