Breast Radiology

Front 1

T/F: Gynaecomastica is the most significant risk factor for male breast cancer?

Back 1

False

Front 2

Most common site of breast metastases?

Back 2

Bone (60%)

Lungs/pleura (25%)

Lymph nodes besides ipsilateral axillary nodes (15%)

Front 3

How small are microcalcifications?

Back 3

< 0.5 mm

Front 4

What tumours metastasise to the breast?

Back 4

Lymphoma (most common)

Melanoma

Ovarian carcinoma

Lung carcinoma (least common)

Also, sarcoma

Front 5

Causes of large (>5 cm) breast opacities on mammography?

Back 5

Phyllodes

Giant cyst

Giant fibroadenoma

Lipoma

Sebaceous cyst

Cystosarcoma phyllodes

Front 6

In which syndrome is there increased risk of breast cancer?

Back 6

Klinefelter's syndrome - 47XXY

Front 7

Drug causes of gynaecomastica

Back 7

• digoxin
• thiazide diuretics
• spironolactone diuretics

Front 8

What is Mondor disease?

Back 8

Thrombophlebitis of the superficial veins of the breast and anterior chest wall (cause unknown). Associated with carcinoma (12%) and DVT.

Front 9

Most common side of ovarian vein thrombosis?

Back 9

• right: 80%
  
• bilateral: 14%
• left: 6%

Front 10

Breast lesions: high T1 C- signal

Back 10

• intramammary lymph nodes
• fat necrosis
• hamaratomas

Breast lesions with high T1C- signal are considered benign unless rapidly growing.

Front 11

Breast lesions: high T2FS signal

Back 11

• cysts
• lymph nodes
• fat necrosis
• colloid carcinoma (rare)

Front 12

Breast MRI: Kinetic analysis (curves) / temporal resolution

Back 12

Divide into two phases:

• initial 1-2 min: slow, medium, rapid
• delayed (2+ min): increased, plateau or washout

Front 13

Breast MRI: types of kinetic curves

Back 13

• type 1: continuous increase - 83% benign; 9% malignant
• type 2: plateau pattern (initial increase) - suggestive of malignancy
• type 3: washout pattern (initial increase) - suggestive of malignancy

Front 14

What is the evidence for breast cancer screening?

Back 14

1. Health Insurance Plan (HIP) study in New York ran in the 1960s and demonstrated 25% decrease in breast cancer mortality in screened (study) vs. non-screened (control) group.

2. Swedish Two-County Trial: 30% reduction in mortality in age group 40-74 years in women invited to screening. One shot. 7 year follow-up.

Front 15

Indications for breast MRI screening?

Back 15

<50 years; asymptomatic and is high risk due to strong family history (≥2-3 relatives with breast/ovarian cancer) especially if young age, bilateral, male, Ashkenazi Jewish ancestry OR genetic testing presence of high risk breast cancer mutation.

Front 16

Indications for breast ultrasound screening?

Back 16

Used as an adjunct to mammography; not stand alone. May be useful in addition to mammography in women with dense breasts.

Front 17

Definition of microinvasive breast cancer?

Back 17

Classification of breast ca by depth of invasion:

• in situ: not beyond the basement membrane
• minimally invasive: <1 mm beyond the basement membrane
• invasive: >1 mm beyond the basement membrane

Front 18

What is sclerosing adenosis?

Back 18

Sclerosing adenosis is a benign (non-cancerous) proliferative condition of the terminal duct lobular units characterized by an increased number of the acini and their glands.

Front 19

Fibrocystic disease of the breast

Back 19

1. Cysts: dilated/unfolded lobules
2. Fibrosis: cyst rupture = chronic inflammation and stromal fibrosis
3. Adenosis = glandular proliferation: increased size/number of acini and adenosis

Ca2+ is a common feature.

Front 20

Sclerosing adenosis

Back 20

• Increased number of acini per terminal duct lobar unit
  
• acini compressed and distorted by stromal fibrosis (sclerosis)
• Ca2+ common

Front 21

Non-proliferative breast disease

Back 21

No increased risk of breast cancer:

• fibrocystic change
• lactational adenoma

Front 22

Proliferative breast disease without atypia

Back 22

Slightly increased risk of breast ca (1.5-2x)

• epithelial hyerplasia
• sclerosing adenosis
• papilloma
• juvenile papillomatosis
• radial scar

Front 23

Proliferative breast disease with atypia

Back 23

Moderate increased risk breast ca (4-5x)

• atypical ductal hyperplasia
• atypical lobular hyperplasia

Front 24

Atypical ductal hyerplasia

Back 24

A lesion which is qualitatively similar to DCIS yet quantitatively is inadequate (< 2 ducts involved) is termed as atypical ductal hyperplasia.

Front 25

Atypical lobular hyperplasia

Back 25

ALH represents a proliferation of monomorphic cells which are morphologically identical to lobular carcinoma in situ (LCIS). The distinction is that ALH occurs in a non-distended lobule or small lobular duct, whereas LCIS is characterised by distention.

Front 26

Paget disease of the breast

Back 26

Malignant cells (Paget cells) extend from DCIS within the ductal system into niiple skin without crossing basement membrane.

Front 27

What is the risk of progression of in situ to invasive carcinoma?

Back 27

1% per year for low-grade DCIS

1% per year for LCIS

Front 28

DCIS: types

Back 28

Comedo carcinoma: high-grade malignant cells with central necrosis

Non-comedo carcinoma: varying nuclear grades including low-grade. Subtypes:

• cribiform
• papillary
• micropappillary
• solid

Paget disease of the nipple/breast

Front 29

Invasive breast cancer: histological subtypes

Back 29

• adenocarcinoma NOS (80%)
• lobular (10%)
• tubular (5%)*
• mucinous (colloid) (2%)*
• medullary (2%)*
• papillary (1%)*
• metaplastic (<1%)

* = adenocarcinoma subtypes

Front 30

What percentage of women with Paget disease have underlying invasive carcinoma?

Back 30

50-60%

Front 31

What percentage of in situ carcinoma is bilateral

Back 31

DCIS: 10-20%

LCIS: 20-40%

Front 32

Breast cancer: staging

Back 32

TNM

• T: <2 cm (T1); 2-5 cm (T2); >5 cm (T3); chest/skin/inflammatory (T4)
• N: mobile ipsi axillary 1-2 LN (N1); fixed ipsi axillary 1-2 +/- internal thoracic LN (N2); ipsi axillary 3 LN or supraclavicular LN (N3)
• M: clinical/radiological mets absent (M0) or present (M1) [n.b. microscopic deposits <0.2 mm are allowed in M0]

Front 33

What is triple negative breast cancer?

Back 33

Combination of:

• oestrogen receptor negative
• progesterone receptor negative
• human epidermal growth factor receptor 2 (HER2) negative
  

Triple negative breast cancer tends to be more aggressive and difficult to treat with a higher propensity to metastasis and recurrence.

Front 34

PASH

Back 34

Pseudoangiomatous stromal hyperplasia

• mimics FA as well-defined mass on mammo
• benign stromal proliferations of interlobular fibroblasts and myofibroblasts

Front 35

BI-RADS: grades

Back 35

• BI-RADS 0 = incomplete work-up
• BI-RADS 1 = negative (i.e. normal)
• BI-RADS 2 = benign findings
• BI-RADS 3 = probably benign
• BI-RADS 4 = suspicious for malignancy
• BI-RADS 5 = highly suggestive of malignancy
• BI-RADS 6 = known malignancy