The most important adjunct to mammography is the ultrasound evaluation of the breast. This is a painless procedure that uses sound waves to visualize structures within the breast. One of the key advantages of the ultrasound is to differentiate between cystic and solid lesions. Cystic lesions are typically benign and can be easily treated whereas solid lesions have an increased risk for breast cancer. The ultrasound is of particular value in evaluating women 30 years of age and younger. These patients have very dense breasts and often are difficult to evaluate on a mammogram. Thus, in a symptomatic younger patient, we start with an ultrasound and reserve the mammogram for special indications.
Ductography (for nipple discharge)
Patients with spontaneous drainage, particularly of clear or bloody material, from one duct of one breast, are at increased risk for breast cancer. We are most concerned for those patients who note a spontaneous occurrence of clear or bloody fluid. These patients require further workup. If on examination there are no specific masses and the mammogram does not reveal a specific cause for the discharge, the next step is a ductogram. In this procedure a small tube is gently placed into the draining duct and an x-ray of the duct system is obtained. In cases where an abnormality can be identified, a biopsy is performed. At the Breast Care Center we do the surgical procedure on the same day as the ductogram. In our experience, approximately 10% of patients with spontaneous nipple discharge will harbor a small cancer and most of these cancers have proved to be highly curable. Approximately 90% of our patients have benign changes, most commonly called a small papilloma. These patients have had excellent results with removal of the duct.
Magnetic resonance imaging (MRI)
The MRI procedure produces images based on how the water content of cells responds to high frequency radio waves. Currently, the MRI is not used for screening. At our Center, it is used on selected patients with known breast cancer to evaluate the extent of the lesion to determine if a cancer patient is a candidate for breast-conserving surgery (see Treatment Procedures). The MRI is also commonly used at our Center to evaluate patients with breast implants, and is approximately 95% accurate in determining the presence of ruptured silicone implants. Newer technical breakthroughs in MRI research suggest that future machines will become even more valuable in the early detection of breast cancer, differentiating between suspected benign and malignant lesions.
Although standard mammography is an extremely valuable tool, it has its limitations. Approximately 15% of all breast cancers are not detected by screening mammography. One of the most exciting new techniques is digital mammography in which an x-ray image is transferred to a digital computer display. This allows the image to be manipulated for brightness, contrast, and size and allows areas of concern to be evaluated in greater detail without bringing the patient back for additional views. Current studies suggest that the digital mammogram is starting to approach the degree of resolution of the standard mammogram. We expect that in the very near future the digital mammogram will surpass the standard mammogram in terms of ability to detect very subtle changes. At this moment digital mammogram has great theoretical advantages in terms of eliminating the mammographic film, improving the ability to transfer data, and adding to the convenience of the patient.
PET/CT can reassure previously treated women they are breast cancer free, and can better predict if their disease is likely to recur than other types of diagnostic imaging according top researchers. The area generating most enthusiasm for PET imaging in breast cancer relates to monitoring therapy. Researchers and clinicians uniformly express optimism about the imaging modality’s potential role in therapeutic decision-making. There are no optimal noninvasive alternatives to PET for detecting recurrent breast cancer in the chest wall, for early treatment monitoring of either neoadjuvant chemotherapy, or for monitoring treatment of distant metastases. PET also has been demonstrated consistently to be more accurate than alternative imaging tests for staging distant disease in breast cancer. Other radiologic studies, such as mammography, sonography, CT, and MRI, provide detailed anatomic information about the size and location of masses, but not the unique metabolic information available with PET. This metabolic information generally affords PET several advantages over the anatomic modalities, including: earlier detection of malignancy; differentiation of scar or benign lesion from active malignancy; detection of metastatic disease in normal-size lymph nodes; and assessment of early tumor treatment response.