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81 Cards in this Set
- Front
- Back
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Congenital anomalies of the breast
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athelia vs. polythelia: nipples
amastia vs. polymastia: breast tissue and nipple (and pec) amazia: breast tissue only |
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Estrogen and progesterone effects on TDLU
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Estrogen promotes ductal growth
Progesterone promotes lobular growth AND secretion |
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Three fibroepithelial lesions (stroma + epithelium)
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Fibroadenoma: benign stroma and epithelium
Phyllodes: hyperplastic or sarcomatous stroma, benign epithelium Carcinosarcoma: both are malignant |
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Fibroadenoma
Location? Cause? Appearance? Importance? Management? |
Begins in TDLU, peripheral
Estrogen influence in young women Popcorn calcs, oval nodule, no invasion Nodules coalesce to form fibroadenoma Follow for 2 years of stability when over 2.5 cm Can have phyllodes or sarcomatous features - rare |
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Phyllodes
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• Benign epithelial elements and cellular spindle cell stroma
• Can act malignant Local recurrence Distant blood-borne metastases Lymph node enlargement reactive usually • Well-circumscribed lobulated mass • Similar appearance on sonography to fibroadenoma, but may have cystic spaces • Treatment Wide local excision • You get 2 tries to get it right Each recurrence may show grade deterioration |
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Invasive Ductal is usually NOS (50%-75%), what are some other types?
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• Medullary
• Papillary • Colloid (mucinous) • Tubular • Metaplastic • Cribriform • Adenoid cystic • Paget disease • Inflammatory |
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What You Need to Remember
• The mass edge represents the aggressiveness of the underlying abnormality • The shape of the calcification |
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Most common benign breast disease for males
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lipoma
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Causes of Gynecomastia
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Increased estrogen: tumors, testicular failure, puberty, Klinefelters, testicular feminization, exogenous estrogen, cirrhosis
Hyperparathyroidism Drugs Starvation |
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Most common appearance of gynecomastia
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Nodular glandular (represents acute/florid phase): Most common, microlobulated pattern, enhances
Dendritic (chronic) Diffuse glandular (very high estrogen levels) |
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What is myofibroblastoma?
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• Solitary palpable firm mass, looks like fibroadenoma
Rarely bilateral No calcifications • Freely moveable • More common in men than women • Mean age late 50 • Circumscribed lobulated mass without calcification • Treated with local excision |
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List three common benign lesions of the breast
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• Fibroadenoma
Juvenile Giant • Phyllodes benign • Granular cell tumor • Lactating adenoma • Hamartoma • Normal breast • Fibrocystic change • Intraductal papilloma • Juvenile papillomatosis • Mastitis • Juvenile hypertrophy • Diabetic mastopathy |
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What is PASH?
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Pseudoangiomatous stromal hyperplasia
Benign lesion of the breast Benign myofibroblastic hyperplastic process i.e. stromal hyperplasia to hormones Contains extensive anastomosing slit-like spaces lined by fibroblasts, mimicking vascular channels Imaging Findings: Best diagnostic clue: Large solid oval mass with well-defined borders, internal heterogeneous echoes Range 1-10 cm, mean 4-6 cm Core biopsy usually diagnostic Best imaging tool: Ultrasound; hypoechoic with internal echoes, nonvascular (pseudoangiomatous) |
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Superficial thrombophlebitis of the breast is called...
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Mondor disease
Superficial thrombophlebitis, Mondor phlebitis Imaging Findings Superficial tubular or beaded structure; may be negative Vessel may undergo calcification in chronic stage Hypo- or anechoic superficial tubular structure Internal echoes ₌ thrombus |
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What is Rosai-Dorfman disease
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Sinus histiocytosis with lymphadenopathy
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What is the significance of juvenile papillomatosis?
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• Firm discrete mass
Localized cystically dilated ducts with intraductal proliferation • 2/3 less than 20 years old • Association with family history of breast carcinoma 10% develop carcinoma within 10 years • Treat with excisional biopsy |
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What does diabetic mastopathy look like on mammography?
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Nonspecific mass or asymmetry
• Focal fibrosis in the breast • Diabetes mellitus type 1 since childhood Poorly controlled Complications from vasculitis elsewhere • Occurs in young to middle age |
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Name for "juvenile carcinoma"
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Secretory carcinoma; good prognosis
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Conclusions for Young Women:
• Ultrasound is the primary modality in this age group • Mammography is reserved for screening, likely malignant lesions and the older patients in this group • MR indications are the same as for adults • Cysts are rare, especially in the younger age groups • Most solid lesions are benign Fibroadenoma most common • Juvenile hypertrophy and juvenile papillomatosis are unique to this age group and have specific appearances on imaging • Malignant lesions occur and look like malignant lesions in older women Invasive ductal carcinoma most common |
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List three indications for Breast MRI when problem solving (i.e. not when evaluating implants or as screening)
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• Metastatic disease with unknown primary
Usually for enlarged axillary or supraclavicular nodes MRI positive in 50% • Pretreatment staging • Residual disease • Recurrence after breast conservation • Response to chemotherapy |
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Reasons to perform pretreatment MRI...
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• MRI changes treatment in 15%–30%
Multifocal/multicentric disease 20% of additional foci are benign Lumpectomy to mastectomy in 15% Larger area for lumpectomy than indicated by mammography or sonography Chest wall involvement 2%–3% have cancer in the opposite breast |
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Who gets screening breast MRI?
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According to ACS:
MRI and annual mammograms beginning at age 30 20% or more lifetime risk (double the general risk) BRCA 1 or 2 Parent, sibling, or child with BRCA 1 or 2 Radiation treatment to chest between ages 10 and 30 −− Begin 10 years after treatment Significant positive family history High risk syndromes • Li-Fraumeni cancer syndrome Multiple cancers • Cowden (multiple hamartoma syndrome) Multiple cancers (breast and thyroid) • Bannayan-Riley-Ruvalcaba Similar to Cowden syndrome |
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List three fat containing lesions in the breast...
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Lipoma
Lymph node Hamartoma Fat necrosis Galactocele |
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List three T2 fluid bright lesions in the breast...
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Cysts
Colloid carcinoma Myxoid fibroadenoma Lymph node Fat necrosis: Fresh and chronic Fibroadenoma Colloid carcinoma |
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List an example of a moderate and low T2 lesion in the breast...
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• Moderate signal
Invasive lobular carcinoma Ductal carcinoma in situ Fibrocystic change • Low signal Invasive ductal carcinoma Sclerotic fibroadenoma Scar |
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What is the sensitivity and specificity of breast MRI for invasive disease?
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Sensitivity and Specificity
• Sensitivity 83%–100% for invasive disease • Specificity 29%–100% for invasive disease |
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What are the false negatives for breast MRI?
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• Poor enhancement pattern
16% DCIS and 3% invasive carcinoma • Invasive lobular carcinoma • Metastatic breast carcinoma • Well-differentiated invasive breast cancer Colloid carcinoma • MRI dense breast High background enhancement |
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During what days of the menstrual cycle should breast MRI be obtained?
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Day 5 to 12; least amount of background enhancement
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Fibroadenoma on MRI
T2? Enhancement? Septations? |
High T2; type I enhancement (slow rise, delayed enhancement); NO enhancement of septations
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Invasive cancer characteristics on MRI
Distribution of enhancement? Septations? Margins? |
Rim enhancement (most commonly); septations enhance; spiculated margins
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Conclusion - Breast MRI
• MRI is a powerful tool in cancer diagnosis • Can find cancer not seen on other imaging Problem solving High risk screening • Can monitor chemotherapy better than other imaging • Changes treatment plan in 15%–30% of cases Larger lumpectomy or prelumpectomy chemotherapy Mastectomy But rate of change to mastectomy is greater than recurrence rate if MRI is not done |
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Morphology of suspicious breast calcifications?
Distribution associated with highest risk of breast CA? |
Fine linear branching; Fine pleomorphic
Segmental |
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Why do fibroadenomas calcify?
What is there calcification pattern, early vs. late? What is there calcification distribution? |
Degeneration
Heterogeneous, then popcorn like Peripheral, then coalescent |
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Radial scars are associated with what three lesions?
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10%–30% associated with atypical ductal hyperplaisa (ADH), ductal carcinoma in situ (DCIS), tubular carcinoma (CA)
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What is a dark star?
What three lesions can have dark stars? |
Archectural distoration without central mass
• Invasive lobular carcinoma • Radial sclerosing lesion • Surgical scar |
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Tubular Carcinoma
High vs. Low grade? Most prominent feature on mammo? Uni or multifocal? Good vs. Bad prognosis? |
• 1% of breast cancers
• Very low grade • Usually present as small spiculated masses; spicules often longer than the central mass • Often multifocal • Excellent prognosis 97% cause specific (survival at 10 years) |
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What age group is affected by Medullary carcinoma?
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Young women
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Papillary Carcinoma
How do they present commonly? Where are they located? |
Nipple discharge
Subareolar mass |
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Fibroadenoma vs. Phyllodes
Age range? young vs. old Size? small vs. large Growth? min. vs. rapid Margins? US characteristics? |
Fibroadenoma: young patients; small size 1-3cm; minimal or no growth; circumscribed margins; internal septations, hypoechoic (dark septations on MR)
Phyllodes: middle to older age patients; very large; very rapid growth; ill-defined margins; cleft spaces |
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In what setting is angiosarcoma of the breast seen?
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Post radiation therapy, typically 5 years, not at lumpectomy bed
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What percentage of Paget disease of the breast is associated with cancer? What type?
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95%; high grade DCIS
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Macrolobulated margins, think...
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Fibroadenoma and benign
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Microlobulated margins...benign or malignant?
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Malignant 25%, higher for U/S
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Name two benign entities that can have spiculated margins
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Radial scar
Fat necrosis |
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Echogenic halo is seen with benign or malignant disease?
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Both: abscesses, invasive ductal CA
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How common is the sternalis muscle?
Is it unilateral or bilateral? More often seen on CC or MLO and why? What additional view would you get to confirm? |
8% of population
typically unilateral seen on CC, when muscle is relaxed cleavage view |
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Most common place for polymastia?
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Axilla
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What are two fat containing lesions that can be malignant?
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Hamartoma in very rare cases
Phyllodes with liposarcomatous transformation |
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Risk factors for Mondor disease...
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surgery
biopsy Inflammatory process breast cancer trauma |
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What is Steatocytoma Multiplex?
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-Bilateral well-circumscribed, round, fat-density nodule on mammography
-Intradermal hypoechoic nodule on sonography -Combined with a family history of steatocystoma multiplex (40%) • Nodules have internal radiolucency and peripheral continuous rim • Sonogram shows well-circumscribed homogeneous hypoechoic cyst with posterior enhancement -Cyst is located in dermis and expands to subcutaneous fat layer of left axilla, mimicking subcutaneous lesion |
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What is incidence screening?
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Incidence screening is the repeated attendance to screening programs. The cancer detection rate is lower, approximately 2~ per 1000
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Breast cancer reduction with routine screening...
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20--40% reduction with routine screening.
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Significance of the Nipple to Pectoralis line for the CC view?
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The distance on the CC view from nipple back to the film edge (or the depth of breast tissue imaged on the CC view) should be no less than 1 cm of the NPL measured on the MLO view.
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How often are the film cassettes to be cleaned? What artifact can result if not?
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Weekly; film screen contact artifact
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What did DMIST conclude about Digital Mammography vs. Film Screen Mammography?
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DMIST data: an improvement in cancer detection was seen in three subgroups: women younger than age 50 years, women with heterogeneously dense or denser breasts, and pre-or perimenopausal women
No increased cancer detection for the GENERAL POPULATION |
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What is the DDx of unilateral breast enlargement?
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Infectious mastitis, inflammatory breast CA, diffuse invasive lobular CA, lymphomatous involvement
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What is the negative predictive value of ultrasound and mammogram?
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Nearly 100%
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What is the DDx for palpable breast mass in pregnancy or lactating female?
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Fibroadenoma
Lactational adenoma Tubular adenoma Focal mastitis Galactocele Normal breast tissue with lactational changes (lobular hyperplasia) Cancer |
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When a mass moves up from MLO to ML views, is it medial or lateral?
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Medial; medial lesions move up
Lateral lesions move lower (Lateral, Lower) |
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What is a complex fibroadenoma?
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complex fibroadenoma describes a fibroadenoma that contains proliferative changes, such as sclerosing adenosis, ductal hyperplasia, or papillary apocrine metaplasia (cyst formation)
these findings represent diffuse proliferative changes that increase the risk for cancer in both breasts |
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Most common mets to the breast?
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Lymphomas and leukemias are the most common metastases to involve the breast, followed by metastases from melanoma, lung, prostate, ovary, gastrointestinal malignancies, and cervical cancers
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DDx of subtle architectural distortion...
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invasive ductal carcinoma not otherwise specified, tubular carcinoma, and a radial sclerosing lesion
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The risk of developing metachronous breast cancers in the contralateral breast is...
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1% per year
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What type of cancer is most commonly bilateral?
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Invasive lobular; 30% of the time
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What are the risk factors for recurrence after conservation breast therapy?
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Young age (<35 yo at presentation)
Extensive intraductal component of IDC, DCIS of more than 2.5cm (microscopic skip lesions towards nipple) Close or positive margins Inadequate tx |
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What size needle do we use for wire locs?
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20 or 21 Gauge
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Contraindications to galactography...
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Mastitis and iodine allergy
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DDx of secretory calcs?
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Plasma cell mastitis
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How common are circumscribed breast cancers?
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less than 10% of the time
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What is the most commonly circumscribed cancer?
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IDC, NOS - as you would expect, but think Medullary carcinoma as well
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LCIS...
Imaging findings? Risk of adjacent cancer? Risk of contralateral cancer? What type? Management? |
No known imaging findings, usually found incidentally
10-20% chance of adj. DCIS or IDC 30% increased risk of IDC or ILC in either breast Rec. Excisional Bx similar to ADH and ALH due to adj. CA risk. |
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What are non-comedo forms of DCIS?
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Micropapillary and Cribiform; slower growth rate compared to comedo forms
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What is the prognosis of Granular Cell Tumor?
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Most are benign, but they should be excised.
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Percentage of synchronous cancer detection in contralateral breast on MRI?
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There is an approximately 4% - 10% synchronous cancer detection rate in the contralateral breast with MRI screening
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Define Multifocal and Multicentric...
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Multifocal - multiple tumors arising or same tumor origininating in one quadrant
Multicentric - multiple tumors arising independently in more than one quadrant |
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By convention how long do we wait post lumpectomy to perform MR to minimize granulation enhancement?
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4 weeks
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How often are screens cleaned?
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Weekly
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If there is a suspected artifact, what Birads is necessary?
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Birads 0: repeat images needed
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What component of deodorant simulates calcs?
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Aluminum
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ACR phantom is tested how often?
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Weekly for testing system resolution
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What does breast tomo improve?
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Conspicuity
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