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How New Technology Is Changing Mammography and Breast Cancer Management

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How New Technology Is Changing Mammography and Breast Cancer Management CANCER DIAGNOSIS AND MANAGEMENT MAURIE MARKMAN, MD, EDITOR GILDA CARDENOSA, MD, MS WILLIAM A. CHILCOTE, MD MARY A. BARRY, RN Section of Breast Imaging, Division of Radiology, Section of Breast Imaging, Division of Radiology, Section of Breast Imaging, Division of Radiology, Cleveland Clinic Cleveland Clinic Cleveland Clinic CHRISTINE A. QUINN, MD MARY G. FOGLIETTI, RN Section of Breast Imaging, Division of Radiology, Section of Breast Imaging, Division of Radiology, Cleveland Clinic Cleveland Clinic How new technology is changing mammography and breast cancer management ABSTRACT HANKS TO IMPROVEMENTS in breast- imaging techniques—ie, mammography Breast-imaging technology has improved in ways that allow and ultrasonography—physicians are changing one not only to detect breast cancer earlier, but also to the way they approach the diagnosis of breast distinguish benign from malignant lesions better. These cancer. More patients are being diagnosed capabilities are influencing the approach to breast cancer. early, before any lump can be palpated, and We review current trends and issues for the non-radiologist. radiologists can often distinguish benign from malignant findings. Thus, the old approach of KEY POINTS "feel it, biopsy it, remove it" is giving way to a more tailored response in which watchful wait- The aim of a screening mammogram is to distinguish ing is an option for some patients. normal from "potentially abnormal." Separate diagnostic studies are done to characterize potentially abnormal • NEW EQUIPMENT IS BETTER findings. To produce images, early mammography The radiologist reviewing a diagnostic mammogram must machines (ie, those used in the 1970s and categorize the study as: 1) normal, 2) benign, 3) probably early 1980s) relied on a process called xerogra- phy—the same photoelectric process used in benign, 4) suspicious, or 5) highly suggestive of malignancy. copy machines. Newer machines use photo- graphic film with an intensifying screen: "film- Ultrasonography of the breast helps to corroborate the screen" mammography. findings from the clinical examination and mammogram, Film-screen mammography has several especially in women with dense breasts, in whom advantages over xeromammography. Image mammography may be less helpful. quality is clearer: contrast is enhanced and glandular tissue shows up more clearly. Radiation doses are lower. The greatest gain, however, is the ability to obtain additional, workup images (eg, spot compression and spot magnification views) to evaluate potentially abnormal areas detected on screening mammo- grams (see "Diagnostic mammography" below). • SCREENING MAMMOGRAPHY By definition, screening mammograms are PATIENT INFORMATION done in asymptomatic women. Women can be Mammography, page 203 considered asymptomatic even if they have a CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 3 MARCH 2000 191 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. BREAST IMAGING CARDENOSA AND COLLEAGUES ic screening had a significantly lower rate of breast cancer mortality than did women who were not. All of the trials included women in their 40s. Four of these trials—the ones with the longest follow-up data—have now also reported statistically significant decreases in breast cancer mortality specifically among women 40 to 49 years of age when enrolled: 25% reductions in the Health Insurance Plan trial and the Two-County Swedish trial, 44% in the Gothenberg trial,3 and 36% in the Malmo trial.4 How often to screen? ! •L If the interval is too long (or if the threshold for intervention is set too high), small, non- palpable lesions have time to grow and poten- - tially metastasize, and the benefit of screening may be lost.5 In premenopausal women, the sojourn time (the time for cancers to progress from a lesion detectable only by mammogra- • a phy to a palpable lesion) is about 1.8 years.6'7 In postmenopausal women, sojourn times vary according to histologic type and patient age; 7 FIGURE 1. Normal screening mammogram. the reported average, however, is 3.5 years. By convention the right and left metallic Annual mammograms are therefore particu- markers are placed closest to the axilla. larly indicated in premenopausal women.8 We recommend Top, right and left mediolateral oblique The American Cancer Society,8 and the annual (MLO) views back-to-back. This is how the Cleveland Clinic Breast Center recommend images are reviewed. On well-positioned annual screening starting at age 40. mammograms MLO views, the pectoral muscle is seen to In the general population, widespread use the level of the nipple and its anterior of mammographic screening is having an effect from age 40 margin is convex, as in this patient. Bottom, right and left craniocaudal views back-to- on the types of patients physicians are now see- back. Pectoral muscle is seen on craniocaudal ing. More women are being diagnosed with views in 30% to 40% of patients (arrow). mammographically detected, clinically occult, node-negative disease.9-11 Ductal carcinoma in situ, considered an unusual disease as recently family history of breast cancer or of mastecto- as 1986,12 now constitutes 15% to 45% of all my for breast cancer, or have had prior biopsy mammographically detected breast cancers.13'14 findings of benign proliferative changes or lobular neoplasia (lobular carcinoma in situ). Technique for screening mammography During the procedure, the breast tissue must Should women in their 40s be screened? be compressed. Compression serves several The value of mammography as a screening test purposes. It thins the breast tissue so that less has been a contentious issue, and particularly radiation can be used. It also reduces scatter the value of screening in 40-to-49-year-old radiation, a deterrent to high-contrast images. women.1 We believe that mammography, per- It optimizes exposure of dense glandular areas. formed at regular intervals, reduces breast can- Immobilizing the breast reduces the likelihood cer mortality rates in women age 40 to 49 and of blurring and helps separate overlapping tis- in women age 50 and older.2 sue, which can make the difference between In seven of eight randomized controlled finding or missing an early cancer.15-16 trials, women who were offered mammograph- We generally obtain two views (FIGURE 1): 192 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 3 MARCH 2000 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. Algorithm for breast cancer screening All women age 40 and older with no signs or symptoms Any woman with possible signs or symptoms of breast cancer , of breast cancer I Screening mammography Normal Possibly abnormal Screen every year Diagnostic mammography Consider ultrasonography as well, especially if the patient has dense breast tissue, or ultrasonography alone if the patient is pregnant or younger than 25 years Normal Probably benign Indeterminate or probably malignant 1 1 Y V Screen every year Follow up in 6 months Consider imaging-guided or excisional biopsy FIGURE 2 • Craniocaudal (CC), ie, with the x-ray mammograms in batches, for two reasons. source placed cranially to the breast and the First is efficiency. As patient volumes film placed caudally. increase or outpatient sites are added, it is not • Mediolateral oblique (MLO), ie, with the realistic to expect immediate interpretation of A screening x-ray source placed above the upper inner screening mammograms and evaluation of mammogram quadrant of the breast and the film positioned patients with potential abnormalities. Given on the lower, outer aspect of the breast. the low rates of reimbursement for screening can detect In addition, approximately 10% of women mammograms, it is necessary to have an effi- lesions, but need a third image to evaluate lateral tissue: cient, cost-effective, and streamlined method the exaggerated craniocaudal (XCC) view. of moving patients through mammographic not tell benign rooms in high volumes. from malignant Interpreting screening mammograms This should not and does not imply sub- In reviewing a screening mammogram, the standard quality imaging or impersonal ser- radiologist must answer one question: Is the vice. Our technologists are trained to review study normal or potentially abnormal? It is a all images for positioning, contrast, optimal mistake to try to characterize a lesion on the exposure, and resolution (no blurring) before basis of a screening mammogram. Time and the patient leaves the department. again, what seems like a true lesion does not The second reason is quality. Error rates persist, or a benign-appearing area turns out to can be minimized if films are systematically be a malignancy. Screening mammography is presented with comparison studies. Right and simply about detecting a lesion, not charac- left CC views and right and left MLO views terizing it as benign or malignant (FIGURE 2). are placed back-to-back for comparison. Another mistake, in our opinion, is to try Attention is focused on the films, not paper- to review each screening mammogram while work or dictation. Interruptions need to be the patient is still there. True, the patient kept to a minimum. The only light in a mam- receives the results immediately, and any addi- mographic interpretation room must be com- tional studies needed can be done then and ing from high-intensity viewboxes through there. However, we believe it is better to review the mammographic images. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 3 MARCH 2000 43 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. FIGURE 3. Diagrams illustrating differences ' \ in compression paddles. Top, large compression paddle used for compression FIGURE 4. Infiltrating ductal carcinoma, of the entire breast (ie, for mediolateral spot compression view. Mass with ill-defined and craniocaudal views). Middle, spot margins and spiculation (white arrow); no compression paddle used for focal associated microcalcifications (to suggest compression. Compression is applied to the ductal carcinoma in situ) or satellite lesions.
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