From the website of
http://www.r2tech.com/pti/index_b.html converted from their .pdf
1. WHAT IS
Breast cancer is a
“malignant neoplasm of the breast.” A cancer cell has
characteristics that differentiates it from normal tissue cells
with respect to: the cell outline, shape, structure of nucleus and
most importantly, its ability to metastasize and infiltrate. When
this happens in the breast, it is commonly termed as ‘Breast
Cancer’. Cancer is confirmed after a biopsy (surgically extracting
a tissue sample) and pathological evaluation.
Microscopic cell differentiation
Breast Cancer is second to Lung Cancer in the fatality
rate due to cancer among women today. In the developed
countries, one out of every nine women gets breast cancer during
Country (I) United States 94.2 Switzerland 73.5
Netherlands 72.7 Canada 71.1 Denmark 68.6 France 66.3 Italy 65.4
Sweden 62.5 Australia 61.7 Great Britain 56.1 Norway 54.8
Germany 46.3 Slovak 34.5 India 24.6 Japan 21.9
Mortality Rate M/I
Incidence and Mortality rates; Cancer
Incidence in Five Continents V6,’83-‘87
In1999, approximately 215,000 new cases of breast cancer are
expected to be diagnosed in the United States and 43,000 women
are expected to die from this disease.
1.2. Risk Factors
The most important risk factor is age. The incidence of
breast cancer increases with age. The majority of women
diagnosed with breast cancer are over the age of 50. Women
under the age of 25 are least likely to develop breast cancer.
However, younger women who do contract breast cancer, suffer
from speedy and aggressive growth of cancer.
Women are the main victims of breast
cancer, but male breast cancer accounts for less than 1% of
the total breast cancer cases.
1.2.3. Family History of Breast Cancer
A family history of breast cancer
increases the risk of getting breast cancer during a woman’s
lifetime. Breast cancer can appear in multiple family members
and can be carried down to up to three generations. The
maternal side of the family contributes to the high risk
category of breast cancer, meaning, if a woman’s grand-mother,
mother, aunt or sister has breast cancer, then she is more
likely to develop breast cancer. The indirect commonalties
are: lifestyles, hormonal and menstrual patterns and dietary
1.2.4. Hormonal Factors
Breast cancer is directly related to
the spurts of hormonal changes through a woman’s lifetime.
Starting menstruation at an early age, no childbirth and late
age of menopause contribute to the high risk category of
breast cancer. A direct co-relation is found between the age
of first pregnancy and breast cancer. It is believed relative
risk of breast cancer increases by 1.4 if the first pregnancy
occurred after the age of 30. On the other hand, women who
experienced their first childbirth before the age of 20, had
decreased relative risk of breast cancer (0.8). Some studies
have shown that the use of oral contraceptives and long-term
estrogen therapy increase the risk of breast cancer.
Lifestyle contributes towards the
probability factor of breast cancer. High fat content in the
diet increases the risk of breast cancer. Some studies
indicate that high meat consumption, high caffeine intake,
smoking, environmental pollution also increases the risk of
breast cancer, but these results are still unconfirmed.
1.3. Signs and Symptoms
1.3.1. Clinical Signs
The most common clinical sign of breast
cancer is a painless, hard and fixed lump in the
breast. This is one of the reason that makes clinical
detection of breast cancer very difficult, as painlessness
gives the woman a false sense of security. If the lump is
movable, it is less likely to be cancer, and more likely to be
benign cysts. Approximately, one-tenth of the patients have
breast pain with no detectable lump.
Other symptoms are categorized under
breast distortion. Dimpling of the skin surface, swelling,
skin irritation, skin edema with ‘peau d’orange appearance’
(looks like orange peel), nipple inversion, tenderness and
nipple discharge. At times, a rapidly growing tumor may cause
dilated superficial veins forming a prominent vascular
patters, visual on the breast surface.
1.4. Staging of cancer
Staging of breast cancer means the
categorization of the type and extent of metastases of cancer.
This determines the path of treatment and long-term follow-up.
1.5. Survival Rate
The survival rate has increased
significantly over the past five years. One of the main reasons
for this is: early diagnosis. Women’s awareness of the
importance of breast self exam and mammograms, as well as the
technological progress, leads to early detection. Survival rate
is expressed in two ways : First, by the stage of detection and
secondly, over time. If the cancer is detected in its initial
stages, chance of recovery are very high. As per the American
Cancer Society, based on the time issue, the relative survival
rate for women diagnosed with breast cancer is 83% five years
after diagnosis, 65% after ten years and 56% after fifteen
Survival by stage of diagnosis; American
1.6. Economic Justification
In 1994, out of 183,000 new cases of
breast cancer diagnosed, 25% were at the late stage (National
Cancer Institute, USA). The Treatment cost for early stage
breast cancer is approximately $ 11,000, whereas at a late stage
diagnosis, the treatment cost is about $ 140,000 per case.
Hence, the difference between early and late stage cancer
treatment is between $ 130,000 to $ 230,000 per case. Recent
studies show that a second reading of mammograms increases the
number of cancers detected by 5% to 15%. We know that very early
detection of breast cancer through well structured screening
programs, availability of a second reader and patient
education, is highly cost-effective.
1.7. Importance of Early Diagnosis
As we can see, early diagnosis is the key
to a higher survival rate. There are three ways in which we can
diagnose breast cancer at its early stage:
- Breast Self Exam
- Clinical Exam
- Mammography findings
1.7.1. Breast Self Exam (BSE)
BSE should be done monthly and is one
basic way for a woman to familiarize herself with her breasts
and keep a close watch on the visual appearance of her breasts
and the changes she feels. The best time to do a BSE is 2 to 3
days after the end of menstruation, as the normal lumpiness of
the breast is then minimized. There are various ways of
performing BSE. One of the best method of BSE is performed in
the supine position (i.e. lying down, as this spreads out the
internal breast tissue and deeper lumps can be felt easily)
with one arm raised over the head. Using the smooth surface of
the fingers of the opposite hand, a woman checks the breast
with small circular motion keying in to any lumps that can be
felt. She works from around the nipple area to the outer edges
of the breast in concentric circles.
1.7.2. Clinical Exam
A clinical exam is performed by a
trained healthcare professional. The Clinician examines the
woman in a sitting position, looking for signs such as nipple
inversion, breast distortion, nipple discharge, dimpling, and
skin irritation. She may then ask the woman to press the palms
of her hands together over her head. This accentuates any
physical abnormality that may be present. In conjunction, an
exam, similar to the BSE may also be performed.
This is a radiographic exam of the
breast and the most important exam to detect early stages of
breast cancer. The American Cancer Society recommends women to
have a ‘Baseline Mammogram’ done between the age of 35 - 40
years, each year or every other year till the age of 50 years
and each year after the age of 50. The National Health Service
Breast Screening Programme of England, recommends women
between the ages of 50 and 65 to have a mammogram once every
Lately, there have been many conferences in
USA and some scheduled to be held in Canada to discuss the
need for mammograms before the age of 40. It is a wide spread
opinion that mammograms of younger breasts are not very
diagnostic. Of course, there are controversies and breast
cancer survivors have come forward as living proof that early
mammograms saved their lives.
40+ : annually
50-65: once every 3 years
50-65: once every 2 years
40+ : annually
40-50:once every 2 years
50+ : annually
Other European countries, such as Germany,
France, Italy, Spain, Norway are in the process of setting up
guidelines for women to have a baseline mammogram at a certain
age and every or every other year thereafter.
Regular mammograms can detect lumps as
small as 0.2 cm, whereas regular BSE detects lumps of about
1.2 cm. An average size lump found by women untrained in BSE
is about 3.75 cm.
Average size of lump detected
Women untrained in BSE
Women practicing occasional BSE
Women practicing regular BSE
Size of tumor found by search Method; Susan
G. Komen Foundation
2. WHAT IS A MAMMOGRAM?
A mammogram is a radiograph of the breast
tissue (refer to the attached copy of a mammogram). It is an
effective non-invasive means of examining the breast, commonly
searching for breast cancer. Cancer is not preventable, but early
detection leads to a much higher chance of recovery and lowers the
mortality rate from this disease.
2.1. Breast Anatomy
CC View : Positioning, Film, & Anatomy
X-rays Compression arm Ribs
Cassette containing film
Infra mammary fold
Compression paddle MLO View : Positioning, Film, & Anatomy
- A younger woman has denser or
fibro-glandular breasts. Her mammogram will look very white or
“cloudy” (Error! Reference source not found.-dense breast).
- Middle-aged women have a mixture of fibrous
and glandular tissues (Error! Reference source not found.-50-50
breast). Their mammograms look black and white.
- In a mature breast, most of the fibrous
tissue is replaced with fatty tissue. The mammograms tend to
look black or gray (Error! Reference source not found.-Fatty
Different breast tissue composition.
2.2. Film sizes
18 x 24 cm used for small to average sized
breasts and 24 x 30 cm used for large sizes.
2.3. Mammography Procedure
Here is what happens, in brief :
- The woman is escorted to the changing
room, where she undresses from the waist up and changes into
the screening center gowns
- She is asked to wipe off any deodorants,
perfumes or powders that she may have used that day, as
these can mimic micro calcifications on the film
- She is taken into the mammography room,
where the mammographer or technologist reviews her history
sheet. The history sheet has questions pertaining to the
woman’s previous mammograms, prior surgeries (if any), if
she felt any lumps, superficial marks (such as prominent
moles, scars from an incision), family history of breast
cancer, number of children, her age when the first child was
born, and last date of menstruation or post-menopausal
(Addendum 2). Then, the mammography procedure is explained.
This opens communication channels and the woman feels free
to voice her concerns, thus increasing her comfort level.
- It is important to prepare the woman for
the compression that would be used for imaging. This device
causes discomfort, but should not hurt the woman. A
Compression Paddle, (see Error! Reference source not found.
and Error! Reference source not found.) is a device used to
compress the breast tissue. This helps to spread out and
separate breast tissue, enabling the Radiologist to get an
unobscured view of possible pathology. Compression also
lowers patient radiation dose and prevents patient motion.
- The required views are performed and the
woman is dismissed with instructions that she might feel
sore for a day or so from the compression.
• Mammography equipment has progressed
rapidly over the last 10 years. In developed countries, a
dedicated mammography unit is used. A whole range of
manufacturers make these machines, for example : GE, Bennett,
Lorad, Siemens, Fischer, Phillips. They generally have a
reciprocating grid to reduce scatter radiation thus avoiding
fog and blurry image. The Filter (to make the beam hard and
more penetrable) used, is 0.03 mm Molybdenum.
Most mammograms are routine mammograms. The woman is
perfectly healthy. Hence, rather than refer to her as
‘patient’, she will typically be considered a ‘customer’ or
‘woman’. Using the word patient would imply that she is ill.
Film Processing is done under specific
conditions. The two ways to develop an exposed film are (1)
Standard Processing and (2) Extended Processing. The choice
depends on the type of film used.
Picture of Mammography Equipment
- Technique used for a mammogram is low
Kilo-voltage Peak (KvP) about 24 to 30.
The milli-Ampere-seconds (mAs) varies
depending on breast tissue density. When the photo timer
cells are used, it provides the optimum mAs for the tissue
to be imaged. This technique results in mammograms with a
high film contrast, making it easier for the Radiologist to
- The Films used for mammography are
single emulsion fast films to enhance image sharpness by
eliminating geometric distortion. Films commonly used are :
Kodak Min- RE, Agfa, Fuji, Dupont, Konica.
- The screens consist of a rare earth
phosphor called terbium activated gadolinium oxysulfide.
Screens have to be compatible with the film. The newest
film-screen combination is responsible for dose reduction by
30 - 50 % .
- Markers are used to indicate the side
and view demonstrated on that particular film. Markers are
placed on the side of the axilla (armpit) of the patient.
This acts as a reference point to understand the orientation
of the breast, especially in the CC view.
2.4.1. Screening Mammograms
These views are done as a regular screening process to get
an overall picture of the breasts and ensure that all is well.
The protocol depends on the specific facility. In America,
four films are required of the breasts: two views for each
breast. In Europe, most countries do one view (MLO) of each
breast and if an area of suspicion is notice, then 15% of the
times, additional CC views are taken.
Direction of the X-Ray
Direction from head (cranium) to the feet
X-ray direction is from medial(inner) to
lateral (outer) aspect; and the orientation
of the breast is at an angle (Oblique)
2.4.2. Alternate Views
These are views done when the patient is
unable to be positioned in certain views due to physical
handicap or when the Radiologist wants to get a better look at
Direction of the X-Ray
Direction of ray is from lateral(outer) to
medial (inner), obliqued breast to
demonstrate lesions in medial area
90 degree Lateral
Direction of ray from one side to the other
and the breast is in the lateral position
2.4.3. Augmented Breast Views
Regular views done and additional “Implant
Displaced” (ID) Views performed. Regular views comprise of the
screening views with minimal compression (too much compression
can damage the implants) and ID views are the screening views
with the implants pushed back against the chest wall and focus
is on breast tissue only.
2.4.4. Diagnostic Mammogram
These views are to be used in addition to
the screening mammograms to localize the exact position of an
abnormality or views to better define the nature of an
abnormality. Some abbreviations for those views are:
Cranio Caudal view eXaggerated to axilLa
Cranio Caudal view eXaggerated Medially
2.5. Interpreting Mammograms
Reading mammograms is a challenge for
Radiologists. Diagnosis is truly subject to interpretation.
Hence the concept of a ‘second reader’ is catching on in USA. In
Europe, a second reading is routine procedure. A powerful
magnifying glass is used to get a better look at suspected
pathology. The ideal reading condition is in a dark room with no
lights other than the ones from behind the mammogram films (on a
film viewer or a motorized film viewer). Usually, in the reading
area, there is a ‘hot light’ which is more powerful, enabling
the Radiologist to get a sharper view of suspected area. If
required, the Radiologist can turn this on and hold the film in
front of it.
Radiologists read films as per certain
- They do a comparative study of current
films and prior films. They look for tissue, structure and
calcification changes. If for example, they see that the
current films have more microcalcifications than the previous,
the woman would be subject to additional views in order to
visualize the suspicious areas.
- The Radiologists also do a comparative
study of both the breasts. This is termed as an ‘ asymmetric
study’. Generally, pathology does not occur in the both the
- Viewing the parenchymal pattern is another
method used by many Radiologists to find some signs leading to
the detection of small invasive tumors. Both the CC views are
placed against each other and they look for asymmetry, which
is indicative of tumors. Similarly, both the MLOs are
compared. Other features they look for are: architectural
distortion, comparison of the nipples and retroareolar areas.
2.6. Work-up process
If the Radiologist detects an area of
suspicion, a series of work-up procedure is recommended. The
criteria for their decision is based on what they see and the
For example, in the course of ‘asymmetric
study’ the Radiologist discovers a density, then he/she has to
decipher if the pathologic abnormality is obvious (stellate
lesion, typical/linear cancerous microcalcifications). If the
answer is ‘Yes’, various procedure and modalities could be used
(core biopsy or ultrasound), if it is ‘No’, then additional
views such as spot compression can be performed to see if see if
the density is an architectural distortion, fibrosis or normal
Here is a table of ‘Protocol for Breast
Cancer Screening Path’ :
Work-up for breast cancer screening; Rhone-Poulenc
Rorer Oncology Slide Library.
3. PATHOLOGY IDENTIFICATION OFF MAMMOGRAMS
For location and identification of pathology,
the breast is divided into segments in the following ways:
‘BB’s are metallic markers that is used in the
United States to mark the nipple or palpable mass for the
Radiologist to locate and detect pathology. This shows up as white
dots/circles on the mammograms as a reference point.
3.1. Frequency and Location of Breast Cancer
Maximum cases are in Upper Outer Quadrant and
in the TDLUs (Terminal Duct Lobular Unit).
Areolar Area 25%
Frequency of Breast Cancer by quadrants
3.2. Morphologic Presentations
As you can see from the mammograms and
diagrams, the breast tissue comprises of small intricate
structures so pathology can easily be overlooked, especially if
the film quality is not good. Not all structures are cancers.
Many structures or macro (big) calcifications are often benign.
Some basic forms of pathology and morphology presentations are
3.2.1. Masses and Densities
‘Masses’ differ from ‘Densities’
because ‘masses’ are seen on two views whereas ‘densities’ are
seen on one view only. Hence, two views of each breast to
identify this abnormality. Masses with smooth rounded edge is
generally a fluid-filled cyst that can be confirmed by an
ultrasound and aspirated to relieve pain for the woman. Hard
lesions with uneven edges might be reason for follow-up
procedures. A mass could be palpable (can feel it during a
physical breast exam) depending on the size and proximity to
the skin surface. A fat containing mass looks radiolucent on
the mammogram. Sometimes, it is very difficult for
radiologists to differentiate between a benign and a malignant
mass off mammograms (as in Fig. below), so additional imaging
modalities and/or biopsy may be required.
Examples of benign mass and a malignant mass
3.2.2. Micro calcifications
Calcifications are small calcium
deposits that can be detected on a mammogram. Minute
calcifications are called micro calcifications and bigger ones
are called macro calcificiations. The latter is generally
benign and does not need additional follow-up. Sometimes,
other structures mimic micro calcifications such as calcified
arteries that appear like ‘train tracks’. This is normal.
Artifacts on mammograms due to specs of dust may look like
micro calcifications, but the difference is that these specs
are bright and shiny whilst a micro calcification looks ‘milky
white’. Radiologists categorize the calcifications as
malignant or benign based on (1) the location of
calcifications, (2) the arrangement (linear or scattered or
clusters) (3) the total number of micro calcifications
(4) the changes with respect to the
Examples of benign and malignant
3.2.3. Spiculated lesions
This is by far the most definitive way
to detect cancer. As a cancer cell proliferates, it shows up
as a ‘star-shaped’ or ‘stellate’ lesion, with spiky lines
radiating in all directions from a central region. A white
star shape is characteristic of a malignant stellate lesion
whereas the black star indicates a radial scar and
post-traumatic fat necrosis. In advanced cases, spicules that
approach the skin or muscle, cause retraction and localized
Examples of benign mass and a malignant
4. BREAST CANCER TREATMENT OPTIONS
Treatment of breast cancer is determined by
the patient’s age and preference, patient’s medical history,
staging at the time of diagnosis, and type of cancer.
Surgery is the most preferred method of
removal of cancer infested sites. There are various types
- Lumpectomy -a ‘lump’ or localized
area that contains cancer cells is removed.
- Partial Mastectomy - a wedge of
breast tissue is removed
- Quadrantectomy - a quadrant of the
breast is removed
- Modified or simple mastectomy -all
breast tissue and some lymph nodes are removed
- Radical Mastectomy- The whole
breast, pectoral muscle and lymph nodes are removed. This
procedure is often combined with a total breast reconstruction
at the same time, as per the patient’s preference.
In most of the above surgical procedures,
ideally, at least a few lymph nodes are removed to determine if
the cancer is localized or spread. Based on this information,
the oncologists work out follow-up therapeutic procedure.
Chemotherapy is the use of drugs or
chemicals to treat and/or prevent the spread of cancer. This
therapy is typically used in cases when the cancer becomes
‘systemic’ (infiltrating into the various systems in the body
for example, the lymphatic system). Each cell goes through
several steps of cell division. The cytotoxic chemicals used for
this therapy interferes with the process of cell division thus
containing the cancer cells and in due course, killing the
cancer cells. The commonly used drugs are : cyclophosphamide,
doxorubicin or Adriamycin, methotrexate, and 5-fluorouracil. To
some extent, these drugs do affect the normal cells too, causing
side effects, such as nausea, vomiting, and skin burn from leaky
veins into which the drugs are injected.
4.3. Radiation Therapy
As the name says, this treatment involves
the use of radiation to kill the cancer cells, primarily for
preventive treatment, after surgery. Usually, this treatment is
split into two parts. At first, the whole breast from the
collarbone to the ribs and breastbone to the sides, including
the lymph nodes are radiated over a period of 5 to 6 weeks.
Second, a ‘Boost’ is given, which involves extra radiation in
the spot where the cancer was found originally.
4.4. Endocrine Treatment
This treatment involves interference with
patient’s hormones. Breast cancer patients test positive for
estrogen or progesterone levels and may be given endocrine
therapy to interfere with the estrogen’s aid in the growth of
malignant cancer cells. Some hormones that are used are :
tamoxifen, progestins, aminoglutethimide, estrogens and
androgens. The choice of the hormone used for therapy depends on
the patient’s age and pre or post menopausal status.
4.5. Adjuvant Therapy
‘Adjuvant’ implies that two or more
therapeutic means are used towards the complete treatment of the
patient. For example, radiation in combination with
chemotherapy, or chemotherapy in combination with hormonal or
hormonal in combination with radiation, or surgery with
chemotherapy and/or radiation. Adjuvant therapy is of great
value to treat metastatic cancers that become systemic.
4.6. Other New Methods of Treatment
Certain types of cancers such as lobular carcinoma
in-situ (LCIS) are not effectively treated with radiation or
chemotherapy. In this case, the patient is treated with an
anti-estrogen hormone like tamoxifen. This is a breast
conservation method, so drugs can be administered without
having to go through a surgery. It is still too early to be
sure if this works, however, studies are now being carried out
Bone Marrow Transplant
The bone marrow is a center which produces red blood
cells, white blood cells, and platelets on a continuous basis.
Chemotherapy slows this process down, hence there are
intervals of time in between chemotherapy to allow the bone
marrow to recover and produce good blood cells for the body. A
compatible donor bone marrow is matched with the patient’s
bone marrow and then it is injected through the bone into the
patients trabeculae (where bone marrow is produced). This is a
painful procedure, but the big advantage is that the patient
has a new production of healthy red blood cells, white blood
cells and platelets.
Caring for breasts, Susan G. Komen Breast Cancer
Foundation Breast Cancer Facts & Figures 1996, American Cancer
Society Mammography Quality Control Manual, American Cancer
Society Cancer Incidence in five Continents, Vol. VI, period
1983-87. Sickles breast Screening Process, E.A. Sickles, Rad.
Clin. North. America, 1992 Rhone-Poulenc Rorer Oncology Slide
T2NO, TON1, T1N1, T2NO
Primary tumor size cannot be assessed
Carcinoma in situ
0.5 - 1.0 cm
1.0 - 2.0 cm
2 - 5 cm
Tumor or any size fixed to the chest wall or skin
Fixation to chest wall only
Edema (peau d’orange), ulceration of skin, satellite skin
Both T4a and T4b
Regional lymph nodes cannot be assessed
regional lymph node metastases
Involved, movable ipsilateral axilliary lymph nodes
Involved, fixed ipsilateral axillary lymph nodes
Involved, ipsilateral internal mammary lymph nodes
Metastases cannot be assessed
Distant metastases present, including non-regional
Addendum 1 : Staging of Breast Cancer
BREAST IMAGING QUESTIONNAIRE
Name…………………………. Patient ID #………………….. Birth Date…………………….
Please answer ALL the questions.
- Mammograms and physical exams are both important in
finding breast cancer. 10% of breast cancers are only by
physical exam; 40% are found only by mammograms and; 50% are
found by both exams.
- Did you have a physical exam by your health practitioner
- Have you had a previous mammogram ?
- Do you have any significant breast problems ?
Yes…………….No……………… If yes, mass……….lump………..pain………..nipple
- discharge………. Which side ? Right………………Left………………..
- Have you had breast surgery ?
- What type of surgery was performed ?
- Did you have breast cancer ? Yes……….Side……………When………….
- Have you had radiation therapy for breast cancer ?
- Have you had non-breast cancer surgery ?
Yes………..Where………….When……….. What kind: needle biopsy,
aspiration, surgical biopsy, breast augmentation by implant,
breast reduction, Other………
- Are you nursing a baby at present ? Yes…………….No………………….
- Are you pregnant ? Yes………………No……………………
- Have you stopped having menstrual periods ? No……….If
- Have you taken female hormone pills (like Premarin or
birth control pills) in the last 10 years ? If yes, date
- Do you have relatives who have had breast cancer ?
No…………………….. Yes…………………Who……………………Age at onset…………………
Today’s date……………………….. Signature…………………….
Space below for Radiologist Technologist
who does your exam :
Mark : X =Lump, ---= Scar, O = Mole,
# = Pain or tenderness