Breast Ultrasound

Front 1

skin

Back 1

-composed of epidermis and dermis layers
-thickness (.5-2 mm)
-slightly thicker in young females and thins with age

Front 2

nipple

Back 2

-consists of dense connective tissue and erectile muscle
-contains many nerve endings
-15-20 collecting (lactiferous) duct openings may be seen (each of which arise from a breast lobe)

Front 3

areola

Back 3

-circular area of darker pigmentation seen around the nipple
-consists of smooth muscle
-slightly thicker than surrounding skin
-contains montgomery's glands (sebaceous glands seen as small bumps in the areola)

Front 4

subcutaneous (premammary) layer

Back 4

-lies just beneath the skin extending to the mammary layer
-is not seen posterior to the nipple
-consists primarily of fat
-amount of fat increases with age, pregnancy, and obesity
-contains retinacula cutis (small ligaments stretching between the skin and superficial fascia)

Front 5

superficial fascia

Back 5

-breast tissue is completely contained between the layers of the superficial fascia
-divides into the superficial and deep layers
-superficial layer of the superficial fascia is known as the superficial fascia
-contained within the subcutaneous layer anterior to the mammary layer

Front 6

mammary layer

Back 6

-also known as the parenchymal or glandular layer
-portion of glandular tissue extends into the axilla (tail of spence)
-composed of two types of tissue:Epithelium(functional tissue which consists of acini, TDLU's, lobules, lobes and lactiferous ducts) and Stroma (supportive tissue which consists of intralobular fat and connective tissue( cooper's ligaments, loose and dense connective tissue

Front 7

acini

Back 7

-smallest functional unit of the breast
-milk producing glad
-hundreds of acini in each breast -each acini gives rise to a terminal duct

Front 8

TDLU(terminal duct lobular unit)

Back 8

-made up of approx. 30 acini and terminal ducts which form a lobule
-usually measures 2 mm or less
*nearly all breast pathology originates in the TDLU

Front 9

lobe

Back 9

-several lobules make up a breast lobe
-15 to 20 lobes in each breast
-one lactiferous duct emerges from each lobe and travels toward the nipple

Front 10

lactiferous ducts

Back 10

-transport milk from the acini to the nipple
-begin with the terminal duct which arises from the acini

Front 11

mammary layer

Back 11

-intralobular ducts travel between the lobes
-the duct enlarges slightly beneath the areola forming the lactiferous sinus
-collecting duct empties milk from the nipple
-lactiferous ducts are lined with a double layer of epithelial cells
9inner epithelial layer and outer myoepithelial layer)
-epithelial cells area supported by a basement membrane which is the outer portion of the duct

Front 12

cooper's ligaments

Back 12

-part of the stroma and supportive tissue of the mammary layer
-provide the architectual "framework" of the breast
-run between the superficial and deep layers of the superficial fascia

Front 13

deep fascia

Back 13

-the deep layer of the superficial fascia
-located within the retromammary space posterior to the mammary layer
-maintaining integrity of the deep fascia is important in deterring the spread of cancer to the chest wall

Front 14

retromammary space

Back 14

-space between the posterior margin of the mammary layer and the pectoral muscles
-contains a thin layer of fat
-amount of fat increases with age, pregnancy, and obesity
-also contains the deep layer of the superficial fascia
-allows movement of the breast over the chest wall

Front 15

Pectoralis Major

Back 15

-arises from the clavicle and costal cartilage of the sternum attaching to the proximal humerus
-located anterior to the pectoralis minor

Front 16

pectoralis minor

Back 16

arises from the 3rd, 4th, and 5th ribs attaching to the scapula

Front 17

chest wall

Back 17

-ribs are located posterior to the pectoral muscles
--in a small breasted female, it is important not to confuse a rib with an intramammary tumor on a physical or sonographic examination
-intercostal muscles are loccated within the rib spaces
-deep to the chest wall layer is the lung

Front 18

amastia

Back 18

abscence of one or both breasts

Front 19

polymastia

Back 19

accessory breast or more than two breast

Front 20

athelia

Back 20

absence of nipple and areola

Front 21

polythelia

Back 21

acessory nipple
*most common developmental anomaly

Front 22

amazia

Back 22

absence of the breast tissue with the development of the nipple

Front 23

unilateral early ripening

Back 23

assymetrical growth of the breasts

Front 24

what are two other developmental anomalies that may occur with the breast?

Back 24

nipple flattening and nipple inversion

Front 25

name two main arteries that supply blood to the breast.

Back 25

1.lateral thoracic artery
2.internal mammary artery

Front 26

lateral thoracic artery

Back 26

-arises from the axillary artery and courses inferior and lateral along the pectoralis major muscle
-gives rise to small mammary branches to supply the lateral regions of the breast

Front 27

internal mammary artery
(internal thoracic artery)

Back 27

-arises from the subclavian artery and courses lateral to the sternum and inferiorly behind the upper ribs
-small perforating branches supply the medial region of the breast
*often used in coronary artery bypass graft(CABG) procedures

Front 28

What two secondary sources supply blood to the breast tissues?

Back 28

1. thoracoacromial artery-supplying a superior region
2. intercostal artery-supplying the inferior region

Front 29

What are the anatomic layers of the breast from anterior to posterior?

Back 29

1.skin
2.subcutaneous (premammary) layer
3.mammary layer
4.retromammary space
5.muscle layers (pectoralis major and minor)
6.chest wall (ribs and intercostal muscles)

Front 30

What are the two venous systems that drain the breast tissues?

Back 30

1.superficial
2.deep

Front 31

superficial veins

Back 31

-located just deep to the superficial fascia
-allows venous communication to occur between the right and left breasts

Front 32

deep veins

Back 32

-include small branches that drain into the internal mammary vein, axillary vein, subclavian vein, and intercostal veins

Front 33

venous drainage

Back 33

-intercostal veins also communicate with the vertebral veins
-may be a route for bone metastasis from breast cancer
-the superficial and deep venous systems communicate within the breast parenchyma
*breast ca most frequently spreads by hematogenous route
-lymphatic vessels of the breast tissues closely follow the same route as the superficial and deep venous systems

Front 34

lymphatic drainage

Back 34

-lymph flow begins deep within the breast tissues through lymphatic vessels that originate in the stroma and lactiferous ducts (deep system)
-intramammary lymph nodes are seen throughout the breast parenchyma as part of the deep system
-approx. 75% of lymphatic drainage,however, is to the axilla
*axillary lymph node chain becomes extremely important in predicting the spread of breast cancer

Front 35

What are the six groups that make up the axillary lymph node chain?

Back 35

1.EXTERNAL MAMMARY-located along the lateral thoracic vessels
2.SCAPULAR-run with subscapular vessels
3.AXILLARY-run with axillary vessels
4.CENTRAL-run with axillary vessels
5.SUBCLAVICULAR-run with subclavian vessels
6.INTERPECTORAL (ROTTER'S) NODES-found between pectoralis major and minor muscles

Front 36

the remaining 25% of lymphatic drainage include?

Back 36

1.internal mammary lymph nodes-lie along the internal mammary vessels
2.intercostal lymph nodes
3.flow to the opposite breast
4.supraclavicular lymph nodes-within the supraclavicular fossa
5.diaphragmatic lymph nodes-allow drainage to the abdomen

Front 37

list the nerves of the breast

Back 37

1.long thoracic nerve
2.thoraco-dorsal nerve
3.thoracic intercostal nerves
4.3rd and 4th branch of the cervical plexus
5.circumflex nerve
6.subscapular nerves
7.anterior thoracic nerves

Front 38

puberty

Back 38

-breast development occurs due to hormonal stimulation by the ovaries
-mature female breasts are sensitive to the menstrual cycle and responds to changing hormones every month
-early in the PROLIFERATIVE stage of the menstrual cycle, changes in the epithelium occur
-later in the SECRETORY phase the ducts and veins increase in size, the stroma becomes edematous and the epithelium produces secretions
-these changes may account for premenstrual breast discomfort
-at the onset of menses, the breast tissues decrease in size

Front 39

estrogen

Back 39

-stimulates elongation of mammary ducts, growth of the connective tissue, increase in adipose tissue, and increased vascularity

Front 40

progesterone

Back 40

stimulates growth of TDLU's

Front 41

pregnancy

Back 41

-considerable change in the breast tissue
-the TDLU's increase in size as the epithelium begins to swell
-the acinar cells enlarge in response to a variety of hormones including estrogen and progesterone, lactogen, prolactin, and chorionic gonadotrpin from the placenta
-late in pregnancy, the lactiferous ducts increase in size as the stroma of the breast is crowded and displaced

Front 42

lactation

Back 42

-shortly after birth, the estrogen and progesterone levels diminish rapidly and prolatin dominates
-this hormone causes acinar cells to secrete milk
-after the termination of the breast-feeding, the ducts and lobules return to their normal size in approx. 3 months

Front 43

menopause

Back 43

-in the peri-menpausal female, the lobules of the breast involute (roll inward, invert, or shrivel)
-also the loose connective tissue turns into dense connective tissue which converts to stroma
-the stroma is then replaced by fat
-involution is thought to begin long before menopause as a gradual decrease in glandular tissue with fatty replacement
-there are only a few occasions when breast parenchyma increases
*hormone replacement therapy (HRT) and weight loss are the most common

Front 44

What are the three steps to examing the breast?

Back 44

1.Breast Self Examinations (BSE)-performed monthly by women of all ages
2.Clinical Breast Examination (CBE)-performed by a physian every 3 years for women over 40
3.Mammagram-baseline study for women 35 to 40; after age 40, mammagram every year

Front 45

examining the breast

Back 45

-breast self examination includes visual inspection and palpating the breast sin both a standing and upright position, as well as lying down
-breast cancer may develop in women younger than 40
-most of these cancers are found by either BSE or by clinical breast examination performed by the pt's physician

Front 46

Medio-Lateral Oblique (MLO) view

Back 46

*the most valuable mammagraphic view
-allows imaging from high in the axilla down to the inframammary fold
-breast tissue is compressed from medial to lateral
-estimates the location of a mss either superior or inferior to the nipple with slight variation due to the x-ray angle

Front 47

Cranio-Caudal (CC) view

Back 47

-the next most valuable view
-x-ray beam is perpendiculr to the floor
-breast tissue is compressed superior to inferior
-cc view describes the location of a mass either medial or lateral to the nipple

Front 48

Lateral (LAT) view

Back 48

-true lateral view with the x-ray beam parallel to the floor
-mos accurately demonstrates pathology located in the superior or inferior quadrants

Front 49

Spot Compression

Back 49

-with or without magnification are used to image samll regions of the breast with greater compression
-a smaller compression paddle is used which allows maximum compression for high quality imaging in a specific area

Front 50

Valley (cleavage) view

Back 50

-view of the medial (inner) portions of the breasts
-valuable when there is a lesion suspected in the most medial portion of the breast

Front 51

Axillary Tail View

Back 51

-similar to the MLO, more focused on the tail of spence

Front 52

Rolled Views

Back 52

-atempts to displace the breast tissues to confirm a lesion

Front 53

LAT view location

Back 53

-above the nipple is the superior region of the breast; below the nipple is the inferior
-no knowledge of superior and inferior

Front 54

CC view location

Back 54

-from nipple to marker is lateal; from nipple away from marker is medial
-no knowledge of superior and inferior
-marker is always in the axilla

Front 55

MLO view location

Back 55

-above the nipple is the superior region of the breast; below the nipple is inferior
-no knowledge of medial and lateral
-since this is not a true lateral view, lesions located in the medial portion of the breast will actually be located slightly higher
-lesions in the lateral portion of the breast will actually be located slightly lower
-MULD(medial up, lateral down)

Front 56

Margins

Back 56

1.smooth (circumscribed)
2.macro-lobulated-gentle large lobulations
3.*Microlobulated-multiple small lobulations
4.*Ill-defined-obscured or indistinctmargins that are poorly defined, usually means tumor invasion in surrounding tissues
5.*angular-irregular,jagged margins
6.*spiculated-straight lines which radiate from the center of the tumor

Front 57

Fat Density

Back 57

-structures are radiolucent
*fat, fatty cysts, lipomas (benign)
-mixed fat and water density structures: lymph nodes, galactocele (benign), fibroadenolipoma (benign)

Front 58

Water Density

Back 58

-radiopaque
-glandular tissue,connective tissue (stroma), lactiferous ducts, pectoralis major muscle, *cysts, hematoma,*fibroadenoma (benign), phyllodes(benign or malignant), *maliganant tumors

Front 59

Calcium Density

Back 59

-radiopaque
-calcifications (both benign and malignant)

Front 60

Density

Back 60

-the density of the fibroglandular tissue of the breastwill gradually decrease with advancing age (due to fatty replacement)
-dense fibroglandular tissue may hide tumors on mammography
-fibroglandular tissue density may be increased and noted in women taking hormone replacement therapy or those that experience weight loss

Front 61

Calcifications

Back 61

-mammo is the only imaging modality that can consistently identify calcifications in the breast
-can occur in both benign and malignant breast disease
-approx. 1/2 of breast cancers contain calcifications

Front 62

Typical calcifications

Back 62

1.vascular-appear as calcified tubes associated with vessels
2.large coarse(popcorn calcifications)-usually larger than 1 mm;commonly caused by an involuted fibroadenoma
3.rod-shaped-calcium deposited within the ducts
4.rim or eggshell-may be seen as a crescent or rim shape or round with a lucent center;either represents calcium deposit in a cyst, milk of calcium cyst, sebaceous cyst, hemorrhagic cyst or fat necrosis

Front 63

suspicious calcifications

Back 63

1.punctuate(microcalcifications)-very small pinpoint calcifications associated with fibrocystic change,fibroadenoma,sckerosing adenosis, or malignancy
2.flake-shaped-small,indistict and fuzzy;tend to be malignant
3.linear branching-fine,interrupted, linear calcifications within the ducts(not solid rods); almost exclusively associated with malignancy

Front 64

Calcification patterns

Back 64

1.diffuse-scattered randomly, associated with benign lesions
2.clustered microcalcifications-usually associated with fibroadenoma or malignant lesions
3.segmental-suggest the calcifications follow a ductal system, associated with malignancy
4.regional-calcifications cover a segment or quadrant of the breast, associated with malignancy

Front 65

What is a targeted breast exam?

Back 65

ultrasound used to evaluate a specific area

Front 66

Breast Sonography

Back 66

-higly valuable in the diagnosis and management of breast disease
-not helpful as a screening tool for breast cancer or for evaluating calcifications

Front 67

What are the indications for breast sonography?

Back 67

1.characterize masses as cystic or solid
2.follow-up to mammo
3.evaluate palpable masses in young women (less than 30) avoiding mammo
4.evaluate masses in pregnant and lactating women
5.evaluate dense breast disease
6.evaluate a mass seen in only one view on mammo
7.evaluate inflammation
8.evaluate irradiated breast
9.evaluate augmented breast
10.evaluate axillary nodes
11.evaluate nipple discharge
12.evaluate pt. when mammo is not possible
13.serial evaluation of a benign mass
14.evaluate the male breast
15.guide interventional procedures

Front 68

What does the pateint history for a sonographic exam include?

Back 68

1.age
2.personal history of breast disease
3.personal history of cancer
4.family history of breast disease
5.medications (esp. hormones)
6.previous breast surgeries and findings
7.pain and location
8.findings from monthly breast exams
9.findings from clinical breast exam

Front 69

What should the sonographer include during a visual inspection of the breast?

Back 69

1.size,shape,contour and symmetry
2.skin redness,edema,dimpling or retraction,protrusions and thickening
3.nipple retraction and discharge
4.surgical scars

Front 70

If a palpable lump is noted what should the sonographer document?

Back 70

1.location
2.size
3.shape
4.consistency of lump
5.mobility
6.distance from the nipple
7.date when first discovered and change over time

Front 71

Sonographic examination

Back 71

-pt is examined in a supine or supine-oblique position with the epsilateral arm raised above the head
-moderate transducer pressure should be applied (improves sound transmissionand detail or resolution, decreases the tissue depth for better penetration, *may eliminate some artifacts

Front 72

Scan Planes

Back 72

-Sagital and transverse (to the body)
-Radial and Antiradial (correlate with the direction of the ductal system)
-radial is longitudinal or parallel with the ducts
-ant-radial is transverse or perpendicular to the ducts
-if a solid lesion is found, tech should scan in radial and ant-radial planes
-allows visualization of tumor or ductal extensions branching outward or toward the nipple

Front 73

Stand-off pad

Back 73

-creates distance between the face of the probe and the skin surface
-the fixed elevation plane focus is moved more superficially
*allows improved focusing and greater detail in the superficial layers of the breast
*improves imaging of :
1.superficial tumors or cysts
2.superficial vessels
3.superficial ducts
4.skin lesions
5.skin thickening
*ideal stand-off pad thickness for breast imaging=1 cm
-this places the elevation plane focus of a 10 MHz transducer at approx. .5 cm depth within the breast

Front 74

List some types of stand-off pad techniques

Back 74

1.commercially produced gel pads
2.water bag
3.large "glob" of gel
4.stand-off transducer attachments

Front 75

Normal Sonographic Appearance

Back 75

-young women will tend to have more dense fibroglandular tissue that appears hyperechoic
-older women tend to have more fatty replacement that appears isoechoic
-lactating pt will have greater density appearing hyperechoic
-obese pt will have more fat appearing isoechoic
-the extremely thin pt will appear to have more dense tissues appearing hyperechoic

Front 76

*What are the breasts composed of?

Back 76

1.fat(superficial,intraparenchymal, and retromammary)
2.Epithelium (TDLU and Acinin)
3.Loose stromal fibrous tissue (intralobular and periductal)
4.Dense stromal fibrous tissue (interlobular and cooper's ligaments)

Front 77

compression

Back 77

-improves image quality,eliminates artifacts
-can be used to evaluate effects on a mass

Front 78

What happens when compression is applied?

Back 78

*cysts will change shape
-soft benign lesions tend to change shape
-hard,malignant lesions tend not to change shape
-internal echoes within a benign lesion may become more uniform
-debris within cysts or ducts may be better visualized

Front 79

skin

Back 79

-hyperechoic
-nay see slight increase in echogenicity at gel/skin interface (sound beam enterance) and the skin /superficial fat interface (exit)

Front 80

Fat

Back 80

-medium gray, found within the superficial layer, parenchymal layer and retromammary layer
*all structures are compared to the mid-level echogenicity of fat

Front 81

Cooper's Ligaments

Back 81

-hyperechoic
-considered part of the dense connective tissue
-best seen in superficial fat layers as a thin, wavy, linear structure
-may produce shadowing artifact(try changing the angle of the transducer)

Front 82

Glandular Epithelium

Back 82

-isoechoic to mildly hypoechoic
-consists of TDLUS and acini found within the parenchymal layer

Front 83

Dense Fibroglandular Tissue

Back 83

-hyperechoic
-fibroglandular tissues are a combination of glandular epithelium and both loose and dense connective tissue in the parenchymal layer

Front 84

Lactiferous Ducts

Back 84

-hypoechoic with hyperechoic striations
-found deep to the retromammary layer

Front 85

Ribs

Back 85

-hyperechoic with posterior shadowing found deep to the retromammary layer

Front 86

Lymph nodes

Back 86

-hypoechoic with hyperechoic fatty hilum
-oval or kidney shaped

Front 87

Calcifications

Back 87

markedly hyperechoic

Front 88

Cysts

Back 88

-anechoic to hypoechoic
-simple cysts will appear anechoic and complex or debris-filled cysts will appear hypoechoic

Front 89

Benign Lesions

Back 89

-mildly hypoechoic, isoechoic, or mildly hyperechoic
-in general, benign lesions are similar to the echogenicity of the fat and the epithelium

Front 90

malignant lesions

Back 90

-mildly to moderately hypoechoic
-in general, malignant lesions are less echogenic than benign lesions
-sonography is not capable of distinguishing benign from malignant
*may cross fibrous planes and have a tendency to grow toward the skin

Front 91

echo palpation

Back 91

*technique used to isolate a palpable mass
-sonographer immobilizes a mass between two fingers while scanning with the opposite hand
-benign masses tend to move slightly within the tissues
-malignant masses tend to be fixed

Front 92

Fremitus

Back 92

-vibration of tissues (usually in the chest) detected during speech
-can be used to evaluate breast tissues

Front 93

Fremitus technique

Back 93

1.isoechoic tumor vs. normal tissue?
2.ill-defined borders or nonvisualized post. boundary?
3.turn on power doppler (use a decrease doppler gain setting-color saturation could "fill-in" a true tumor)
4.have pt hum or say "EEE"
5.normal breast tissues surrounding a tumor will vibrate creating a doppler signal
6.tumor will not vibrate-no signal

Front 94

What is the shape and orientation of benign diseases?

Back 94

1.Round-characteristic of tense cysts and small, solid, benign tumors
2.Oval or Ellipsoid-typical of non-tense cysts and most benign tumors
3.Horizontal-also known as "wider than tall"; long axis of tumor is parallel to the chest wall
*Benign tumors tend to grow along the tissue plane (NOT ACROSS)

Front 95

What are the margins of benign disease?

Back 95

1.Smooth, well-defined, or circumscribed-indicates the tumor is displacing adjacent tissues rather than invading
2.Macrolobulation-gentle, large lobulations

Front 96

What is the border thickness for benign disease?

Back 96

thin, echogenic pseudocapsule caused by compression or rimming of adjacent tissues around the lesion (instead of invasion)

Front 97

What is the echogenicity of benign disease?

Back 97

1.anechoic-simple cyst
2.hyperechoic-indicates a fibroglandular pseudo-mass or lipoma
3.moderately hypoechoic to isoechoic-solid, benign tumors (may also be malignant)
4.homogeneous-internal echoes are a consistent, single shade of gray;typically a benign characteristic;some heterogeneous tumors could also be benign with internal fibrosis, degeneration, or calcification;complex cystic masses are also heterogeneous

Front 98

What artifacts are involved in benign disease?

Back 98

1.acoustic enhancement-caused by an increase in sound energy passing through tissue;typically a benign characteristic;cysts;solid, benign tumors may also display enhancement; *offers good visualization of the posterior tumor wall; some malignant tumors (highly cellular) may enhance
2.shadowing-cooper's ligaments may shadow due to refraction;some benign lesions such as calcified fibroadenoma, radial scar,fat necrosis and granular cell tumor may demonstrate shadowing
3.edge shadowing-attenuation of the sound beam at the lateral margins of a mass due to refraction; typically a benign characteristic

Front 99

What does the doppler flow consist of in benign diseases?

Back 99

-cysts have no internal flow
-benign solid masses demonstrate no flow or are hypovascular(little doppler signal)
-inflammation may demonstrate hypervascularity (increased doppler signal)

Front 100

Fibrous planes in benign disease

Back 100

-benign lesions tend to grow within or along fibrous planes, compressing or displacing adjacent tissues
-some benign processes such as inflammation or trauma may interrupt planes

Front 101

Ducts in benign disease

Back 101

-measure less than 3mm and increase in size as they run toward the nipple
*dilatation or duct ectasia may occur due to a variety of normal conditions: lactation, 3rd trimester of pregnancy and perimenopausal changes
-may also be due to mastitis and fibrocystic change or papillomas

Front 102

Describe the calcifications in benign disease.

Back 102

-large calcifications causing shadowing artifact are typically a benign characteristic
-usually have a diffuse pattern
-may arise from scarring, necrosis, hemorrhage, cysts or fibroadenomas
-small curvilinear calcifications in the gravity-dependent portion of a cyst likely represent milk of calcium

Front 103

Describe the shape and orientation of malignant disease.

Back 103

1.vertical orientation
*also known as "Taller-Than-Wide"
-long axis of tumor is perpendicular to chest wall
*demonstrate invasion into other tissue planes
2.Irregular Shape-common malignant shape; usually with angles and straight lines
3.Spiculated-most specific feature of malignancy on sonography and mammography; straight lines which radiate from the center of a tumor

Front 104

Describe the margins of malignant disease.

Back 104

1.microlobulation-multiple, small (2mm) lubulations
2.ill-defined-obscured or indistinct margins that are poorly defined; usually indicates tumor invasion into surrounding tissues
*3.angular-irregular jagged margins;*highly sensitive for malignancy
4.spiculated-straight lines which radiate from the center of the tumor
5.radial extensions-seen while scanning in the radial plane
*duct extension-extension of a tumor into a duct coursing toward the nipple
*branch pattern-extension of tumor into a duct coursing away from the nipple(usually involves multiple ducts)

Front 105

Describe the border thickness of malignant disease.

Back 105

-thick echogenic halo
*usually indicates tumor invasion with fibrotic host response (despoplasia)

Front 106

Describe the echogenicity of malignant disease.

Back 106

1.markedly to moderately hypoechoic ("almost anechoic")-highly suspicious for malignancy; some malignancies are hypoechoic to isoechoic
2.heterogeneous-internal echoes are not consistent having many gray shades; typically a maligant characteristic

Front 107

Describe the artifacts of malignant disease.

Back 107

1.Shadowing-caused by attenuation of sound energy passing through the tissue
-most solid, malignant tumors demonstrate some degree of shadowing
*may cause limited or lack of visualization of the posterior tumor wall
-shadowing may arise from only part of the lesion
-some benign tumors may shadow
-some malignant tumors may shadow
-some malignant tumors (highly cellular) such as medullary, colloid and papillary may demonstrate enhancement

Front 108

Describe the doppler and malignant disease.

Back 108

-neoangiogenesis or neovascularity is the ability of a malignancy to develop new blood vessels
-malignant lesions tend to demonstrate more peripheral and internal blood flow with incresed doppler signal
-conventional or power doppler are not reliable, however, in ditsinguishing benign from malignant lesions

Front 109

Describe the fibrous planes and malignant disease.

Back 109

-malignant lesions tend to invade tissue planes and disrupt adjacent tissues
-some tumors may invade the superficial fascia allowing spread to the superficial structures
-may see skin dimpling, skin thickening, nipple retraction, or retraction of cooper's ligaments
-tumors may also invade the deep fascia and pectoral fascia planes

Front 110

Describe the ducts and malignant disease.

Back 110

-malignant lesions may invade the ducts causing dilataion,internal echoes and irregular tumor extension within the duct
-radial scanning should be performed to assess duct extension and branch pattern

Front 111

Describe calcifications and malignant disease.

Back 111

-small microcalcifications (often assoiciated with malignancy)
-may be visualized within a tumor

Front 112

Simple Cysts

Back 112

-very common (ages 35-40)
-typically regress after menopause but may persist in women taking HRT
-result from obstructed lactiferous ducts (*usually the TDLU) due to fibrosis or proliferative changes in the duct epithelium
-also result from hormonal dilatation
-secretions continue to accumulate and a cyst develops

Front 113

Simple Cysts

Back 113

Can Be:
1.single or multiple
2.unilateral or bilateral
3.variable size
4.palpable or non-palpable
5.silent or painful
6.moveable
7.compressible

Front 114

Simple Cysts On Mammo

Back 114

-round or oval
-smooth (circumscribed margins)
-radiopaque-water density
-halo sign (lucent rim of fat)

Front 115

Simple Cysts On Sonography

Back 115

-round or oval
-anechoic
-smooth margins
-sharp borders
-acoustic enhancement
-may have edge shadowing
-occasionally lobulated
-compressible
-no internal doppler signal

Front 116

What may cause artifacts within a cyst?

Back 116

-improper TGC
-over all gain too high
-improper focal position
-small cyst size
-superficial location (stand-off pad)
-deep location
-diminished acoustic enhancement (dense stroma surrounding the cyst, deep location, small cyst size)

Front 117

What is a complex cyst?

Back 117

-cysts that contain internal echoes or changes in the cystic wall

Front 118

List the types of complex cysts.

Back 118

1.debris-filled,foam,or inspissated cyst-cellular debris,epithelial cells,apocrine cells,foam cells and cholesterol crystals
2.Fatty Cyst-fat and protein cells
3.Hemorrhagic-blood cells
4.Inflammatory-inflammatory cells and purulent fluid may have thick walls
5.Abscess-purulent fluid, may have thick walls
*6.Galactocele-milk
7.milk of calcium cyst-calcium in dependent portion
*8.sebaceous cyst(epidermal inclusion cyst)-sebum(greasy substance)
9.Oil cyst-oil cells
10.Septated-fibrous stromal cells
11.Calcified-calcium deposits in the wall of the cyst
12.Malignant-malignant neoplastic cells, may have thick walls

Front 119

What may complex cysts demonstrate?

Back 119

-low to medium level echoes
-heterogeneous internal appearance
-gravity dependent fluid-fluid levels
-septations
-wall-thickening
-total or partial wall calcifications
-partial enhancement or shadowing

Front 120

Galactocele

Back 120

-milk-filled cyst caused by the obstruction of a lactiferous duct
-usually associated with childbirth, affecting both breast feeding and non-breast feeding mothers
-cyst is typically located in the subareolar region

Front 121

What does sonography reveal about a galactocele?

Back 121

1.round, oval or lobulated well-defined mass
2.hypoechoic to isoechoic
3.homogeneous internal appearance
4.acoustic enhancement
5.no internal doppler signal
6.may also see dilated ducts,mastitis, abscess

Front 122

Sebaceous cyst

Back 122

*also known as an epidermal inclusion cyst
-results from an obstructed sebaceous gland within the dermis
*cyst contains sebum, an oily substance
-commonly associated with the montogomery glands of the areola or found at the inframammary fold

Front 123

What does sonography reveal about a sebaceous cyst?

Back 123

1.round,well-defined
2.hypoechoic to isoechoic(oily sebum)
3.superficial location (stand-off pad)
4.acoustic enhancement
5.no internal doppler signal

Front 124

Fibrocystic Changes

Back 124

*most common disorder of the breast
-accounts for half of all surgical procedures
-affects 60-90% of females between the ages of 20-40
-may produce no symptoms, palpable lumps, and/or cyclic pain
-often bilateral
-caused by a battle between proliferation and resorption of the epithelial and stromal tissues of the breast
-outcome is cyst formation,fibrosis, and possible epithelial hyperplasia
-mammo demonstrates increased density of the fibroglandular tissue

Front 125

What may ultrasound reveal with fibrocystic changes?

Back 125

1.cysts of various sizes (simple and complex)
*2.clusters of cysts
3.increased fibrosis of the parenchymal layer (hyperechoic fibroglandular tissue)
4.dilated ducts

Front 126

Fibroadenoma

Back 126

*most common benign solid tumor of the breast
-estrogen related (ages 20-40)
-arise from the epithelial and stromal tissue of the breast

Front 127

List the common characteristics of a fibroadenoma.

Back 127

1.arise from the TDLU
2.<3 cm in size
*3.increased incidence in African-American females
4.pregnancy may influence rapid growth
5.single or multiple
6.presents as painless, palpable mass
7.firm or rubbery
8.moveable, not fixed
*9.pseudo-encapsulated-capsule like structure due to compression of adjacent tissues
10.may undergo changes-necrosis,partial calcification,hyalinization

Front 128

What does a fibroadenoma look like on mammo?

Back 128

*round,oval,lobulated
-circumscribed
-radiopaque-water density
-may have halo
may have calcifications
-unable to differentiate from cyst

Front 129

What does fibroadenoma look like on ultrasound?

Back 129

*round,oval, or lobulated
-well-defined borders
-mildly hypoechoic or isoechoic
-homogeneous
*thin, echogenic pseudocapsule
*wider than tall
-may compress (due to soft nature
-edge shadowing
-no significant enhancement or shadowing
-peripheral and internal flow may be detected by doppler

Front 130

Juvenile Fibroadenoma

Back 130

-adolescent girls
-highly cellular type of benign fibroadenoma
-grow rapidly (up to 5 cm)
-doppler signal could be increased (to accomodate growth)

Front 131

Giant Fibroadenoma

Back 131

-6 cm or larger
-appear the same as smaller fibroadenomas
-increased vascularity due to size

Front 132

Intraductal Papilloma

Back 132

-benign tumor growing from the ductal epithelium projecting into the lumen of the duct
-most often in women age 30-55
*most common cause of bloody nipple discharge

Front 133

What are the characteristics of an intraductal papilloma?

Back 133

1.typically located in the subareoalar region
2.may be single or multiple(papillomatosis)
3.usually <2 com
4.non-palpable
5.tumor may cause duct obstruction
6.most frequent symptom is nipple discharge (serous or bloody)
7.ductography may be helpful in the diagnosis

Front 134

What is a ductogram?

Back 134

-galactogram
-an injection of contrast into the lactiferous duct demonstrates "filling defect"
-confirms intraductal papilloma or papillary carcinoma

Front 135

Describe an intraductal papilloma on ultrasound?

Back 135

-small solid lesion within duct
-hypoechoic or isoechoic
-round,oval, or tubular
-associated duct dilatation
*doppler signal within solid component confirms papilloma or papillary carcinoma
-radial scanning is optimal for duct visualization

Front 136

Intracystic Papilloma

Back 136

-focal dilatation of a duct caused by an obstructing papilloma
-papilloma within a cyst(clear or hemorrhagic)
-lesion is usually small, but can become large
-clinical symptoms are the same as intraductal papilloma

Front 137

Describe an intracystic papilloma.

Back 137

-round or oval cyst containing a solid,mural tumor
-cyst could be anechoic or complex
-papilloma will appear hypoechoic or isoechoic
-doppler signal within the solid component confirms papilloma or papillary carcinoma

Front 138

Juvenile Papillomatosis (Swiss Cheese Disease)

Back 138

-rare condition affecting females less than 30 yrs of age
-characterized by cyst,duct ectasia,intraductal hyperplasia, and sclerosing adenosis
-usually presents as a mass located in the periphery of the breast resembling a fibroadenoma
-25% of the pt have a positive family hx of breast cancer

Front 139

Describe an juvenile papillomatosis on ultrasound.

Back 139

-hypoechic, ill-defined mass
-heterogeneous appearance
-may have visible cysts and/or duct ectasia

Front 140

Lipoma

Back 140

-encapsulated tumor of mature adipose tissue
-typically arises from the subcutaneous fat layer
-usually located superficially
clinically:soft,compressible,mobile masses

Front 141

Describe a lipoma on mammo.

Back 141

-radiolucent,circumscribed, thin capsule

Front 142

Describe a lipoma on ultrasound.

Back 142

-oval and well-defined
-usually superficial
-isoechoic (although hyperechoic and hypoechoic lesions are seen)
-homogeneous
-compressible
-may be mistaken for a fat lobule

Front 143

Fibradenolipoma

Back 143

*also know as a hamartoma
-rare type of fatty tumor occurring in the breast
-non-encapsulated tumor composed of fat, fibrous and glandular tissues
-develops due to an overgrowth of normal breast tissues
-occurs in women over 35 years of age
-

Front 144

How does a fibradenolipoma appear on ultrasound?

Back 144

-well-defined, pseudocapsule
-oval or lobulated
-echogenicity depends on amounts of fat,fibrous, and glandular tissue
-possible shadowing
-maybe quite large

Front 145

*Mastitis

Back 145

-often causes marked pain,swelling and redness of the breast
-most common form is lactational (puerperal) mastitis
-a cracked nipple, common from breast feeding, allows the staphylococcal aureus bacteria access to the ducts
-ducts may become inflamed and plugged causing milk stasis
-nonlactational forms:infected cysts,subareolar abscess, post-surgical inflammation,plasma cell mastitis,tuberculosis,inflammatory carcinoma and other non-specific forms
-usually respond to antibiotic therapy

Front 146

Acute Mastitis

Back 146

-firm, tender, swollen breast
-localized skin thickening,redness,purulent discharge,tender axillary lymph nodes, leukocytosis and fever

Front 147

What does ultrasound reveal with acute mastitis?

Back 147

-increased echogenicity of superficial fat and parenchymal layers
-possible shadowing due to cellulitis
-blurred tissue planes
-skin thickening
-possible dilated ducts
-increased doppler signal (increased vascularity)

Front 148

*Abscess

Back 148

-complication of lactational or non-lactational mastitis
-typically found in the subareolar region, but may develop anywhere in the breast tissues
-may require surgical drainage

Front 149

What does ultrasound reveal with an abscess?

Back 149

-complex,predominantly cystic mass
-thick, irregular borders
-acoustic enhancement
-localized skin thickening
-increased dopplersignal at the periphery (increased vascularity)

Front 150

*Plasma Cell Mastitis (Penductal Mastitis)

Back 150

-usually begins with dilated lactiferous ducts
-a secondary infection develops due to debris and ulceration of the ducts
-plasma cells and other white blood cells cause irritationof the duct lining
-common characteristics-nipple discharge,palpable hard mass, subareolar location, nipple retraction,possible linear calcifications, and symptoms of breast inflammation

Front 151

What will ultrasound reveal with plasma cell mastitis?

Back 151

-dilated ducts with internal debris or wall thickening
-localized skin thickening

Front 152

Skin Thickening

Back 152

-usually .5-2 mm
-interruption of the dermis layer is suspicious for carcinoma
*stand-off pad is extremely useful in evaluating skin thickness

Front 153

What may skin thickening suggest?

Back 153

1.trauma
2.benign inflammation-mastitis, abscess, plasma cell mastitis
3.fat necrosis
4.post-surgical scarring
5.malignancy-tumor invasion, inflammatory carcinoma (peaud'orange),lymphoma, cross lymphatic mets
6.radiation therapy
7.restriction of venous return-CHF obstruction of superior vena cava

Front 154

Nipple Discharge

Back 154

-may be accidental or due to disease
-may be seen in non-lactating and non-pregnant females
-usually arises from a single duct

Front 155

Galactorrhea

Back 155

-bilateral milk discharge from a non-lactating and non-pregnant female
-usually endocrine-induced(caused by pituitary adenoma) or medication-induced (oral contraceptives, antihypertensive,etc.)

Front 156

Purulent Discharge

Back 156

-have the characteristic appearance of pus as a result of breast inflammation
-usually unilateral and arise from multiple ducts

Front 157

What breast diseases cause nipple discharge?

Back 157

1.Benign-intraductal papilloma,duct ectasia
2.malignant-intraductal papillary carcinoma

Front 158

List the types of discharge that may indicate breast cancer?

Back 158

1.serous-clear,yellow fluid
2.serosanguineous-pink color,both serous and bloody fluid
3.sanguineous-red,bloody fluid
4.watery-clear,pale yellow fluid

Front 159

Ductography

Back 159

-diagnostic procedure of choice in evaluating patient with suspicious nipple discharge

Front 160

Breast Trauma:Fat Necrosis

Back 160

-thickening or scarring in the fatty tissue that is caused by an injury to the breast
-can occur at any age
*more common in obese women with fatty,pendulous breasts
-secondary to biopsy,surgery,radiation therapy, or other iatrogenic causes
-may present as:oil cyst or firm,fixed,spiculated mass (resembles breast ca)

Front 161

Breast Trauma:Hematoma

Back 161

-blood-filled tumor of the breast following direct trauma
-usually demonstrate bruising of the skin
-echogenicity depends on the amount of coagulation present
-may appear anechoic,complex,or hyperechoic

Front 162

Breast Trauma:Lymphocele

Back 162

-may occur following breast surgery
-represents a cystic tumor filled with lymph fluid
-imaging features are similar to a simple or complex cyst

Front 163

Breast Trauma:Post-operative scanning

Back 163

-may present as a palpable mass following breast surgery
-scars usually do not pose a problem unless they have associated fat necrosis
-may appear similar to a cancer

Front 164

What may ultrasound reveal with post-operative scanning?

Back 164

-thin shadow from the skin surface
-spiculated,fixed,hypoechoic mass with shadowing
-doppler demonstrates no increase in flow

Front 165

Sclerosing Adenosis

Back 165

-benign enlargement of a breast lobule due to epithelial and stromal hyperplasia
-acini of the TDLU increase in number and produce a distroted, spiking, infiltrative appearance
-enlarged lobule occasionally presents as a palpable mass and may have calcifications
-primary signicance-primary significance-its ability to mimic carcinoma (biopsy is suggested)
-on mammo:architectual distortion;spiculated appearance;microcalcification
-on ultrasound:irregular,spiculated or lobulated mass;hypoechoic;possible shadowing;no increased doppler signal

Front 166

Radial Scar

Back 166

-invasion of ductal epithelium into the surrounding stromal tissues
-results in a scar formation that may present as a suspicious mass
-benign process not associated with trauma
-less than 1 sm and palpable
-may simulate a carcinoma on mammo, ultrasound, and microscopic examination (local excision is suggested treatment)
-on mammo: spiculated, may have calcifications
-on ultrasound:irregular,spiculated,scarred lesion;possible shadowing;no increased doppler signal

Front 167

Mondor's Disease

Back 167

*rare thrombophlebitis of a superficial vein of the breast
-usually associated with the lateral thoracic vein and therefore, causes pain in the lateral half of the breast
-may be idiopathic, but is most often caused by trauma
-there have benn some cases associated with breast cancer
-clinically:palpable,tender,cord-like,superficial mass;pt may also have fever
-with hot compress therapy, the phlebitis usually resolves in 2-8 wks
-on ultrasound:superficial,tortuous, tubular lesion;anechoic or hypoechoic;stand-off pad may be useful

Front 168

Precocious Puberty

Back 168

-breast enlargement during puberty= ages 9-16
-the onset of breast enlargement before age 8=precocious puberty
-caused by an endocrine disorder
-ovarian enlargement and hyperstimulation is the most common cause
*several causes may include:
1.ovarian-ovarian enlargement,ovarian cyst
2.adrenal gland-adrenal gland tumor,adrenal cortex hyperplasia,adrenogenital syndrome
3.thyroid-primary hypothyroidism

Front 169

Gynecomastia

Back 169

*non-neoplastic enlargement of the male breast
-associated with an increase in estrogen and/or a decrease in testosterone
-may be unilateral or bilateral
-must be differentiated from male breast cancer, endocrine and hormonal disorders
-results in increased fat and stromal elements,duct enlargement and possible glandular development
-may present as:breast enlargement,palpable subareolar nodule,breast tenderness/soreness,skin thickening,possible nipple discharge

Front 170

What are the causes of gynecomastia?

Back 170

1.hormonal changes in the male (neonate,puberty,after age 50)
2.estrogen treatment of prostate cancer
3.testicular failure
4.neoplasms:testicular,adrenal and lung
5.chronic disease:liver,renal, and pulmonary
6.medications:digitalis,antidepressant,antihypertensive,estrogen,marijuana
7.Klinefelter's syndrome (xxy sex chromosome)
8.idiopathic

Front 171

What may ultrasound reveal with gynecomastia?

Back 171

-presence of glandular tissue
-possible dilated ducts
-increased fat

Front 172

Malignant Breast Disease

Back 172

*most common sign of breast cancer is a new lump or mass
-90% of breast ca originate in the duct
*most ca arise from the TDLU
*most ca are located in the upper outer quadrant
-atypical hyperplasia may give rise to cancer cells, known as invasive carcinoma
-invasive carcinoma has the ability to metastasize to other organs

Front 173

Epidemiology of Breast Cancer

Back 173

*breast cancer is the most common cancer among women
-second leading cause of cancer death in women, exceeded only by lung cancer
-one in every 9 women will develop breast ca
-most cases occur in middle-aged and older women

Front 174

Risk Factors

Back 174

1.Gender-breast ca is approximately 100 times more common in women than men
*most significant risk factor
2.Age-a woman's risk of developing breast ca increases with age
*2nd strongest risk factor
3.Family history of breast cancer: *the risk of breast ca is higher among women whose blood relatives have the disease
-having a first-degree relative (mother, sister, or daughter) with breast cancer approximately doubles a woman's risk
-Genetic research: 10% of breast ca cases result from mutations of the BRCA1 and BRCA2 genes
-BRCA genes help prevent cancer by producing a protein that controls normal cell growth
-if a person inherits mutations of the BRCA genes, chances of developing breast ca increases
-BRCA mutations also increase the risk of ovarian ca
4.Personal hx of breast ca- a woman with ca in one breast has a 3-4 fold increased risk of developing a new ca in either breast
5.Menstrual periods-women who start menstruating at an early age (before 12) or women who went through menopause at a late age (after 50) have a slightly higher risk of breast ca
(Early menarche/Late menopause=increased risk)
7.Hormonal Influence:longer periods of estrogen and progesterone activity within a woman's lifetime seem to increase the risk
-prolonged use of oral contraceptives may increase the risk of breast ca
8.Personal hx of cancer:especially ovarian or endometrial cancer, have a slightly higher risk
9.Biospy finding of atypical hyperplasia
10.Radiation therapy (to the chest area)
11.Obesity:associated with the development of breast ca, especially after menopause
-having more fatty tissue can increase a woman's estrogen level

Front 175

Ductal Carcinoma (In Situ)

Back 175

*microcalcifications are common
-represents malignant changes of the ductal epithelium without extension past the basement membrane
-in situ means the ca is confined within the space it occupies (the duct) and has not spread.
*the most common non-invasive ca

Front 176

What are the clinical features of ductal carcinoma (in situ)?

Back 176

-asymptomatic pt
-possible palpable mass of varying size,shape, and consistency
-possible nipple discharge

Front 177

What is non-comedo DCIS?

Back 177

-low grade DCIS
-slow growing and less aggressive than comedo DCIS
-makes up 40% of all DCIS
-carries a 10-fold risk for the development of invasive carcinoma
-has three cellular classifications each with different architectural patterns witht the duct that may be only distiguished on biopsy

Front 178

What are the three clasifications of non-comedo DCIS?

Back 178

1.cribiform-perforated form (sieve-like)
2.micropapillary-clumpy, along the wall
3.solid-occupy entire lumen of duct

Front 179

What is Comedo DCIS?

Back 179

-high grade DCIS
-an aggressive intraductal carcinoma
-ducts completely fill and dilate with abnormal cells that quickly spread
*Necrosis-distinguishes comedo from non-comedo
-up to 60% of all DCIS
-carries a high risk of for development of invasive carcinoma
-has central necrosis within the tumor (probable cause of microcalcifications)
-involves multiple ducts within a segment
-usually much larger than non-comedo
-may have micro-invasion
*mammo is the most effective imaging method for detecting DCIS (microcalcifications)

Front 180

What will ultrasound reveal with comedo DCIS?

Back 180

*possible mass
-architectual distortion
-ductal dilatation
*microcacifications (not reliable)

Front 181

What will mammo detect with comedo DCIS?

Back 181

-clustered microcalcifications
-linear, branch pattern microcalcifications with or without a distinct mass
-distinct mass with internal microcalcifications

Front 182

Lobular Carcinoma In Situ (LCIS)

Back 182

-lobular neoplasia
-malignant changes in the lobular epithelium without invasion outside the lobule (non-invasive cancer)
-arises from the lobule
-generally affects premenopausal women
-involves tumor growth that completely fills the lobule
-is usually extremely small
-usually does not present as palpable mass
*is often bilateral and multicentric (found in more than one quadrant) on initial diagnosis
-carries a 10-fold risk for the development of invasive carcinoma
-is associated with invasive carcinoma to the opposite breast
-generally not associated with microcalcifications
*is diffivult to detect on mammoa nd ultrasound
-may be detected as an incidental finding on biopsy

Front 183

Invasive Carcinoma

Back 183

-represents a spectrum of breast cancers that offer malignant extension beyond the duct or lobule
-tumor arises from the TDLU and invades the surrounding stroma and fatty tissues having the potential to metastasize
-the different types of invasive carcinomas are categorized into the usual-type (not specified) and the specified-type
-cancers of the usual type (not specified) are characterized by a lack of specific histologic features
-cancers of the specified-type have unique histologic patterns that are consistent for a certain type of cancer

Front 184

What is a usual-type cancer?

Back 184

-invasive ductal carcinoma NOS (not otherwise specified)
-worst prognosis**

Front 185

What is a specified-type cancer?

Back 185

-invasive lobular carcinoma
*medullary carcinoma
*colloid(mucinous) carcinoma
*tubular carcinoma
-papillary carcinoma
-paget's disease

Front 186

Invasive Ductal Carcinoma

Back 186

-malignant changes of the ductal epithelium with invasion through the basement membrane outside the duct
-has the ability to metastasize to other parts of the body through the lymphatic system and bloodstream
*most common type of breast cancer accounting for 75% of cases
-most invasive ductal carcinomas are scirrhous-type, which present the classic hard, gritty texture with an irregular margin
-a few may be soft and circumscribed
-most present as a palpable mass
-likely cused by the invasion of surrounding tissue creating a host response or fibrotic reaction (*DESMOPLASIA)
-as the tumor continues to grow, the margins become more angular and spiculated
-some pt. feel pain while others are asymptomatic

Front 187

What are the clinical features of invasive ductal carcinoma?

Back 187

-palpable mass (often larger than imaging appearance)
-hard, gritty texture
-tumor is fixed (immovable)
-skin dimpling
-skin retraction
-nipple retraction

Front 188

How will invasive ductal carcinoma appear on mammo?

Back 188

-radiopaque density
-spiculated,lobulated or irregular margins
-microcalcifications
-thickened and/or retracted cooper's ligaments

Front 189

How will invasive ductal carcinoma appeear on u/s?

Back 189

-solid mass
-irregular,angular or spiculated margins
-taller-than-wide
-markedly hypoechoic
-heterogeneous internal appearance
-partial or complete posterior shadowing
-duct extension or branch pattern
-thickened, straightened,or retracted cooper's ligaments
-fascia plane disruption
-occasionally, IDC may appear as a well-circumscribed homogeneous, hypoechoic mass with no shadowing (benign appearance)

Front 190

Invasive Lobular Carcinoma

Back 190

-represents malignant changes of the lobular epithelium with invasion outside the lobule
-has the ability to metastasize to other parts of the body through the lymphatic system and bloodstream
*the second most common type of breast cancer accounting for 8-15% of cases
-most frequently missed breast cancer
-usually non-palpable
-usually does not have microcalcifications
-tumors are highly infiltrative and aggressive
-may produce an area of architectual distortion without a mass
-more likely to be multifocal,multicentric, and bilateral than IDC
-difficult to detect on mammo and u/s
-if a mass is present, u/s may be more effective at demonstrating ILC than mammo
-may not be differentiated from IDC on mammo and u/s
-mass may appear as a spiculated,ill-defined,radiopaque density on mammo
-may appear as an ill-defined, markedly hypoechic lesion

Front 191

medullary carcinoma

Back 191

-accounts for 5% of all invasive cancers
-tends to occur in younger women
-highly cellular tumors which tend to grow rapidly and can become quite large
-well-circumscribed, soft tumor
-non-tender,compressible and slightly moveable
-tends to be non-infiltrative
-not associated with microcalcifications
-commonly mistaken for a fibroadenoma
-more common among asians and african-american women
-carries a good prognosis

Front 192

What may ultrasound reveal about medullary carcinoma?

Back 192

-large,solid mass
-round,oval or macrolobulated shape
-smooth borders may have irregular margins on close inspection
-may be taller-than-wide
-hypoechoic appearance
-homogeneous or mild heterogeneous internal appearance
-possible enhancement (due to highly cellular nature)

Front 193

Colloid (Mucinous) Carcinoma

Back 193

-contains mucous-producing cancer cells that create a gelatinous or syrup-like interior
-as the tumor grows, it forms a large, firm, smooth mass
-slow-growing, non aggressive tumor
-circumscribed, soft tumor
-typically affects elderly women
-carries a good prognosis and mets are uncommon

Front 194

What may ultrasound demonstrate with colloid (mucinous) carcinoma?

Back 194

-hypoechoic or isoechoic in comparison to fat
-well-circumscribed lesion
-may have microlobulation
-homogeneous internal appearance
-shadowing is uncommon
-may appear as a compex cystic mass

Front 195

Tubular Carcinoma

Back 195

-appears as a relatively small lesion
-good prognosis
-associated witha benign radial scar

Front 196

what may mammo reveal about tubular carcinoma?

Back 196

-long spicules radiating from a small radiolucent mass

Front 197

what may ultrasound reveal about tubular carcinoma?

Back 197

-small, hypoechoic mass
-ill-defined margins
-posterior shadowing

Front 198

Papillary carcinoma

Back 198

-non-invasive or invasive and represents the malignant version of an intraductal papilloma
-affects postmenopausal women
-subareolar mass
-may present with bloody nipple discharge
-imahing features will likely not distinguish between benign intraductal papilloma, non-invasive papillary carcinoma and invasive papillary carcinoma

Front 199

What may ultrasound reveal about papillary carcinoma?

Back 199

-well marginated, solid mass
-may also appear complex
-may have ductal dilatation
-may have microcalcifications
-if the duct becomes obstructed, and intracystic papillary carcinoma may develop (must be differentiated from a benign intracystic papilloma)

Front 200

Paget's disease

Back 200

-rare form of breast cancer
-begins in the lactiferous ducts and spreads to the skin of the nipple and areola
-almost always associated with invasive carcinoma but may be seen with carcinoma in situ
*causes the skin of the nipple and areola to appear crusted,scaly and red
-may cause skin to bleed or ooze
-may cause burning and itching of the affected area
-generally diagnosed clinically

Front 201

What may mammo reveal with paget's diseae?

Back 201

-negative exam
-possible subareolar mass

Front 202

What may ultrasound reveal with paget's disease?

Back 202

-skin thickening of the nipple or areola
-possible duct dilatation
-possible subareolar mass

Front 203

Inflammatory carcinoma

Back 203

-rare but aggressive type of breast cancer
-due to primary breast cancer invading lymphatic vessels of the breast
-invasive ductal carcinoma is the most common primary
-spread of cancer throughout the lymphatics is rapid and diffuse with possible mets to the opposite breast
-poor prognosis
-often referred to as the "hot, red breast"
-causes the breast to become warm,red,swollen,hard and painful
*skin demonstrates classic sign- "peaud'orange" or orange peal appearance due to edema and thickening
-may cause flattening or retraction of the nipple
-may present with a palpable mass (primary ca)
-may present with axillary lymph node enlargement
-must be differentiated from severe mastitis

Front 204

What may ultrasound reveal about inflammatory carcinom?

Back 204

-skin thickening
-dilated lymphatic vessels
-diffuse appearance of the parenchymal layer
-tissue plane disruption
-increased doppler signals in all tissues

Front 205

Multifocal carcinoma

Back 205

-2 or more cancer lesions found within the same ductal system or same quadrant
-likely represents one primary cancer that spreads up and down the ducts
-may represent two distinct cancers along the same ductal system or same quadrant
-25-50% of all invasive ca are mutifocal
*2 or more cancers found within a 5 cm distance

Front 206

Muticentric carcinoma

Back 206

*2 or more cancer lesions found in seperate quadrants of the same breast or found in both breasts (greater than 5 cm distance)
-whole breast sonography may be warranted in assessing mutifocal and/or muticentric breast disease

Front 207

Male breast cancer

Back 207

-1% of all breast ca
-usually arises in the subareolar region
-most commonly DCIS or Invasive Ductal Carcinoma
-symptoms similar to female breast ca
-mammo and u/s features similar to female breast ca

Front 208

What are the risk factors of male breast cancer?

Back 208

-advanced age
-family hx of breast ca
-radiation exposure
-cryptorchidism (undescended testes)
-testicular injury or surgical removal of testes
-klinefelter's syndrome (xxy sex chromosomes)

Front 209

Phyllodes

Back 209

-previously known as cystosarcoma phyllodes
-rare type of lesion arising from the stroma (connective tissue) of the breast
-usually benign but in occasion may be malignant
-considered a transitional type of tumor
-occur in women age 30-50 (later than fibroadenoma)
-contain stromal tissue with mucinous, hemorrhagic or cystic fluid
-usually solitary
-tend to grow rapidly and become quite large
-have large lobulations presenting a leaf-like (cleft) shape
-appear as a large, palpable, firm, mobile mass that may bulge the skin
-have a tendency to occur

Front 210

Malignant Phyllode Tumors

Back 210

-form of sarcoma
-tend to be polylobulated (large,mutiple lobulations)
-may grow faster than the benign form
-may demonstrate central degeneration
-may spread to the lung through the bloodstream (unlike carcinomas that spread to the axillary lymph nodes)
-treated by lumpectomy or masectomy
-do not respond well to hormonal, chemo or radiation therapy

Front 211

What may ultrasound reveal about malignant phyllodes?

Back 211

-large, well-circumscribed, solid mass
-smooth, lobulated borders
-hypoechoic or isoechoic internal echogenicity
-homogeneous or heterogeneous appearance (with necrosis)
-possible acoustic enhancement

Front 212

Lymphoma

Back 212

*may be a primary or secondary disease
-primary lymphoma originates within the lymph nodes associated with the breast, especially the axillary or intramammary lymph nodes
-lymphoma arising from the lymphatic system somewhere else in the body and metastasizing to the breast is considered secondary or metastatic lymphoma (more common than primary lymphoma)

Front 213

Primary and Metastatic Lymphoma

Back 213

-make up less than 1% of breast cancer
-affects women ages 50 to 60
-usually presents as a palpable mass with palpable axillary lymph nodes
-cannot be differentiated from other breast cancer on mammo or sonography
-biopsy is warranted for definitive diagnosis

Front 214

What will ultrasound demonstrate with primary and metastatic lymphoma?

Back 214

-singular or multiple solid masses within the brease and/or axilla
-hypoechoic
-oval shaped mass indicates a singular lymph node
-large lobulated tumors likely represent multiple fixed lymph nodes
-smooth to irregular borders
-loss of definition of the fatty hilum of the lymph node
-possible acoustic enhancement

Front 215

Metastasis

Back 215

-cancer may metastasize to and from the breast through the lymphatic system,bloodstream or by direct invasion
*axillary lymph nodes are the most common lacation of nodal metastasis
-sentinel node procedures will help to determine the presence or absence of axillary node metastasis
-MRI is an excellent tool in evaluating lymph node metastasis
-Nuc Med bone scan and CXR are common procedures to evaluate the presence of bone and lung metastasis from breast cancer
-ultrasound and CT may also be used in the assessment and staging of primary breast cancer

Front 216

How does metastatic disease from primary breast cancer spread?

Back 216

-lymph nodes
-bone
-lung
-liver
-opposite breast

Front 217

Metastatic disease to the breast from another primary cancer.

Back 217

-is uncommon and accounts for less than 2% of cancers found in breast
-Metastasizes from:
*melanoma
-lymphoma
-lung
-sarcoma
-ovary
-opposite breast (likely lymphatic route)

Front 218

How will breast metastasis appear on sonography?

Back 218

-multiple, weel-circumscribed palpable masses
-hypoechoic
-usually located in the superficial fat layer
-often bilateral

Front 219

BIRADS (category of breast disease)

Back 219

-Breast Imaging Reporting and Data System

Front 220

BIRADS: Category 0

Back 220

-needs additional imaging
-represents inconclusive findings requiring additional evaluation including spot compression, magnification or special mammogrphic views, us, Mr, etc.

Front 221

BIRADS: Category 1

Back 221

-normal
-generally fatty replaced breasts that are without clinical breast probems
-routine follow-up

Front 222

BIRADS: Category 2

Back 222

-benign
-breast with dense tissue, implants or with many benign lesions, such as cysts, lymph nodes or fibroadenomas
-routine follow-up

Front 223

BIRADS: Category 3

Back 223

-probably benign
-findings that are very unlikely to be cancer (ie. round or oval solid masses)
-short term follow-up or biopsy is considered

Front 224

BIRADS: Category 4

Back 224

-suspicious
-findings that are often cancer (ie. irregular solid masses, microcalcifications, growth of a solid mass)
-biopsy considered

Front 225

BIRADS: Category 5

Back 225

-malignant
-most breast lesions that fall into this category are cancer (ie. spiculated mass, solid mass with nipple retraction or skin thickening)
-appropriate action should be taken

Front 226

MRI

Back 226

-MRI plays a significant role in evaluating breast disease
-often used as a follow-up to breast lesions found by mammo, physical examination or other imaging studies
*most accurate modality in evaluating the augmented breast
-useful for staging breast ca (especially evaluating the extent of lymph node involvement)
-studies are underway to investigate the use of MRI as a screening tool for women under age 40 (especially women with a strong family hx and/or positive BRCA1 and BRCA2 genes)

Front 227

What are the advantages of MR breast imaging?

Back 227

-creates image slices from any plane
-provides a landscape image
-demonstrates both breasts simultaneously
-effectively evaluates dense breasts
-sensitive to small lesions
-sensitive to malignant lesions with the use of contrast (Gadolinium) and fat and water suppression techniques
-detects breast implant ruptures (most accurate imaging modality)
-detects residual cancer after lumpectomy

Front 228

What are the disadvantages of MR breast imaging?

Back 228

-difficulty in distinguishing benign from malignant lesions
-cannot image microcalcifications
-requires the use of contrast injection
-claustrophobic patients may not tolerate the study
-more time consuming than mammo
-expensive and not widely available

Front 229

Ductography (Galactography)

Back 229

-effective means of imaging the lactiferous ducts of the breast
-in the case of suspicious, single-duct nipple dischargem this procedure is often done to iidentify an intraductal mass
*primary indication for ductography is nipple discharge in the non-pregnant and non-lactating patient

Front 230

What does ductography involve?

Back 230

-inserting a small needle (30 gauge) in the duct orifice where the discharge was noted
-a small amount of radiopaque dye is injected into the duct
-the duct is imaged under mammogrpahic or fluoroscopic technique
-a cranio-caudal (CC) mammographic view with light compression is often used

Front 231

Ductography findings

Back 231

-if the duct fills completely with no internal deviation of the dye, the duct is normal
-if the duct is obstructed or a "filling defect" is noted within the duct, the study is positive
-filling defects usually represent an intraductal papilloma
-approx. 1 in 10 studies reveal a papillary carcinoma

Front 232

Sentinel Node Procedure

Back 232

*uses a dye and radioisotope that are injected around a confirmed breast cancer
-by following the flow of dye and radioactivity to the lymph nodes, the sentinel node can be identified and biopsied
-if this node is free of cancer, chances are great the cancer has not metastasized to the lymph nodes
*sentinel node-first node that drains lymphatic fluid from a specific area of the breast
-usually found in the axilla

Front 233

What does a sentinel node procedure involve?

Back 233

-takes place 2 hours prior to surgery
-combination of dye, saline, and radioactive isotope
-physicain injects the solution into the breast tissues surrounding the confirmed cancer
-if the cancer is palpable, imaging guidance methods may not be necessary
-if the cancer is non-palpable, sonography may be used to help locate the cancer and guide injection techniques
-2 hours later in surgery, a gamma probe is used to trace the radioactive sentinel node
-through a surgical incision, the node is identified (via dye) and removed
-biopsy id performed with an immediate reading confirming the presence or absence of metastasis

Front 234

What happens if the sentinel node is cancer free?

Back 234

*there is a 95-100% likelihood of a clear axillary node basin
-axillary lymph node dissection (ALND) may be alleviated
-lumpectomy may be considered

Front 235

What happens if the sentinel node is cancerous?

Back 235

-ALND is warranted
-mastectomy is considered

Front 236

Histology

Back 236

-study of microscopic structures (cells) of normal and abnormal tissues
-hitology for evaluating breast disease follows a biopsy procedure
-ca classified based on the type of cells and patterns seen
-true tissue sample "as is"
-more accurate diagnosis-distinction can be made between invasive and noninvasive cancer
-more invasive retrieval
-expensive
-results in 2-3 days

Front 237

Cytology

Back 237

-peformed following a biopsy technique to evaluate tissue samples under a microscope for the presence of abnormal cells
-preparation involves a smear of cells on a slide taken froma Fine Needle Aspiration (FNA) technique
-possible false-negative
-less invasive retrieval
-cost effective
-results in 1-2 hours

Front 238

Types of Implants

Back 238

-most are filled with saline, silicone gel or a combination of both
-imprtant to understand the type of implant being imaged to offer an accurate diagnosis regarding complications
1.single lumen-silicone or saline
2.souble lumen-inner silicone, outer saline
3.revere double lumen-inner saline, outer silicone
4.smooth surface
5.textured surface
6.foam-filled implant
7.expandable implant (expander valve may be visualized)

Front 239

Implant Placement

Back 239

-breast implants may be surgically placed in one of two areas:
*subglandular-posterior to the parenchymal layer and anterior to the pectoralis muscles (most common location)
*subpectoral-posterior to the pectoralis major muscle

Front 240

Imaging implants under mommography

Back 240

-contradicted in the evaluation of breast implants
-the compression technique used to evaluate the non-augmented breast may not be used for fear of trauma and possible rupture of the implant
-capable of detecting silicone leakage and saline collapse
-relatively insensitive compared to MRI and ultrasound

Front 241

Imaging implants under MRI

Back 241

*most accurate imaging modality in the detection of implant rupture
-extremely effective in assessing the integrity of the implant and nearly all complications

Front 242

Imaging implants under sonography

Back 242

-provides excellent evaluationof the augmented breast
*effective in examining the exising breast tissue surrounding the implant for diease and also the implant for complications

Front 243

What is the appearance of implants under ultrasound?

Back 243

-both saline and silicone gel implants have an anechoic internal appearance
-single lumen implants appear large, oval and anechoic
-the inner bag of a double lumen implant is occasionally identified (not consistently)
-on close inspection of the anterior tissue/implant interface, 3 horizontal echogenic ares may be appreciated

Front 244

What do the three horizontal lines at the anterior tissue/implant interface represent?

Back 244

1.fibrous capsule-most anterior
2.anterior surface of the implant (entrance echo of the elastomer shell)
3.posterior surface of the implant (exiting echo of the shell)

Front 245

Imaging Implants and Artifacts

Back 245

1.Reverberation-common along the anterior surface of the implant; can present a challenge when attemtping to differentiate intracapsular rupture
2.Speed error-speed of sound through silicone is much slower (approx. 1/2 the spped) than through soft tissue
-posterior wall of the silicone imlpant appears much deeper in the chest wall than the surrounding tissue (this artifact is not a problem with saline implants

Front 246

Implant Complications

Back 246

-Implant rupture and silicone leakage have become the main focus of the investigation
-sonography and MRI have played a critical role
-once an implant is surgically inserted, a fibrous capsule of connective tissue usually forms around the implant; this capsule creates a barrier and further defines intracapsular vs. extracapsular ruptures

Front 247

What are the signs and symptoms of implant rupture?

Back 247

-change in appearance, shape and consistency of the breast
-hardening of the breast
-tenderness and burning sensation
-breast lump
-autoimmune diseases have been suggested (including rheumatoid arthritis)
-old implant (average age of rupture is 13 years)

Front 248

What are the complications of implant rupture?

Back 248

-hematoma
-abscess
-migration of the implant
-partial or total collapse
-silicone or saline bleed with an intact implant

Front 249

Capsular Contracture

Back 249

-the implant becomes fixed in the breast due to fibrosis
-causes the breast to become hard and painful
-may cause the presentation of a radial fold
-radial folds represent a folding or outside compression of the implant-usually not indicative of a rupture

Front 250

*Intracapsular Rupture

Back 250

-rupture of the implant shell (envelope) with the escape of silicone into the intact fibrous capsule
-accounts for 80% of implant ruptures

Front 251

*Extracapsular rupture

Back 251

-rupture of both the implant shell and fibrous capsule with the escape of silicone into the surrounding breast tissues
*silicone may then spread through the lymph nodes and to distant sites through the bloodstream

Front 252

What will ultrasound reveal with Intracapsular rupture?

Back 252

*stepladder sign
-series of parallel echogenic lines within the implant
-visualization of silicone between the implant shell and fibrous capsule

Front 253

What will MRI reveal with intracapsular rupture?

Back 253

*linguini sign
-wavy lines represent the ruptured implant shel within the fibrous capsule

Front 254

What will ultrasound reveal with extracapsular rupture?

Back 254

*snowstorm appearance
*represents a silicone granuloma (siliconoma)
-silicone in the soft tissues of the breast are rapidly walled-off by and inflammatory response forming a granuloma
-appears as noise or dirty shadowing

Front 255

What will MRI reveal with extracapsular rupture?

Back 255

*silicone granuloma or free silicone
*may also visualize a siliconized lymph node

Front 256

Saline Implant Rupture

Back 256

-presents much less of a clinical concern than silicone ruptures
*is usually diagnosed clinically due to rapid deflation and deformation

Front 257

Reduction Mammoplasty (Breast Reduction)

Back 257

-large portions of breast tissue are removed and the remaining tissues are pulled together leaving a swirled appearance
-a series of surgical incisions are along the inframammary fold, the 6'oclock position of the breast (from nipple to fold), and encircling the areola
-mammo demonstrates a swirling pattern and shadowing from scar formation

Front 258

Challenges of Breast Reduction

Back 258

-superficial and deep scar tissue may present as a palpable mass
-fat necrosis and oil cysts are common

Front 259

TRAM Flap

Back 259

-Transverse Rectus Abdoominis Myocutaneous Flap
-type of breast reduction commonly used following mastectomy from breast cancer
-uses pt own flesh to form a new breast
-one of the rectus abdominus muscles is used for blood supply, while a flap of skin and fat is removed from the suprapubic region of the abdomen will form the new breast
-no breast parenchyma-mammo no longer necessary
-MRI may be more helpful

Front 260

What is the role of sonography with invasive breast procedures?

Back 260

-has a unique advantage of real-time imaging during invasive procedures
-allows direct visualization of the needle tip as it approaches and enters the lesion

Front 261

Invasive Breast Procedure

Back 261

-transducer is placed directly over the mass
*needle is advanced along the long axis of the transducer parallel to the chestwall or at a slight angle
-often ohysician will advance the needle and control the transducer in concert

Front 262

Cyst Aspiration

Back 262

-an effective way of:
1.confirming the presence (diagnosis) of a cyst
2.therapeautically reducing a cyst

Front 263

When may a biopsy be required?

Back 263

-if aspirated fluid is suspicious
-if the cyst is not completely reduced
-if the cyst reoccurs several times

Front 264

Needle Localization

Back 264

-when lesions are non-palpable, needle localizations are performed to guide the surgeon to the correct location within the breast
-mammo or ultrasound guidance
-placement of a small, hollow needle at the site of a lesion
-wire is placed through the needle and into the breast at the site to be biopsied
-wire remains in breast until surgery
-surgeon follows wire directly to the lesion

Front 265

*Fine needle Aspiration (FNA)

Back 265

-usesa very thin (fine) needle, 18-25 gauge, attached to a syringe to withdraw a small prtion of tissue from a solid tumor
-with small, quick, agitating movements a number of cells may be aspirated into the needle
-tissue is smeared onto a slide for microscopic examination by a cytopathologist
-cance cells tend to break off more easily than benign or normal cells
-FNA:effective alternative to more invasive biopsy techniques
*FNA is not considered a true biopsy technique, considering it offers cytologic evaluation of individual cells rather than histologic evaluation of a core sample

Front 266

What are the advantages of an FNA?

Back 266

-does not require open surgical biopsy(less invasive)
-local anesthesia
-safe,cost effective
-minimal complications (small hematoma)
-results in 1-2 hours

Front 267

Wha are the disadvantages to an FNA?

Back 267

-inadequate tissue sample thru small needle
-possible false negative
-cytologic evaluation is less accurate than histologic evaluation

Front 268

Core Needle Biopsy (CNB)

Back 268

-usesa larger, 14 gauge needle to remove several cores of tissue rather than individual cells
-the arrangement of cells remain intact for accurate histologic evaluation
-several types of biopsy needles are available including tru-cut manual design (outdated), spring loaded "gun" design and echogenic needles for sonography guidance
-for lesions that are palpable, physicians can perform core biopsies with no imaging guidance
-stereotactic mammo and sonography are commonly used as guidance techniques

Front 269

What are the advantages of a core biopsy?

Back 269

-does not require open surgicak biopsy (less invasive)
-local anesthesia
-core sample is sufficient for accurate diagnosis (low false negative)
-histologic evaluation

Front 270

What are the disadvantages of a core biopsy?

Back 270

-greater risk of complications than FNAdense lesions may not be adequately sampled
-results in 2-3 days

Front 271

Mammotome

Back 271

-minimally invasive breast biopsy procedure superior to CNB and less invasive thann open surgical biopsy

Front 272

Describe the mammotome procedure.

Back 272

-use sonography or stereotactic mammo guidance
-the mammotome biopsy probe is mounted on an srticulated arm
-the probe uses a large (11 gauge) needle inserted through a 1/4 inch skin incision
-the probe is advanced to the location of the tumor and the articulated arm is locked in place
-the rotating cutting device and vaccum system retrieves mutiple tissue samples in one single pass
-large tissue samples are obtained for biopsy
-small lesions may be completely removed

Front 273

What are the advantages of a mammotome?

Back 273

-does not require open surgical biopsy (less invasive)
-greater accuracy of dense lesions
-larger tissue sample
-vacuum assisted
-one needle pass
-outpatient procedure
-local anesthesia
-small tumors may be completely removed

Front 274

What are the disadvantages of a mammotome?

Back 274

-greater risk of complications
-some healthy tissue is removed

Front 275

Advanced Breast Biopsy Instrument (ABBI)

Back 275

-percutaneous biopsy procedure offering both diagnostic and theraputic treatment of a breast mass
-uses a rotating circular knife to remove a cylinder of tissue larger than CNB and mammotome

Front 276

Describe the procedure of an advanced breast biopsy instrument.

Back 276

-patient lies in prone position on a specially designed table with an opening in the chest are
*uses computer-guided stereotactic mammo to pinpoint the lesion
-through a 1/2-1 inch skin incision, the ABBI instrument is advanced into the breast
-a 2 cm core sample is removed
-attempt is made to excise the entire lesion when possible
-specimen is examined for tumor completeness
-the breast is also re-examined mammographically to assure complete removal

Front 277

What are the advantages of an ABBI?

Back 277

*does not require sonographic guidance
-does not require open surgical biopsy (less invasive)
-pinpoint accuracy
-total excision of a tumor
-outpatient procedure
-local anesthesia

Front 278

What are the disadvantages of an ABBI?

Back 278

-greater risk of complications
-requires sutures to close incision
-healthy breast tissue is compromised

Front 279

Surgical Biopsy

Back 279

-has always been the absolut predictor and gold standard in the diagnosis of breast disease
-surgeon performs a surgical biopsy procedure using local, regional or general anesthesia
-incision is made through the skin of the breast to allow partial or complete tumor removal
-an incisional biopsy removes only part of the tumor for histologic evaluation
-an excisional biopsy removes the entire tumor and some surrounding tissue for histologic evaluation
-one of the safest surgical procedures performed in day surgery or outpatient surgery facilities

Front 280

What factors are breast cancer treatment options based on?

Back 280

-type of cancer
-stage of cancer
-age of the patient
-patients personal lifestyle

Front 281

Breast Cancer Staging

Back 281

-proces of gathering information from all diagnostic studies available to determine how widespread the cancer is
*staging is one of the most important factors in selecting treatment options

Front 282

TNM classification system

Back 282

-also used to help stage a cancer
1.T-Tumor (size and spread within the breast is considered)
2.N-Lymph Nodes (spread to the lymph nodes is considered)
3.M-Metastasis (involves spread to distant organs such as the lungs, bones or liver)

Front 283

Breast Cancer Treatment

Back 283

-once staging has occured, treatment can be considered

Front 284

What are the two main categories of treatment?

Back 284

1. Local-Regional Therapy:
-goal is to eradicate the disease in the breast and lymph nodes
-types include surgery and radiation therapy
2.Systemic Therapy:
-goal is to eradicate the disease in all parts of the body
-types include chemotherapy, hormone therapy, and others

Front 285

Lumpectomy

Back 285

-removal of the breast lump and a small amount of surrounding tissue
-10 to 20 lymph nodes are also removed and evaluated (axillary lymph node dissection-ALND)
-usually followed by Radiation Therapy
-is considered a type of Breast Conservation Therapy

Front 286

Total or Simple Mastectomy

Back 286

-removal of the breast
-usually not performed alone

Front 287

Modified Radical Mastectomy

Back 287

-removal of the breast (total mstectomy), lymph nodes (ALND), and pectoral fascia
-Gold standard for the treatment of breast cancer for decades

Front 288

Radical Matectomy

Back 288

-removal of breast, lymph nodes, pectoralis major and minor
-extremely disfiguring
-outdated (only performes in extreme cases)

Front 289

Axillary Lymph Node Dissection (ALND)

Back 289

-removal and/or sampling of lymph odes
-may be performed with lumpectomy or modified radical mastectomy
-metastatic progression of cancer through the axillary lymph nodes usually proceeds in an orderly manner through Level 1 (laterl to pectoralis minor muscle), Level 2 (posterior to pectoralis minor), then Level 3 (medial to pectoralis minor)
-typically surgeons perform a Level 1 and 2 ALND procedure
-if Level 1 and 2 nodes are cancer free, it is extremely unlikely level 3 nodes contain metastatic disease

Front 290

Radiation Therapy

Back 290

-a type of of local-regional therapy for breast cancer
-6 to 7 weeks of daily radiation treatments to the site of the tumor is common
-side-effects: radiation burn to the chest wall, treatment kills normal cells, fatigue

Front 291

Chemotherapy

Back 291

-type of systemic therapy for breast cancer
-uses ant-cancer drugs given intravenously(IV) or orally
-6 to 20 month treatments are common
-side-effects: fatigue, hair loss, nausea and vomiting, may kill bone marrow cells

Front 292

Hormone Therapy

Back 292

-tamoxifen is a popular ant-estrogen agent used to treat breast cancer
-because many tumors need estrogen to grow, tamoxifen attempts to block estrogen from reaching the tumor
-dose is one tablet daily
-side-effects: hot flashes, vaginal discharge, hair thinning and increased risk of endometrial cancer