Breast Imaging in Pregnant and Lactating Patients

BIV • Sep 20, 2015

The presentation of a pregnant or lactating woman with a palpable breast mass is a common and important scenario encountered in a breast imaging practice.

The physiological changes secondary to hormonal changes result in increased breast volume and firmness, associated with nodules and increased parenchymal density. All these changes make radiological assessment of the breasts difficult.

The aim of imaging in this setting is to exclude a pregnancy-associated breast cancer, which is defined as a breast cancer occurring during pregnancy or within 1 year of delivery.

Ultrasound

Ultrasound is the first procedure in the workup of a palpable breast mass in pregnancy or lactation with some studies reporting a sensitivity and negative predictive value of 100% in detecting malignant lesions in this patient group.

Ultrasound-guided core biopsy can be easily performed in this group for a suspicious lesion.

Subsequent bilateral breast ultrasound and axillary assessment can then be performed for confirmed malignancy.

MRI

Contrast enhanced MRI is not recommended in pregnancy, as no studies have been performed on possible teratogenic risks from Gadolinium based contrast. MRI is safe in the lactating woman, who may wish to discard milk for 12-24 hours after the examination, although the excretion into breast milk is minimal.

Mammography

Mammography is safe in pregnancy and lactation, with the radiation dose from bilateral two view digital mammography being less than 7 mGy, with an estimated dose to the uterus of 0.03 micro Gy, which is significantly less than the 50mGy threshold below which no teratogenic effects have been reported.

In spite of these facts, mammography is generally not performed as a first line tool in this patient group, as the increased breast density reduces the efficacy of diagnosis. Once a malignancy has been diagnosed however, bilateral mammography is performed in order to exclude suspicious microcalcifications not seen on ultrasound, and to determine the extent of possible multifocal, multicentric or contralateral disease.

Lactating patients are asked to breast feed or express immediately prior to undergoing mammography to decrease parenchymal density related to residual milk products.

Digital Tomosynthesis

Digital Tomosynthesis creates a three dimensional picture of the breast using Xrays.

Digital tomosynthesis is approved by the U.S. Food and Drug Administration, but is not yet considered the standard of care for breast cancer screening and is not available through Breastscreen. Because it is relatively new and advanced technology, it is only available at a limited number of hospitals in Melbourne, one of them being Breast Imaging Victoria.

It takes multiple x-ray pictures of each breast from many angles. The breast is positioned the same way it is in a conventional mammogram, but only a little pressure is applied — just enough to keep the breast in a stable position during the procedure. The x-ray tube moves in an arc around the breast while 11 images are taken during a 7-second examination. Then the information is sent to a computer, where it is assembled to produce clear, highly focused 3-dimensional images throughout the breast.*

*Reference: Breast Imaging in the Pregnant and Lactating State. Imaging Modulates and Pregnancy Associated Breast Cancer. AJR February 2013 Volume 200. No2.321-3228

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