Gregorys Vernissage

The week in neuroradiology has been a breeze. As Greg has taken a day offto work on yet another paper, Paul hopes to get by without the usual pimping procedure. It is 5 p.m. on a Friday and he unwinds more with every minute that goes by. Giufeng, however, is a little tense and looks around nervously. A few minutes later, Greg walks through the door with a bunch of films under his arm. With a big grin he whips four test cases up on the viewbox (Fig. 11.57). "Now you didn't really think I'd let you down, Paul, did you?" he jokes benevolently. Giufeng sets herself up in front of the viewbox. "Are you coming along after this?" Greg whispers in her ear. Paul pricks up his ears: "Now what's going on, the two of you?" he asks sharply. "Ahem, well, Giufeng and I are going to a spiffy vernissage, my dear Paul!" says Greg. "Oh, dear, naive art, I presume?" Paul fires back. Giufeng takes the sting out of the situation: "First things first, you guys. I'll start with this case and you, Paul, will do the next."

I Test Cases abc

Radiography Jokes
Fig. 11.57a-g All histories are withheld.

The radiological examination of the female breast (mammography) assumes a very special status within the spectrum of all imaging modalities, for several reasons. First of all, it is a pure soft tissue examination with which ultrafine calcifications are supposed to be detected. For that reason it is performed with a much lower exposure voltage than normal in projection radiography (25-32 kVp) (see p. 34).

f With this technology carcinomas can be found that are i only a few millimeters in size. Nowhere else in the body can current radiology hope to achieve anything like that.

Secondly, the contact between the radiologist and the patient is particularly close—something that is not the rule in other radiology subspecialties (with the exception of interventional radiology). The time of the examination is often a period of intense psychological stress for the women involved. Within a few minutes a recently palpated breast lump might turn out to be a harmless cyst or a potentially lethal carcinoma with all its implications for the private and professional future of the patient. The resulting turmoil of emotions does not leave the diagnostician unaffected. A clear decision cannot always be reached right away; uncertainty must be carefully considered and explained by the radiologist, who needs to make very specific recommendations for further diagnostic work-up at the conclusion of the encounter with the patient.

Eventually, however, and this is something to rub in real deep, mammography is a modality that can lower breast cancer mortality by up to 40% if done technically well by expert mammographers in the context of a well-organized population-based breast screening program. No other imaging modality even comes close to that kind of extraordinary impact on women's health! Ultrasound and MRI of the breast are secondary but essential auxiliary modalities for evaluation of the breast (Table 12.1).

Table 12.1 Suggestions for diagnostic modalities in breast imaging1

Clinical problem

Investigation

Comment

Mammographie screening in asymptomatic patients2

Screening <40 years

Mammography

Not indicated because there is no proven benefit to screening of women <40 years old who are not at increased risk of breast cancer. Breast cancer is uncommon under the age of 35 and the sensitivity of mammography for detection of malignancy can be reduced in younger patients owing to dense breast parenchyma.

Screening 40-49 years

Mammography

Women seeking screening at this age should be made aware of the risks and benefits. While cancers can be diagnosed by screening, total benefit to the population of this age group is limited.

US

Only as special adjunct to mammography in women with dense breasts and those with implants.

Screening 50-64 years

Mammography

Decreased mortality results from regular population-based and quality-controlled certified screening in this age group.

US

Only as a special adjunct to mammography in women with dense breasts and those with implants.

Screening 65+ years

Mammography

Screening by invitation in some programs until 70 years. Self-referral required in some programs.

US

Useful adjunct to mammography in women with dense breasts and those with implants.

Table 12.1 Suggestions for diagnostic modalities in breast imaging1 (Continued)

Clinical problem

Investigation

Comment

Family history of breast cancer

Mammography

Evidence of benefit is emerging for women at significantly increased risk in their 40s and appears to outweigh the harm of screening. Screening should only be undertaken after genetic risk assessments and appropriate counseling as to the risks and unproven benefits. Consensus is that screening of women <50 years old with a family history should only be undertaken when the lifetime risk of breast cancer is greater than twice the average. Further guidelines for mammographic and other forms of screening in these women remain under review.

Useful adjunct to mammography in women with dense breasts and those with implants.

Women <50 years having or being considered for hormone replacement therapy (HRT)

Mammography

HRT has been shown to increase density and benign changes in the breast. There is a related drop in sensitivity and specificity and an increased recall rate in screening of such breasts. There is no evidence to support performance of routine mammography prior to starting HRT. Women on HRT 50 years old and over can be appropriately monitored within a regular breast screening program.

Only as a special adjunct to mammography in women with dense breasts and those with implants.

Augmentation mammoplasty (50 years and over)

Mammography, US

As part of the regular breast screening program: mammography is best performed at a static unit as there may be a need for extra (implant displacement) views and US.

Symptomatic patients

Clinical suspicion of carcinoma

Mammography

Referral to a breast clinic should precede any radiological investigation. Mammography ± US should be used in the context of triple assessment—clinical examination, imaging, and cytology/biopsy.

US

The modality of choice for women <35 years old. Should be performed at specialist breast clinic.

MRI

Breast MRI should be considered after histological proof of cancer to exclude multifocality or multicentricity and if disagreement arises between imaging and pathology results.

? Carcinoma recurrence (posttherapy)

Mammography

For detection.

US

For detection and image-guided biopsy.

MRI

In ambivalent cases at least 6 months after surgery or 12 months after radiotherapy.

Generalized lumpiness, generalized breast pain or tenderness, or long-standing nipple retraction

In the absence of other signs suggestive of malignancy, imaging is unlikely to influence management. Focal, rather than generalized pain may warrant investigation.

Cyclical painful breasts (mastalgia)

-

In the absence of other clinical signs suggestive of malignancy and localized pain, investigation is unlikely to influence management.

Augmentation mammoplasty (clinical suspicion of carcinoma, rupture)

US, MRI

The assessment of integrity of breast implants and potentially coexisting palpable masses requires specialist skills and facilities. MRI is the most comprehensive study.

Table 12.1 Suggestions for diagnostic modalities in breast imaging1 (Continued)

Clinical problem

Investigation

Comment

Paget disease of the nipple

Mammography

Will show abnormality in 50% of women. Helpful to determine the possibility of image-guided biopsy. When invasive disease is confirmed, it influences surgical management of the axilla.

Breast inflammation

US

Can distinguish between an abscess requiring drainage and diffuse inflammation, and can guide aspiration when appropriate.

Mammography May be of value where malignancy is possible.

1 Modified after: RCR Working Party. Making the best use of a Department of Clinical Radiology. Guidelines For Doctors, 5th ed. London: The Royal College of Radiologists, 2003.

2 In many countries quality-assured population based mammographie breast screening is not yet in place. MRI, magnetic resonance imaging; US, ultrasound.

1 Modified after: RCR Working Party. Making the best use of a Department of Clinical Radiology. Guidelines For Doctors, 5th ed. London: The Royal College of Radiologists, 2003.

2 In many countries quality-assured population based mammographie breast screening is not yet in place. MRI, magnetic resonance imaging; US, ultrasound.

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