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64 Cards in this Set
- Front
- Back
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Calcifications, malignant appearance
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• Invasive ductal carcinoma
• Ductal carcinoma in situ • Fat necrosis • Early vascular disease • Early fibroadenoma degeneration • Fibrous capsule adjacent to implant • Fibrocystic change • Artifacts: scratches, dust, fingerprints, static, antiperspirant, talc, ECG paste, tatoos, gold treatment for RA, crystallization of processing chemicals |
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Calcifications, benign appearance
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• Skin (dermal)
• Vascular (small “quirky”) • Degenerating fibroadenoma • Secretory calcification (duct ectasia, plasma cell mastitis) • Oil cyst (rim Ca++, egg shell calcification) • Milk of calcium • Adenosis • Foreign body • Dermatomyositis (rare) |
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Mass, circumscribed margins
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• Cyst
• Fibroadenoma • Phyllodes tumor • Intramammary lymph node: infection, inflammation, primary breast carcinoma, lymphoma, metastasis • Papilloma • Medullary carcinoma (young), mucinous carcinoma (old), papillary carcinoma, invasive ductal carcinoma NOS • Metastasis: lymphoma, melanoma, lung, contralateral breast primary, ovarian, gastric, RCC |
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Mass, indistinct margins
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• Carcinoma: invasive ductal NOS, medullary, mucinous, papillary, invasive lobular
• Biopsy scar • Fat necrosis (mass-like, cyst-like with fat density, architectural distortion, calcifications) • Abscess • Hematoma: post-surgical, blunt trauma, bleeding diathesis • Sclerosing adenosis, fibrous mastopathy (thyroiditis, diabetes mellitus, autoimmune disorders) |
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Mass, spiculated margins
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• Invasive carcinoma: lobular, ductal, tubular, maybe DCIS
• Radial scar (sclerosing duct hyperplasia, elastosis, indurative mastopathy) • Biopsy scar • Fat necrosis • Breast abscess • Sclerosing adenosis • Granular cell tumor (anterior), desmoid tumor (pectoralis fascia, rare but may be seen after trauma/surgery or in Gardner’s syndrome) |
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Subareolar mass
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• Papillary carcinoma, complex cyst
• Post-trauma (resolving seroma, hematoma) • Papilloma |
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Masses, multiple
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• Cysts (35-50 y/o)
• Fibroadenomas (<35 y/o) • Intramammary lymph nodes • Papillomas • Metastases, lymphoma • Multifocal or multicentric breast cancer • Skin lesions: moles, neurofibromatosis, keratosis, sebaceous/epidermal cysts |
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Masses, fat-containing
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• Oil cyst
• Fat necrosis • Lipoma (liposarcoma rare) • Galactocele • Hamartoma (fibroadenolipoma) • Intramammary lymph node • Steatocystoma multiplex (AD, multiple subcutaneous oil cysts, more common in males) |
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Architectural distortion
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• Carcinoma (especially tubular subtype)
• Radial scar • Post-traumatic fat necrosis (oil cyst, mass, AD, calcification) • Prior surgery (AD, trabecular thickening, skin thickening) • Prior radiation (AD, trabecular thickening, skin thickening) • Fibrocystic change |
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Asymmetry
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• Asymmetric breast tissue: NL variant, congenital mammary aplasia, Poland’s syndrome, surgical excision of breast bud (child), radiation (child), post-reduction mammoplasty. Assumes a different appearance in two views. If it’s not palpable, it’s B9
• Carcinoma (especially invasive lobular) |
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Diffusely increased breast density, trabecular thickening, skin thickening
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• Diffuse invasive carcinoma, inflammatory carcinoma
• Lumpectomy/surgical biopsies or axillary dissection (edema) • Radiation therapy (skin thickening, engorged lymphatics) • Mastitis or inflammation: acute related to lactation, chronic plasma cell mastitis related to extravasated secretions, TB (rare) • Dermatologic disorders: psoriasis • Generalized edema: CHF, cirrhosis, nephrotic syndrome, anasarca |
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Diffusely increased breast density, trabecular thickening
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• Interval weight loss
• Hormone replacement therapy • Generalized edema • Endogenous hormone production from adrenal or ovarian tumors |
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Axillary lymph nodes
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• Breast carcinoma metastatic to lymph node (contralateral or ipsilateral)
• Lymphoma (mass, diffuse increase in breast density) • Other malignancies • Reactive hyperplasia: infection or inflammation • Drugs or systemic diseases: gold therapy for RA, psoriatic arthritis, SLE, sarcoidosis |
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Single dilated duct/bloody nipple discharge
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• Duct ectasia
• Papilloma • Malignancy |
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Subtypes of ductal carcinoma
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• Invasive ductal NOS
• Tubular • Medullary • Mucinous • Papillary |
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Subtypes of DCIS
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• Comedo
• Cribiform • Micropapillary • Solid |
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Increased risk marker lesions
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1.5-2x: sclerosing adenosis, peripheral papillomas, proliferation without atypia, moderate florid ductal hyperplasia
4-5x: atypical ductal hyperplasia, atypical lobular hyperplasia, proliferative changes with atypia 8-10x: lobular neoplasia (LCIS), well-differentiated DCIS, atypical ductal hyperplasia with positive family history (1st degree relative) |
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Gynecomastia causes
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• Drugs: marijuana, cimetidine, reserpine, cardiac glycosides, exogenous estrogens for prostate CA
• Tumor: testicular seminoma, embryonal cell carcinoma, choriocarcinoma • Cirrhosis |
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MRI uses
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• Check extent of disease (multifocal)
• Help staging • Evaluate implants (rupture, gel bleed, migration of implant, capsular contraction), assess recurrence vs. scar after lumpectomy/radiation • Evaluate dense breast tissue |
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Spot compression to verify?
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Spot compression to verify a density is a true mass and better define margins
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Spot magnification to?
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Spot magnification to evaluate margins of a mass and check for microcalcifications
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US echogenicity is relative to
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US echogenicity is relative to subcutaneous fat
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US findings of benignity
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• Hyperechoic
• Macrolobulations • Oval (shorter than wide) • Thin, echogenic pseudocapsule |
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US intermediate findings
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• Isoechoic
• Mildly hypoechoic • NL sound transmission • Enhanced through transmission • Heterogeneous echotexture • Homogeneous echotexture |
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US findings suggesting malignancy
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• Spiculated margins
• Taller than wide • Angular margins • Shadowing • Branching pattern • Markedly hypoechoic • Duct extension • Microlobulation • Microcalcifications |
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ROLI (shape):
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ROLI (shape):
Round, Oval, Lobular, Irregular |
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C MOI S (margins):
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C MOI S (margins):
Circumscribed, Microlobulated, Obscured, Indistinct, Spiculated |
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High density
Equal density (isodense) Low density Fat-containing (radiolucent) |
High density
Equal density (isodense) Low density Fat-containing (radiolucent) |
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Calcification distributions
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Clustered, linear, segmental, regional, diffuse
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Core biopsy is contraindicated if
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Core biopsy is contraindicated if lesion is too close to chest wall/skin, in a very small breast, or if throw of needle is greater than compression of tissue
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• Low/intermediate suspicion before biopsy with B9 pathology:
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• Low/intermediate suspicion before biopsy with B9 pathology: 6-month follow up only to establish a new baseline
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• If B9 diagnosis, but does not correlate with imaging:
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• If B9 diagnosis, but does not correlate with imaging: excisional bx
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• If pathology shows high risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular neoplasia):
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• If pathology shows high risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular neoplasia): excisional bx
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• High suspicion before biopsy with DCIS pathology:
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• High suspicion before biopsy with DCIS pathology: excisional bx
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Evaluate focal asymmetric density by
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Evaluate focal asymmetric density by additional views (rolled, lateral), spot compression, and correlate with physical exam. This has a similar appearance in two views, but not the defined margins of a true mass
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focal asymmetry• If palpable,
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• If palpable, US to check for NL tissue and bx, if deemed necessary
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focal asymmetry• If not palpable and no US findings
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• If not palpable and no US findings, BI-RADS 3 with short-interval follow-up
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focal asymmetry• If palpable but no US abnormality
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• If palpable but no US abnormality, bx is recommended
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focal asymmetry• If on HRT,
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• If on HRT, consider discontinuing treatment and follow-up in 2-3 months
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Staging of breast cancer (TNM)
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• T1: <2cm, T2: 2-5cm, T3: >5cm, T4: any size with chest wall extension, skin edema/ulceration, inflammatory carcinoma
• N1: mobile ipsilateral LN, N2: fixed axillary LNs, N3: ipsilateral internal mammary LNs • M1: distant metastases |
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Notable breast cancer stages (0-4)
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• Stage 0: DCIS
• Stage 1: mass <2cm only • Stage 2A: <2cm with or w/out mobile axillary LNs • Stage 2B: <5cm w/out mobile axillary LNs • Stage 3B: inflammatory carcinoma, skin ulceration • Stage 4: distant metastases |
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Male breast cancer is probably not related to gynecomastia, and is more common in patients with?
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Kleinfelter’s syndrome, mumps orchitis after age 20, and Jewish background
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Skin lesions
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• Epidermal/sebaceous cyst
• NF-1 • Mondor’s disease (thrombophlebitis of thoracoepigastric or lateral thoracic vein) • Steatocystoma multiplex • Inflammatory carcinoma |
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Nipple-areolar complex
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• Nipple adenoma
• Hidradenitis suppurativa • Leiomyoma • Paget’s disease |
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Major duct lesions
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• Duct ectasia
• Solitary papilloma • Papillary carcinoma |
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Terminal duct lesions
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• Hyperplasia
• Multiple peripheral papillomas • Radial scar/complex sclerosis lesion (>1 cm) • Ductal adenoma • DCIS • Invasive ductal carcinoma • Tubular, medullary, mucinous, invasive cribiform, adenoid cystic, SCC, metaplastic, secretory carcinoma |
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Lobules lesions
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• Cysts
• Galactocele • Juvenile papillomatosis • Fibroadenoma • Complex fibroadenoma (cysts, sclerosing adenosis) • Juvenile fibroadenoma • Phyllodes tumor • Tubular adenoma • Lactating adenoma • Sclerosing adenosis • Lobular neoplasia • Invasive lobular carcinoma |
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Stroma lesions
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• Fat necrosis
• Lipoma • Hamartoma • Fibrosis • Mastitis/abscess • Pseudoangiomatous stromal hyperplasia • Sutural calcification • Hemangioma • Diabetic fibrous breast disease • Extra-abdominal desmoid • Lymphoma • Angiosarcoma • Metastases: contralateral breast, melanoma, lung, ovary, stomach, cervical cancer |
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Preoperative needle localization
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in nonpalpable lesion or to ensure 1-to-1 correlation with mammographic and clinical lesion. Use mammography, US, stereotactic system. Needle-wire combination (lengths 3, 5, 7, 9, 11, 15 cm) with hook wire, j-wire or Hawkins retractable barb. Decide what type of needle-wire, needle length, approach AP or parallel to chest wall). Use compression paddle with fenestration and alphanumeric grid.
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1. If patient has undergone a mastectomy
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1. If patient has undergone a mastectomy, a clinical breast exam is all that is necessary for follow-up
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2. A follow-up mammogram is recommended 6 months post-biopsy to
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2. A follow-up mammogram is recommended 6 months post-biopsy to establish a new baseline. Re-biopsy if there is increased density or distortion at the site
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3. A biopsy site should
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3. A biopsy site should remain stable or decrease in size/density over time
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ductagram what to use
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5. Use Conray 60 and 30g blunt-tipped sialography needle for ductagram
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6. A “complex fibroadenoma” has
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6. A “complex fibroadenoma” has cysts, sclerosing adenosis
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7. On the CC view, one sees
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7. On the CC view, one sees the pectoralis muscle in 20-40 cases. If not seen, look for cleavage, retroglandular fat laterally
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8. On MLO view,
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8. On MLO view, the breast is pulled up and out to open the inframammary fold. May include a small amount of abdomen, but should have a convex pectoral muscle. Always check the posterior nipple line
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10. The average glandular dose
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10. The average glandular dose (with 4.2 cm compression) is 0.3 rads/view using film-screen technique
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11. Tubular carcinoma is multicentric in
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11. Tubular carcinoma is multicentric in ~28% cases
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13. If a pneumocystogram is desired
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13. If a pneumocystogram is desired after an atypical cyst aspiration, simply use 1/2 the amount of aspirated fluid
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14. If there are islands of breast tissue in a non-anatomic distribution,
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14. If there are islands of breast tissue in a non-anatomic distribution, consider reduction mammoplasty
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15. The differential diagnosis for inflammatory carcinoma
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15. The differential diagnosis for inflammatory carcinoma is XRT, mastitis, edema, lymphatic obstruction, trauma, post-lumpectomy, invasive lobular carcinoma
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16. Mimics of DCIS calcifications
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16. Mimics of DCIS calcifications include sclerosing adenosis, atypical ductal hyperplasia, fibroadenoma, papilloma
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17. Weight loss, HRT, and lactation increase
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17. Weight loss, HRT, and lactation increase breast density, while weight loss and tamoxifen (used in Europe to treat severe fibrocystic change) decrease breast density
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20. Mondor’s disease
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20. Mondor’s disease (superficial thrombophlebitis) usually involves the thoracoepigastric or lateral thoracic vein
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