Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Guidelines Individual work of students During preparation for Practical classes educational qualifications "Master of Medicine", "Master of Pediatrics" professional qualifications "Doctor", "Pediatrician" Educational discipline Radiology Module № І Theme lesson: Radiation methods of research and radiation anatomy of the breast. Radiation signs of breast diseases. Course ІІІ Faculty Medical №1, №2

Poltava

1. Actuality of the topic. At present, when methods have appeared that are not associated with radiation exposure to gonads (ultrasound, MRI, radionuclide analysis), it is impossible to imagine obstetrics, gynecology, mammology without them. Diseases of the mammary glands are the most common in women. Therefore, students should know the radiation signs of the normal state of the mammary gland and the signs of their pathological conditions. 2. The objectives of the studies: 1. To analyze the possibilities of various methods of radiation research in the study of the state of the mammary glands 2. Explain the radiation signs of the normal state of the mammary glands; 3. To interpret the signs of some pathological conditions of the mammary glands. 4. Analyze the normal state of the mammary glands; 5. To classify some pathological conditions of the mammary glands 3.1. Basic knowledge, skills, skills necessary to study the topic (interdisciplinary integration). Name of previous disciplines To know Physics Demonstrate the physical basics of imaging Anatomy and ray anatomy To describe the features of the structure and radiation image of the mammary glands. Histology Show schematically the histological structure of the mammary glands. Physiology Determination of physiological processes that occur in the mammary glands.

4. Tasks for independent work in preparation for the lesson and in the lesson. 4.1. A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term Definition Mastitis A nonspecific inflammatory disease of the breast that can be acute or chronic along the course. In 80-90% of cases, acute mastitis develops during lactation (lactation mastitis) Abscess is a local, encapsulated collection of pus in the breast tissue. Ductography X-ray examination carried out with the introduction of 0.5-2 ml of a water-soluble iodine-containing contrast agent into the lactiferous ducts of the mammary gland through the nipple. Pneumocystography is a technique consisting in puncture of a cyst, removing fluid from it, followed by the introduction of air, after which survey mammograms are performed in frontal and lateral projections. 4.2. Theoretical questions for the lesson: 1. Methods of radiation examination of the mammary glands (advantages, disadvantages) 2. Radiation signs of diseases of the mammary glands: • lipomas; • fibroadenoma; • malignant tumors; • cysts; • mastopathy. 4.3. Practical works (tasks) are performed in the class: 1. List the methods of radiation diagnostics used in the diagnosis of diseases of the mammary glands (indications and contraindications). 2. Name the radiation signs of the normal state of the mammary glands on mammograms, ultrasound, MRI; 3. Name the radiation signs of breast diseases on mammograms, ultrasound, MRI; • lipomas; • fibroadenoma; • malignant tumors; • cysts; • mastopathy. Theme contents. Mammography - X-ray of the breast without the use of contrast agents. It is performed on special X-ray diagnostic devices specially designed for this purpose - a mammograph. During the shooting, breast compression is applied so that the thickness of the breast tissue is the same in all zones. Due to this, the scattering of the radiation beam is reduced, the radiation dose is reduced and the image clarity is improved. Unpleasant sensations can be reduced by conducting research in the first half of the cycle: from 5-6 to 12-14 days from the beginning of menstruation. Despite the development of new technologies, mammography remains the “gold standard” of research of the mammary glands, in particular the early stages of breast cancer. When breast cancer is detected in the early stages, the effectiveness of treatment increases to 90%. X-ray examination of the breast includes: - Overview mammography; - Sighting mammography with direct magnification of the image; - Sighting mammography with local compression; - X-ray of the soft tissues of the axillary areas (axillography); - Ductography; - Double contrasting of ducts; - Pneumocystography; - Targeted fine needle aspiration biopsy; - Stereotactic puncture biopsy; - Stereotactic vacuum biopsy; - Intra-tissue marking of education; - X-ray of the removed sector of the breast - Tomosynthesis When conducting a plain mammography, the following projections are used: - Mediolateral braid; - Craniocaudal; - Increased craniocaudal lateral projection - Lateral medial lateral; - Caudocranial; - Axillary; - Tangential; - Lateromedial braid Mediolateral oblique (MLO) and craniocaudal (CC) are used as standard projections. For a reliable assessment of mammography data, optimal positioning when taking images is necessary. Aiming radiographs (contact or tangential) are performed mainly for a more detailed study of the structure of individual sections of the mammary gland; to obtain an image of those areas of the mammary gland that were not displayed on the overview images; to establish a connection between the palpable formation with the skin and subcutaneous tissue. For better identification of the smallest details that have an important differential diagnostic value, the production of targeted radiographs with a direct image magnification of 1.5-2 times is shown. Targeted mammography with local compression. If, after performing a standard mammogram, the diagnosis remains unclear or only symptoms suspicious of cancer are detected, targeted radiography with local compression of the breast is used. In a significant part of cases, this allows us to clarify the true nature of the nosological process. Axillography is an x-ray of the soft tissue in the armpit. It can be used to detect metastatic lesions of the lymph nodes in this area in breast cancer and to obtain a complete image of tumors in the subaxillary segment of the gland. Ductography is an X-ray examination performed with the introduction of 0.5-2 ml of a water- soluble iodine-containing contrast agent into the lactiferous ducts of the mammary gland through the nipple. The indication for ductography is the presence of pathological secretion from the nipple, especially bloody and purulent discharge. Contraindications are acute mastitis and palpation of a tumor in the area of the excretory duct of the gland. Pneumocystography is a technique consisting in puncture of a cyst, removal of fluid from it, followed by the introduction of air, after which survey mammograms are performed in frontal and lateral projections. At the same time, against the background of air, the outlines of the inner surface of the cyst become clearly visible, which allows one to reliably establish its irregularities, tuberosities, thickenings, which are signs of a malignant tumor process. The use of pneumocystography, in addition to diagnostic purposes, pursues a therapeutic effect (enhances the adhesive processes in the cyst and reduces the risk of recurrence). Stereotactic puncture biopsy. If a suspicious shadow, determined on a mammogram, is not palpable and is not detected by ultrasound examination and, accordingly, the diagnosis cannot be verified morphologically by puncture under ultrasound control, a puncture biopsy is performed under radiological control ( rheotactic puncture biopsy). Intra-tissue marking of education. Recently, in connection with the identification of an increasing number of suspicious shadows and accumulations of microcalcifications, it is necessary to more often perform interstitial preoperative marking under X-ray control. First, an X-ray of the breast is performed in one of the projections. A needle is inserted to a deliberately great depth through the pathological formation. A control image is taken at an angle of 90 degrees to the first one and the depth of needle insertion is adjusted from it. If the position of the needle is satisfactory, it is removed, while the harpoon remains in the mammary gland. Fine-needle aspiration biopsy (TAB) of palpable breast masses clarifies the diagnosis in 84- 95%. The use of TAB under ultrasound and X-ray control allows obtaining material from altered areas up to 5 mm in diameter and non-palpable formations. At the same time, the accuracy of preoperative diagnostics increases to 95%. Vacuum aspiration biopsy (VAB) is performed both under X-ray and ultrasound guidance. The advantages of a vacuum biopsy are the ability to obtain complete tissue samples, eight times more voluminous than with a conventional puncture biopsy using "spring guns". Tomosynthesis is a special type of mammography that produces a three-dimensional image of the breast. For this, low-dose X-rays are used at different angles. With tomosynthesis, the mammary gland is located in the apparatus and compressed in the same way as with conventional mammography, but the X-ray tube in the apparatus moves in an arc-like manner around the mammary gland. The whole process takes 10 seconds. All information is transmitted immediately to the computer, which synthesizes a three-dimensional image of the breast. The X- ray dose for tomosynthesis is the same as for conventional mammography. X-ray anatomy of the breast An X-ray image of the breast is individual and depends on age, hormonal status, phase of the menstrual cycle and individual characteristics of a woman. When describing radiographs, it is necessary to analyze: 1 - skin, nipple, areola, 2 - subcutaneous adipose tissue with Cooper's ligaments and vessels, 3 - glandular tissue with lactiferous ducts, 4 - retromammary space. The skin is defined in the form of a uniform, dark strip with a width of 0.5 to 2 mm, bordering the mammary gland in front and directly passing to the adjacent parts of the chest. From the back surface of the skin, thin strands extending towards the glandular tissue extend in a direction perpendicular or slightly oblique to it. This is an X-ray image of the elements of the supporting ligament of the breast (Cooper's ligament). In the anterior section, the skin gradually thickens, passing without a clear border into the areola. The nipple gives in the pictures a protruding uniform shadow of a conical or cylindrical shape with even or wavy outlines. The premammary space is a zone of enlightenment between the skin and the glandular tissue due to the presence of adipose tissue there. The thickness of the fat layer of the premammary zone depends on the age, constitution, hormonal status of the woman and is 3-30mm. The glandular triangle, or the body of the mammary gland, has the form of a triangle or semi-oval, located between the premammary tissue and the retromammary space. The top of the triangle is directed toward the nipple, the base toward the chest. The shadow of the glandular triangle is rather dense, heterogeneous. The intensity of the shadow depends on the amount of fatty tissue, age, hormonal status of the woman. The retromammary space, due to the presence of adipose tissue, is visualized as a strip of enlightenment located behind the glandular triangle and separating the body of the mammary gland from the pectoralis major muscle. The pectoralis muscle gives an intense shadow 2-3 cm wide behind the retromammary space. It always has clear, even contours. Better traced in the upper parts of the gland in an oblique projection. X-ray diagnosis of breast diseases Lipoma is a benign tumor consisting of adipose tissue surrounded by a capsule. Re- ntgenologicheskoe, against the background of the glandular tissue, there is an area of enlightenment (according to the density of zpivs-tavimia with the density of adipose tissue) with clear even contours. Lipoma can be difficult to visualize against the background of fatty involutive changes. Fibroadenoma is a benign tumor consisting of proliferating epithelial elements and connective tissue. The most common breast pathology in women aged 20-30 years. More often the tumor is single, but in 20% of cases there are multiple fibroadenomas, and in 10% bilateral formations are diagnosed. A direct X-ray sign of fibroadenoma is the presence of a formation in the mammary gland of a round, oval or lobular shape with clear even contours. Sometimes radiologically the impression is created that the tumor consists of several nodes, since its contours are polycyclic. Inequality and indistinctness of the contours of fibroadenoma indicates a malignant transformation of the tumor. The characteristic deformation of the structural pattern and the appearance of a zone of enlightenment around the formation is due to the appearance of the surrounding tissues. Usually the size of fibroadenoma is clinically and radiologically the same. Macrocalcifications of the "popcorn" type are often found, which are localized on the periphery and then slowly can occupy the entire tissue of the formation. Mastitis. Non-specific inflammatory disease of the breast, along the course, can be acute and chronic. In 80-90% of cases, acute mastitis develops during lactation (lactational mastitis). An increase, engorgement and soreness of the mammary gland, an increase in body temperature, and redness of the skin are clinically determined. Mammography is not specific. This form of mastitis is well visualized by ultrasound examination. It should be noted that mammographic and ultrasound pictures of mastitis (diffuse) and edematous-infiltrative forms of breast cancer are practically the same. An abscess is a local, encapsulated collection of pus in the breast tissue. Usually seen in breastfeeding women (postpartum mastitis). In other cases, it rarely develops. Mammographic signs are nonspecific: a round or oval formation of increased density with variable characteristics of the contours. Granulomatous, plasmacytic mastitis. The etiology is unknown. In pathogenesis, the leading role is played by the autoimmune process. A characteristic ray sign is the identification of “rod” type secretory calcifications more than 10 mm long (calcium surrounds, rather than fills the duct), which have a duct or linear distribution. Mastopathy is a polyetiological disease associated with both genetic, endocrine factors, and environmental factors. It is characterized by a wide range of proliferative and regressive changes in the mammary gland with an impaired ratio of epithelial and connective components. Clinically, mastopathy appears with painful sensations, especially in the premenstrual period, swelling and compaction of the mammary glands, sometimes discharge from the nipple. In accordance with the X-ray picture, the following forms of mastopathy are distinguished: - diffuse fibrocystic breast disease with a predominance of the glandular component (adenosis); - diffuse fibrocystic mastopathy with a predominance of the fibrous component; - diffuse fibrocystic breast disease with a predominance of the cystic component; - mixed form of diffuse fibrocystic mastopathy; - sclerosing adenosis; - nodular fibrocystic mastopathy. Cysts are the most common benign breast masses in women. They can spontaneously disappear or grow rapidly, have different sizes and different localization. With mammography, a round or oval formation with smooth contours is determined, in terms of density comparable to the density of the gland or high density. Palpation and radiological sizes of the cysts are the same. Differentiating cyst and fibroadenoma on MMA is problematic. Leaf-like tumor. There are two peaks in incidence: 11-20 years and 40-50 years (active hormonal periods of life). It is characterized by rapid growth. The tumor size can be from 1.0 to 35.0 cm. With large and giant tumors, the x-ray picture is typical: an intense, more often more uniform formation of an oval or irregularly rounded shape with clear tuberous contours. Often determined against the background of fibrocystic mastopathy. Malignant tumors Non-invasive lobular carcinoma in situ (LCIS) is a histologically proliferative process in the terminal ducts and acini. Accidental microscopic finding in breast tissue removed for other reasons. There are no specific clinical and radiological signs. Rarely, microcalcifications are determined against the background of unchanged surrounding tissues or stellate severity. The process is multifocal, often bilateral, and is a marker of a high risk of breast cancer. Non-invasive intraductal cancer in situ (DCIS). In most cases, it has no clinical symptoms. Seals in the mammary gland (5%), a cyst with growths (4%), discharge from the nipple (4%) of a serous or bloody nature are rarely detected. Therefore, the main determination method is mammography, because almost the only sign of intraductal cancer in situ is the presence of microcalcifications. Only in 10% of cases it manifests itself as an asymmetric violation of tissue architectonics without microcalcifications. Microcalcifications are usually polymorphic or amorphous, sometimes monomorphic. They can be very small (dotted, slightly over the resolution limit). Their location matters: in groups (cluster), segmentally or linearly. In the distal parts of the ductal system, the distribution can be chaotic (regional or diffuse), respectively, between the mezhlobular and intralobular ducts. Invasive breast cancer. X-ray signs of invasive breast cancer are divided into direct and indirect. The main mammographic sign of invasive breast cancer is the presence of an irregularly shaped mass without clear contours, with strands in the surrounding tissues, high density, with the presence of microcalcifications in the tumor projection or in adjacent areas. It is very important that all calcifications are identified before surgery and then completely removed. Indirect signs include: retraction of the nipple, thickening of the skin, its retraction, enlargement of lymph nodes, subareolar dilatation of the ducts, tightness towards the nipple, fixation of the formation to the chest wall, changes in the vascular pattern and surrounding tissues. Usually, the size of the tumor during malpation does not coincide with the size determined by mammography. Edematous infiltrative form of breast cancer. Prognostically unfavorable form of breast cancer, in the structure of breast cancer morbidity is 15%. Mammograms detect diffuse thickening of the skin, a decrease in the transparency of the subcutaneous fat layer and premammary space, thickening of Cooper's ligaments, a decrease in the clarity of the image of the entire gland, a diffuse or local asymmetric increase in the density of the parenchyma. Axillary lymph nodes are almost always affected. The indicated X-ray signs are not specific and do not allow differentiating this form of breast cancer and diffuse form of mastitis. Medullary breast cancer. It accounts for up to 10% of all breast cancer. It can be found in all age groups, the age peak is 45-55 years, and 10% of patients are under 35 years old. Cases of bilateral defeat are 5%. Mammographic signs: round, oval or lobular formation, sometimes irregular in shape. The contours are usually small-knobby, the density is high or comparable to the density of the surrounding parenchyma. Microcalcifications are rare. Mucous BC. It accounts for about 3% of all types of breast cancer. It occurs more often at the age of 60-70 years. Long-term existence and slow growth rates are characteristic. On mammograms, the formation is more often of a rounded shape, with even contours (on sighting ma-mmograms, the contours become partially fuzzy, blurred), the density is high or comparable with the density of the surrounding parenchyma. Microcalcifications are rare. BI-RADS system. The BI-RADS (Breast Imaging Reporting and Data System) system is designed to standardize the descriptions of mammographic examinations and eliminate discrepancies when detecting deviations from the norm, its use facilitates the collection of statistical data, allows monitoring the results and assessing the quality of diagnostics. Translated into Ukrainian, BIRADS stands for breast imaging interpretation and logging system. The first edition of BI-RADS appeared in 1992 and included mammography (MG) only. In 2003. The fourth edition of BI-RADS-MG, the first edition of BI-RADS ultrasound and BI-RADS-MRI has been released. In 2013, a combined fifth edition was issued for three ray methods. The use of BI-RADS is generally accepted in Europe, the United States and other countries of the world (in some countries, like in France, it is mandatory), which proves its relevance and practical value. Type of structure of the mammary glands According to the BI-RADS scale (2003), the definition of the type of structure of the mammary glands was based on the measurement of the total density (in% ratio) and affected by the numbers - 1, 2, 3, 4. In 2013, the digital designations of the types of the structure of the mammary glands were replaced by letters: A, B, C, D, and the use of percentages is not recommended, it is much more important Try to turn off the likelihood that a mass will be masked by dense tissue • A: adipose tissue predominates, the sensitivity of the method (mammography) is high; • B: scattered areas of fibrous-glandular tissue of high density are determined. • С: glands of heterogeneous density, small volumetric formations can be masked with dense fibrous tissue; • D: the glands are very dense, the sensitivity of the method is low. BI-RADS Scale Categories The use of the BI-RADS system is fundamentally different from the traditional assessment of the resulting image. The main goal of the study is not so much the formulation of a morphological diagnosis as the determination of the tactics of further management of the patient. The classification system has its own vocabulary (terminology) and definitions of localization, and after the protocol description of the image, a diagnosis is made and the category BI-RADS must be indicated: BI-RADS 0 (incomplete data, final conclusion is not possible) - additional information or data from a previous study is required, usually used in screening studies BI-RADS 1 (no changes detected) - no pathological changes, breast cancer probability 0%. The recommendation is control mammography after 1 year. BI-RADS 2 (benign changes) - signs are found that are assessed as benign (fibroa-Dan cysts, adenosis, fat necrosis, etc.), the probability of breast cancer is 0%. Recommended - control mother after 1 year. BI-RADS 3 (probably benign changes) - signs are found and are estimated as possibly benign changes, the probability of breast cancer is 2%. A control study after a short interval (6 months) was recommended. BI-RADS 4 (suspicious pathological changes) - signs are found that are suspicious, but do not have typical characteristics of malignancy, the probability of breast cancer is from 2% to 95%. Subcategories: 4a - low probability (2% to 35%), 4b - moderate probability (35% to 75%), 4c - high (75% to 95%). Performing a biopsy. BI-RADS 5 (high suspicion of malignancy) - practically reliable malignant changes, and the speech-rate of breast cancer is over 95%. Performing a biopsy. BI-RADS 6 (histologically verified cancer) - the histological report was received before the head of the treatment. start treatment Ultrasound of the mammary glands. X-ray mammography is the leading diagnostic method, but along with it, ultrasound mammography (USM) is also successfully used. UZM today is one of the most promising methods for diagnosing breast pathology. And with the advent of close- focus small-sized high-frequency sensors 5.0-7.5 MHz, UZM became competitive with such an established diagnostic method as RM. The UZM accuracy depends on: -technical parameters of the device; -experience of the researcher; -the age and hormonal status of the patient; -type and stage of the disease. Indications for ultrasound mammography: 1. Differential diagnosis of cysts and solid formations revealed by palpation and RM. 2. Examination of radiologically dense mammary glands. 3. Examination of the mammary glands in pregnant and lactating mothers. 4. Examination of the mammary glands in women under 30 years of age. 5. Examination of the mammary glands in children and adolescents of both sexes. 6. Examination of the mammary glands in the acute period of injury or inflammation. 7. Assessment of the state of silicone breast prostheses. 8.Ultrasound control during puncture biopsy of palpable and non-palpable formations in the mammary glands and surrounding tissues. 9. Examination of the mammary glands in men. 10. Evaluation of seals of unclear etiology in the mammary glands. 11. As an adjunct to RM in a group of premenopausal women. 12. As an adjunct to RM for ambiguous radiological findings. Materials for self-control: A. Tasks for self-control. 1. To analyze the methods of research of the mammary glands. 2. Get acquainted with the normal image of the mammary glands on mammograms, MRI, ultrasound. 3. To analyze the radiation signs of benign diseases of the mammary glands. 4. To disassemble the radiation signs of mastopathy. 5. To analyze the radiation signs of malignant diseases of the mammary glands. 6. To get acquainted with the images of mammary glands on mammograms, MRI, ultrasound for the listed diseases. 7. Solve situational tasks. B. Tasks for self-control. Level I tasks: 1. A 59-year-old woman has a mammogram with a high density of glandular tissue and diffuse monomorphic calcifications. Your prisoner. Answer: Mastopathy. 2. On the mammogram in the lower outer quadrant of the right breast, a lobular mass of medium density with smooth contours was revealed. Your conclusion. Answer: Fibroadenoma. Tasks of the II-III level: 1. On a mammogram in the upper outer quadrant of the right breast, grouped polymorphic microcalcifications were revealed. Your conclusion. Answer: Malignant tumor. 2. On a mammogram in the lower outer quadrant of the left breast, a medium density formation with smooth contours was revealed. Your conclusion. Answer: Benign tumor. Literature recommended: Main Source: 1. Radiology (radiation diagnostics and radiation therapy). Kiev, Kniga plus, 2013.-743 p. 2. Radiology under the editorship of V. I. Milko, Kiev "Vishcha school", 1983. - 238 p. 3. LD Lindenbraten, IP Korolyuk Medical radiology and radiology. Moscow "Medicine", 1993. - 556 p. 4. LD Lindenbraten, LB Naumov Medical radiology. Moscow "Medicine", 1974. - 480 p. Additional (scientific, professional, monographic and periodicals): 5. Radiation diagnostics. under the general editorship of G. Yu. Koval. Kiev: "Orbis", 2002. - 640 p. 6. Clinical Radiology: The Essentials Fourth Edition by Daffner M.D. F.A.C.R., Dr. Richard H., Hartman M.D., Dr. Ma (2014) - 4th edition. 2014.546 p. 7. Radiology for the wards / a student - to - student guide. Latha G. Stead, Matthew S. Kaufman, S. Matthew Stead, Anjali Bhagra, Nora E. Dajani. 2009. 265 p. Internet resources. https://radiographia.info/ http://nld.by/help.htm http://learningradiology.com http://www.radiologyeducation.com/ http://www.radiologyeducation.com/ https://www.sonosite.com