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119 Cards in this Set
- Front
- Back
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Mammographic signs of malignancy
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Spiculated mass. Pleomorphic microcalcifications. (40% of breast cancers)
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Definition of breast mass
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Space occupying lesion seen in two different projections. Convex borders. Distorts normal architecture. Increased central density.
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Definition of breast focal asymmetry
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Confined asymmetry with similar shape on two views. Lacks borders conspicuity of a true mass.
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Definition of breast asymmetry
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Space occupying lesion seen in only one view.
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Descriptors of breast mass (5)
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Size. Morphology. Associated calcifications. Associated findings. Location.
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Descriptors of breast shapes (4)
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Round. Oval. Lobular. Irregular.
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Descriptors of breast margins (5)
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Circumscribed (>75%). Microlobulated (undulated). Obscured. Indistinct (ill-defined). Spiculated.
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Definition of circumscribed breast mass
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>75% of mass is circumscribed (well-defined).
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Definition of obscured breast mass
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Border is likely circumscribed but hidden by normal tissue.
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Descriptors of breast density (4)
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High. Equal. Fat-containing radiolucency. Non-fat-containing radiolucency.
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Differential for breast mass with spiculated margins and or architectural distortion (4)
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Breast cancer. Fat necrosis. Scar. Radial Scar.
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Definition of Radial Scar/Complex Sclerosing Lesion
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Central sclerosis with varying degrees of epithelial proliferation (precancerous).
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Differential for well-defined mass (6)
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Cyst. Fibrosis. Fibroadenomas. Breast cancer. Lymphoma. Metestases.
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Differential for multiple bilateral masses (5)
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Cysts. Fibroadenomas. Multiple Papillomas. Metastises. Multifocal breast cancer.
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Differential for ill-defined breast mass (3)
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Breast cancer. Abscess (usually subareolar in lactating women). Spontaneous Hematomas (coagulopathy).
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Differential for fat-containing radiolucent breast mass (5)
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Oil cyst (result of trauma). Lipoma. Galactocele. Hamartoma. Fibroadenolipoma.
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Description of a breast fibroadenoma
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Most common well-defined homogeneous solid mass. Large, coarse and irregular calcifications.
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Descriptors of calcifications (4)
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Morphology (shape). Distribution. Associated findings. Location.
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Benign breast calcifications (10)
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Skin/lucent center. Vascular. Coarse/Popcorn. Large/Rod-like. Round (small less than 1 mm, punctuate less than 0.5 mm). Eggshell/Rim. Milk of calcium. Suture. Dystrophic.
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Milk of calcium
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Sedimented calcifications in macro/microcysts. Amorphous on cranial caudal view. Semilunar, crescent, tea cup shaped on medial lateral oblique view.
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Coarse popcorn calcifications
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Involuting fibroadenoma.
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Large rod-like calcifications
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Ductal ectasia and/or secretory calcifications.
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Lucent centered calcification
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Fat necrosis or calcified debris in ducts.
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Eggshell/rim calcifications
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Fat necrosis. Calcifications within wall of cysts
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Dystrophic calcifications
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Post trauma. Radiation changes.
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Dot-dash or casting calcifications
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Comedocarcinoma type of intraductal carcinoma.
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Intermediate concern breast calcifications (2)
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Amorphous/Indistinct. Coarse heterogeneous (>0.5 mm but not the size of dystrophic calcifications).
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High probability breast calcifications (2)
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Fine pleomorphic (varying in size and shapes, less than 0.5 mm). Linear or branching (suggests filling of involved duct).
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Calcification distribution modifiers (5)
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Diffuse/Scattered. Regional. Grouped/Clustered. Linear. Segmental.
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Definition of regional distribution
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Scattered in large volume (>2cc) of Breast tissue. Does not conform to duct distribution. Less likely to be malignant.
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Definition of grouped/clustered distribution
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At least 5 calcifications occupy small volume (less than 1 cc).
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Definition of segmental distribution
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Calcifications distributed in ductal distribution. Worrisome for malignancy.
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Definition of architectural distortion
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Distorted architecture without definite mass. Suspicious for malignancy or radial scar, if no prior trauma or surgery.
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Significance of asymmetric tubular structure/solitary dilated duct
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Little as long as no other findings.
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Intramammary lymph node
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Typically reniform with radiolucent notch. Typically within upper outer breasts. Intramammary lymph nodes less than 1 cm.
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Definition of global asymmetry
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Greater volume of Breast tissue in one breast relative to the other. No mass, distorted architecture or associated suspicious calcifications.
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Associated breast findings (6)
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Skin retraction, Skin lesion, Skin thickening (>2 mm), Nipple retraction, Trabecular thickening, Axillary adenopathy (> 2cm, non-fatty replaced are worrisome)
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Descriptors of mammography location (3) and depth (3)
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Subareolar, Central, Axillary tail. Anterior, Middle, Posterior.
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Descriptors of Breast composition (4)
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Almost entirely fat (less than 25% glandular). Scattered fibroglandular densities (25-50%). Heterogeneously dense (51-75%). Extremely dense (>75%).
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BIRADS Classification
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0, Incomplete. 1, Negative. 2, Benign Findings. 3, Probably Benign (3-94%). 4, Suspicious abnormality (A,B,C). 5, Highly suggestive (>95%). 6, Proven malignancy.
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BIRADS 3
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Probably Benign. Less than 2% chance of malignancy. Low grade cancer if present.
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Imaging decisionin patient less than 30 years with palpable abnormality
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1st: US. 2nd: Single oblique view (only if necessary).
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Breast US, background echotexture descriptors (3)
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Homogeneous: fibroglandular or fat. Heterogeneous: typically occurs in younger patients.
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Breast US, Mass Shapes (3)
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Oval. Round. Irregular.
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Breast US, Orientation descriptors (2)
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Parallel (wider than tall). Not Parallel.
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Breast US, Margin descriptors (5)
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Circumscribed. Indistinct. Angular. Spiculated. Microlobulated.
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Breast US, Lesion boundary descriptors (2)
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Abrupt. Echogenic: no sharp demarcation between mass and surrounding tissue.
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Echo Patterns (5)
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Anechoic. Hyperechoic. Complex. Hypoechoic. Isoechoic.
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Posterior Acoustic Features (4)
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None. Enhancement (echogenic deep to mass). Shadowing (echopenic deep to mass). Combined.
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Breast US, Clustered Microcysts (2)
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Fibrocystic changes. Apocrine metaplasia: Tiny anechoic foci (less than 2 to 3 mm) with thin (less than 0.5 mm) septations.
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Differential for mass in or on skin (6)
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Sebaceous or epidermal inclusion cysts. Keloids. Moles. Neurofibromas. Accessory nipples.
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Breast US, Normal lymph node appearance
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Reniform (hypoechoic cortex and echogenic fatty hilus). Axillary LN typically less than 2 cm.
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Differential for abnormal lymph nodes (7)
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Metastatic disease. Infectious. Connective tissue disorder (RA, Sarcoidosis). Lymphoma. Leukemia. Granulomatous disease (calcifications).
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Breast US, BIRADS 3
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Solid mass with circumscribed margins, oval shape and parallel orientation. Likely fibroadenoma, nonpalpable complicated cysts, or cluster of microcysts.
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Breast MR, Focus versus Foci
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Small (less than 5 mm) isolated spot(s) of enhancement. Not seen on precontrast images.
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Breast MR, Non-mass-like enhancement descriptors (7)
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Focal area. Linear. Ductal. Segmental. Regional. Diffuse. Multiple areas of enhancement.
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Breast MR, Focal area definition
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Internal enhancement. Non-mass like. Occupies less than 25% of breast quadrant.
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Breast MR, Difference between linear and ductal enhancement
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Ductal: resembles a line on 2 views, points towards nipple. Linear: resembles a sheet rather than a line.
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Breast MR, Difference between segmental and regional enhancement
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Segmental: triangular enhancement with apex towards nipple, suggests ductal morphology. Regional: geographic enhancement, not conforming to a duct.
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Breast MR, Internal MR enhancement patterns (5)
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Homogeneous. Heterogeneous. Stippled/Punctate. Clumped. Reticular/Dendritic.
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Breast MR, Kinetic Curve
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Initial phase: Slow, Medium, Rapid. Delayed phase: Washout (malignant), Plateau (either), Persistent (benign).
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Breast MR, Screening population selection criteria
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>25% risk, based on family history, PMH, etc.
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Risk factors for Breast cancer (6)
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Personal History. Age. Mother, Sister, Daughter with breast cancer. Atypical or precancerous lesions on biopsy. Nulliparity or first child at or older than 30 years.
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Expected outcomes in group of 1000 asymptomatic women
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80 require additional studies. 17 biopsied. 6 cancers.
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Percent of breast cancer not detected at mammography.
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9-16%.
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Percent of malignancies found with biopsy of mammographically suspicious abnormalities
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25-35%.
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Mammography radiation risk
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Life time risk of breast cancer from 1 mammogram. 40-49 y/o: 2/mil, 50-59 y/o: 1/mil. Risk of dying from Breast cancer, 40-49: 700/mil, 50-59: 1000/mil.
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Convention labeling of Breast radiographs
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Marker (l/r/cc/mlo) always placed by axillary tail/lateral breast.
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MLO view
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Depicts most tissue. Must visualize posterior nipple line (perpendicular line from pec through nipple) and inframammary fold.
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CC view
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Pec visualized central on the film (only occurs at 30%) with nipple in profile at 1 cm from image edge.
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Associated with indeterminate calcifications
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Fibrocystic Change. Fibrosis adenosis. Sclerosing adenosis. Epithelial hyperplasia. Cysts. Apocrine metaplasia. Atypical hyperplasia.
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Differential for increased breast density
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Hormone therapy (bilateral). Inflammatory cancer (skin thickening). Radiation therapy (at 6 months). Diffuse mastitis. Lymphatic/venous obstruction.
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Intracapsular versus Extracapsular implant Rupture
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Intravascular: contained. Extravascular: free. Mammography can't detect intracapsular silicone rupture (MR).
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Description of Gynecomastia
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Triangular or flame shaped area of subglandular tissue with interspersed fat. Unilateral more common than bilateral.
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Causes of gynecomastia
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Chronic liver disease. Meds (cimetidine, thiazides, digitalis). Marijuana. Testicular, adrenal, or pituitary tumor.
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What view is used to assess the tail of Spence?
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XCCL view
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What view is used to determine dermal location of lesions?
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Tangential view
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Duct dilation > 2 mm in diameter and extending >2cm in length are usually due to what?
Symmetrical duct ectasia is considered benign or malignant? |
Benign ductal ectasia
Benign. |
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Breast lesions that arise in main segmental ducts? (2)
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Papillomas
Papillary cancer |
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Breast lesions that arise in the terminal ducts? (4)
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Peripheral papillomas
epithelial hyperplasia DCIS Invasive ductal carcinoma |
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Lymph node calcification differential (3)
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Metastasis (most common)
Lymphoma Rheumatoid arthritis and previous gold injections. |
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Asymmetrical breast tissue can be normal unless what?
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Unless it is palpable or has associated
-mass -calcifications, -architectural distortion, -asymmetry developed over time. |
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If given a birads 3 category, what is the percent risk of malignancy?
What are examples in this category? |
<2%
Noncalcified circumscribed solid mass, focal asymmetry, and cluster of round/punctate calcifications. |
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Evaluation with short term followup less than 6 months is usually never useful, except with what lesion?
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Hematomas would show signs of regression at 3 months.
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Palpable lump in a patient <28 years old most likely represents what?
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a fibroadenoma
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How do fibroadenomas usually appear in Ultrasound?
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hypoechoic and well circumscribed.
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What are MR characteristics of silicone?
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Long T1 and Long T2
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Indications for core needle biopsy (3)
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1. solid mass lesion in young patient that is most likely benign.
2. solid mass lesion that is most likely malignant. 3. some may biopsy suspicious calcifications but this is not universally accepted. |
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Positive supraclavicular and internal mammary nodes are considered what?
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Distant metastases
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Cancer fixed to the pectoralis is what stage?
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3
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Most common mets to the breast
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Melanoma
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3 tumors with the breast prognosis
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Tubular
mucinous medullary |
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does LCIS increase risk of cancer?
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yes, 30% eventual risk of either ductal or lobular cancer.
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specific type of ductal carcinoma that is soft to palpation due to lack of desmoplastic reaction. Also typically absent calcifications.
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Medullary carcinoma
-also may get very large. |
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Ductal carcinoma that typically presents with bloody discharge.
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Papillary carcinoma
- usually large at diagnosis but have slow growth rate. |
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Most benign of ductal carcinomas
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Tubular carcinoma.
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What percent of phyloddes tumors will metastasize?
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10 % metastasize
25% recur |
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Metastases usually have calcifications? T/F?
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False
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Most reliable mamographic signs of malignancy (2)
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mass with spiculated or ill-defined margins
malignant calcifications |
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1. Fibrocystic change that increases risk for developing cancer by 5 times.
2. Increased risk by 2x? 3. no increased risk? |
1. Atypical hyperplasia
2. Hyperplasia, sclerosig adenoma 3. Cysts fibroadenoma, fibrosis, adenosis, duct ectasia, mild hyperplasia, mastitis, metaplasia |
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Most common intracystic neoplasm
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Papillary carcinoma
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Are fibroadenomas sensitive to hormonal influences?
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yes. Enlarge during pregnancy and involute during menopause.
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Between papillomatosis and intraductal papilloma, which increases risk for malignancy?
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Papillomatosis.
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What are the four views used to screen those with breast implants?
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routine CC and MLO
Implant displaced CC and MLO (Ecklund) |
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How do implants appear on ultrasound?
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usually hypoechoic
*have a snowstorm or stepladder appearance with ruptures. |
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Post radiation diffuse density (edema) of the breast is most pronounced when?
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at 6 months and usually gone at 24 months.
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Does gynecomastia predispose a male to breast cancer?
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No
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Giant masses (>5 cm)
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Hamartoma (older patients)
cystosarcoma phyllodes Giant fibroadenoma (young patients) Abscess |
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DDX nipple discharge
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1. Papilloma (most common)
2. Duct ectasia (2nd) 3. cancer (5% of cancers as solitary finding) 4. papillomatosis, fibrocystic changes |
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Ring-like peripheral calcification in mass (4)
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Fibroadenoma
calcified cyst oil cyst fat necrosis |
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First round screening (prevalence) detects how many cases of cancer?
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6-10 per 1000
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What percent of breast cancers have known genetic etiology?
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25%
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How do dense breasts affect risk of cancer?
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Dense breasts have been shown in some studies to have an increased risk of breast cancer—four to six times the rate of less dense breasts.
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WHat is the nipple-to-pectoralis line?
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The nipple-to-pectoralis line (NPL) is a measure- ment on the MLO view from the nipple straight back to the edge of the muscle, perpendicular to the axis of the pectoralis. The NPL length measured on the MLO view is then compared to the nipple to film edge on the cranial caudad view. 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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On what view is motion blur most likely to occur?
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inferior breast on MLO views
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What is the sternalis muscle?
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The sternalis muscle is an uncommon variant of the chest wall musculature that may be seen mammo- graphically and misinterpreted as a mass or tumor. This thin slip of muscle runs longitudinally along the medial border of the sternum.
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How often are ILC bilateral? should other breast be imaged?
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LC has a higher inci- dence of being multicentric or bilateral than invasive ductal carcinoma. Some authors suggest that the bilat- erality is approximately 10–15%. Therefore, imaging evaluation of the contralateral breast is imperative.
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WHere are intramammary lymph nodes usually located?
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upper outer breast
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What modality has the highest sensitivity and specificty for diagnosing intracapsular implant rupture?
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MRI
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