• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

Card Range To Study



Play button


Play button




Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

292 Cards in this Set

  • Front
  • Back
-composed of epidermis and dermis layers
-thickness (.5-2 mm)
-slightly thicker in young females and thins with age
-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)
-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)
subcutaneous (premammary) layer
-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)
superficial fascia
-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
mammary layer
-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
-smallest functional unit of the breast
-milk producing glad
-hundreds of acini in each breast -each acini gives rise to a terminal duct
TDLU(terminal duct lobular unit)
-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
-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
lactiferous ducts
-transport milk from the acini to the nipple
-begin with the terminal duct which arises from the acini
mammary layer
-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
cooper's ligaments
-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
deep fascia
-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
retromammary space
-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
Pectoralis Major
-arises from the clavicle and costal cartilage of the sternum attaching to the proximal humerus
-located anterior to the pectoralis minor
pectoralis minor
arises from the 3rd, 4th, and 5th ribs attaching to the scapula
chest wall
-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
abscence of one or both breasts
accessory breast or more than two breast
absence of nipple
acessory nipple
*most common developmental anomaly
absence of the breast tissue with the development of the nipple
unilateral early ripening
assymetrical growth of the breasts
what are two other developmental anomalies that may occur with the breast?
nipple flattening and nipple inversion
name two main arteries that supply blood to the breast.
1.lateral thoracic artery
2.internal mammary artery
lateral thoracic artery
-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
internal mammary artery
(internal thoracic artery)
-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
What two secondary sources supply blood to the breast tissues?
1. thoracoacromial artery-supplying a superior region
2. intercostal artery-supplying the inferior region
What are the anatomic layers of the breast from anterior to posterior?
2.subcutaneous (premammary) layer
3.mammary layer
4.retromammary space
5.muscle layers (pectoralis major and minor)
6.chest wall (ribs and intercostal muscles)
What are the two venous systems that drain the breast tissues?
superficial veins
-located just deep to the superficial fascia
-allows venous communication to occur between the right and left breasts
deep veins
-include small branches that drain into the internal mammary vein, axillary vein, subclavian vein, and intercostal veins
venous drainage
-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
lymphatic drainage
-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
What are the six groups that make up the axillary lymph node chain?
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
the remaining 25% of lymphatic drainage include?
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
list the nerves of the breast
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
-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
-stimulates elongation of mammary ducts, growth of the connective tissue, increase in adipose tissue, and increased vascularity
stimulates growth of TDLU's
-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
-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
-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
What are the three steps to examing the breast?
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
examining the breast
-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
Medio-Lateral Oblique (MLO) view
*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
Cranio-Caudal (CC) view
-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
Lateral (LAT) view
-true lateral view with the x-ray beam parallel to the floor
-mos accurately demonstrates pathology located in the superior or inferior quadrants
Spot Compression
-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
Valley (cleavage) view
-view of the medial (inner) portions of the breasts
-valuable when there is a lesion suspected in the most medial portion of the breast
Axillary Tail View
-similar to the MLO, more focused on the tail of spence
Rolled Views
-atempts to displace the breast tissues to confirm a lesion
LAT view location
-above the nipple is the superior region of the breast; below the nipple is the inferior
-no knowledge of superior and inferior
CC view location
-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
MLO view location
-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)
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
Fat Density
-structures are radiolucent
*fat, fatty cysts, lipomas (benign)
-mixed fat and water density structures: lymph nodes, galactocele (benign), fibroadenolipoma (benign)
Water Density
-glandular tissue,connective tissue (stroma), lactiferous ducts, pectoralis major muscle, *cysts, hematoma,*fibroadenoma (benign), phyllodes(benign or malignant), *maliganant tumors
Calcium Density
-calcifications (both benign and malignant)
-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
-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
Typical calcifications
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
suspicious calcifications
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
Calcification patterns
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
What is a targeted breast exam?
ultrasound used to evaluate a specific area
Breast Sonography
-higly valuable in the diagnosis and management of breast disease
-not helpful as a screening tool for breast cancer or for evaluating calcifications
What are the indications for breast sonography?
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
What does the pateint history for a sonographic exam include?
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
What should the sonographer include during a visual inspection of the breast?
1.size,shape,contour and symmetry
2.skin redness,edema,dimpling or retraction,protrusions and thickening
3.nipple retraction and discharge
4.surgical scars
If a palpable lump is noted what should the sonographer document?
4.consistency of lump
6.distance from the nipple
7.date when first discovered and change over time
Sonographic examination
-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
Scan Planes
-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
Stand-off pad
-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
List some types of stand-off pad techniques
1.commercially produced gel pads
2.water bag
3.large "glob" of gel
4.stand-off transducer attachments
Normal Sonographic Appearance
-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
*What are the breasts composed of?
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)
-improves image quality,eliminates artifacts
-can be used to evaluate effects on a mass
What happens when compression is applied?
*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
-nay see slight increase in echogenicity at gel/skin interface (sound beam enterance) and the skin /superficial fat interface (exit)
-medium gray, found within the superficial layer, parenchymal layer and retromammary layer
*all structures are compared to the mid-level echogenicity of fat
Cooper's Ligaments
-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)
Glandular Epithelium
-isoechoic to mildly hypoechoic
-consists of TDLUS and acini found within the parenchymal layer
Dense Fibroglandular Tissue
-fibroglandular tissues are a combination of glandular epithelium and both loose and dense connective tissue in the parenchymal layer
Lactiferous Ducts
-hypoechoic with hyperechoic striations
-found deep to the retromammary layer
-hyperechoic with posterior shadowing found deep to the retromammary layer
Lymph nodes
-hypoechoic with hyperechoic fatty hilum
-oval or kidney shaped
markedly hyperechoic
-anechoic to hypoechoic
-simple cysts will appear anechoic and complex or debris-filled cysts will appear hypoechoic
Benign Lesions
-mildly hypoechoic, isoechoic, or mildly hyperechoic
-in general, benign lesions are similar to the echogenicity of the fat and the epithelium
malignant lesions
-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
echo palpation
*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
-vibration of tissues (usually in the chest) detected during speech
-can be used to evaluate breast tissues
Fremitus technique
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
What is the shape and orientation of benign diseases?
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)
What are the margins of benign disease?
1.Smooth, well-defined, or circumscribed-indicates the tumor is displacing adjacent tissues rather than invading
2.Macrolobulation-gentle, large lobulations
What is the border thickness for benign disease?
thin, echogenic pseudocapsule caused by compression or rimming of adjacent tissues around the lesion (instead of invasion)
What is the echogenicity of benign disease?
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
What artifacts are involved in benign disease?
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
What does the doppler flow consist of in benign diseases?
-cysts have no internal flow
-benign solid masses demonstrate no flow or are hypovascular(little doppler signal)
-inflammation may demonstrate hypervascularity (increased doppler signal)
Fibrous planes in benign disease
-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
Ducts in benign disease
-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
Describe the calcifications in benign disease.
-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
Describe the shape and orientation of malignant disease.
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
Describe the margins of malignant disease.
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)
Describe the border thickness of malignant disease.
-thick echogenic halo
*usually indicates tumor invasion with fibrotic host response (despoplasia)
Describe the echogenicity of malignant disease.
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
Describe the artifacts of malignant disease.
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
Describe the doppler and malignant disease.
-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
Describe the fibrous planes and malignant disease.
-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
Describe the ducts and malignant disease.
-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
Describe calcifications and malignant disease.
-small microcalcifications (often assoiciated with malignancy)
-may be visualized within a tumor
Simple Cysts
-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
Simple Cysts
Can Be:
1.single or multiple
2.unilateral or bilateral
3.variable size
4.palpable or non-palpable
5.silent or painful
Simple Cysts On Mammo
-round or oval
-smooth (circumscribed margins)
-radiopaque-water density
-halo sign (lucent rim of fat)
Simple Cysts On Sonography
-round or oval
-smooth margins
-sharp borders
-acoustic enhancement
-may have edge shadowing
-occasionally lobulated
-no internal doppler signal
What may cause artifacts within a cyst?
-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)
What is a complex cyst?
-cysts that contain internal echoes or changes in the cystic wall
List the types of complex cysts.
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
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
What may complex cysts demonstrate?
-low to medium level echoes
-heterogeneous internal appearance
-gravity dependent fluid-fluid levels
-total or partial wall calcifications
-partial enhancement or shadowing
-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
What does sonography reveal about a galactocele?
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
Sebaceous cyst
*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
What does sonography reveal about a sebaceous cyst?
2.hypoechoic to isoechoic(oily sebum)
3.superficial location (stand-off pad)
4.acoustic enhancement
5.no internal doppler signal
Fibrocystic Changes
*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
What may ultrasound reveal with fibrocystic changes?
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
*most common benign solid tumor of the breast
-estrogen related (ages 20-40)
-arise from the epithelial and stromal tissue of the breast
List the common characteristics of a fibroadenoma.
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
What does a fibroadenoma look like on mammo?
-radiopaque-water density
-may have halo
may have calcifications
-unable to differentiate from cyst
What does fibroadenoma look like on ultrasound?
*round,oval, or lobulated
-well-defined borders
-mildly hypoechoic or isoechoic
*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
Juvenile Fibroadenoma
-adolescent girls
-highly cellular type of benign fibroadenoma
-grow rapidly (up to 5 cm)
-doppler signal could be increased (to accomodate growth)
Giant Fibroadenoma
-6 cm or larger
-appear the same as smaller fibroadenomas
-increased vascularity due to size
Intraductal Papilloma
-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
What are the characteristics of an intraductal papilloma?
1.typically located in the subareoalar region
2.may be single or multiple(papillomatosis)
3.usually <2 com
5.tumor may cause duct obstruction
6.most frequent symptom is nipple discharge (serous or bloody)
7.ductography may be helpful in the diagnosis
What is a ductogram?
-an injection of contrast into the lactiferous duct demonstrates "filling defect"
-confirms intraductal papilloma or papillary carcinoma
Describe an intraductal papilloma on ultrasound?
-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
Intracystic Papilloma
-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
Describe an intracystic papilloma.
-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
Juvenile Papillomatosis (Swiss Cheese Disease)
-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
Describe an juvenile papillomatosis on ultrasound.
-hypoechic, ill-defined mass
-heterogeneous appearance
-may have visible cysts and/or duct ectasia
-encapsulated tumor of mature adipose tissue
-typically arises from the subcutaneous fat layer
-usually located superficially
clinically:soft,compressible,mobile masses
Describe a lipoma on mammo.
-radiolucent,circumscribed, thin capsule
Describe a lipoma on ultrasound.
-oval and well-defined
-usually superficial
-isoechoic (although hyperechoic and hypoechoic lesions are seen)
-may be mistaken for a fat lobule
*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
How does a fibradenolipoma appear on ultrasound?
-well-defined, pseudocapsule
-oval or lobulated
-echogenicity depends on amounts of fat,fibrous, and glandular tissue
-possible shadowing
-maybe quite large
-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
Acute Mastitis
-firm, tender, swollen breast
-localized skin thickening,redness,purulent discharge,tender axillary lymph nodes, leukocytosis and fever
What does ultrasound reveal with acute mastitis?
-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)
-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
What does ultrasound reveal with an abscess?
-complex,predominantly cystic mass
-thick, irregular borders
-acoustic enhancement
-localized skin thickening
-increased dopplersignal at the periphery (increased vascularity)
*Plasma Cell Mastitis (Penductal Mastitis)
-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
What will ultrasound reveal with plasma cell mastitis?
-dilated ducts with internal debris or wall thickening
-localized skin thickening
Skin Thickening
-usually .5-2 mm
-interruption of the dermis layer is suspicious for carcinoma
*stand-off pad is extremely useful in evaluating skin thickness
What may skin thickening suggest?
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
Nipple Discharge
-may be accidental or due to disease
-may be seen in non-lactating and non-pregnant females
-usually arises from a single duct
-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.)
Purulent Discharge
-have the characteristic appearance of pus as a result of breast inflammation
-usually unilateral and arise from multiple ducts
What breast diseases cause nipple discharge?
1.Benign-intraductal papilloma,duct ectasia
2.malignant-intraductal papillary carcinoma
List the types of discharge that may indicate breast cancer?
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
-diagnostic procedure of choice in evaluating patient with suspicious nipple discharge
Breast Trauma:Fat Necrosis
-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)
Breast Trauma:Hematoma
-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
Breast Trauma:Lymphocele
-may occur following breast surgery
-represents a cystic tumor filled with lymph fluid
-imaging features are similar to a simple or complex cyst
Breast Trauma:Post-operative scanning
-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
What may ultrasound reveal with post-operative scanning?
-thin shadow from the skin surface
-spiculated,fixed,hypoechoic mass with shadowing
-doppler demonstrates no increase in flow
Sclerosing Adenosis
-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
Radial Scar
-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
Mondor's Disease
*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
Precocious Puberty
-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
*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
What are the causes of gynecomastia?
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
7.Klinefelter's syndrome (xxy sex chromosome)
What may ultrasound reveal with gynecomastia?
-presence of glandular tissue
-possible dilated ducts
-increased fat
Malignant Breast Disease
*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
Epidemiology of Breast Cancer
*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
Risk Factors
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
Ductal Carcinoma (In Situ)
*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
What are the clinical features of ductal carcinoma (in situ)?
-asymptomatic pt
-possible palpable mass of varying size,shape, and consistency
-possible nipple discharge
What is non-comedo DCIS?
-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
What are the three clasifications of non-comedo DCIS?
1.cribiform-perforated form (sieve-like)
2.micropapillary-clumpy, along the wall
3.solid-occupy entire lumen of duct
What is Comedo DCIS?
-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)
What will ultrasound reveal with comedo DCIS?
*possible mass
-architectual distortion
-ductal dilatation
*microcacifications (not reliable)
What will mammo detect with comedo DCIS?
-clustered microcalcifications
-linear, branch pattern microcalcifications with or without a distinct mass
-distinct mass with internal microcalcifications
Lobular Carcinoma In Situ (LCIS)
-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
Invasive Carcinoma
-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
What is a usual-type cancer?
-invasive ductal carcinoma NOS (not otherwise specified)
What is a specified-type cancer?
-invasive lobular carcinoma
*medullary carcinoma
*colloid(mucinous) carcinoma
*tubular carcinoma
-papillary carcinoma
-paget's disease
Invasive Ductal Carcinoma
-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
What are the clinical features of invasive ductal carcinoma?
-palpable mass (often larger than imaging appearance)
-hard, gritty texture
-tumor is fixed (immovable)
-skin dimpling
-skin retraction
-nipple retraction
How will invasive ductal carcinoma appear on mammo?
-radiopaque density
-spiculated,lobulated or irregular margins
-thickened and/or retracted cooper's ligaments
How will invasive ductal carcinoma appeear on u/s?
-solid mass
-irregular,angular or spiculated margins
-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)
Invasive Lobular Carcinoma
-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
medullary carcinoma
-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
What may ultrasound reveal about medullary carcinoma?
-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)
Colloid (Mucinous) Carcinoma
-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
What may ultrasound demonstrate with colloid (mucinous) carcinoma?
-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
Tubular Carcinoma
-appears as a relatively small lesion
-good prognosis
-associated witha benign radial scar
what may mammo reveal about tubular carcinoma?
-long spicules radiating from a small radiolucent mass
what may ultrasound reveal about tubular carcinoma?
-small, hypoechoic mass
-ill-defined margins
-posterior shadowing
Papillary carcinoma
-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
What may ultrasound reveal about papillary carcinoma?
-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)
Paget's disease
-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
What may mammo reveal with paget's diseae?
-negative exam
-possible subareolar mass
What may ultrasound reveal with paget's disease?
-skin thickening of the nipple or areola
-possible duct dilatation
-possible subareolar mass
Inflammatory carcinoma
-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
What may ultrasound reveal about inflammatory carcinom?
-skin thickening
-dilated lymphatic vessels
-diffuse appearance of the parenchymal layer
-tissue plane disruption
-increased doppler signals in all tissues
Multifocal carcinoma
-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
Muticentric carcinoma
*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
Male breast cancer
-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
What are the risk factors of male breast cancer?
-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)
-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
Malignant Phyllode Tumors
-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
What may ultrasound reveal about malignant phyllodes?
-large, well-circumscribed, solid mass
-smooth, lobulated borders
-hypoechoic or isoechoic internal echogenicity
-homogeneous or heterogeneous appearance (with necrosis)
-possible acoustic enhancement
*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)
Primary and Metastatic Lymphoma
-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
What will ultrasound demonstrate with primary and metastatic lymphoma?
-singular or multiple solid masses within the brease and/or axilla
-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
-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
How does metastatic disease from primary breast cancer spread?
-lymph nodes
-opposite breast
Metastatic disease to the breast from another primary cancer.
-is uncommon and accounts for less than 2% of cancers found in breast
-Metastasizes from:
-opposite breast (likely lymphatic route)
How will breast metastasis appear on sonography?
-multiple, weel-circumscribed palpable masses
-usually located in the superficial fat layer
-often bilateral
BIRADS (category of breast disease)
-Breast Imaging Reporting and Data System
BIRADS: Category 0
-needs additional imaging
-represents inconclusive findings requiring additional evaluation including spot compression, magnification or special mammogrphic views, us, Mr, etc.
BIRADS: Category 1
-generally fatty replaced breasts that are without clinical breast probems
-routine follow-up
BIRADS: Category 2
-breast with dense tissue, implants or with many benign lesions, such as cysts, lymph nodes or fibroadenomas
-routine follow-up
BIRADS: Category 3
-probably benign
-findings that are very unlikely to be cancer (ie. round or oval solid masses)
-short term follow-up or biopsy is considered
BIRADS: Category 4
-findings that are often cancer (ie. irregular solid masses, microcalcifications, growth of a solid mass)
-biopsy considered
BIRADS: Category 5
-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
-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)
What are the advantages of MR breast imaging?
-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
What are the disadvantages of MR breast imaging?
-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
Ductography (Galactography)
-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
What does ductography involve?
-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
Ductography findings
-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
Sentinel Node Procedure
*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
What does a sentinel node procedure involve?
-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
What happens if the sentinel node is cancer free?
*there is a 95-100% likelihood of a clear axillary node basin
-axillary lymph node dissection (ALND) may be alleviated
-lumpectomy may be considered
What happens if the sentinel node is cancerous?
-ALND is warranted
-mastectomy is considered
-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
-results in 2-3 days
-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
Types of Implants
-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)
Implant Placement
-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
Imaging implants under mommography
-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
Imaging implants under MRI
*most accurate imaging modality in the detection of implant rupture
-extremely effective in assessing the integrity of the implant and nearly all complications
Imaging implants under sonography
-provides excellent evaluationof the augmented breast
*effective in examining the exising breast tissue surrounding the implant for diease and also the implant for complications
What is the appearance of implants under ultrasound?
-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
What do the three horizontal lines at the anterior tissue/implant interface represent?
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)
Imaging Implants and Artifacts
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
Implant Complications
-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
What are the signs and symptoms of implant rupture?
-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)
What are the complications of implant rupture?
-migration of the implant
-partial or total collapse
-silicone or saline bleed with an intact implant
Capsular Contracture
-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
*Intracapsular Rupture
-rupture of the implant shell (envelope) with the escape of silicone into the intact fibrous capsule
-accounts for 80% of implant ruptures
*Extracapsular rupture
-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
What will ultrasound reveal with Intracapsular rupture?
*stepladder sign
-series of parallel echogenic lines within the implant
-visualization of silicone between the implant shell and fibrous capsule
What will MRI reveal with intracapsular rupture?
*linguini sign
-wavy lines represent the ruptured implant shel within the fibrous capsule
What will ultrasound reveal with extracapsular rupture?
*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
What will MRI reveal with extracapsular rupture?
*silicone granuloma or free silicone
*may also visualize a siliconized lymph node
Saline Implant Rupture
-presents much less of a clinical concern than silicone ruptures
*is usually diagnosed clinically due to rapid deflation and deformation
Reduction Mammoplasty (Breast Reduction)
-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
Challenges of Breast Reduction
-superficial and deep scar tissue may present as a palpable mass
-fat necrosis and oil cysts are common
-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
What is the role of sonography with invasive breast procedures?
-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
Invasive Breast Procedure
-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
Cyst Aspiration
-an effective way of:
1.confirming the presence (diagnosis) of a cyst
2.therapeautically reducing a cyst
When may a biopsy be required?
-if aspirated fluid is suspicious
-if the cyst is not completely reduced
-if the cyst reoccurs several times
Needle Localization
-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
*Fine needle Aspiration (FNA)
-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
What are the advantages of an FNA?
-does not require open surgical biopsy(less invasive)
-local anesthesia
-safe,cost effective
-minimal complications (small hematoma)
-results in 1-2 hours
Wha are the disadvantages to an FNA?
-inadequate tissue sample thru small needle
-possible false negative
-cytologic evaluation is less accurate than histologic evaluation
Core Needle Biopsy (CNB)
-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
What are the advantages of a core biopsy?
-does not require open surgicak biopsy (less invasive)
-local anesthesia
-core sample is sufficient for accurate diagnosis (low false negative)
-histologic evaluation
What are the disadvantages of a core biopsy?
-greater risk of complications than FNAdense lesions may not be adequately sampled
-results in 2-3 days
-minimally invasive breast biopsy procedure superior to CNB and less invasive thann open surgical biopsy
Describe the mammotome procedure.
-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
What are the advantages of a mammotome?
-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
What are the disadvantages of a mammotome?
-greater risk of complications
-some healthy tissue is removed
Advanced Breast Biopsy Instrument (ABBI)
-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
Describe the procedure of an advanced breast biopsy instrument.
-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
What are the advantages of an ABBI?
*does not require sonographic guidance
-does not require open surgical biopsy (less invasive)
-pinpoint accuracy
-total excision of a tumor
-outpatient procedure
-local anesthesia
What are the disadvantages of an ABBI?
-greater risk of complications
-requires sutures to close incision
-healthy breast tissue is compromised
Surgical Biopsy
-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
What factors are breast cancer treatment options based on?
-type of cancer
-stage of cancer
-age of the patient
-patients personal lifestyle
Breast Cancer Staging
-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
TNM classification system
-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)
Breast Cancer Treatment
-once staging has occured, treatment can be considered
What are the two main categories of treatment?
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
-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
Total or Simple Mastectomy
-removal of the breast
-usually not performed alone
Modified Radical Mastectomy
-removal of the breast (total mstectomy), lymph nodes (ALND), and pectoral fascia
-Gold standard for the treatment of breast cancer for decades
Radical Matectomy
-removal of breast, lymph nodes, pectoralis major and minor
-extremely disfiguring
-outdated (only performes in extreme cases)
Axillary Lymph Node Dissection (ALND)
-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
Radiation Therapy
-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
-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
Hormone Therapy
-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