Breast cancer: the art and science of early detection with mammography: perception, interpretation, histopathologic correlation

485 Pages·2005·155.31 MB·English

by  Dean

I
II
Breast Cancer
The Art and Science of Early Detection
with Mammography
Perception, Interpretation, Histopathologic Correlation
László Tabár, M.D.
Professor and Director
Department of Mammography
Central Hospital
Falun, Sweden
University of Uppsala School of Medicine
Uppsala, Sweden
Tibor Tot, M.D., Ph.D.
Associate Professor of Pathology and Chairman
Department of Pathology and Clinical Cytology
Central Hospital
Falun, Sweden
University of Uppsala
Uppsala, Sweden
Peter B. Dean, M.D.
Professor
Department of Diagnostic Radiology
University of Turku
Turku, Finland
Visiting Professor
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA, USA
1590 illustrations
Thieme
Stuttgart · New York
III
LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscienceunder-
Tabár,László. going continual development. Research and clinical ex-
Breastcancer:theartandscienceofearlydetectionwith periencearecontinuallyexpandingourknowledge,inpartic-
mammography/LászlóTabár,TiborTot,PeterB.Dean. ularourknowledgeofpropertreatmentanddrugtherapy.In-
p.;cm sofarasthisbookmentionsanydosageorapplication,readers
ISBN3-13-135371-6(GTV:alk,paper)--ISBN1-58890-259-5 may rest assured that the authors, editors, and publishers
(TNY:alk.paper) havemadeeveryefforttoensurethatsuchreferencesarein
1. Breast--Radiography--Atlases. 2. Breast--Cancer-Imaging-- accordancewiththestateofknowledgeatthetimeofpro-
Atlases. ductionofthebook.
[DNLM:1.BreastNeoplasms--radiography.2.EarlyDiagno- Nevertheless, this does not involve, imply, or express any
sis.3.Mammography--methods.4.RadiographicImageInter- guaranteeorresponsibilityonthepartofthepublishersinre-
pretation, Computer-Assisted. WP 870 T112b 2005] I. Tot, spect to any dosage instructions and forms of applications
Tibor.II.Dean,PeterB.III.Title. statedinthebook.Everyuserisrequestedtoexaminecare-
RG493.5.R33T3182005 fullythemanufacturers’leafletsaccompanyingeachdrugand
618.1’907572--dc22 2004025269 tocheck,ifnecessaryinconsultationwithaphysicianorspe-
cialist, whether the dosage schedules mentioned therein or
thecontraindicationsstatedbythemanufacturersdifferfrom
thestatementsmadeinthepresentbook.Suchexaminationis
particularlyimportantwithdrugsthatareeitherrarelyused
or have been newly released on the market. Every dosage
scheduleoreveryformofapplicationusedisentirelyatthe
user’sownriskandresponsibility.Theauthorsandpublishers
requesteveryusertoreporttothepublishersanydiscrepan-
cies or inaccuracies noticed. If errors in this work are found
after publication, errata will be posted at www.thieme.com
ontheproductdescriptionpage.
Some of the product names, patents, and registered designs
referred to in this book are in fact registered trademarks or
proprietarynameseventhoughspecificreferencetothisfact
isnotalwaysmadeinthetext.Therefore,theappearanceofa
name without designation as proprietary is not to be con-
strued as a representation by the publisher that it is in the
publicdomain.
©2005GeorgThiemeVerlag, Thisbook,includingallpartsthereof,islegallyprotectedby
Rüdigerstrasse14,70469Stuttgart,Germany copyright.Anyuse,exploitation,orcommercializationoutside
http://www.thieme.de the narrow limits set by copyright legislation, without the
ThiemeNewYork,333SeventhAvenue, publisher’s consent, is illegal and liable to prosecution. This
NewYork,NY10001USA applies in particular to photostat reproduction, copying,
http://www.thieme.com mimeographing, preparation of microfilms, and electronic
dataprocessingandstorage.
Coverdesign:Cyclus,Stuttgart
TypesettingbyprimustypeHurlerGmbH,Notzingen
PrintedinGermanybyGrammlich,Pliezhausen
ISBN3-13-135371-6(GTV)
ISBN1-58890-259-5(TNY) 12345
IV
This book is dedicated to the task of
finding breast cancer when it is still
curable, and to the more difficult task of
ruling out the presence of breast cancer
in those women who do not have the
disease.
V
Preface
For decades, early detection has been our most effective lowerresolution.Wehaveendeavoredtonarrowthisgulf
means of reducing the number of unnecessary deaths by correlating mammography with subgross, three-di-
causedbybreastcancer.Althoughthemethodsofearlyde- mensional pathology images and large, thin-section
tectionhaveimprovedandcontinuetodoso,theirapplica- pathologyimages.
tiontothewomenwhoneedthemhasalwayslaggedbe-
hind.Notonlyhashigh-qualitymammographybeenavail- Thisbookhasbeenmorethantwodecadesinthewriting,
abletotoofewwomen,buttherehavealwaysbeentoofew having gone through innumerable versions as we have
radiologistsskilledindetectingearlystagebreastcancer. sought to bring László Tabár’s teaching courses to the
printed page. It is our sincerest hope that this book will
Radiologistswhohavetakenthetroubletolearnthemany enableevermoreradiologiststoobtaintheskillsnecessary
facetsofnormalbreastradiologicalanatomycaninterpret todetectbreastcanceratitsearliestpossiblestages,while
mammograms more effectively and with greater confi- atthesametimebeingabletoassurethevastmajorityof
dence. Also, knowledge of the pathophysiological thescreenedwomenthattherearetrulynosignsofbreast
processesleadingtothepathologicalchangesinthebreast cancerontheirimages.
isnecessaryfortheradiologisttomastertheintricaciesof
breastimaging.However,awidegulfseparatesthepathol- November2004 LászlóTabár
ogist’s high-resolution images of a small, thin section of TiborTot
tissuefromtheradiologist’simagesoftheentirebreastata PeterB.Dean
VI
Contents
Introduction—The Normal Breast: Comparative Subgross Anatomy and Mammography 1
Introduction—TheNormalBreast:Comparative Homogeneous,StructurelessDensities ........... 24
SubgrossAnatomyandMammography ............ 3 RadiolucentAreas .............................. 30
InterrelationshipbetweenHistologyand OverviewoftheFiveMammographicParenchymal
Mammography ................................... 4 Patterns .......................................... 32
NodularDensities .............................. 16 MammographicParenchymalPatternI........... 33
CorrelativeMammographic−Histological MammographicParenchymalPatternII .......... 35
DemonstrationoftheFourBuildingBlocks ......... 16 MammographicParenchymalPatternIII ......... 36
Ducts ........................................ 17 MammographicParenchymalPatternIV ......... 37
FibrousStrands............................... 22 MammographicParenchymalPatternV .......... 38
Vessels....................................... 23
Chapter 1: Pattern I 39
CharacteristicsofPatternI ........................ 40 PathologicalLesionsinPatternITypeBreasts ...... 70
RadiopaqueDensities ............................. 46 HowDothePathologicalLesionsChangethe
NodularDensities .............................. 46 MammographicImageofPatternITypeBreasts
FibrousTissue .................................. 54 andHowCanWePerceiveThem? ............... 70
TheParenchymal LesionswithConvexRadiopaqueContours ....... 71
Contour ........................................ 56 LesionswithArchitecturalDistortion ............ 80
RadiolucentAreas ................................ 62 TheEvolutionofaTinySpiculatedTumor ........ 82
Involution ........................................ 66 CalcificationsinaPatternITypeBreast .......... 84
MammographicallyOccultLesionsinPatternI ... 86
Chapter 2: Pattern II 93
CharacteristicsofPatternII........................ 94 BloodVessels................................... 112
LinearDensitiesinPatternII ...................... 95 PathologicalLesionsinPatternIIBreasts ........... 114
Ducts .......................................... 95 SpiculatedInvasiveDuctalCarcinomaina
AtrophicDuctsandTheirBranches ............ 95 PatternIIBreast ................................ 114
PersistentLobulesinPatternII ................ 97 MicrocalcificationsinPatternIIBreasts .......... 115
NormalDucts ................................ 98 ScreeningFindingsinAsymptomaticWomen
Ductectasia .................................. 99 withPatternIIBreasts .......................... 116
FibrousStrands ................................. 109
Chapter 3: Pattern III 119
CharacteristicsofPatternIII ....................... 120
Chapter 4: Pattern IV 123
CharacteristicsofPatternIV ....................... 124 FibroadenomatoidChangeoftheLobule ........... 132
Adenosis ......................................... 125 PatchyFibrosis ................................... 133
SclerosingAdenosis ............................... 128 PathologicalLesionsinPatternIVBreasts .......... 134
Chapter 5: Pattern V 141
CharacteristicsofPatternV........................ 142 DistributionofMammographicParenchymal
InvolutingLobulewithFibrousReplacement ....... 144 PatternsbyAgeinaScreeningPopulationversus
CalcificationsinPatternVBreasts ................. 145 ClinicallyReferredWomen ........................ 162
PerceptionofNoncalcifiedLesionsinPatternV ThePrevalenceofBreastCancerAccording
TypeBreasts ..................................... 151 toMammographicParenchymalPatternandAge ... 163
RelativeFrequenciesoftheMammographic Summary ........................................ 163
PatternsintheGeneralPopulation................. 160
Chapter 6: Finding Breast Cancer When It Is Still Small: Rationale and Scientific Evidence 165
ANewEraintheDiagnosisandTreatment ANewParadigm:PreventBreastCancerfrom
ofBreastCancer .................................. 166 GrowingtoAdvancedStages .................... 168
DetectionofBreastCancerinthePreclinical TheMostImportantTaskIstoPreventBreast
Phase .......................................... 166 CancerfromDevelopingtoLarge,AdvancedTumors 170
VII
Contents
Nonpalpable,Screen-DetectedBreastCancer ..... 172 Conclusion ..................................... 187
MechanismfortheImpactofScreening .......... 174 FactorsInfluencingEarlyDetection ................ 188
TumorSize ................................... 174 MultipleFactorsThatDetermineHowEarlyinthe
NodeStatus .................................. 175 PreclinicalDetectablePhaseIndividualMalignant
HistologicalMalignancyGrade ................ 176 TumorsCanBeDetected ........................ 188
TheRelativeBenefitsofDownwardStage TheNatureoftheSurroundingBreastTissue ... 188
Shifting ........................................ 178 MorphologicalHeterogeneityofBreastCancer
MechanismfortheEffectofEarlyDetectionof atHistology .................................. 190
BreastCancer:CommentsandConclusions....... 180 MorphologicalHeterogeneityofBreastCancer
Summary ...................................... 185 atMammography ............................ 194
TheImpactofEarlyDetectiononBreastCancer TheProgressiveNatureofBreastCancerand
Death ............................................ 186 theVariabilityintheRateofDiseaseProgression
MammographyScreeningandTreatmentinEarly AccordingtoHistologicalTypeandPatientAge . 216
StageCanDramaticallyReduceMortalityfrom Conclusions .................................. 235
BreastCancerinaPopulation ................... 186
Chapter 7: Finding Breast Cancer When It Is Still Small: Use of Systematic Viewing Methods 237
ASystematicMethodforViewingMammograms ... 238 DefinitePathologicalLesionCausingan
BasicPhilosophy................................ 238 AsymmetricDensityontheMammogram ...... 256
Prerequisites ................................... 238 DistributionofHistologicalDiagnosesatOpen
SuperbMammographicTechniqueIsEssential . 238 Biopsy ......................................... 257
ViewingConditionsduringImageReadingWill AlgorithmfortheWork-upandManagementof
HaveaDecisiveImpactupontheDiagnostic anAsymmetricDensityontheMammogram ..... 258
Outcome ..................................... 238 PracticeinPerceptionandWork-upofFindings .... 259
PerceptionofSubtleRadiographicAbnormali- BreastRegionswithaHigherFrequencyofBreast
tiesCanBeEnhancedbytheUseofaHand- Cancer ......................................... 259
heldMammographyViewer................... 238 LesionsLocalizedintheUpperOuterQuadrant. 259
ASystematicApproachIsEssentialforViewing LesionsLocalizedintheMedialHalfofthe
AnyDiagnosticImage ........................... 239 Breast........................................ 318
SystematicApproachtotheAnalysisofthe LesionsLocalizedintheRetroglandularClear
Findings.......................................... 240 SpaceontheCCProjection .................... 328
AsymmetricDensitiesontheMammogram ...... 240 LesionsLocalizedintheRetroareolarArea ..... 346
SystematicWork-upofAsymmetricDensities CharacteristicsofLesionsRegardlessofLocation . 358
ontheMammogram .......................... 242 LesionsCausingArchitecturalDistortion ....... 358
NormalFibroglandularTissue ................. 243 LesionsCausingParenchymalContour
NonspecificAsymmetricDensitywithArchitec- Changes...................................... 394
turalDistortionontheMammogram .......... 250
Chapter 8: Large-Section Histology of the Breast 405
Introduction...................................... 406 Subgross,Thick-SectionHistologyTechnique ....... 420
RationaleforLarge-SectionTechnique ............. 406 StepsoftheTechnique .......................... 420
Prerequisites ................................... 406 ExamplesofSubgross,Thick-SectionHistopathology
HandlingoftheSpecimen ......................... 407 ImagesofBreastTissue ........................... 423
CuttingwiththeMacrotome ...................... 412 CaseDemonstrations ............................. 425
HandlingandStainingtheSections ................ 413 Conclusions ...................................... 438
TheFinalProduct:TheLarge-SectionSlide ......... 414
Chapter 9: Mammography Positioning Technique 439
References 467
Subject Index 471
VIII
Introduction
T
he Normal Breast:
Comparative Subgross Anatomy
and Mammography
1