Diagnosis of breast diseases integrating the findings of clinical presentation, mammography, and ultrasound PDF
Preview Diagnosis of breast diseases integrating the findings of clinical presentation, mammography, and ultrasound
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 Coverdesign:ThiemePublishingGroup copyright. Any use,exploitation, or commercialization outside the TypesettingbyZiegler+Müller,Kirchentellinsfurt,Germany narrow limits set bycopyright legislation, without the publisher’s PrintedinChinabyEverbestPrintingCoLtd,HongKong consent,isillegalandliabletoprosecution.Thisappliesinparticular tophotostatreproduction,copying,mimeographing,preparationof 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.
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