Diagnosis of breast diseases integrating the findings of clinical presentation, mammography, and ultrasound

447 Pages·2011·44.945 MB·English, German

by  Foster, Julie, Kramer, Angelika, Telger, Terry C., Frohwein, Volker, Barth, Volker

Diagnosis of Breast Diseases
Integrating the Findings of Clinical Presentation,
Mammography, and Ultrasound
Volker Barth
Professor
BreastImagingCenter
Esslingen,Germany
Withcontributionsby
VolkerFrohwein,JohannesHerrmann,BrigitteKoellner,ElfiSteinhilber,
OliverWild,AndreaBarth,StephanBarth
1560illustrations
Thieme
Stuttgart·NewYork
IV
LibraryofCongressCataloging-in-PublicationData Important note: Medicine is an ever-changing science undergoing
Barth,Volker. continual development. Research and clinical experience are con-
[AtlasderMammadiagnostik.English.] tinuallyexpandingourknowledge,inparticular ourknowledge of
Diagnosisofbreastdiseases:mammographyandultrasound/ proper treatmentanddrugtherapy.Insofarasthisbook mentions
VolkerBarth;withcontributionsbyJohannesHerrmann...[etal.]. any dosage or application, readers may rest assured that the au-
p.;cm. thors,editors,andpublishershavemadeeveryefforttoensurethat
Includesbibliographicalreferencesandindex. such references are in accordance with the state of knowledge at
Summary:“Apracticalapproachtotheearlydetectionandman- thetimeofproductionofthebook.
agementofbreastcancer.Thislavishlyillustratedatlasprovidesradi- Nevertheless,thisdoesnotinvolve,imply,orexpressanyguaran-
ologistswithessentialinformationfor thedifferentialdiagnosisof teeorresponsibilityonthepartofthepublishersinrespecttoany
breastdiseasesonthebasisofclinicalpresentation,mammography, dosage instructions and forms of applications stated in the book.
and ultrasound. Thebook begins with chapters on tumor biology, Every user is requested to examine carefully the manufacturers’
prognosticfactors,andhistology.Theauthorsthenprovideathor- leafletsaccompanyingeachdrugandtocheck,ifnecessaryincon-
oughevaluationofvariousmethodsforearlydetectionandaccurate sultationwithaphysicianorspecialist,whetherthedosagesched-
diagnosis,includinganaloganddigitalmammography,ultrasound, ulesmentionedthereinorthecontraindicationsstatedbytheman-
MRimaging,PET/CT,andinterventionalprocedures.Theydiscussin ufacturers differ from the statements made in the present book.
detail the strengths and limitations of each imaging modality, as- Such examination is particularly important with drugs that are
pectsofqualitycontrol,testintervals,peri-andpostoperativeman- eitherrarelyusedorhavebeennewlyreleasedonthemarket.Every
agementprinciples,andfollow-upcare.Highlights:–Presentationof dosagescheduleoreveryformofapplicationusedisentirelyatthe
difficult cases that effectively demonstrate the diagnostic hurdles user’s own risk and responsibility. The authors and publishers re-
andforensicpitfallsinbreastdiagnosis–Specialsectionsonbreast quest every user to report to the publishers any discrepancies or
cancerinmenandyoungwomen,withdiscussionof womenwho inaccuraciesnoticed.Iferrorsinthisworkarefoundafterpublica-
are pregnant or lactating – Color-coded practical tips and clinical tion,erratawillbepostedatwww.thieme.comontheproductde-
notesfor optimalcomprehension of the material – Extensive Q&A scriptionpage.
sections for self-testing in two major chapters – More than 1,700
high-qualityillustrations,includingclinicalcolorphotographs,ultra-
soundimages,andmammograms”–Providedbypublisher.
ISBN978-3-13-143831-7(hardback:alk.paper)1.Breast–Ultra-
sonic imaging–Atlases. 2. Breast–Diseases–Diagnosis–Atlases. I.
Herrmann,Johannes,Dr.med.II.Title.
[DNLM: 1. Breast Diseases–radiography–Atlases. 2. Breast Neo-
plasms–radiography–Atlases. 3. Diagnosis, Differential–Atlases.
4.Mammography–Atlases. 5. Ultrasonography, Mammary–Atlases.
WP17]
RG493.5.U47B36132010
618.1'90754–dc22 2010042870
Thisbookisanauthorized,revised,andenlargedtranslationof
the2ndGermaneditionpublishedandcopyrighted2006by
GeorgThiemeVerlag,Stuttgart,Germany.TitleoftheGerman
edition:AtlasderMammadiagnostik:Mammographieund
Sonographieintensivtrainieren.
Translators:TerryTelgerandJulieFoster,FortWorth,Texas,USA
Illustrators:AngelikaKramer,Stuttgart,Germany,
andAndreaSchnitzler,Innsbruck,Austria
Someoftheproductnames,patents,andregistereddesignsreferred
©2010GeorgThiemeVerlag, to in this book are in fact registered trademarks or proprietary
Rüdigerstrasse14,70469Stuttgart,Germany names even though specific reference to this fact is not always
http://www.thieme.de madeinthetext.Therefore,theappearanceofanamewithoutdes-
ThiemeNewYork,333SeventhAvenue,NewYork,NY10001,USA ignationasproprietaryisnottobeconstruedasarepresentationby
http://www.thieme.com thepublisherthatitisinthepublicdomain.
This book, including all parts thereof, is legally protected by
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TypesettingbyZiegler+Müller,Kirchentellinsfurt,Germany narrow limits set bycopyright legislation, without the publisher’s
PrintedinChinabyEverbestPrintingCoLtd,HongKong consent,isillegalandliabletoprosecution.Thisappliesinparticular
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ISBN978-3-13-143831-7 1 2 3 4 5 6 microfilms,andelectronicdataprocessingandstorage.
V
Dedicated toKlaus-Dieter Schulz(of Marburg),
forhis decadesofcommitment tothe early
detection ofbreastcancer.

VII
Preface
The European Guidelines for Quality Assurance in Breast Cancer conventional and digital mammography and should be required
Screening and Diagnosis of the European Commission (Perry et al. readingforeverybreastdiagnostician.
2004)pertainbasicallytomammography,andverylittletoadjunc- Mycomputerexpert,OliverWild,authoredthesectionondigital
tivemethods.Buttheearlydetectionofbreastcancercanbeeffec- full-fieldmammography.Heexplainstheadvantagesofthistechnol-
tiveonlywhenthethreepillars—clinicalinvestigation,mammogra- ogyforscreeningandmoderndiagnostictestingandformakinga
phy, ultrasound—are united within a structured, quality-assured detailed comparison of current and previous mammograms—pri-
program. The German S3 guidelines (Albert et al. 2003, 2008; mary digital images as well as images that have been secondarily
Kreienbergetal. 2008) comeclosest to meeting this requirement. scannedintothecomputer.
The European and American guidelines are very similar to each A section written by my practice partner, Dr. Johannes Herr-
other but arebasicallylimited to mammography. Professor Klaus- mann, gives readers the opportunity to interpret subtle mammo-
Dieter Schultz and his teamwere instrumental in introducing the graphicchanges(inmammgraphiccasepresentationandtrainingin
S3 guidelines, which were revised in 2008 to become the quality interpretation).Theseimagessimulateascreeningsituation.Some
standardthroughoutGermany.TheGermanandEnglisheditionsof ofthemammogramsshowonlyminimalchangesorappearnormal
thisatlaswerethereforededicatedtoProfessorSchultz,whosesud- despitethepresenceofabreast tumor.Thissectionillustratesthe
dendeathleftagapingholeintheGermanSenologySociety.Icredit limitationsofmammogramsandshowsthatmammographyalone
ProfessorSchultzwithmanyvaluableideasthatsetmyprofessional is(outsideofscreening)nolongerthegoldstandardandcanyield
horizonduringmyyearsofworkingwithhimintheSociety. optimum results only in concert with other modalities. Typical
Rigorous efforts at early detection (secondary prevention) as screeningcasesarealsoillustrated.
wellasadjuvantsurgicalandmedicaltreatments(tertiarypreven- Recall the publications of Nakama et al. (1991), Gordon and
tionofrecurrenceandmetastasis)havesignificantlyimprovedthe Goldenberg(1995),TeboulandHalliwell(1995),Kolbetal.(2002),
survivalratesandmortalityratesforbreastcancerthroughoutthe andLeconteetal.2003tounderstandthepossibilitiesofultrasound,
worldduringthepast25years.Thesefactorsdonotaccountforthe andthe2006studybyDr.WendieBergofJohnsHopkinsUniversity
decliningaggressivenessofmalignanttumorsthathasbeendocu- (Bergetal.2008),inwhichmammographyplusbreast ultrasound
mentedinrecentdecades. detectedalmostone-thirdmorecancersthanmammographyalone.
Primaryprevention,orthepreventionofgradualmalignanttu- Sowhatarewewaitingfor?
mor development in response to tumor-stimulating biological or Itshouldbeaddedthatultrasoundmayyieldfalse-positivesthat
synthetic agents, is not yet a reality. This atlas is concerned with prompt unnecessaryinterventions,butthisdoesnotalter thefact
secondarycancerprevention. that ultrasound reduces interval cancers and improves the pros-
Theillustrationsinthisbookdonotincludemammogramsthat pects for a cure. Mammography generates a significantly higher
displayobvioustumorswithassociatedpalpablenodules.Thereare rate of false-positive findings (30%), which cause serious distress
verygoodtextbooksandatlasesofmammographythatpresentim- for theaffectedwomen.Theadditionofultrasoundeliminatesap-
agesofthiskind(forexample,BarthandPrechtel1991;Tabaretal. proximately 50% of recalls, fully compensating for the 5% rate of
2000;FischerandBaum2005).Agreatmanyofthemammograms false-positivesonographic findings.Fine-needleaspiration (FNA) is
inthisbookshowonlyminimalchangesornoabnormalitiesatall, particularlyusefulforidentifyingfalse-positiveultrasoundfindings
which makes the ultrasound findings all the more impressive by atlowcostandveryquickly(Bergetal.1962;Zajicek1974;Schön-
comparison. This is typical of the cases that are seen outside of dorf1977;Lindholm1999;Orell1999;Frohwein2002).
screening programs. I havefocused mainlyondifficultcasesillus- Thesectiononscreeningandtumorprogressionunderscoresthis
tratingthediagnostichurdlesandforensicpitfallsthatareencoun- themebyshowinghowtumorsthatweremissedonpreviousmam-
tered in breast diagnosis.I hopethateven experiencedcolleagues mogramscanbedetectedretrospectivelyonthebasisofrelatively
willfindthisbookavaluableteachingaid. subtle findings. Every breast diagnostician has missed a tumor or
Icouldnotillustrateeverythingthatwouldbeimportantinrou- delayeditsdiagnosisatonetimeoranother.Thisshouldnotbeafre-
tinesituations—thescopeofmodernbreastdiagnosisistooexten- quentoccurrence,however.Wepractitionerscannottreatthecon-
sive.Butthebookisintendedtoshowhowimportantitistoknow cept of interval cancer as an abstraction; sometimes we must ex-
allthediagnosticpossibilitiesinthebreast,notonlymammography. plain in a court of law why we missed a tumor that may have
Becausesuchhighstandardsareplacedonthetechnicalquality harmedourpatient.
ofmammogramsthroughouttheworld,ourradiologictechnologist, Other sections in this book deal with breast cancer in young
ElfiSteinhilber,contributedaspecialsectiondealingwithmammo- womenandduringpregnancy.Diseasesofthemalebreastarealso
graphic positioningand quality assurance. Using the PGMI system, addressed.
physicians and their assistants who perform mammography can Weexaminethepitfallsofpre-andpostoperativediagnosisand
rate the technical quality of their mammograms as “perfect,” thepossibilitiesandlimitationsofbreastdiagnosisinthepostoper-
“good,” “moderate,” or “inadequate.” This section pertains to both ative care setting. Performed by nonscreening radiologists and
VIII Preface
gynecologists,thesefollow-upexaminationsrequirespecialexper- homewhilecaringforherchild.Ialsoexpresssincerethankstomy
tise in the differenzial diagnosis of mammographic, sonographic, assistantsHaticeKaraandDeryaCelik,HeideScherbaum,MilkaLeo-
andMRIfindings. vac, and Tuğçe Yiğit. They painstakingly collected the published
Breastimplantsareincludedbecauseofthegrowingnumbersof mammograms and sonograms, scanned them into the computer,
women who present with these devices after breast-conserving andlookedupnumerouscasehistories.
therapy. These cases cannot be adequately evaluated by single- IamgratefultomycolleaguesProfessorDr.ThorstenKuehn,chief
viewmammography,andwemustobtainasecondvieworevena ofgynecologyatEsslingenHospital,andProfessorDr.StefanKraemer,
thirdviewinselectedcases.Familiaritywithdifferenttypesofim- whosucceededmeasheadoftheradiologydepartmentatEsslin-
plantisessentialinordertobeabletomakeanaccuratedifferenzial genHospital,forprovidingmewithvaluablesuggestionsandillus-
diagnosis. trativematerials.IthankDr.Hans-HelmutDahmandhispartnerDr.
Wetakeacriticallookatimagingmodalitiesthateitherareused JoernStraeterforprovidingsomeofthecytologyillustrationsanda
asamatterofcourseorarewithheldfrompatientsduetotheirhigh large portion of the histologic illustrations that were included in
cost. These include magnetic resonance imaging (MRI), positron this book. I supplemented these illustrations with material from
emission tomography (PET), and PET/CT. Why should MRI be used thecollectionsoftheleadingGermanbreastpathologistsofrecent
onlyinpatientswithlobularcarcinomatodefinetumorextentand decades, Professor Roland Baessler (Fulda, Germany) and Professor
evaluatethehealthybreast,merelybecauseMRIhasbeenidentified KlausPrechtel(Starnberg,Germany),withwhomIworkedforyears
as the best evidence-based modality for lobular cancer detection? andstillmaintainfriendlyties.Theyprovidedmewithillustrations
MRI should be availablefor the preoperative analysis ofall malig- forthisatlas,andtheircontributionisgratefullyacknowledged.
nanttumors,especiallyinyoungerwomen,ifitwilladvancetreat- I also thank theformerdirector of St. Joseph Hospital in Haan,
mentplanning.Mostdoctorswouldnotthinktwiceaboutevaluat- Dr. Heinz Uedelhoven, who left me a large portion of his valuable
ingthekneejointoralittlefingerwithMRI.Why,then,istherea mammogramandsonogramcollectionforuseinscientificpublica-
reluctance to apply this modality to breast cancer, with its many tions.Ihaveputseveraloftheseimagestoexcellentuseintheatlas.
therapeuticchallengesandpotenzialforrecurrence? IexpressspecialthankstotheradiologistDr.VolkerFrohweinof
Wetouchontheimportanceofdedicated,certifiedbreastcenters Landstuhl,Germany,nowretired.Asaradiologistandcytologist(an
as an effective approach to early cancer detection and treatment. extremelyrarecombination!),hewasanenthusiastic,life-longcol-
Thesebreast centers have been an important factor in the world- lectorofcytologicspecimensfromthebreast.Hepublishedhisex-
wide decline of breast cancer mortality. Centers are springing up periencewithbreastcytologyinthepaperFrühdiagnostikdesMam-
everywhereintheworld,whichisapositivedevelopment(Kreien- makarzinoms (2002). Dr. Volker Frohwein supplied most of the
bergetal.2008). cytologicspecimenspicturedinthisatlas.
It is unacceptable for a woman to be referred to a hospital for Onecouldhardlyexpect thatimagescollectedoveraperiodof
cancertreatmentsimplybecausethereferringphysicianisafriend decades would consistently satisfy todayʼs quality standards. For
ofthedepartmenthead.Theinternationalcarestandardforbreast this reason, I have replaced earlier images of poorer quality, and
cancertreatmentismetonlyataspecializedcarecenterwhereall the materials from Dr. Frohweinwere valuable in this regard. MR
diagnostic and therapeutic information is coordinated, archived, images of marginal quality have been replaced wherever possible
andreviewedatmultidisciplinarycaseconferences—aplacewhere bysimilar imagesacquiredwith a 1.5-tesla scanner and thelatest
alltherapeuticoptionsareavailableandcanbepracticedinanopti- coiltechnology.Dr.StefanKraemerhelpedmewiththistask.
mal way. Digital patient databases are essential in this setting, al- I appreciate the help of my two former doctoral candidates
thoughsecurityandconfidentiallyissueshavekeptthemfrombe- CoscinaWeiningandOskarWeining-Klemm,whoanalyzedmycase
ingestablishedonabroad,interdisciplinaryscale. files from the past 10 years to identify the most economical and
Theaxillaisaregionofprofoundimportance.Untoldmiseryhas effectiveearlydetectionstrategiesaspartoftheirdoctoraldisserta-
resulted from aggressive, often unnecessary, axillary lymph node tion.Iampleasedtonotethattheyfoundonlya1.5%incidenceof
dissections(withor withoutirradiation)inbreastcancerpatients. intervalcancers.
Theworldwideintroductionofthesentinelnodebiopsyhasspared Mydaughter,AndreaBarth,notonlyeditedthisbooktimeand
many women the sufferings of arm edema, axillary foreign-body again,makingstylisticrevisionsandofferingexcellentorganization-
sensation, and radiating pains. My former colleagues Dr. Brigitte alsuggestions,butalsohelpedmewiththestatisticalmaterials.She
KoellnerandDr.PetraZimmerhavedealtwiththistopicforyears. hasthusmadeavaluablecontributiontotheconceptof thebook.
They introduced the sentinel node biopsy at Esslingen Hospital Myson,Dr.StephanBarth(St.Johann,Austria),didextensivelitera-
10years ago and worked with the gynecology chief Professor Dr. tureresearchthatwasnecessarytoensurethatthecontentsofthe
Thorsten Kuehn and his team to optimize the procedure. I extend atlaswereuptodate.Healsorevisedthechapteronbreastcancerin
specialthankstoDr.Koellnerforwritingthesectiononthesentinel males.
lymphnodeprocedure. IthankthestaffatThiemePublishers,especiallyGabrieleKuhn-
Giovannini,andElisabethKurzfortheirworkinproducingtheEng-
lishedition.Iextend special thankstothetranslatorsof thebook,
Acknowledgments TerryTelgerandJulieFoster,andtothecopyeditorLenCegielkafor
hisexcellentwork.
Anatlasofthiskindisalwaysateameffort.Manyhavehelpedmein FinallyIwouldliketothankalltheretireddepartmentheadsat
bringingthebooktocompletion,includingthosewhoworkedinthe Esslingen Hospital for decades of friendly cooperation and wish
background. I am particularly indebted to my secretary, Cornelia themallthebest.
Wahl, who typed the manuscript and made revisions from her VolkerBarth,MD
IX
List of Contributors
VolkerFrohwein,MD OliverWild PhotoCredits
SpecialistforRadiology OwiCom Thefollowingcolleagueshavekindly
givenuspermissiontousetheirimages:
andNuclearMedicine Esslingen,Germany
Landstuhl/Pfalz,Germany Prof.RolandBaessler,MD
Pathologist
AndreaBarth
Fulda,Germany
JohannesHerrmann,MD Nutritionist,EditorialJournalist
BreastImagingCenter BreastImagingCenter
Esslingen,Germany Esslingen,Germany
BrigitteKoellner,MD StephanBarth,MD Hans-HelmutDahm,MD
AssistantProfessor
CentralInstituteforRadiology SupervisingPhysician
Pathologist
EsslingenHospital DepartmentofGeneralSurgery Esslingen,Germany
Esslingen,Germany DistrictHospital
St.Johann/Tirol,Austria
ElfiSteinhilber
Esslingen,Germany VolkerFrohwein,MD
Radiologist/Cytologist
Landstuhl/Pfalz,Germany
Prof.StefanKraemer,MD
Radiologist
Esslingen,Germany
Prof.ThorstenKuehn,MD
Gynecologist
Esslingen,Germany
Prof.KlausPrechtel,MD
Pathologist
Starnberg,Germany
JoernStraeter,MD
AssistantProfessor
Pathologist
Esslingen,Germany
HeinzUedelhoven,MD
Radiologist
Haan,Germany
Fromlefttoright:Dr.StephanBarth,Dr.JohannesHerrmann,AndreaBarth,OliverWild,ElfiSteinhilber,Dr.Brigitte
Koellner,Prof.VolkerBarth.