The second goal of this book is to emphasize the multidisciplinary nature of breast imaging. This multidisciplinary approach is emphasized by the secondary table of contents (Pattern Approach to Breast Sonography) that organizes the individual cases into sonographic patterns. Furthermore, the cases in this book include other imaging modalities such as magnetic resonance and various nuclear medicine techniques. The utility of these modalities is discussed in the context of common clinical problems that are illustrated in the individual imaging cases.
Sonographic examination of the breast has become more important in breast imaging. As equipment improves, imagers are able to see lesions that previously were not visible sonographically. This improved detection not only enhances one's confidence in finding malignancies earlier, but also in identifying benign lesions. However, the potentially important contribution of sonography is greatly hindered by inadequate equipment, suboptimal imaging technique, and inconsistent operator training. The third purpose of this book is to demonstrate the importance of high-resolution sonography in breast imaging. Several cases show images of the same lesion with both with highand low-resolution equipment. These cases also demonstrate the importance of utilizing high contrast, post-processing techniques in the detection of benign and malignant entities. Hopefully, this book will enhance the sonographic skills of breast imagers by encouraging the use of high quality, high-resolution equipment and optimal technique. Furthermore, by reviewing the sonographic appearance of the numerous breast abnormalities presented in this book, one can broaden one's visual sonographic experience.
The final objective of this book is to provide an atlas of a wide variety of pathologic entities within the breast. This book includes both unusual mammographic and sonographic appearances of common pathologies as well as examples of rare breast abnormalities. By grouping the pathologies within mammographic imaging patterns, one can use this book as a base for developing differential diagnoses.
In summary, I hope this book is used both as a quick reference guide to review the schematic work-up of a particular mammographic finding as well as a more detailed reference to study methods to optimize sonographic technique and integrate alternative imaging modalities.
Beverly E. Hashimoto
Acknowledgments
I could not have completed this book without the help of Jennifer Sonntag. Her enthusiastic effort allowed me to keep on schedule and her creative ideas solved many unanticipated logistical problems. I am also indebted to Lynn Wiitala who supported me at the beginning of this project and helped organize the patient data and imaging. Dr. Donald Bauermeister contributed pathology expertise for this project. Our conversations cross correlating specific cases have greatly improved my ability to understand the imaging appearance of benign and malignant lesions. The contributors, Drs. Kramer, Lee, and Morgan, have not only written part of the material in this book, but also have helped choose images and edit text. I am also grateful for the radiologists at Virginia Mason Medical Center. They have unselfishly shared their clinical and technical expertise. I especially appreciate the magnetic resonance imaging advice from Dr. Larry Holder and the administrative support from my department chiefs during this project: Drs. Michael Morishima and Lucy Glenn.
My sanity was saved by Morris Ferensen from Virginia Mason Medical Photography who answered all my imaging questions and processed the sonographic images. Nancy Honssinger created all the schematic diagrams.
A special acknowledgment goes to the technical and support personnel of the John H. Walker Center for Diagnostic Imaging at Virginia Mason Medical Center. Although I am indebted to everyone in the film room, I want to express individual thanks to Scott Borman, Michael Whiting, Alice Wirth, Jon Komatsu, Mary Ann Fernandez, Linda O'Connell, and Melissa Park. I am also lucky to be associated with wonderful imaging technologists including sonographers Shannon Boswell, Karen Adler, Irina Askerova, Becky Brickson, Stacy Buck, Shelly Carlisle, Chris Chapman, Danielle Ashour, Nancy Honssinger, Lisa Levan, Lori Lewis, Suzy Murray Dirks, Lynette Passey, Gisele Sodell, Jeff Thiel, Terri Jarvi, Jane Nova, Selwyn Pacleb; mammography technologists Mary Anne Madsen, Diana Pearsail, Darlene Fanus, Lori Carrier, Kay Molenaar, Barbara Zaragoza; general radiology technologist Heather Lyon; radiology administrative director John Eusek; and manager Vicki Wiitala.
Medical librarians Ann Robertson and Jan Gallagher kept me up-to-date on the literature and found difficult foreign or old references. Maggie Womack was vital in obtaining pathology material for all the patients in the book.
At Thieme Publishers, Jane Pennington initially provided guidance in the development of this project and is responsible for getting this project started. Diane Sardini, Felicity Edge, and Becky Dille have patiently provided support and advice in the completion of the project.
I also want to thank Drs. Roy Filly and Peter Callen. You have taught me the importance of approaching clinical questions in a creative yet systematic manner.
Finally, I am particularly grateful for the constant emotional support from my family: parents Doris and Ben, sister Claire, husband Vincent, and children Ben, Dean and Elissa. Without your cheerleading, I could never have attempted this project.
To Doris and Claire Hashimoto for your positive spirit
and courage in facing breast cancer.
List of Contributors
Donald Bauermeister, M.D.
Department of Pathology
Virginia Mason Medical Center
Seattle, Washington
Beverly E. Hashimoto, M.D., F.A.C.R.
Section Head, Ultrasound
Virginia Mason Medical Center
Seattle, Washington
Dawna J. Kramer, M.D.
Deputy Chief, Radiology
Virginia Mason Medical Center
Seattle, Washington
Marie E. Lee, M.D., F.A. C.R.
Section Head, Nuclear Medicine
Virginia Mason Medical Center
Seattle, Washington
Gail N. Morgan, M.D.
Section Head, Eastside Satellite Radiology Clinics
Virginia Mason Medical Center
Seattle, Washington
Section I
Approach to Mammographic Analysis
Chapter 1
General Overview
There are three critical factors that lead to identifying mammographic abnormalities: production of high-quality images, perception of a lesion, and characterization of the finding. A team of people is needed to produce high-quality mammograms. The radiologist and the technologist should constantly be evaluating images for film contrast, exposure parameters, patient position, and image processing. Furthermore, a radiation physicist should work with the technologists to monitor equipment performance.
Perception of mammographic abnormality is the first step in identifying a breast malignancy. Perception is aided by a systematic review of the mammographic examination. Consistent systematic review of the mammogram is critical in avoiding perceptual errors. Tabar and Dean's Teaching Atlas of Mammography has an