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91 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.1 (continued)
10
1 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.1 (continued)
111 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.2 1–2 Mammography. Calci fi cations within breast carcinoma
12
1 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.2 (continued)
procedure used to be widely used for the analysis
of fl uid-containing breast lesions. It is now almost
completely replaced by US, which is radiationfree, more informative, and easy to perform.
Magnetic resonance mammography becomes
a valuable tool in diagnosis of breast tumors
(Korzhenkova et al. 2006 ; Serebryakova et al.
2011 ) . Breast MRI enables T1- and T2-weighted
imaging with complete acquisition sequences in
all projections (axial, sagittal, and coronary).
The technology of MRI is based on the analysis of the data on behavior of protons in hydrogen
atoms. The motion of protons in one plane in
high-energy magnetic fi eld is detected and analyzed to reconstruct an image. MRI enables to
assess breast structure, detect abnormal focus,
characterize its capsule, specify the signs of invasion into surrounding tissues, and visualize lymph
nodes. Dynamic MRI is a modality, which bases
on a series of variables, including different image
characteristics (contrast, signal-to-noise ratio,
resolution, time interval) and a series of other
parameters. It allows to fi nd and interpret the
minimum changes in the breast (Fig. 1.4 ). Breast
131 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.3 1–4 Ductography. Intraductal tumor
14
1 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.4 1–3 MRI. Breast carcinoma (T1)
MRI has two important technical requirements:
special magnetic coils and contrast agents.
According to Tyurin ( 2011 ) , breast MRI makes
0.2 % of total MRIs.
The decision about the necessity of breast
MRI is discussed in every individual case. MRI is
not a screening test. Nevertheless, it is applicable
for detection of pathological processes and
dynamic observation in women of the groups
with high risk of breast carcinoma, for example,
with mutations of genes BRCA 1 and 2.
Contrast agents signi fi cantly increase the diagnostic value of breast MRI. The sensitivity of MRI
with contrast enhancement in diagnosis of breast
tumors is 83–100 % with speci fi city of 29–97 %
(Haylenko et al. 2005 ; Korzhenkova 2004 ) .
MRI exhibits the following advantages
(Ternovoy et al. 1996 ; Kachanova 2000 ;
Lukyanchenko and Gaurova 2001 ; Serebryakova
et al. 2011 ) :
High resolution and contrast of soft tissues of •
the breast
Possibility of acquisition of images in any •
plane without patient’s movements
Noninvasiveness •
Absence of ionizing radiation •
Impressive possibilities of MRI in detection of
multifocal breast carcinoma were reported by
Berg et al. ( 2009 ).
However, high sensitivity of MRI in diagnosis
of breast pathology is accompanied by low
speci fi city and accuracy in revealing breast cancer. High cost of the equipment forces to use the
technology only in dif fi cult diagnostic cases
(Haylenko et al. 2005 ) .
Computed tomography (CT) is a modern
radiological technology (Fig.
1.5 ). However, the
technology is not a screening modality for breast
carcinoma either. It is due to signi fi cant radiation,
high cost of examination, and low throughput.
CT practically has no advantages in early
recognition of breast carcinoma as compared to
mammography. However, the method is of great
importance in assessment of cancer invasion and
is indicated to detect spreading of the tumor to
retromammary space, metastases in lymph nodes,
and remote metastases. The diagnostic value of
CT in detection of breast cancer is 60–62 %, sensitivity is 100 %, and speci fi city is 84 % (Dixon
et al. 1993 ; Shevchenko 1997 , Shishmareva 1997 ;
Haylenko et al. 2005 ) .
Mammoscintigraphy is a method of func-
tional diagnostics of breast pathology, which
is based on the assessment of distribution of
99m
radiopharmaceuticals in breast tissues.
MIBI,
99m
Tc-tehnetril,
99m
Tc-teoksim,
99m
Tc-
Tctetrofosmin, and others can be utilized for the
examination. Mammoscintigraphy along with
studying of the breast permits assessment of
isotope distribution in other chest structures
including axillary areas and other regions of
possible metastases.
151 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.5 1–3 CT. Breast carcinoma
The technology can be performed in two varieties: with gamma chamber (planar scanning,
emission gamma tomography) or positron-emission tomography. In those cases, it can be carried
out as an isolated breast scintigraphy, a polypositional scintigraphy of the chest, or as a singlephoton emission computer tomography of breast
area and thorax.
The sensitivity of mammoscintigraphy with
99m
Tc-tehnetril in primary breast tumors ranges
from 62 to 96.7 % with speci fi city of 71–100 %
(Svensson et al. 2000 ; Haylenko et al. 2005 ) .
99m
Mammoscintigraphy with
Tc-MIBI is not of
great value in revealing primary breast carcinoma.
Its sensitivity depends on the size of the lesion.
The sensitivity differs in different cancer stages:
at T1a (up to 0.5 cm), 26 %; at T1b (up to 1 cm),
56 %; at T1c (up to 2 cm), 95 %; and at T2, 97 %
( Usov et al. 1997 ). The sensitivity of scintigraphy
in the detection of metastases of breast carcinoma
in axillary lymph nodes is 51–85 %, speci fi city is
91–93 %, and diagnostic accuracy is 76–93 %
( Perre et al. 1997 ; Svensson et al. 2000 ) .
Positron-emission tomography (PET) is the
nuclear medicine technology based on utilization
of various agents (monosaccharides, fat acids,
antibodies, peptides, etc.), marked with positronemitting radionuclides. A modi fi ed gamma chamber is applied. It permits detection of gamma
photons, which result from annihilation of positron with electron. Since gamma photons are
emitted in opposite directions, it is possible to
localize the place of their formation. Short-lived
radioactive tracer isotope, which is chemically
incorporated into a biologically active molecule
(more often 18F- fl uor
deoxyglucose ), allows to
detect areas with increased metabolic activity
that is often the characteristic of malignant cells.
PET is not widely applied in diagnosis of
breast carcinoma now. Nevertheless, it is quite a
promising technology ( Tyutin and Stanzhevsky
2003 ) . Indications for PET are limited due to low
diagnostic value in small cancers, which are
smaller than 1 cm in size. However, PET surpasses all known anatomic imaging methods in
the localization of centers of breast carcinoma in
soft tissues. Its possibilities should be applied for
individualization of therapy and monitoring, since
tumor metabolism decreases much faster than
tumor size with effective treatment. Alternatively,
absence of changes in tumor metabolism after
treatment predicts its inef fi ciency.
Electrical impedance tomography is a method
of scanning of electrical impedance (full resistance) of breast tissues ( Korzhenevsky 2003 ) . It
permits quantitative assessment of breast structure
for differential diagnosis of various physiological
conditions and changes, which accompany breast
16
a
1 Diagnosis of Breast Cancer: Modern Aspects
b
Fig. 1.6 Electrical impedance tomography. ( a ) Normal breast. ( b ) Breast carcinoma
cancer. It analyzes distribution of electrical conductivity of breast tissues in several cross sections and detects pathological focus with abnormal value of electrical conductivity (Fig. 1.6 ).
According to Trohanova ( 2010 ) , electrical impedance mammography is a simple and ef fi cient
method of screening of focal breast pathology
in women of different ages. The sensitivity,
speci fi city, and positive and negative prognostic
values account for the following fi gures: for cysts,
91, 99, 93, and 99 %; for diffuse cystic mastopathy, 98, 97, 95, and 99 %; and for breast carcinoma, 92, 98, 92, and 98 % (Trohanova 2010 ) .
Radiothermometry is a modality, which per-
mits noninvasive measurement of the temperature
in deep tissues. It is based on remote registration
of infrared radiation by means of special devices.
The results of the examination are presented as a
thermogram (temperature plot). The areas with
increased temperature are suspicious for breast
malignancy due to higher metabolism and good
vascularity. The character of breast thermograms
depends on the age. Besides, there are individual
features of location of “cold” and “hot” areas that
sometimes complicate correct interpretation of
the results. Radiothermometry is not often used
nowadays in diagnosis of breast cancer because
of a large number of false-positive tests, which
can exceed 25 %. The speci fi city of radiothermometry in diagnosis of breast carcinoma is
reported 85 %, sensitivity 84 %, and in combination with US 91 % ( Yemelyanov et al. 2011 ) .
171 Diagnosis of Breast Cancer: Modern Aspects
MRI, CT, radiothermometry, electrical impedance tomography, radioisotope tests, laser mammography, microwave spectroscopy, and other
sophisticated modalities have limited number of
indications and are not often used in daily practice.
Evidence-based medicine forces to perform
the most signi fi cant diagnostic tests to work out
the strategy of treatment. It seeks to obtain the
data about tumor morphology. The conclusion
about tumor structure results from invasive diagnostic procedures.
Core needle biopsy of the breast can be done
several different ways. Stereotactic X-ray-guided
breast biopsy is utilized more often. Special
instruments, such as biopsy gun and Tru-Cut
a1
needles, are necessary. The procedure aims to
obtain material from the tumor for histological
examination (Fig. 1.7 ).
Indications for core needle biopsy of the
breast:
Suspicion for malignant lesion •
Undetermined or doubtful breast masses •
Impalpable tumors •
Calci fi cations in breast structure (pathologi-•
cal, doubtful, uncertain)
Asymmetric breast fi brosis •
Stereotactic biopsy is the fi nal stage of modern complex diagnostics of impalpable breast
cancer. Its sensitivity in diagnosis of breast carcinoma is 97.6 %, speci fi city is 100 %, and
Fig. 1.7 ( a1 , a2 ) X-ray
guidance for core needle
biopsy with tumor coordinates. ( b1 , b2 ) Core needle
breast biopsy
a2
18
1 Diagnosis of Breast Cancer: Modern Aspects
Fig. 1.7 (continued)
b1
b2
diagnostic accuracy is 98 % (Kuplevatskaya
2004 ) .
Wide application of US as a navigation method
permits targeted fi ne needle aspiration biopsy
(FNAB), which is highly ef fi cient in obtaining samples from pathological foci (Fig.
1.8 ). Subsequent
cytology allows to de fi ne cellular structures in the
sample and to differentiate lesions of various nature.
According to Sinyukova et al. ( 2007 ) , US-guided
FNAB of breast lesions in combination with mammography and routine breast US improves early
detection of breast cancer (up to 95–98 %).
FNAB with US guidance offers advantages in
the following cases:
Impalpable X-ray-negative breast lesions •
Puncture of cysts •
Lesions within a scar •
Lesions on the margin with thoracic wall •
( retromammary space)
Irregular breast lesions (for exact choice of the •
most suspicious area)
Enlargement of regional lymph nodes •
However, the amount of obtained cells with
breast FNAB in 13.4–25 % of cases does not