Detection and early diagnosis of breast cancer

The Seven Corporal Works of Mercy 1. feed the hungry 2. give water to the thirsty 3. clothe the naked 4. shelter the homeless 5. visit the sick 6. visit the imprisoned 7. bury the dead

DETECTION AND EARLY DIAGNOSIS OF BREAST CANCER Renzo Taschini Ancient Ceppo Hospital of Pistoia – Mario Romagnoli Library November 13th 2021

BREAST CARCINOMA is the cancer of breast glandular tissue

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Let us first begin this topic by reviewing some basics on Breast Cancer :

- EPIDEMIOLOGY - ANATOMY - PATHOPHYSIOLOGY

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EPIDEMIOLOGY

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BREAST CANCER q is the most common cancer in women worldwide q 2 million cases annually (2020) q 700.000 death annually (2020) q highest incidence rates - in Australia, New Zealand - Western Europe - Northern America q lowest incidence - Middle Africa - South-Central Asia 5

BREAST CANCER EPIDEMIOLOGY

q Incidence is higher in developed countries q Mortality is higher in developing countries

paradox : mortality is higher where the incidence is lower 6

BREAST CANCER EPIDEMIOLOGY Nigeria 2020 (WHO data)

Nigeria 2020 : Breast cancer is the most common cancer in women (28380 cases – 38.7 of all cancers)

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BREAST CANCER EPIDEMIOLOGY Nigeria vs Western Europe (2020)

Nigeria Western Europe Incidence

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91

Mortality

25.5

15.6

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Multiple reasons behind this high mortality statistics

q poor awareness among women of breast cancer signs and symptoms q absence of early detection programs such a mammography screening q late stage presentation q limited access to treatment in term of both availability and cost of individual treatment for the patient on these points work must be carry on by health system and healthcare practitioners 9

BREAST ANATOMY

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BREAST NORMAL ANATOMY A. B. C. D. E. F. G.

lactiferous duct breast lobule lactiferous sinus nipple fat tissue pectoralis major muscle ribs - intercostal muscle

A. ductal cells B. basal membrane C. ductal lumen 11

NORMAL BREAST

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PATHOPHYSIOLOGY

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BREAST NORMAL ANATOMY AND CARCINOMA A. B. C. D. E. F. G.

duct à Ductal Carcinoma lobule à Lobular Carcinoma lactiferous sinus nipple fat tissue pectoralis major muscle ribs - intercostal muscle

A. ductal cells B. basal membrane C. ductal lumen 14

BREAST CARCINOMA

According to the site of onset is defined :

§ 85% Ductal (ductal carcinoma) § 15% Lobular (lobular carcinoma) ① DUCTAL

85%

② LOBULAR

15% 15

natural history of Ductal Carcinoma (85% of breast carcinoma) Ductal Hyperplasia

Normal Duct

Invasive Carcinoma (IDC)

Atipical Tipical

in situ Carcinoma (DCIS - DIN)

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natural history of Ductal Carcinoma (85% of breast carcinoma)

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BREAST CANCER PREVENTION

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WHAT IS PREVENTION IN MEDICINE

PREVENTION :

is to implement all those measures which aim is to reduce : q

mortality

q

morbidity

q

negative outcome

due to patologies or risk factors The goal of prevention is to promote individual and social health and well being 19

CANCER PREVENTION

1.ary

PRIMARY : identification and removal of causes of cancer or of those factors helping cancer growth (risk factors)

2.ary

SECONDARY : early diagnosis, that means to detect cancer in early stage (before clinical symptoms)

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BREAST CANCER PRIMARY PREVENTION identification and removal q of the causes of cancer q of factors helping cancer growth risk factors : • indipendent (sex, age, genetic susceptibility and family history) • dependent (lifestyle, diet)

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BREAST CANCER SECONDARY PREVENTION early diagnosis q detect breast cancer in early stage q best : before clinical symptoms means: • Mammography (ultrasound) • Breast Clinical Examination • Breast Self Examination

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- the greatest impact on breast cancer mortality reduction is achieved by early diagnosis , which means by cancer detection in a pre-clinical stage - Mammography, because of its sensibility (power to detect in a population the women affected by breast cancer), is the most effective tool for early diagnosis - in a women regular risk population (lifetime risk < 15 % according to Gail e Claus models) Screening Mammography cuts down breast cancer mortality by 30-40%

Screening Mammography ----------> early diagnosis ----------> 30-40% reduction Breast Cancer mortality

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BREAST CANCER SECONDARY PREVENTION (early diagnosis) HOW DO YOU DO IT ?

WITH MAMMOGRAPHY !! q annual mammography between age 40-50 q biannual mammography over age 50

(possibly taking part to organized mammography screening programs)

mammography is the procedure of choice for early diagnosis because its high sensitivity in identify small lesions

please note : - before age 35 cancer is very rare : no suggestion (exception : familial cases) - xray dose for a mammogram is very small

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BREAST CANCER SECONDARY PREVENTION Breast Clinical Examination always useful. Among malignancy, can detect: q palpable tumoral lesions located outside mammographic field or in very dense breast at mammography q Paget disease of the nipple and nipple discharge q skin primary or secondary sign of cancer (like dimpling, peau d’orange, skin metastases) q pathological limph nodes of the axilla Breast Self Examination and Breast awareness

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BREAST SELF EXAMINATION BREAST AWARENESS q LUMP q SKIN DIMPLING q CHANGE IN SKIN COLOUR OR TEXTURE q CHANGE IN NIPPLE MORPHOLOGY OR PRESENCE OF NIPPLE DICHARGE

Breast Awareness means being familiar with how your breasts look and feel so you can spot any changes straight away 26

BREAST CANCER SECONDARY PREVENTION (early diagnosis) allows : q best breast cancer survival rate q less aggressive therapy q better aesthetic surgical outcome Breast Cancer Stage

5-Year Breast CancerSpecific Survival

I

98-100%

II

90-99%

III

66-98%

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BREAST CANCER EARLY DIAGNOSIS

Breast Cancer early diagnosis is a diagnostic:

BREAST CANCER II ary PREVENTION = EARLY DIAGNOSIS = Diagnostic Radiology Modalities

§ tipically Radiological - because of the modality commonly used : Mammography, Ultrasound, Magnetic resonance, Nuclear medicine - because of close radio-pathological correlation § Radiological modalities work in synergy

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BREAST DIAGNOSTIC PATHWAY

DETECTION : Mammography is the procedure of choice for early diagnosis because its high sensitivity in identify small lesions (this is the goal of mammography population screening)

is organized in three following steps :

Clinical Breast Examination Breast Self Examination (better Breast Awareness)

① DETECTION

CHARACTERIZATION

② CHARACTERIZATION ③ LOCAL STAGING

is to assign character of benignity o malignity to a lesion detected by mammography or by clinical examination Breast Ultrasound Needle Biopsy - FNAB Fine Needle Aspiration Byopsy - CNB Core Needle Biopsy («tissue is the issue») LOCAL STAGING Magnetic Resonance 29

DM

DBT

DM

DBT

ULTRASOUND

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BREAST DIAGNOSTICS

is organized in three following steps :

DETECTION : MAMMOGRAPHY

① DETECTION ② CHARACTERIZATION ③ LOCAL STAGING

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CHARLES MARIE GROS RADIO-DIAGNOSTIC ET RADIO-ANATOMIE (1910 -1984) DE PRECISION in 1966 Dr Gros , french Radiologist, conceived the first Mammography System his book « Les maladies du sein » is the foundation of modern Breast Diagnostics

1965 – Senographe Tripod

1963 1966 – CGR Senographe 32

breast mammographic anatomy Radiology is “anatomy on the living”

glandular tissue

fat tissue

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Radiology is «anatomy on the living» because of its

RADIO-PATOLOGICAL CLOSE CORRELATION

DCIS mm 4

IDC mm 9 34

« screen-film mammography » (1979-1990)

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MAMMOGRAPHIC DENSITY < 25%

25-50%

50-75%

> 75%

Breast density is very important : - for its effetcs on mammographic accuracy - for its association with increased risk of breast cancer 36

< 25%

25-50%

50-75%

> 75%

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4 MAMMOGRAPHIC DENSITY < 25%

25-50%

50-75%

higher risk

> 75%

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DIGITAL MAMMOGRAPHY

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Digital Mammograpy (2000) from “screen-film” to “digital” mammogram X-Ray Tube

Face Shield

Compression Paddle

Grid and Digital Detector solid state aSe CeI

Pedals

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Digital Mammography (2000)

« solid detectors - aSe CsI » Mammography 41

BREAST TOMOSYNTHESIS ‘breast computer tomography’

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Prof. Albert Salomon 1913

Hologic firm 2011

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Digital Mammography (2D) and Breast Tomosynthesis (3D)

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BREAST DIAGNOSTICS

is organized in three consecutive steps : ① DETECTION ② CHARACTERIZATION ③ LOCAL STAGING

CHARACTERIZATION : BREAST ULTRASOUND

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ULTRASOUNDS PLACE IN BREAST DIAGNOSTIC PATHWAY

1 2 3

gives more diagnostic clues about the structure of the lesion detected by mammography or clinic examination : - liquid (always benign) - solid (benign) - solid (malignant) lesion confirmation in case of minimal mammographic or clinical signs reliable guide for biopsy

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SIMPLE CYSTS

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SINERGY OF RADIOLOGICAL MODALITIES

mammography: mass with indistinct margins

Fluid = Benign

Solid Benign

Solid Malignant

ultrasound :

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FIBROADENOMA

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MAMMOGRAPHY STANDARD VIEWS

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MAMMOGRAPHY CLOSE-UP WITH SPOT COMPRESSION

BREAST ULTRASOUND :

1. lesion confirmation 2. lesion caracterization 3. guide for biopsy 52

BREAST DIAGNOSTICS

is organized in three consecutive steps : ① DETECTION ② CHARACTERIZATION ③ LOCAL STAGING

CHARACTERIZATION : BREAST NEEDLE BIOPSY « TISSUE IS THE ISSUE »

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DIAGNOSTIC PATHWAY BREAST CLINICAL EXAM

Mammography > 40 yo

NEGATIVE

STOP

Breast Ultrasound < 40 yo

DOUBT (even minimal)

POSITIVE

NEEDLE BIOPSY 54

CORE NEEDLE BIOPSY GOALS 1. Benign lesions (very common!!!) chracterization without surgery 2. Malignant lesions presurgical nature definition invasiveness diagnosis loco-regional staging 3. Minimal invasivity and costs 4. Faster time to diagnosis 55

MICROBIOPSY

(Core Needle Biopsy)

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CORE NEEDLE BIOPSY (CNB 14Gauge – the core)

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CORE NEEDLE BIOPSY (the cores : diagnostic accuracy as reliable as surgical biopsy)

s old lady automass in the adrant of her mmotome

biopsies of excellent quality

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BREAST DIAGNOSTICS

is organized in three consecutive steps : ① DETECTION ② CHARACTERIZATION ③ LOCAL STAGING

LOCAL STAGING MAGNETIC RESONANCE

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BREAST MAGNETIC RESONANCE

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Breast MR : the requisites • 1- TECHNOLOGY • Magnet strenght at least 1.5 T • Best spatial resolution • Best temporal resolution

• Dedicated multi-element coil • Iniezione a bolo di mdc (gadolinio) • 2- WELL TRAINED RADIOLOGIST AND RADIOGRAPHER

Breast MR: presupposti fisiopatologici

• 1- TUMORAL NEOANGIOGENESIS • increased vascularity • increased vascular permeability • increased interstitial space

• 2- CONTRAST AGENT IV : gadolinium

Increased RM signal in tumoral lesions (enhancement)

AXIAL

CORONAL

SAGITTAL

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to avoid « enhancement » artifacts Breast MR should be performed during the second (third) week of the menstrual cycle (best from the 7th to 14th day of the menstrual cycle)

6 months after a breast surgery 12 monthes after breast radiotherapy 2-4 weeks from interruption of Hormone Replacement Therapy

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« enhancement » artifacts 40 yo – MR for high risk – 27th day menstrual cycle

a. 58 in HRT– MR done for distortion on MX

same woman – MR repeated on the 9th day of the menstrual cycle

same woman – MR repeated after interrupting HRT for 6 months

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BREAST MAGNETIC RESONANCE

in high risk population is absolutely the most sensitive modality in detecting breast cancer

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BREAST MAGNETIC RESONANCE

Magnetic Resonance sensitivity is not reduced by breast density as it happens in Mammography

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MAMMOGRAPHY – CRANIO-CAUDAL

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MAMMOGRAPHY – MEDIO-LATERAL OBLIQUE

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MIP AXIAL

MIP CORONAL

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MIP left coronal

MIP left sagittal

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MIP right coronal

MIP right sagittal

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B5 – invasive carcinoma

C2 - benign

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ONCOLOGIC PREVENTION = EARLY DIAGNOSIS (detect cancer in a pre-clinical stage)

Early Diagnosis

Carcinoma in situ

Conservative Surgery Efficacy

Better quality of life

CONSERVATIVE SURGERY

MORTALITY REDUCTION

SURVIVAL BENEFITS

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THANKS FOR LISTENING Renzo Taschini renzotaschini@ymail.com