In this physician presentation, Dr. Babita Panigrahi, breast imaging radiologist, explains the difference between screening and diagnostic breast imaging and what diagnostic imaging is needed for various breast symptoms such as palpable masses, breast pain, nipple discharge and breast symptoms in men.
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Hi my name is bobby Tapani groggy and I am a breast radiologist in the division of breast imaging at johNS Hopkins. I am going to talk to you all today about evaluation of the symptomatic breast. This is a common complaint of patients and providers and both patients and providers need to know how the evaluation works on the imaging side. I have no disclosures. This is the outline of our presentation today. First we're going to go over screening versus diagnostic breast imaging and then we're going to focus on one of the main topics of diagnostic breast imaging which is the symptomatic breast. So the most common breast symptoms we're going to go over today are palpable masses, breast pain, nipple discharge and breast symptoms in men. When we go over each of these symptoms, we're going to go over the imaging worker for each of these symptoms as outlined by the A. C. R. Appropriateness criteria. So first we're going to discuss who needs a screening breast imaging and who needs diagnostic breast imaging. So screening mammography is indicated for asymptomatic women at average risk annually starting at age 40. Those are the guidelines recommended by the A. C. R. The American College of Radiology and FBI. The Society of breast imaging which we follow screening mammography includes just standard demographic fuse which include cranial coddle and medial lateral oblique. These are compressing the breast in different ways from above and below and then from side to side. Diagnostic breast imaging may include a combination of mammogram and ultrasound diagnostic breast imaging is indicated in patients of any age with clinical breast findings. Diagnostic breast imaging can also be used for further evaluation of findings recalled from screening mammography or seen on another modality such as Ct pet ct or MRI diagnostic imaging is also used for follow up a probably benign breast findings and for patients with a history of breast cancer within three years after their treatment, diagnostic breast imaging may include specialist ma'am. A graphic views rather than the standard C. C. N. M. Alot views and these include true lateral views, spot compression views and magnification views. This may also include ultrasound to target for targeted evaluation of specific areas of concern in this presentation. We are going to go over diagnostic breast imaging indications for patients with clinical breast findings. So the first finding we're going to talk about is palpable masses. So some breast cancers can present as a new lump rather than only being seen on a screening mammogram. These lumps are either noted by the patient during a self exam or by a provider. During the annual breast checkup imaging can characterize these lesions as physical exam findings cannot always distinguish benign from malignant disease. Although negative imaging is helpful to rule out malignancy, a highly suspicious physical exam does not magnate the need for biopsy. This is the first chart of how to evaluate a palpable mass in women over the age of 40. This uh is what the PcR recommends as how each finding should be evaluated initially. So in the first column you see the different procedures that are available in breast imaging. And our workhorse is mammograms and ultrasounds. All of the additional imaging that's listed below including MRI F. D. G. Positron emission, tomography and system. Maybe molecular breast imaging are all specialist forms of breast imaging that may be used for further evaluation of findings that aren't characteristic on mammograms and ultrasounds. So all of the findings that we're going to talk about today are initially worked up with a combination of mammogram and ultrasound. The second column which is rating gives us a scale of how appropriate each emitting Beijing mortality is for the specific finding initially. So a rating of seven through 9 means that it's usually appropriate. A rating of six, four through six is may be appropriate and a rating of one through three is usually not appropriate. So the lower the number the less appropriate the study for the initial ordering of the imaging modality, uh then on the last column it has the relative radiation level and that's our R. L. And you can see the more number of filled in circles. The greater the amount of radiation is for that study. So for mammography you're going to have a small amount of radiation but for ultrasound there is no radiation. So for a palpable mass in a woman over the age of 40. The initial work up is mammography with or without tomoe synthesis which is the three D. Mammogram that is considered superior to two D. Mammograms. There is a situation where ultrasound may be used first rather than mammograms. If the patient has had a negative mammogram in the past six months. If she has not had a negative mammogram and it's in the past six months it's been more than six months since her last screening mammogram. We would start again with another mammogram and then go to ultrasound afterwards. Rather than just starting with ultrasound In a patient that's between the ages of 30 and 40 assuming that she has not had a mammogram before. We would recommend that she starts with both a mammogram and an ultrasound. And then finally in patients who are less than 30 years old we first start with ultrasound and that's given a rating of nine and then plus or minus a mammogram which is given a rating of three depending on the findings that we see on the ultrasound. And this is for a couple of reasons Women less than 30 have. You generally have denser breasts than women who as they age, get less dense breasts and the denser the breast the less sensitive than mammogram. So ultrasound is generally more sensitive than mammography. In patients of this age group. Also mammograms have some level of radiation and the younger the patient more sensitive to radiation they are. So if the patients are less than 30 years old. We start with ultrasound. And if findings are suspicious on ultrasound, then we would obtain a mammogram. This is an example of an 84 year old woman with a history of right breast cancer in 2013. Who presented with a lump near her surgery site. So on the left you can see her right Emma loe view in 2019 and you see her lump back to me scar in her right upper outer breast with a little bit of a dividend the skin in that superior breast region. She didn't get a mammogram in 2020 because of COVID and instead presented in 2021 with a new lump at her lumpectomy site. And you can see when we got the specialist mammogram views at the time of her right diagnostic mammogram we place a triangle palpable marker, right at the site that the patient feels the lump and subject isn't too that marker. You can see a new mass that's right along her lumpectomy scar and that persisted on spot compression views that we got as well. The next step when we have a suspicious finding is to go to ultrasound. Mhm. So there is the maths. And here's the ultrasound. So here we can see an oval mass with slightly micro elaborated margins and a little bit of internal vascular charity. Given her history this was considered suspicious and the biopsy was recommended she had an ultrasound guided biopsy and this demonstrated invasive ductal carcinoma Because she hadn't had radiation when she initially had her right breast cancer in 2013, she was able to still undergo breast conservation in that right breast and then also undergo radiation because she had not been radiated before. This next example is a 36 year old female with a right breast lump on her baseline exam. So she had not started getting screening mammography because she's 36. But because she did have a new clinical symptom of a palpable mass, we obtained a bilateral mammogram and the right mammogram demonstrated a oval mass with obscured margins on the mammogram that you can see subject isn't to the triangle palpable marker. The next step would be again to go to ultrasound and we again see an awful mass with predominantly circumscribed margins and some peripheral vascular charity that corresponds to the area of palpable concern. This was considered suspicious given her clinical symptoms and it was biopsied. It came back as a cellular fiber epithelial lesion, which is a still a benign lesion but considered a spectrum of fiber adenomas and fibroids tumors. Sometimes when the pathologist cannot tell which one it is. They call it a cellular fiber epithelial lesion and surgical excision is recommended to completely remove the mass to make sure that it's not something like a by Lloyd's tumor that can grow rapidly and have a small incidents of associated malignancy to make sure that there's no malignancy in that mass that she was feeling. So this patient will go on to surgical excision. The next symptom we're going to talk about is breast pain. Breast pain is a common symptom in women. The most common symptom that's reported in the breast with a low association with malignancy. If no other symptoms are present, these are divided into clinically significant and clinically insignificant pain. Clinically significant pain usually requires diagnostic imaging And this is defined as focal, involving less than 25% of the breast and persistent. So we usually ask our patients if you could use one finger to point to the area of pain, then this is considered clinically significant pain. Clinically insignificant pain is usually diffuse or non focal, where the patient cannot specifically point to one area where the pain is, It is also considered cyclical related to menstruation. So, if the breast pain is diffuse and comes right before the period and then subsides. That's considered clinically insignificant Peyton and diagnostic imaging is usually not appropriate in those patients. So the initial work up of clinically significant pain. If the patient is over 30 years old, is with a mammogram and an ultrasound. So again, both mammogram and ultrasound. If the patient is over 30, just like in patients who are presenting with a breast lump. However, if patients are under 30, the first step is usually breast ultrasound, just given the dense tissue and the radiation concerns for this young patient age group. If there is anything suspicious on the ultrasound, we would recommend a mammogram. This is our first example of a 40 year old female with focal breast pain on her baseline exam. So here we, instead of using a triangle palpable marker, as we did in the other cases, here we use a square pain marker and there's nothing on the mammogram. It just looks like fatty tissue. We then go to ultrasound and there's also nothing on the ultrasound. You can see normal the glandular tissue, but no focal mass like we saw in the other cases. So this would be considered a negative exam and we would recommend clinical evaluation and follow up the next symptom we're going to talk about is nipple discharge. So nipple discharge is divided into being physiologic or pathologic physiologic nipple discharge does not usually prompt diagnostic imaging. However, a clinical exam is recommended. So physiologic discharge is usually bilateral, non spontaneous, meaning that it is only elicited when the patient presses on the nipple or if there is some pressure near the nipple, then the discharge comes out. It's usually from multiple ducks and it can be white, green or yellow, basically any color other than bloody or clear is considered physiologic discharge. And physiologic discharge could be from a patient who has been recently lactating from normal fiber cystic change from certain medication side effects that can increase estrogen levels. All of those are considered benign physiologic discharge pathologic discharge is when diagnostic imaging is usually appropriate. And this includes unilateral nipple discharge only coming from one Nipple spontaneous, meaning it's coming out without the patient putting any pressure around the nipple from a single duct and the colour being clear or bloody. Any one of these these characteristics can characteristics. The discharge is being pathologic. We'll go on to the initial mammogram and image mammogram and ultrasound imaging work up for nipple discharge. That is pathologic. However, pathologic discharge, despite negative imaging may warrant surgical consultation and or MRI. So this chart is the initial work up of women with pathologic nipple discharge with age over 40 years. So we are going to get both a mammogram and an ultrasound for a patient who's having pathologic discharge, MRI may be indicated if there is negative imaging at the end of this work up. But in the initial work up it is not yet indicated. Mhm. If the patient's age is between 30 and 40 years, We recommend both mammogram and ultrasound as well, just the same as patients who are greater than 40 years old. And then finally, if the patient's age is less than 30 years old, there's a difference in women versus men, Which will get into more about the male breast work up. But because pathologic discharge in men has such a high association with malignancy higher than in women, we do recommend that even if the patient is under 30, the initial work up in men would be a mammogram and an ultrasound. Whereas in women who are less than 30 years old. The initial work up for Nipple discharge would be an ultrasound and then possible mammogram depending on the ultrasound findings. The next case we're going to go over is a 70 year old female with bloody nipple discharge. Here you can see her bilateral mammogram and in her left breast which is on the right side of the images. That's how we view our radiology images. You can see a diffuse global asymmetry in the left superior breast and this is a high density asymmetry that was new compared to her prior mammograms. We went on to do specialist magnification views just behind the nipple to see if there were any calcifications associated with this global asymmetry. There were no calcifications that we could identify on these magnification views. However, because the mammogram findings were so suspicious. We did go on to ultrasound ultrasound demonstrated diffuse dilated ducts throughout the left superior breast, some of which contained internal vascular charity that you can see on the color images that that although this did not have a discreet mass corresponding to the global asymmetry on the mammogram because the ultrasound findings were so diffused we did decide to do an ultrasound biopsy. This came back as invasive ductal carcinoma with associated ductal carcinoma in side too because the abnormality was so diffused on her mammogram, we did get an MRI to evaluate the extent of disease and you can see on this MRI myth image. We can see a large area of abnormal enhancement in the left superior blast corresponding to the area of the mammogram and ultrasound abnormalities. The patient went on to have a left mastectomy and had negative margins with complete removal of this area. The last topic we're going to discuss today is a symptomatic male breast. So men can have breast symptoms just the same as women and it's very important that they come in to get diagnostic imaging. If any of these symptoms are persistent. These can include lumps, pain, breast enlargement, nipple discharge or retract action or axillary lymph retinopathy. The majority of male breast findings are benign. However, imaging is indicated when there are symptoms that are inconsistent with benign findings such as Dina calmus to on the physical exam. So the initial work up for men with clinical breast findings. If there are over 25 years old is a mammogram with possible ultrasound. The male is less than 25 years old. We would start with ultrasound and then go on to mammography if the findings are suspicious on the ultrasound. Yeah. The first case we're going to go over is a 70 year old male with left breast tenderness here. You can see a bilateral mammogram and there is a B B marker placed on the left retro a region where the man is feeling some tenderness on the mammogram. We can't see any discrete mass calcifications or distortion. However, it does look like diffuse glandular tissue almost like a female breast. We don't always need to do an ultrasound to confirm that this is gynecomastia, which is how it looks like on the mammogram. However, because his specific location of tenderness was slightly eccentric to the nipple. We did go on to get an ultrasound in this patient and here we can see normal glandular tissue that corresponds to the area of clinical concern. This diagnosis is benign gynecomastia and does not require further imaging. Work up. Clinical evaluation and follow up would be recommended. This is our last case of a 70 year old male with bloody left nipple discharge and that is considered a pathologic type of nipple discharge. And you can see on the mammogram, we got specialist views just as we did for women with nipple discharge magnification views in the left lateral or region. We can see on those magnification views that there are linear calcifications, just subjects into the nipple that are suspicious. This also is associated with a mass that is just adjacent to the nipple. Unlike our other case of benign gynecomastia, this mass appears more focal, more dense and is associated with nipple retraction. The next step would be to go on to ultrasound on ultrasound. You can see an irregular HIPPA colic mass with speculated margins, just subject ace into the nipple and you can actually see the calcifications on ultrasound as well, but you can't always see an ultrasound but here because they were so prominent just underneath the nipple, you can see them as the bright white spots that are extending just underneath the nipple in a linear distribution like we see on the mammogram. This was considered suspicious and was biopsied under ultrasound guidance and it returned invasive ductal carcinoma. This case is important to highlight that men can have breast cancer as well. It is certainly not as common as in women. However, certain genetic syndromes such as the B. R. C. A mutation, client filter syndrome, hormone usage or any strong family history of breast cancer can predispose. Men to also have breast cancer. In summary clinical breast symptoms weren't diagnostic breast imaging. Breast imaging can distinguish benign from malignant disease. Initial imaging work up as for the A. CR criteria depends on patient age and symptoms. These are my references and you can reference the A. C. R. Appropriateness criteria of management of any breast symptoms or any symptom in general on their website. Thank you for your attention and please let us know if you have any questions. You are welcome to reach out
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