Modern Imaging in Breast

Cancer
Dr Linda Hacking
Consultant Radiologist

October is Breast Cancer

Awareness Month
Breast cancer is commonest cancer
in UK (excluding non-melanoma skin
cancer)
46,000 new cases per year
300 men, remainder women
80% over 50 years of age
1 in 9 women will get it in their
lifetime

Bad news/Good news

Incidence has increased by 50% in
last 25years
12,000 women and 70 men died from
breast cancer in 2008
1,300 deaths in women under 50
More than half deaths are in women
over 70

Bad news/Good news

Since 1980s breast cancer death rates have
fallen by one third
Breast cancer is no longer the commonest
cause of cancer death in women
More than 8 out of 10 women survive beyond
5 years (5 out of 10 in 1970s)
Now twice as likely to survive 10 years as 40
years ago.
2 out of 3 women survive beyond 20 years
Breast cancer death rates falling faster in UK
than rest of Europe

Reasons for improvements in

outcomes
Screening
Improved treatments (Tamoxifen etc)
Improved cancer services including
imaging

Why are these improvements

happening
Breast screening?? (also increased
diagnosis rate)
Improved treatments (tamoxifen etc.)
Overall improvements in care
(including imaging)

Breast Screening
NHS Breast Screening Programme
(NHSBSP)
Began 1988-90
Not Blackpool Victoria.
Nearest centre Lancaster (vans, WGD)
Invited for Mammograms from age 50-69
Extended from 47-73 years from 2012
(target)
Past upper age limit, option to arrange
mammogram.

Breast Screening
Will cause increase in incidence of
cancer
Early cancers and pre-cancer (DCIS)
are found that would never have led
to a problem

For Breast Screening

One woman will be over-treated for
every two lives saved
1000 lives a year saved
Impact on population vs individual
womans life.

Against breast screening

10% of cancers are over-diagnosis
and therefore over treatment
It is impossible to estimate lives
saved because of all other factors
Impact on population vs impact on
individual womans life

Today we are talking about

diagnosis

The Symptomatic Breast

Clinic

Lump or thickening
Change in size or shape
Redness or rash in skin or nipple
Indrawing of nipple
Skin puckering or dimpling
Lump in armpit

Referral to Breast Clinic

May simply need to see senior
clinician- no further advice, no
further investigations.
Triple assessment/Double
assessment
See Senior Clinician (1)
Imaging (2)
Biopsy or needle test (FNA) (3)

Modern Imaging and Biopsy

Tests to be done at first clinic
appointment for most patients
Most patients will have a benign diagnosis
Less than 1 in 10 patients attending our
clinic will have a malignant diagnosis
9 out of 10 will be benign
In new clinic, results for patients seen
Monday, Tuesday available for Friday
Wednesday, within a week

Modern Imaging and Biopsy

Quick accurate diagnosis for the
majority of patients who will have a
benign diagnosis
As much information as possible about
what we are dealing with in the
minority if patients who have a
malignant diagnosis
Treatment can then be tailored to the
individual patient

Mammography

Symptomatic patients
Women >35 years of age
Uses x-radiation
Invented in 1960s, modern type of machine
1969
Still not in universal use 1986 (when I started
in radiology)
First unit Blackpool 1990 (Fylde Coast incl.NHS)
Blackpool Victoria Mammography unit 1999.
October 2010 Full Field Digital mammography

Mammography

Problems
X-radiation
Dense breasts
Young women
Men
Implants
No imaging 100% accurate

Field Digital Mammography

Better on all counts

Dense breast
Younger women
Less radiation

Ultrasound
First imaging <35, and men
To clarify lumps and cysts on
mammogram
To do image guided biopsy
To look at axilla (armpit)

Ultrasound

Cyst

Fibroadenoma

Ultrasound guided biopsy

Ultrasound guided biopsy

Needle guided into abnormality
under direct vision
Can be needle test (FNA)
Or Core biopsy
Uses local anaesthetic
Takes 5-10 minutes
a bit like getting ears pierced
Complications- bruising, pain

Ultrasound guided biopsy

Quick very accurate results
A patient specific individual plan if
surgery required
Tumour grade if malignant
Hormone receptor status (Tamoxifen,
herceptin)
Size and extent of mass(es)
Lymphnodes
Test done Tuesday, results Friday

Core Biopsy Needle

Ultrasound guided biopsy

Mammographic stereotactic
biopsy
Mass seen on mammogram, not on
ultrasound
Micro-calcification chalky bits- can be
benign, can be malignant or premalignant (DCIS)
No lump felt
Standard core biopsy
Vacuum assisted core biopsy
Special devices

Mammographic stereotactic
biopsy
Previously may have needed general
anaesthetic surgery to remove
abnormality
Now outpatient procedure under
local anaesthetic
Most turn out to be benign

Vacuum assisted biopsy

Vacora vs 14G biopsy

Sample can be x-rayed

Breast MR (magnetic
resonance)

Breast MR
Also major investment in breast coils
and software for new MR scanner
Increased comfort
Ease of interpretation (software)

Breast MR

Recently in press
In UK not used in every case
Lobular carcinoma
Multifocal carcinoma
Problem solving when
imaging/clinical/pathology do not match
Doubts about mastectomy/ local excision
Question of recurrence
Implants

Breast MRI
Adds to planning of surgery

So far
We have been talking about diagnosis
Imaging also helps during surgery

Localisation of mass not felt

Marker with ultrasound
Wire with stereotactic mammography
Mass can be x-rayed while patient
still anaesthetised

Excised specimen

Also during surgery-Sentinel

Lymph Node Biopsy (SLNB)

SNLB
Small amount radioactivity injected into
breast
On morning before afternoon surgery
Or afternoon before morning surgery
Also blue dye in theatre
Goes to first lymph node
Surgeon uses probe in theatre
No drain, much reduced complication rate
compared with Node Clearance
Seroma, lymphoedema, pain, numbness
Overnight stay vs several day stay

SLNB
A small percentage will require
further surgery once node examined
in lab
Nodes examined with ultrasound and
FNA prior to surgery
Not suitable for everyone

Surgical probe

The Future
Tomosynthesis
On table sentinel node diagnosis
Answers about breast screening

http://www.youtube.com/watch?v=P5
n3Avqqo2c

To Summarise
Blackpool Victoria has opened a brand
new breast clinic
We have the latest technology available
for the best possible care for our patients
The new clinic pathway for rapid access
and diagnosis will benefit all of our
patients
Most patients will have a benign
diagnosis delivered quickly

 For the few patients who

unfortunately have a malignant
diagnosis
They will be treated quickly, with all
of the latest technologies available
We should be able to upgrade for the
future

The outlook is good

Thanks to the team!