Breast Imaging
MAMMOGRAPHY
Mammography uses low-dose x-rays to create images of breast tissue. Digital 2D mammography and digital breast tomosynthesis (3D mammography) are both accepted screening methods.
Pregnancy and lactation
Breastfeeding is not a reason to delay a mammogram. Screening and diagnostic mammography can be performed during lactation; feeding or pumping shortly before the exam may reduce breast density and discomfort.
Mammography can also be performed during pregnancy when clinically appropriate. Tell the imaging team if you are or may be pregnant so the radiologist can choose the safest, most useful evaluation. A new lump or other concerning change during pregnancy or lactation should not be ignored.
Screening mammography
Screening is for people without a new breast symptom. Guidelines differ among professional organizations. The USPSTF recommends mammography every two years from ages 40 through 74 for people assigned female at birth who are at average risk. Other organizations recommend annual screening beginning at 40 or 45. People with a personal history of breast cancer, a high-risk genetic variant, prior high-dose chest radiation, certain high-risk biopsy results, or substantially elevated calculated risk need an individualized plan.
A simple “10 years before the youngest relative” rule is not appropriate for everyone. Ask for a formal risk assessment and discuss when to begin, how often to screen, and whether MRI or another supplemental test is indicated.
Comparing current images with prior studies helps radiologists identify change. If the facility does not already have your earlier images, ask how to transfer them. First-time screening exams are called back somewhat more often because there is no prior comparison. A callback means more information is needed; it does not mean cancer was found.
Diagnostic mammography
Diagnostic imaging is used for a symptom, a screening callback, or planned follow-up of a finding. Depending on age, pregnancy or lactation status, and the symptom, the evaluation may include targeted ultrasound, diagnostic mammographic views, or both. Tell the scheduler and technologist about any lump, focal pain, nipple discharge, skin or nipple change, swelling, or other concern so the correct exam is scheduled.
Contrast-enhanced mammography (CEM)
CEM combines mammography with iodinated intravenous contrast to show areas of increased enhancement. It may be useful in selected situations when MRI is unavailable, unsuitable, or not preferred. It is not the right test for everyone; kidney function, prior contrast reactions, pregnancy, and the specific clinical question should be reviewed with the imaging team.
Tissue Density
Extremely Dense
Heterogeneously Dense
Scattered Fibroglandular
Fatty Replaced
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.
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.
THERMOGRAPHY
Thermography uses an infrared camera to map patterns of heat at the skin’s surface. It does not use radiation or compression, but those features do not make it an effective breast-cancer screening or diagnostic test.
The FDA is not aware of scientific evidence showing that thermography can replace mammography for detecting breast cancer. Devices have been cleared only as adjunctive tools—meaning they may be used alongside a primary test, not instead of one.
Thermography cannot directly show a mass, calcifications, architectural distortion, or many deep lesions. Temperature changes are also nonspecific: inflammation, infection, hormones, blood flow, and other noncancerous processes may affect the image, while a cancer may produce no detectable surface-temperature change.
A “normal” thermogram does not rule out cancer, and an abnormal thermogram still requires appropriate clinical and breast-imaging evaluation. Do not delay a recommended mammogram, ultrasound, MRI, biopsy, or evaluation of a new symptom because of thermography results.
If the appeal is a less painful or more accessible exam, tell the imaging team about your concerns. They may be able to adjust positioning, compression, timing, communication, or the care plan without substituting an unproven test.
IMAGE GUIDED BREAST PROCEDURES
Most image-guided breast procedures are done with local numbing medicine and do not require general anesthesia. Experiences vary: some people feel pressure, pulling, vibration, or brief discomfort. Tell the team if you are hurting, faint, anxious, pregnant, breastfeeding, allergic to medicines or adhesive, or need trauma-informed accommodations.
Before the procedure
Follow the facility’s medication instructions. Do not stop aspirin, anticoagulants, antiplatelet medicines, supplements, or other prescribed treatment on your own. The ordering or procedure team should tell you what to continue, pause, or adjust and when to restart it.
Common risks and aftercare
Bruising, soreness, and a small hematoma are common. Bleeding and infection are less common, and other complications depend on the procedure and location. Follow the written aftercare directions from your facility because pressure, activity limits, dressings, bathing, and pain-relief instructions vary.
Contact the procedure team promptly for bleeding that does not stop with the recommended pressure, a rapidly enlarging breast or lump, severe or worsening pain, spreading redness or warmth, pus or unusual drainage, fever, or other symptoms listed in your discharge instructions. Seek urgent care for severe bleeding, fainting, trouble breathing, or another emergency.
Needle biopsy
The radiologist uses ultrasound, mammography/tomosynthesis, or MRI to guide the needle to the finding. After the skin is cleaned and numbed, tissue samples are collected and sent to pathology.
A small tissue marker is often placed at the biopsy site. It documents the sampled location for future imaging or surgery and is designed to remain in the breast. The marker does not replace the pathology report, and it does not guarantee that an area will never need evaluation again.
The radiologist must decide whether the pathology result is concordant—whether it adequately explains what was seen on imaging. A benign result may lead to routine screening or short-interval follow-up. A discordant, high-risk, or malignant result may require more tissue, surgical consultation, or treatment planning.
Getting a biopsy recommendation does not mean that cancer has already been diagnosed. It means imaging alone cannot give the team enough certainty. Ask when and how results will be delivered, who will explain them, and what follow-up is expected.
Select the procedure links below for more specific preparation and aftercare information.
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