Before attending Specialist Breast Cancer Surgery, patients will be required to have up-to-date breast imaging. If patients do not have current breast imaging, the staff at Specialist Breast Cancer Surgery are happy to make arrangements for you to have your imaging on site at the hospital before the consultation.
For women over the age of 35, we suggest that you have a bilateral mammogram and a bilateral breast ultrasound before attending the appointment. Women younger than the age of 35, with require a bilateral breast ultrasound.
It is likely, particularly when a women presents with a symptom (e.g. breast lump, nipple discharge, or changes in the contour of the breast or shape of the breast) that imaging that is older than 6 months old will need to be repeated.
Patients that have already had imaging performed, need to ensure that they bring all of the imaging with them to the appointment. It is very difficult for the doctor to give a professional opinion if the imaging cannot be seen. The imaging contributes significantly to the diagnosis and management of breast conditions, and mammography and ultrasound are essential components of the triple assessment.
The triple assessment is vital in the diagnosis of any breast abnormality. The diagnosis of breast abnormality cannot be based reliably on a single diagnostic modality as there are no tests currently available which are sufficiently sensitive and specific to make a definitive diagnosis and therefore, triple assessment will be required. This is a combination of clinical assessment (patient’s history and physical examination), imaging which is usually in the form of mammography and ultrasound, and microscopic assessment of the breast tissue (cytology or histopathology from a fine-needle aspiration or a core biopsy reviewed by specialist breast pathologist). Each of these parts of the assessment compliment the other and none should be interpreted in isolation.
When all 3 methods of assessment agree, the level of diagnostic accuracy exceeds 99%, allowing reliable preoperative diagnosis and avoiding the need for an excision biopsy. An open excisional biopsy is indicated when doubt exists after the triple assessment (also known as the triple test).
The results of the triple assessment will be calculated using a 5‑point scale. Each component of the triple assessment (clinical assessment, imaging, and biopsy) will be assigned a number; 1 normal, 2 benign, 3 indeterminate, 4 suspicious, and 5 malignant (cancer). A score of 3 or above on any of the triple assessment parameters will often mandate an open-excisional biopsy.
It is important that a multidisciplinary triple assessment is carried out on all patients presenting with a breast lump. This will enable the diagnosis of breast cancer in 99% of suspected cases. However, the absolute sensitivity of 100% will never be achieved and this means that there will always be a few false negatives from a triple assessment; this is usually in younger patients and may lead to delay in diagnosis and treatment. Therefore, if there is any doubt regarding the triple assessment, an excisional biopsy is required.
Regular multidisciplinary team meetings ( MDM) provide a forum for reviewing results of the triple assessment and the postoperative histology. The MDM will allow all of the members involved in the specialist breast team (breast surgeon, pathologist, radiologist, breast care nurse, medical oncologist, radiation oncologist, and geneticist) to formulate a management plan for the patient.
Mammography is a sensitive method for detection of breast cancer with a sensitivity of 90% and a specificity of 87%. This sensitivity has improved with the use of tomosynthesis. It is usually undertaken to investigate a symptom in women over the age of 35 years.
It is also used for the surveillance of breast cancer and other high-risk patients and it can be used to localise impalpable lesion for fine-needle aspiration, core biopsies, or surgical excision.
Digital mammography is also employed to screen women over the age of 40 for breast cancer. This is through the breast screening program. Women with ‘population ‘/ average risk of breast cancer are recommended to undergo mammographic screening of the breast every two years after the age of 40.
A mammogram is a low dose Xray examination of a womans breast. It diagnoses approximately 1/3rd of all breast cancers in Australia per year( 4500/ 15,000 new cases per year).
Screening mammogram detect cancers at an early stage. Early detection (small cancers) decrease the death rate from breast cancer.( This reduces the rate of dying from breast cancer by one third).
There have been recent developments in mammography with the introduction of mammography using digital breast tomosynthesis.
Digital breast tomosynthesis is a relatively new technology, especially in Australasia, where mammography units with this technology are being installed in the last few years.
The impact on both false positives and false negatives in the general screening setting has been evaluated overseas, but no Australasian data, nor data from high risk populations currently exists.
The imaging is similar to that created by a CTscan, it creates a 3D reconstructed volumetric image of the breast.
In full field digital mammography normal overlapping breast tissue can obscure cancer lesions thereby causing false negative diagnostics (ie- missed breast cancers. Tomosynthesis alleviates this problem.
It is an exciting technology that is emerging as a significant improvement to current standard digital mammography. It is however associated with a minimal increase in radiation dose.
Ultrasound is less sensitive than mammography but more useful in ladies that have extremely dense breasts, particularly young women. It is unsuitable as a screening tool but its use is well-established during the triple assessment of breast lump.
Fewer unnecessary benign biopsies are now being carried out due to the use of ultrasound. Ultrasound may be the only modality that indicates malignancy in about 3% of patients with palpable lumps, in particular when mammography and biopsy are normal.
It has a diagnostic role in the assessment of palpable breast lumps, and in diagnosing malignancy is approximately 75% sensitive and 97% specific. It is helpful particularly in differentiating solid from cystic lesions and in assessing dominant nodules in areas of nodularity.
It is useful in localisation of impalpable lesions that will be subjected to fine-needle aspiration, core biopsy, or surgical excision. It can be used to accurately measure breast cancers to help in selecting the most appropriate surgical procedure and in monitoring response of systemic therapy such as neoadjuvant chemotherapy or endocrine treatment. In lactation mastitis and breast abscesses, ultrasound can confirm collections of pus and assist guidance of aspiration of multiloculated and deep seated abscess.
MRI or magnetic resonance imaging is now widely available; however, magnetic resonance mammography (MRM) of the breasts requires dedicated breast coils and not all MRI centres will have a dedicated breast MRI.
It is important than an MRI is performed at a specialist breast MRI centre. In order to adequately image the breast, the patient is placed in a prone position (lying on their abdomen) and an injection of IV gadolinium contrast is required.
MRM is the most sensitive test for the detection of breast cancer; it is approaching 100% for invasive cancer and 80% for ductal carcinoma in situ. It does, however, have a high false-positive rate.
Rapid acquisition of images facilitates assessment of the breast tissue and it is helpful in distinguishing between benign and malignant disease. However, there can be significant overlap in enhancement patterns particularly at different stages during a female’s menstrual cycle and therefore this may cause false-positive results. It is a useful tool often employed in women that have extremely dense breasts or in women where the breast cancer has not been well-seen on mammogram.
It is also the best imaging technique for women with breast implants and it is useful for screening patients at high risk of breast cancer, in particular BRCA carriers. It is also better at identifying recurrent disease when conventional imaging and biopsies have failed to exclude recurrence. It can adequately distinguish between scarring, fat necrosis, and tumour recurrence.
It is increasingly being used in the assessment of women who have multifocal/multi centric disease prior to them undergoing conventional breast conserving surgery.
The sensitivity for demonstrating axillary disease is low and therefore it does not replace surgical staging of the axilla. It may be useful when there is a clinical question, particularly ongoing breast pain or in patients who are taking HRT where there is increased breast density and this reduces the sensitivity of mammography. The use of HRT has been shown to reduce the sensitivity and specificity of mammographic screening and therefore, MRI may be helpful in this subgroup.
