MAMMOGRAPHY BASICS.

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The aim of this section is to provide readers with information about the essentials of pathways in the UK with regards to Mammography. I would like to thank Dr Monica Patil for writing this article. I had the pleasure of working with Monica in her preparation of the January FRCR 2020 Exam. She did the December 2020 edition of my FRCR course and passed the exam with flying colours. 


Breast imaging can appear scary to most candidates especially if they have not had enough exposure during their residency. However, it is worth noting that the spectrum of diseases would be limited and the findings would not be subtle. Remember 2b is a test of competence, not excellence. Try to train your eyes to understand what normal breast would look like on mammogram. This can be done by accessing the cases at your centre/hospital. If you do not have access to these, then please go through rad cases and chapters in different 2 b books. The cases would be of a similar difficulty. This bit you can understand with practice. The bit that I want to emphasize on is how breast department works in the UK. If you understand it, then there is nothing stopping you from getting a 8 in that case!

  1. Remember that NHS breast screening program gives invitation to all ladies for screening mammogram every 3 years from 50 to 70 yrs- therefore always ask for comparison with a previous screening mammogram.
  2. As part of age extension trial, some ladies receive one additional invitation before 50yrs and some after 70 yrs.
  3. All screening mammograms are double read. If both readers agree that it is normal, patient goes to routine recall, which means she will visit when she gets next invitation.
  4. 4.If both readers do not agree-it goes in discussion where few more radiologists see it and decide whether patient needs a routine recall or an early recall
  1. When we recall the patient we first do further views and tomosynthesis.
  2. Then a triple assessment is done with clinical examination, USG and if needed tissue biopsy.
  3. If lesion is not visible on USG, we go for a stereotactic biopsy.
  4. The other clinic is symptomatic clinic where ladies who are symptomatic are assessed. The surgeon examines and decides whether patient needs an USG or mammogram and the patient comes to the radiology side of symptomatic clinic
  5. BIRADS is not used here by most. I have not seen anyone use it really!  Instead a simpler version of 1 to 5 is used where 1=normal, 2=benign, 3=indeterminate, 4=suspicious for malignancy, 5=malignant. This is prefixed by U for USG, M for mammogram, P for palpation, C for cytology.
  6. Biopsy needle specifications may vary slightly as per trust policy. We use 14G for core and 9G for vacuum assisted biopsy. 12 cores are taken in stereotactic VAB.
  7. If any sample is collected in the clinic, the patient goes to MDM discussion. The aim is for different relevant specialists to come together and decide whether the patient needs any further management or she can be discharged
  8. There is no male screening for breast cancer, however symptomatic patients are seen in the breast clinic.
  9. CT is done for staging if decided by MDM. It is not routinely done for all patients. Please refrain from saying that as a routine plan in your management!
  10. MRI surveillance is used for females with family history and it is done annually.

Here are a few examples of structured answers-

 

Case 1

Case 1 MloCase 1 Cc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The structured answer would be something like this-

” These are MLO and CC views of both breasts. The breasts are predominantly fatty. There is a lesion seen in the outer and upper quadrant of right breast with lobulated smooth margins. I cannot see any microcalcifications. There is no architectural distortion, no nipple areolar retraction or significant axillary adenopathy. I would like to compare with the previous mammogram. This looks essentially benign- M2. If this is a new finding- I would recall the patient to the assessment clinic and do further views like mag views of the lesion. I will do triple assessment, which involves clinical examination, USG and image guided biopsy. I will further refer the case to MDM.”

 

Case 2

F Breast 20200219 133612 01F Breast 20200219 134531 01

 

” These are MLO and CC views of left breast. The breasts are mixed fibroglandular. There is a lesion seen in the outer and lower quadrant with spiculated margins. I can see calcification within it. There is a linear calcification extending to the nipple. There is surrounding architectural distortion, no nipple areolar retraction or significant axillary adenopathy. I would like to compare with the previous mammogram. This looks malignant- M5. The linear calcification could represent DCIS. I would recall the patient to the assessment clinic and do further views like mag views of the lesion and tomosynthesis. I will do triple assessment, which involves clinical examination, USG and image guided biopsy. I will further refer the case to MDM.”

 

Case 3

1583277139808 L Cc 01  1583277131167 Oil Cyst L Mlo 01R Mlo Oil Cyst 01 011583277120875 R Cc Oil Cyst 01 01

” These are MLO and CC views of both breasts. The breasts are mixed fibroglandular. There are round lucent lesions in both breasts with peripheral rim calcification. I cannot see any suspicious microcalcifications. There is no architectural distortion, no nipple areolar retraction or significant axillary adenopathy. This looks essentially benign- M2, oil cysts. This does not need any further assessment and patient can be returned to routine recall.”

 

Author, Dr Monica Patil, Senior Clinical Fellow, Breast Imaging Kings College Hospital London. Passed FRCR January 2020