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Breast Cancer

Breast Cancer. Screening. What is screening?. Screening involves the testing of asymptomatic individuals to detect disease before it becomes clinically apparent An ideal screening situation should have the following criteria: done for a disease that is not very rare

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Breast Cancer

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  1. Breast Cancer Screening

  2. What is screening? • Screening involves the testing of asymptomatic individuals to detect disease before it becomes clinically apparent • An ideal screening situation should have the following criteria: • done for a disease that is not very rare • the test should be relatively simple and cost-effective • there should be a treatment available for early detected disease • treatment options for early disease should be less radical • there should be a survival benefit for patients treated with early disease

  3. Breast cancer screening • Pros • Breast cancer is not a rare disease • There is a long latent period between the onset of the disease and its actual clinical appearance • the screening modalities are non-invasive & relatively simple. • Non invasive forms of the disease are detectable by screening • Lesions detected at these stages have improved breast cancer survival often with less radical treatment options • Cons • 10-15% of breast cancers will not be detectable by mammography • A large number of ‘unnecessary biopsies’ may need to be performed • Mammography is relatively expensive

  4. Mammography basics • Mammography is basically an xray of the breast. • A mammography machine delivers the following features: • Low dose of radiation to the breast. The total glandular dose of a two view mammogram is 0.04 - 0.08 rads1. • Breast compression is an important part of the procedure and is achieved by mildly compressing the breast between two plates prior to taking the xray. • reduces the depth of breast tissue that the xrays need to penetrate thereby reducing the necessary dose. • Separates tissues preventing overlap, of structures improving image quality and accuracy. • Holds the breast motionless, also improving quality

  5. Mammography basics (cont.) • Multiple views of the the breast. • Common views include lateral, oblique and craniocaudal. • It is customary to take two views per breast to improve accuracy. In Single view mammograms a significantly larger number of malignant lesions will be missed. • Occasionally magnified views of specific areas may be taken to give additions information on suspicious lesions. • Bilateral mammograms are always taken • detection of abnormalities by comparison of both breast • to detect possible abnormalities in the opposite breast as it is a well documented fact that breast cancer is a multicentric disease.

  6. Indications for mammography • As a screening test for an symptomatic woman • In patients who have a suspicious breast lump • Gives additional information on the lump itself • it screens the rest of the breast and the opposite breast for sub-clinical synchronous disease. • As a follow up investigations in treated cases of breast cancer • Mammography study of the ipsilateral breast in conservative surgery • to rule out recurrence • to rule out a metachronous primary in the ipsilateral breast • Contralateral breast • in Modified Radical Mastectomy patients and BCS patients to rule out metachronous lesions in the opposite breast.

  7. Features of malignancy • Dense, irregular, spiculated mass • This is the finding most likely to be malignant • Clustered micro-calcifications • A cluster can be defined as 3 or more calcifications in an area of 0.5cm2. • The more the number of micro-calcifications in a cluster the higher is the suspicion of malignancy3. • Indirect signs of malignancy • As many as 20% of non palpable cancers may be identified by subtle mammographic changes. These include: • Architectural distortion and parynchymal asymetry, • developing neodensity • Nipple and skin retraction and thickening • these changes are often diagnosed by comparing mammograms of both breasts and/or those taken serially different time intervals

  8. Benign changes • Benign Masses • These are well circumscribed with well defined borders • Benign lesions include • cysts, • fibroadenomas • lymph nodes etc. • Benign Calcifications • Usually coarse and scattered • More uniformly distributed

  9. Mammographic guided biopsy • Mammography guided FNAC/ Core needle biopsy. • For non palpable lesions a stereotatic mammographic (or ultrasonographically) guided biopsy may be performed which allows precise placement of the needle in the suspicious lesions • Hookwire guided biopsy • This is done for a non palpable mammographically detected irregularity in the breast • A mammographically guided wire is inserted such that the tip of the wire is in close proximity to the suspicious area. • A surgeon then uses the wire as a guide to biospy the lesion. • A post op xray of the excised tissue is taken to ensure that the abnormality has been included in the biopsy.

  10. Breast Self examination • Breast Self Examination (BSE) is where a woman examines her own breasts once a month a week after her menses, in an attempt to detect abnormal areas as early as possible. • To be effective it needs to be done systematically, regularly and properly. • Advantages of this procedure is that it is • simple • cost effective (Free!) • Despite its possible advantages it not reliable as it is: • not done regularly • not done properly

  11. Recommendations for screening Women 20 years of age and older should perform breast self-examination every month. Women 20-39 should have a physical examination of the breast every three years. • Women 40 and older: • Practice breast self examination • Physical examination of the breast every year. • Mammogram every year.

  12. Other Modalities • Digital mammography • This is basically a mammography where the xrays are recorded digitally on a computer instead directly on an xray film. Advantages include: • the pictures are available immediately • the images can be digitally manipulated and a variety of digital enhancemanets are possible to overcome regular mammographic shortcommings (e.g. dense brests etc.) • MRI / PET scanning • Imaging of the breasts with this modality is significantly superior to mammography, however the cost factor is a major drawback. • Ductoscopy • A very fine scope has been devised that access the ducts via the nipple and visualize the ductal system of the breast where the majority of cancers arise. This is still in the experimental stage. • ductal lavage • This is based on the assumption that cytology of cells obtained from washing of individual ducts via a fine catheter entered through the nipple can reveal early malignancies.

  13. References 1.Mammography-User’s guide Recommendations of the National Council on Radiation Protection and Measurements (NCRP Reprot No. 85) The Council, 1986 2. Andersson I, Hildell J, Muhlow A, et al: Number of porjections in mamography; Influence on detection of breast disease, AJR 130: 349, 1978 3.Murphy WA, DeSchryver-Decshemeti K: Isolated clustered microcalcifications in the breast: Radiologic-pathologic correlation. Radiology 127:335, 1978

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