Breast Imaging

Although breast cancer continues to be the second-leading cause of cancer death among women in the United States, screening mammography has made a significant impact by identifying early, treatable cancers. Since the introduction of widespread mammography screening in the mid-1980s, the U.S. breast cancer mortality rate has declined by as much as 40 percent, after the rate had remained largely unchanged over the previous four-plus decades.

Breast Cancer Early Detection and Diagnosis

Early detection decreases breast cancer mortality. The ACR recommends annual mammographic screening beginning at age 40 for women of average risk. Higher-risk women should start mammographic screening earlier and may benefit from supplemental screening modalities. For women with genetics-based increased risk (and their untested first-degree relatives), with a calculated lifetime risk of 20% or more or a history of chest or mantle radiation therapy at a young age, supplemental screening with contrast-enhanced breast MRI is recommended. Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening.

Breast Imaging Techniques

Different imaging tests can be used to detect and diagnose breast cancer.  The most common are

• Mammography
• Ultrasound
• MRI
• Mammograms

Screening vs Diagnostic Mammograms

Mammograms are low-dose x-rays of each breast that can help find breast cancer. A screening mammogram is done when the patient has no symptoms. Screening mammograms take two views of the breast. It takes views from the top to bottom of the breast and from side to side of the breast.  When the patient presents with a complaint or symptom, a diagnostic mammogram is done. Diagnostic mammograms are also performed when the patient returns for a possible abnormality seen on a screening mammogram. Diagnostic mammograms take several views of the breast in different projections and magnifies the area of concern. 

Types of Mammograms

Mammograms are recorded and saved as files in a computer in a digital format.  Until recently the computer puts the images together in a 2-dimensional format, but more recently a newer type of mammogram has been developed. It is known as breast tomosynthesis or 3D mammography. In this new technique the computer puts the images together into a 3-dimensional picture which allows the breast tissues to be seen more clearly.   Numerous recent studies have shown 3D mammography increased invasive breast cancer detection rates by 40%. Additionally, 15% fewer patients were "called back" and asked to return for additional evaluation. 3D digital breast tomosynthesis improves evaluation of dense breast tissue.

Are Mammograms Safe?

Mammograms expose the breasts to small amounts of radiation. But the benefits of mammography outweigh any possible harm from the radiation exposure. Modern machines use low radiation doses to get breast x-rays that are high in image quality.

Dense Breasts and Mammograms

Some women have denser breast tissue than others.  Having dense breasts is very common and is not abnormal. For most women, breasts become less dense with age. But in some women, there’s little change. In California, and many other states, women whose mammograms show heterogeneously dense or extremely dense breasts must be told that they have dense breasts in the summary of the mammogram report so that they know to speak to their doctors about any additional imaging that should be done.

Since mammograms can be less accurate in women with dense breasts there are additional imaging options. Studies have shown that breast ultrasound and magnetic resonance imaging (MRI) can increase the sensitivity of screening in women with dense breasts. MRI can help find some breast cancers that can’t be seen on mammograms. However, MRI and ultrasound both can show more findings that turn out not to be cancer. This can lead to more tests and unnecessary biopsies. The cost of ultrasound and MRI may not be covered by insurance and must be discussed with your doctor.

Breast Ultrasound

Ultrasound is a type of technology that uses high-frequency sound waves to generate an image of your breast tissue. Ultrasound is a safe, noninvasive exam with no radiation. Ultrasound is useful for looking at some breast changes, such as lumps (especially those that can be felt but not seen on a mammogram) or changes in women with dense breast tissue. It also can be used to look at a change that was seen on a mammogram. Ultrasound is useful because it can often tell the difference between fluid-filled cysts (which are very unlikely to be cancer) and solid masses (which might need further testing to be sure they're not cancer). Ultrasound can show a finding not seen on a mammogram and vice versa. Both technologies (mammogram and ultrasound) are complimentary to one another.

Ultrasound can also be used to help guide a biopsy needle into an area so that cells can be taken out and tested for cancer. This can also be done in swollen lymph nodes under the arm.

Breast MRI Scans

Breast MRI (magnetic resonance imaging) uses radio waves and strong magnets to make detailed pictures of the inside of the breast. MRI does not have radiation or use x-rays. In order for the exam to be diagnostic and evaluate for the presence of breast cancer, contrast is required.

When is breast MRI used?

Breast MRI is often used in women who already have been diagnosed with breast cancer, to help measure the size of the cancer, look for other tumors in the breast, and to check for tumors in the opposite breast. Each MRI exam produces thin slices of both breasts which can be viewed in all 3 directions (top to bottom, right to left, and front to back). The MRI images are used for diagnosis, treatment planning, and screening for high risk women for breast cancer, among other indications

For certain women at high risk for breast cancer, a screening MRI is recommended along with a yearly mammogram. MRI is not recommended as a screening test by itself because it can miss some cancers that a mammogram would find.  MRI is also more likely to find something that turns out not to be cancer (called a false positive). False-positive findings have to be checked out to know that cancer isn’t present. This can mean more tests and/or biopsies.

Diagnostic evaluation of women with suspected breast cancer

Stereotactic Breast Biopsy

Stereotactic Mammography Guided Breast Biopsy is considered a minimally invasive alternative to surgical biopsy. A biopsy needle is placed into the breast tissue. Computerized mammographic pictures help confirm the needle placement using digital imaging so the exact location of breast tissue is biopsied. Tissue samples are then taken through the needle It is completed on an outpatient basis with minimal discomfort and recovery time. You will be awake throughout the procedure. Biopsies are the only definitive way to confirm that a breast abnormality is benign (non-cancerous) or cancerous.

Ultrasound Guided Breast Biopsy

Ultrasound Guided Breast Biopsy is considered a minimally invasive alternative to surgical biopsy to evaluate suspicious masses within the breast that are visible on ultrasound. A biopsy needle is placed into the breast tissue. Ultrasound helps confirm the needle placement using sound waves reflected off breast tissue so the exact location of breast tissue is biopsied It is completed on an outpatient basis with minimal discomfort and recovery time. You will be awake throughout the procedure. Biopsies are the only definitive way to confirm that a breast abnormality is benign (non-cancerous) or cancerous.

MRI Guided Breast Biopsy

MRI Guided Breast Biopsy is a minimally invasive alternative to surgical biopsy to evaluate suspicious masses within the breast that are only visible on MRI. A biopsy needle is placed into the breast and the MRI images are utilized to confirm location of the abnormality. You will be awake throughout the procedure. Biopsies are the only definitive way to confirm that a breast abnormality is benign (non-cancerous) or cancerous.

Pre-surgical Wire Localization

Pre-surgical Wire Location procedure is performed in order to identify the location of the abnormality that may not be palpable to assist the surgeon in finding the area to excise. The procedure is performed with mammography or ultrasound guidance. The modality is pre-determined at the time of the pre-operative workup which may have included a mammogram, ultrasound or needle biopsy.

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