Breast Imaging

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MAMMOGRAPHY

Mammograms are x-rays and use radiation to produce images. You should not have a mammogram if you are pregnant or actively breast feeding unless absolutely necessary.

Currently tomosynthesis or 3D mammography is the standard of care and has been accepted by the FDA as an acceptable screening tool.

 

Screening Mammography

Routine screening mammograms are recommended for female patients over age 40 with no breast problems or concerns.

 

If you have a family history of breast cancer, the recommendation is that you begin screening mammograms 10 years earlier than the earliest breast cancer diagnosis in your family, but should not begin prior to age 25.

When your mammo is interpreted by the radiologist a comparison will be made from your prior imaging. If it is your first mammogram there is an increased likelihood that you will be called back for more imaging because the radiologist doesn't have anything to compare your breast tissue to - don't be alarmed by this.

 

If you had previous breast imaging we would encourage you to bring it with you or in advance so that the radiologist can compare your current mammogram to your prior studies. If you do not have it your studies may be labeled incomplete your you may be asked to return for additional imaging. 

If there is a finding on your screening mammogram you may be called back for additional and diagnostic imaging.

To learn about reasons you may be called back Click Here

Diagnostic Mammography

These exams need to be scheduled in a specific manner and require immediate radiologist review. Most facilities provide results at the time of service.

If you have been called  back from your screening exam you will be returning for diagnostic imaging. If your radiologist has found an area in the breast that are classifying as "probably benign" you will need to come back for short interval diagnostic imaging as well. 

Breast lump, discharge, focal pain, dimpling or any other concerning symptoms need to be looked at with more scrutiny; if you present with a symptom please let your technologist know - these types of symptoms need to be evaluated with diagnostic imaging.

Diagnostic mammography is also indicated for those with a history of breast cancer. In some facilities you would remain a diagnostic study for 3, 5 or 10 years.

Tissue Density

Extremely Dense

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Heterogeneously Dense

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Scattered Fibroglandular

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Fatty Replaced

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ULTRASOUND

Sonography utilizes sound waves to create an image and is best used in conjunction with mammography. Ultrasound is not an effective replacement for screening mammography as there are findings, like calcifications, that ultrasound cannot appreciate well due to how small they can be.

Ultrasound provides a dynamic - live time perspective into your tissues. If you have what is classified as extremely or heterogeneously dense tissue you may be recommended to have a screening breast ultrasound to supplement and compliment your mammographic imaging. 

If you are having a problem, like a lump, ultrasound will be utilized in addition to your mammogram most of the time. The sound waves can show the radiologist if your lump is a simple cyst or a probably benign process like a fibroadenoma. There are also certain characteristics that may be more indicative of a malignant process. 

Ultrasound takes time to learn so the experience of the technologist is also an important factor. Due to the nature of the imaging if your technologist is not skilled enough to find an area your radiologist may never see it. Look for facilities that have sonographers certified by The American Registry for Diagnostic Medical Sonography (ARDMS®) when choosing your breast imaging facility. 

Screening breast ultrasound is supposed to be covered by insurance in the State of Connecticut, where we are located. Unfortunately some insurance companies have found loop-holes in the legislation so our recommendation in CT and the rest of the country is that you take a few minutes to check with your provider to make sure you aren't incurring the cost of a hefty medical bill.

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MAGNETIC RESONANCE IMAGING of the BREAST

An incredibly sensitive modality that utilizes a powerful magnetic field and radio waves to produce images.  Generally MRI is used as a supplement to mammography and breast ultrasound but may also be used by patient with a higher than average risk of developing breast cancer as a screening tool. 

Breast MRI may also be used to evaluate the extent of disease for patients recently diagnosed with breast cancer. Occasionally if there is a finding that is indeterminate with mammography and sonography breast MRI may also be utilized as an additional imaging tool. For patients with breast implants MRI would be used to determine if an implant may have ruptured.

Many people find the positioning and the test to be quite uncomfortable.  Breast MRI also typically requires the use of intravenous contrast to highlight any areas with increase vascular activity so an IV will be started prior to your imaging study. You will be asked to lay face down with your breasts hanging down in a dedicated apparatus called a coil to acquire these images. Scans can take anywhere from 15 to 45 minutes depending on the strength of the magnetic field.

 

This modality also tends to show more findings than just cancer and you may need a second look ultrasound to classify what was seen on your scan. 

Due to the sensitivity of the magnet used to make the pictures you must inform your technologist if you have any metal implanted in your body or on your person as the magnet can turn metal objects into deadly projectiles. You will be comprehensively screened before your are allowed to enter into the magnetic zone for your safety and the safety of others. 

MRI in general is one of the most expensive medical imaging tools and your doctor will need to get this exam authorized prior to you even being able to schedule it. Please talk with your doctors to determine if MRI of the breast is the correct imaging tool for you.

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THERMOGRAPHY

Thermal imaging is another breast imaging technique. It can be used with another screening tool in supplemental fashion. The FDA has not approved thermography as a standalone screening modality. 

Images are acquired using a very sensitive camera that maps heat at the skin's surface. Images produced are essentially high resolution infrared photos. The idea behind this technique is that cancer cells require blood flow to replicate and thusly will be warmer areas on the images. An area of increased heat would be indicative of a problem.

 

Unfortunately thermography is limited to only mapping temperature. It is incapable of appreciating lumps, calcifications or skin changes unless there is an associated temperature increase at the skin's surface. Deep lesions at the chest wall might go unnoticed as well.

Cancer is not the only reason that our breasts might read hot. Inflammatory response like fighting off an infection would also  make the imaging appear concerning so additional work up would be required to determine what the cause is. 

Thermography does not hurt and is not invasive. You might go to your doctors office, be asked to put on a gown and then simple stand still at a specific distance from the camera while it acquires your images. Images may be taken in various positions as well. 

Watch this modality - everyone wants a painless breast imaging technique, perhaps technology will advance and thermography will become more sensitive and refined. 

 
 
 
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IMAGE GUIDED BREAST PROCEDURES

Sorry to hear you have a finding that requires an interventional procedure. Good news is - these procedures are relatively painless and frequently result in benign (non-cancerous) findings. Getting a sample of the area is typically the first step in determining if something is amiss. 

For all procedures that break the surface of your skin there are some potential risks that you need to be aware of. 

1. You may bleed. Bleeding should not be excessive - if you are bleeding post procedure put a lot of pressure on the area to allow your body to clot. Be careful to avoid medications that have blood thinning properties around the time of your procedure and after as a precaution. In some cases bleeding may be internal and you may develop a hematoma - collection of blood in your breast. Your body will break this down but it's a slow process. If you are concerned that you are bleeding too much or if you have a new lump that seems to be getting bigger you should ask to be seen again to evlautate the area.

2. You may get an infection. This is relatively uncommon, the breast is designed to have an infant's mouth attached to it so it is pretty resistant to infections. Most facilities use sterile technique to reduce this risk as well. All that aside, if you have any oozing, weeping, redness or other  nastiness around the area where a needle went in OR you develop a fever - it is best to be evaluated to rule out the possibility of infection. 

3. You may experience some pain. Honestly, for most women capable of childbirth these procedures are no sweat. We tell our patients to expect to be a bit sore, but pain should never be extreme - if this happens contact your clinician for further evaluation.

NEEDLE BIOPSY

For almost all needle biopsies the procedure is generally similar. A doctor will clean the surface of your skin before giving you an injection of numbing medication - like the Novocain you would get before dental work. Most people say that the numbing medicine is the worst part of the exam.

Once your are sufficiently numb a doctor will advance a needle into the area in question and take a sample of the tissue to send to the lab. Typically you will get a small titanium tissue marker placed through the same needle before it is removed to mark the location of the biopsy. We do this for a couple reasons, first - if there is something that needs to be surgically removed we know where we biopsied so that your surgeon can be conservative. Secondly and far more commonly - if you get a lovely benign result we know that this area was already biopsied and we don't put you through this process again for the same area. This is standard of care and if you move to a different state or imaging facility your radiologist would understand that you had a benign biopsy and might be able to get the pathology results to understand what they are seeing. 

Click on each of the items below to learn more about each procedure.

Ultrasound guided biopsy

Stereotactic breast biopsy

Tomo guided biopsy

MRI breast biopsy

OTHER PROCEDURES

Cyst Aspiration

Ductogram

Pre-Operative Breast Localization

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NUCLEAR MEDICINE SCANS

BSGI/MB - Breast Specific Gamma Imaging and Molecular Breast Imaging

Can be used in conjunction with screening or diagnostic mammography. Both involve and administration of a radioactive tracer being injected into the body, this tracer connects with cells with a higher metabolic rate - like breast cancer. The camera used to acquire the images can see this substance and creates pictures. 

 

Tests normally take about an hour. it is highly unlikely for you to be allergic to this tracer. Unfortunately with this test like many other imaging modalities areas my enhance when they are benign and cancers may be missed. 

PEM - Positron Emission Mammography

Uses tomographic mammography methods combined with an injection of a positron-emitting radionuclide. So think of a mammogram and a targeted PET scan combined into one machine. It is a highly sensitive modality and can be utilized for breast cancer patients to determine if there are satellite lesions or multifocal disease patterns. 

Unfortunately this modality uses quite a bit of radiation when compared to standard mammography so the risk of causing cancer by using PEM as a screening modality is increased. This may change in the future as the technology becomes more refined. 

Lymphoscintigraphy 

Normally lymphoscintigraphy studies are reserved for cancer patients and done the day before or morning of surgery. A few injections of a very small amount of a radioactive dye is injected around the areola. Your body's natural lymphatic response will pick up the dye to filter it through the lymph nodes and most will end up in the first or sentinel lymph node which would be biopsied at the time of surgery to rule out metastatic disease. The camera will pick up the pathway that the dye takes and create images like a road map for your surgeon. 

You do not have to have cancer for this study to work - but why would you have it if you didn't need it?

PET CT - Positron Emission Tomography - Computed Tomography

Images acquired like a CT scan but with the added element of a radioactive pharmaceutical  or tracer. A special computer and camera receive information and create images based on the behavior of the radioactive element to determine if there are areas of high concentration or disease presentation. 

PET CT may be used to check for metastatic disease. Learn more: Click Here