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FRCR 2A (Crack The FRCR 2A) > 4. Breast > Flashcards

4. Breast Flashcards

1
Q

Nipple (normal) (7)

A

Circular smooth muscle overlying 4th intercostal space.
Typically 5-10 ductal openings.
Inversion: nipple invaginates into the breast.
Retraction: nipple pulled back slightly.
Can both be normal if chronic, if acute, think underlying cancer.
Areola will darken with puberty and parity.
Nipple enhancement on MRI is normal.

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2
Q

Cooper ligaments (3)

A

Thin sheets of fascia holding the breasts up.
Tiny white lines on mammography, echogenic lines on US.
Straightening and tethering manifests as architectural distortion, occurs in surgical scars, radial scars and IDC.

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2
Q

Fibroglandular tissue (5)

A

Breast mound is fibrous tissue with fat, ducts and glands laying on top of anterior chest wall.
Axillary extension is called “tail of spence”.
Upper outer quadrant is more densely populated with breast tissue, hence more cancers start there.
No dense tissue usually in medial/inferior breast and retroglandular regions.
These are considered danger zones, where cancer can hide.

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3
Q

Breast asymmetry (3)

A

Common and usually normal, as long as no other findings.
Can be a sign of “Shrinking breast” in invasive lobular breast cancer.
Think cancer if size difference is new or parenchyma looks asymmetrically dense.

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4
Q

Lobules (3)

A

Flower shaped milk producing areas. Terminal duct and lobule are referred to as a “terminal duct lobule unit” or TDLU.
Most breast cancers start here.

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5
Q

Ducts (3)

A

Ductal system branches like roots or branches of a tree.
Branches overlap wide areas and not clearly segmented.
Calcifications that appear to follow the duct “linear or segmental” are most sus for cancer.

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6
Q

Lactiferous sinus (3)

A

Milk from lobules drains into major duct under the nipple.
The dilated portion of the major duct is sometimes called Lactiferous Sinus.
It’s normal and not a mass.

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7
Q

Blood supply/lymphatic drainage (3)

A

60% blood supply by internal mammary.
Rest is via lateral thoracic and intercostal perforators.
97% lymph drainage is to axilla, 3% to internal mammary nodes.

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8
Q

Axillary lymph node levels (4)

A

Level 1: Lateral to pec minor
Level 2: under pec minor
Level 3: Medial to pec minor
Rotter node: Between pec major and minor

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9
Q

Mets to internal mammary nodes (3)

A

If you can see the nodes on US, they’re abnormal.
Isolated mets to these nodes is uncommon, and if seen it’s usually from a medial cancer

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10
Q

Sternalis muscle (3)

A

Non functional muscle next to sternum, can simulate a mass.
ONLY seen in CC view.
Usually unilateral.
Will be seen on previous imaging.

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11
Q

Breast development/physiology (6)

A

“Milk streak” is the embryological buzzword to explain location of normal breast and location of ectopic breast tissue.
Most common location for ectopic breast tissue is the axilla (then inframammary fold).
Extra nipples are most commonly in the same locations, but can be anywhere along the “milk streak”.
Males and females can have breast enlargement at birth and produce milk (maternal hormones).
As girls enter puberty, ducts elongate and branch (due to oestrogen), then their lobules proliferate (progesterone).
Biopsying a breast bud can damage it and affect breast development.

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12
Q

Follicular phase (breast) (3)

A

Day 7-14.
Oestrogen dominates.
Best time for mammogram and MRI.

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13
Q

Luteal phase (breast) (4)

A

Day 15-30.
Progresterone dominates.
Some breast tenderness (max day 28-30).
Breast density increases slightly.

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14
Q

Pregnancy (breast) (3)

A

Tubes and ducts proliferate.
Breast gets a lot denser (more hypoechoic on US).
US may be best bet if suspecting mass.

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15
Q

Perimenipausal breast (3)

A

Shortening of follicular phase means breast gets more progesterone exposure, which means more breast pain, more fibrocystic change and more cyst formation.

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16
Q

Menopausal (breast) (4)

A

Lobules decrease.
Ducts stay but become more ectatic.
Fibroadenomas degenerate (they like oestrogen) and get their popcorn calcifications.
Secretory calcifications will develop, but not for 15-20 years post menopause.

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17
Q

Hormone replacement therapy (breast) (2)

A

Breast can get more dense (even more oestrogen-progesterone combos).
Breast pain can occur, peaking usually in first year.
Fibroadenomas can grow.

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18
Q

Lactation (4)

A

Breast gets a lot denser in third trimester. Mammogram is more difficult and US becomes more useful.
Pituitary prolactinoma or meds (classically antipsychotics) can create similar bilateral increased density.
Biopsying a breast at this time risks creating a milk fistula. Need to stop breastfeeding to stop the fistula. The fistula can (rarely) get infected.

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19
Q

Galactocele (3)

A

Benign fat containing lesion, typically seen on cessation of lactation.
Location is usually subareolar.
Appearance is varied, but can have classic fat-fluid level.

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20
Q

Lactating adenoma (3)

A

Look like fibroadenomas, usually multiple.
Follow up 4-6 months post partum, post delivery or after cessation of lactation (ultrasound).
Rapidly regress after you stop lactation.

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21
Q

Mammogram - technique (7)

A

2 standard views, craniocaudal (CC) and Medial Lateral Oblique (MLO)
Posterior Nipple Line is drawn on MLO, from nipple to chest wall. Needs to touch pec muscle to be adequate.
On CC, draw line from nipple back to chest wall. Should be within 1cm of length of posterior nipple line.
Ideally inframammary fold should be visualised.
“Camel nose” buzzword used to describe a breast on MLO that has not been pulled up and out by radiographer.
Nipple should be in profile in one of 2 views to avoid missing subareolar cancer.
Relaxed pec muscles preferred (concave instead of convex), showing more breast tissue.

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22
Q

LMO view (3)

A

MLO view is standard, sometimes LMO view is used:
- Women with kyphosis or pectus excavatum.
- to avoid medial pacemaker or central line.

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23
Q

MLO view trivia (1)

A

MLO contains most breast tissue of any view

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24
Q

Spot compression views (2)

A

usually need to leave the collumnator open, to give the largest field of view.
Small paddles give better focal compression, large paddles allow good visualisation of land marks.

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25
Q

Magnification views (2)

A

CC and ML (true lateral are obtained). ML (as opposed to MLO) used to help catch “milk of calcium”

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26
Q

ML vs LM for true lateral view (4)

A

True lateral is useful for localising things seen on single view only (CC).
If a mass is lateral on CC (screening mammo) then use ML for diagnostic. If medial, use LM.
This is to move the mass closer to the detector.
If mass only visible on MLO, use ML, as 70% of breast cancers occur laterally.

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27
Q

Blur artefact (4)

A

Blur:
- Can be breathing or inadequate compression, typically inferior breast on MLO.
- Can be tricky to pick up.
- Look at cooper ligaments, they should be thin white lines in fat. If thick or fuzzy, this is likely blur (or oedema)
- If skin thickening, think oedema

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28
Q

Grid lines (4)

A

Mammograms should always use a grid, unless mag view.
Grid works by moving really fast and keeping only X rays that move in straight line.
Blur is seen in 3 scenarios
- Patient moved.
- Exposure too long
- Exposure too short

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29
Q

Screening mammograms - general tips (6)

A

Trying to find 3-8 cancers per 1000 mammograms.
Certain areas can only be seen on a single view, e.g. medial breast on CC may not be seen on MLO.
Inferior posterior breast may not be seen on CC.
Makes these areas high risk for missing cancer.
Recommended to look at mammograms from 2 years prior for comparison, makes it easier to see early changes.

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30
Q

Localising lesion (3)

A

Medial lesion on CC film will be more superior on MLO, and even more superior on ML.
Opposite is true of lateral lesions.
Lead Sinks and Muffins Rise (from CC to MLO to ML)

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31
Q

Localising lesion (only seen in CC) (4)

A

Rolled CC view can help determine if lesion is in superior or inferior breast.
Position breast for CC view, but prior to compression, the breast is rotated medially or laterally along axis of nipple.
Reference point is top of breast.
If you roll the breast medially, superior tumour will move medial and inferior tumour will move lateral.
Opposite is true of you roll breast laterally.

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32
Q

BI-RADS/UK System (3)

A

BI-RADS developed by Americal College of Radiology.
UK uses a 5 point breast imaging scoring system for communication and diagnosis.
M1-5 and U1-5 for mammograms and ultrasound respectively.

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33
Q

Calcifications (4)

A

Earliest sign of breast cancer.
3 types
- Artefact
- Benign
- Suspicious

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34
Q

Artefact calcifications (3)

A

Deoderant
- high density material seen in axilla
- High density speck that doesn’t change position with different views (implies it’s on the receptor)
Zinc oxide
- Ointment for breasts, can collect on moles and mimic calcifications.
- Disappears on follow up
Metallic artefact
- Electrocautery devices can leave small metal fragments in the breast.
- Will be very dense and adjacent to a scar

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35
Q

Benign vs suspicious (3)

A

Based on morphology and distribution.
Most cancers start in ducts, so linear or segmental calcification is most concernng.
Bilateral scattered calcifications are least concerning.

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36
Q

Dermal calcifications (4)

A

Benign, found anywhere women sweat (folds, cleavage, axilla).
Often grouped like paw of a bear, or foot of a baby.
They stay in same place on CC and MLO views (tattoo sign).
Tangential view to confirm they’re dermal.

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37
Q

Vascular calcifications

A

Parallel linear calcifications, usually obviously vascular.

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38
Q

Popcorn calcifications (2)

A

Immediate buzzord for degenerating fibroadenomas.
Usually begin around the periphery and slowly coalesce over subsequent images.

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39
Q

Secretory, rod like calcifications (5)

A

Big, easily seen and point to the nipple.
Usually bilateral
“Cigar chaped with lucent center”
“Dashes but no dots”
10-20 years after menopause, happen after duct has involuted.

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40
Q

Eggshell calcifications (4)

A

Due to fat necrosis.
Can be from any trauma (surgical or accident).
If very big, can be called “liponecrosis macrocystica”.
Lucent centered is a buzzword.

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41
Q

Dystrophic calcifications (3)

A

Seen after radiation, trauma or surgery.
Usually big.
“Irregular in shape”, can also have lucent centre.

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42
Q

Milk of calcium (4)

A

Very characteristic look.
On CC, calcifications look powdery and spread out, on MLO they may layer.
on ML, they layer into a more linear appearance, with a curved bottom “tea cupped”.
Due to fibrocystic change, it’s fluid-fluid in a lobule.

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43
Q

No calcification on biopsy? (2)

A

Milk of calcium needs to be viewed with polarised light to assess birefringence.
Otherwise calcifications can’t be seen.

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44
Q

Round calcifications (4)

A

Develop in lobules, usually scattered, bilateral and benign.
Usually due to fibrocystic change when benign.
If bilateral, multiple and similar, they’re benign.
If solitary or different, it’s suspcious. (like a mass).

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45
Q

Amorphous calcifications (8)

A

Suspicious.
Look like powdered sugar, should not be able to count each one.
Scattered and bilateral suggest benign, segmental is concerning.
DDx
- Fibrocystic change (most likely)
- Sclerosing adenitis
- Columnar cell change
- DCIS (low grade)

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46
Q

Coarse heterogenous calcifications (9)

A

Suspicious.
Countable, but their tips are dull.
Usually bigger than 0.5mm.
Distribution and comparison to priors is important.
Can be associated with mass (fibroadenoma or papilloma)
DDx
- Fibroadenoma
- Papilloma
- Fibrocystic change
- DCIS (low to intermediate grade)

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47
Q

Fine pleomorphic calcifications (6)

A

Countable and sharp, usually smaller than 0.5mm.
Highest suspicion for malignancy
DDx
- Fibroadenoma (less likely)
- Papilloma (less likely)
- Fibrocystic change
- DCIS (high grade)

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48
Q

Fine linear/fine linear branching calcifications (2)

A

This distribution makes fine pleomorphic calcifications look even more suspicious.
DDx narrows to basically DCIS or atypical look for secretory or vascular calcifications.

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49
Q

Calcifications associated with focal asymmetry/mass (3)

A

Increased density around suspicious calcifications increases risk of cancer.
Sometimes called “puff of smoke” sign or a “warning shot”.
US is useful for extent of disease.

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50
Q

Calcifications in/near lumpectomy scar (2)

A

Local recurrence rate is around 6%.
New calcifications with suspicious morphology (not fat necrosis) should be biopsied.

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51
Q

When to US calcifications (3)

A

US not usually used to evaluate pure calcification finding.
Exceptions are
- If patient had mass associated with calcifications
- if patient had palpable finding

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52
Q

Mondor disease (4)

A

Thrombosed vein presenting as tender palpable cord.
Looks like thrombosed vessel on US.
Not a DVT, doesn’t need anticoag.
Rx: NSAIDs and warm compress.

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53
Q

Fat containing lesions (5)

A

5 classic causes, all are benign.
- Hamartoma
- Galactocele
- Lymph node
- Lipoma
- Oil cyst/fat necrosis
Only last 2 are consudered pure fat containing lesions

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54
Q

Hamartoma (2)

A

“breast within a breast”. Difficult to see on US as they blend into breast tissue

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55
Q

Galactocele (2)

A

Young lactating women, usually on cessation of lactation.
Usually subareolar, varied appearance, but can have fat-fluid level.

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56
Q

Oil cyst/fat necrosis (4)

A

Areas of fat necrosis walled off by fibrous tissue.
Seen randomly, post trauma or post surgery.
Peripheral calcifications pattern is usually egg shell.
Lots of them may suggest Steatocystoma Multiplex.

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57
Q

Lipoma (2)

A

Usually radiolucent with no calcifications.
Enlargement of a lipoma is a criteria for biopsy.

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58
Q

Intramammary lymph node (2)

A

Normal, typically located in tissue along pectoral muscle, often close to vessels.
NOT seen in fibroglandular tissue.

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59
Q

When to US (3)

A

Usually palpable finding will get US, and under 30s will mostly skip mammography.
One exception is a fat containing lesion is a definate benign finding on diagnostic mammography

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60
Q

Pseudoaneurysmal Stromal Hyperplasia (PASH) (4)

A

Benign myofibroblastic hyperplastic process.
Usually a big (4-6cm) solid, oval shaped lesion with well defined borders.
Can be seen between 18-50 years old.
Usually recommend annual follow up.

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61
Q

Fibroadenoma (4)

A

Commonest palpable mass in young women.
Usually oval, circumscribed mass with homogenous, hyopechoic echotexture and central hyperechoic band.
If shown in an older patient, more likely to have course, popcorn calcifications.
MRI: T2 bright with type 1 enhancement (progressive)

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62
Q

Phylloides (5)

A

10% risk of malignant degeneration.
Can metastasize, usually haematogenous to the lungs and bone.
Fast growing breast mass.
Need wide margins on resection, higher recurrence if margin <2cm.
Occurs in older age than fibroadenomas (40s-50s).
Biopsy of sentinel node is not needed, as mets to lymphatics are rare.

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63
Q

Distinguishing features of Phylodes tumour (4)

A

Rapid growth.
Haematogenous mets
Middle age to older women
Mimics a fibroadenoma

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64
Q

Invasive ductal carcinoma (4)

A

Most common invasive ductal carcinoma.
Ductal in origin but not confined to the duct (unlike DCIS).
Clinically: Hard, non-mobile, painless mass.
Imaging: irregular, high density mass with indistinct, spiculated margins and associated pleomorphic calcifications, and anti-parallel shadowing mass with echogenic halo on US.

65
Q

Invasive ductal NOS (4)

A

Most common breast cancer is undifferentiated and has no distinguishing histological features.
“Not Otherwise Specified”.
Make up 65% of invasive breast cancers.

66
Q

IDC subtypes (4)

A

Tubular
Mucinous
Medullary
Papillary

67
Q

Tubular IDC (4)

A

Small spiculated slow growing mass, favourable prognosis.
Often conspicuous on US.
Associated with radial scar.
Contralateral breast cancer 10-15%

68
Q

Mucinous IDC (2)

A

Round or lobulated, circumscribed mass.
Uncommon, better outcomes than IDC-NOS

69
Q

Medullary IDC (5)

A

Round or oval circumscribed mass without calcifications.
Axillary nodes can be large even in the absence of mets.
Typically younger patients (40s-50s).
Better outcome than IDC-NOS.
25% have BRCA 1 mutation.

70
Q

Papillary (4)

A

Complex cystic and solid.
Axillary nodes not common.
Typically elderly people, favours non-white people.
Second most common behind IDC-NOS

71
Q

Multifocal vs Multicentric breast cancer (3)

A

Multifocal: Multiple primaries in the same quadrant, classically same duct system.
- Less than 4-5cm from one another
Multicentric: Multiple primaries in different quadrants.
- Multiple discrete un-related sites.

72
Q

Synchronous bilateral breast cancer (2)

A

2-3% of women on mammography, with another 3-6% found on MRI.
Risk of bilateral disease is increased in infiltrating lobular types and multi-centric disease.

73
Q

DCIS (8)

A

Earliest form of breast cancer.
Cancer is confined to the duct.
Low, intermediate or high grade on histology.
Also split between comedo and non comedo on histology. Comedo is more aggressive.
3 potential appearances
- Suspicious calcifications (fine linear, branching or fine pleomorphic)
- Non-mass like enhancement on MRI
- Multiple intraductal masses on galactography.

74
Q

DCIS trivia (4)

A

10% of DCIS on imaging may have invasive component at time of biopsy.
25% of DCIS on core biopsy may have invasive component on surgical excision.
8% of DCIS will present as a mass without calcification.
Most common US appearance: Multilobulated mildly hypoechoic mass with ductal extension and normal acoustic transmission.

75
Q

Lobular (ILC) (4)

A

Second most common type of breast cancer after IDC-NOS.
Pathophysiology:
Cells lose e-cadherin, they no longer adhere to one another and infiltrate the breast like a spider web. This eventually causes architectural distorsion without a central mass, on CC view,
US: ill defined area of shadowing without a mass.

76
Q

“Shrinking breast” (3)

A

Buzzword for ILC. Breast isn’t actually smaller, just doesn’t compress as much.
Compared to normal breast, appears to be getting smaller.
May look the same size on physical exam.

77
Q

Dark Star (2)

A

Architectural distortion without a central mass.
DDx includes ILC, radial scar, surgical scar and IDC-NOS

78
Q

ILC vs IDC (3)

A

ILC is more often multifocal, less often mets to axilla, instead prefers to met to peritoneal surfaces.
ILC often has positive margins and more often treated with mastectomy.
Both have similar prognosis

79
Q

ILC trivia (8)

A

Tends to present later than IDC.
Usually older person.
Often only seen in CC view.
Calcification less common than ductal cancers.
Mammo buzzwords “dark star” and “shrinking breast”
US buzzword “shadowing without mass”
MRI: washout less common than IDC.
Axillary mets less common.
Prognosis similar to IDC (unless pleomorphic ILC, very aggressive).
More often multifocal and bilateral (1/3)

80
Q

Inflammatory breast cancer (4)

A

Poor prognosis.
Will usually get chemo before surgery, chance of positive margin is high.
Mastectomy is done for local control.
Swollen red breast similar to mastitis.
Skin thickening on mammogram (non specific).
Inflammation can improve with antibiotics but doesn’t resolve.
Dermal biopsy done if cannot fund underlying mass.

81
Q

Pagets (4)

A

Carcinoma in the nipple epidermis.
50% have palpable finding associated with skin changes.
Associated with high grade DCIS.
Wedge biopsy NOT to be done on any skin lesion affecting the nipple-areolar complex that doesn’t resolve with skin changes.
Pagets NOT considered T4, skin involvement doesn’t affect staging in this setting.

82
Q

High risk lesions (5)

A

These must come out after biopsy.
- Radial scar
- Atypical ductal hyperplasia
- Atypical lobulat hyperplasia
- LCIS
- Papilloma

83
Q

Radial scar (4)

A

Not actually a scar, but looks like one on histology.
Dense fibrosis around ducts, causing architectural distortion (dark scar).
High risk, needs excised.
Associated with DCIS or IDC (10-30%) and tubular carcinoma

84
Q

Atypical ductal hyperplasia (2)

A

DCIS but lacks quantitative definition by histology (>2 ducts involved).
Needs excision because it’s high risk and DCIS burden is often underestimated when this is present.

85
Q

LCIS (Lobular carcinoma in situ) (3)

A

Classically occult on mammogram.
Can be precursor to ILC. lower risk of malignancy than DCIS to IDC.
Pleomophic LCIS is worse than regular LCIS.

86
Q

Atypical lobular hyperplasia (2)

A

Similar to LCIS, but histologists differ based on distension of lobule (LCIS is distended).
Less risk of cancer (4-6x vs 11x with LCIS), but should be excised

87
Q

Papilloma (5)

A

Most common intraductal mass.
Most common cause of bloody discharge.
Usually seen in perimenopausal women, 1cm from nipple in 90%.
Mammogram: often normal, sometimes just calcifications.
US: Well defined smooth walled hypoechoic mass, sometimes cystic with solid components.
Usually associated duct dilatation.
Galactography: solitary filling detected with dilated duct.

88
Q

Multiple papillomas (2)

A

Tend to be more peripheral.
Mammogram: either mass (or masses) or cluster of calcifications without a mass.

89
Q

Phyllodes tumour (2)

A

10% risk of malignant degeneration.
Fast growing breast mass, occurs in older age than fibroadenomas (40-50s)

90
Q

Multiple masses (2)

A

Need at least 3 bilateral well circumscribed masses without suspicious features.
Need to be bilateral to consider them benign.

91
Q

Breast pain (4)

A

Common, usually worse during luteal phase.
Cyclical, bilateral pain is benign and doesn’t need evaluation.
Focal, non-cyclical pain needs evaluation.
Negative predictive value of US and mammogram (combined) for “focal pain” is almost 100%. If cancer is found, it’s usually elsewhere (asymptomatic)

92
Q

Worrisome symptoms for cancer (3)

A

Skin dimpling,
focal skin thickening,
nipple retraction

93
Q

Non-focal skin thickening/breast oedema (2)

A

Usually due to benign conditions (CHF, renal failure), especially if the breast isn’t red.
Mammogram: trabecular thickening (diffuse, favouring dependent portions of breast)

94
Q

Breast inflammation (2)

A

Swollen red breast, suggests either mastitis/abscess or inflammatory breast cancer

95
Q

Mastitis/abscess (4)

A

Swollen red breast, painful.
Systemically unwell pt.
Associated with breast feeding, smokers and diabetics.
Abscess can develop, usually staph A.

96
Q

Inflammatory breast cancer (5)

A

Terrible prognosis.
Inflammatory breast that doesn’t respond to antibiotics needs biopsy.
Typically 40-50s.
Enlarged, red breast with peau d’orange appearance. often NOT painful.
Mammogram may show mass/masses, but shows diffuse skin and trabecular thickening.
Rx: Chemo/radio then surgery (unlike other breast cancers)

97
Q

Discharge (4)

A

Usually benign (90%).
Spontaneous, bloody discharge from a single duct is most suspicious.
Serous discharge is also very sus.
Higher age = more risk of cancer.

98
Q

Milky discharge (2)

A

NOT suspicous for breast cancer, but can be due to thyroid issues or pituitary adenoma (prolactinoma).
Any meds affecting dopamine can stimulate prolactin production (antidepressants, neuroleptics)

99
Q

Causes of discharge (not milky) (4)

A

Benign
- Premenopause: Fibrocystic change
- Postmenopause: Ductal ectasia
Malignant
- Intraductal papilloma (90%): single intraductal mass near nipple
- DCIS (10%) - multiple intraductal masses

100
Q

Ductal ectasia (2)

A

Commonest benign cause of nipple discharge in postmenopausal women.
Galactography: dilated ducts near subareolar region, with progressive attenuation more posteriorly.

101
Q

Galactography (8)

A

Leaking duct is cannulated (27 or 30 guage, blunt tipped needle).
0.2-0.3cc of contrast injected.
Mammograms (CC and ML) performed.
Filling defects get wire localisation.
Contraindications
- Active infection (mastitis)
- Inability to express discharge at the time
- Contrast allergy
- Post surgery to nipple/areolar complex.

102
Q

Architectural distortion (2)

A

Distortion of normal architecture without visible mass.
Can be focal retraction, distortion of edge of parenchyma, or radiation of normal thin lines into a focal point.

103
Q

Architectural distortion vs summation artefact

A

Summation of normal vessels and ducts will NOT radiate to a central point, AD will.

104
Q

Surgical scar vs pathology (2)

A

Scars should progressively get lighter and more difficult to see.
Lumpectomy scars may stay around longer than a benign biopsy.
If increasing, needs biopsy.

105
Q

Work up of AD (3)

A

Needs recall for spot compression views.
If persists, needs biopsy, unless it’s definately surgical scar.
US still recommended for further characterisation

106
Q

US trivia (AD) (4)

A

Use of harmonic tissue imaging makes easier to see lesions.
Compound imaging can make you lose posterior features, especially if soft to begin with, like shadowing in ILC.
Needs biopsy even if can’t see a mass.
Harmonics can also make more complex cysts look simpler.

107
Q

Architectural distortion trivia (7)

A

AD = radiating lines to a single point.
AD + Calcifications = IDC + DCIS
AD without calcifications = ILC
Even with no US or MRI correlate, AD gets biopsy.
Even if there for a while, needs workup
ILC can grow slow.
Surgical scars should get less dense with time, unlike cancer

108
Q

Unilateral vs bilateral nodes

A

Unilateral lymphadenopathy is more worrying for cancers on that side.

109
Q

When to biopsy lymph nodes (3)

A

Cortical thickness greater than 3mm
Loss of central fatty hilum
Irregular outer margins

110
Q

Staging trivia (nodes) (3)

A

Level 1 and 2 nodes are treated equally.
Rotter nodes are treated as level 2.
Level 3 and supraclavicular nodes are treated equally.

111
Q

Gold therapy (2)

A

RA used to be treated with gold.
This can cause very dense calcifications within a lymph node

112
Q

Snow storm nodes (2)

A

Silicone infiltration of a node from either silicone leaking or rupture.

113
Q

Male breast - basics (3)

A

Male breast cancer is rare, but often advanced and invasive at the time of diagnosis.
Male breast does NOT have the elongated and branching ducts, or proliferated lobules that women have.
Therefore men do not get lobule associated pathology, lobular carcinoma, fibroadenoma or cysts

114
Q

Gynaecomastia (9)

A

Non-neoplastic enlargement of the epithelial and stromal elements in a man’s breast.
Occurs physiologically in adolescents, affecting 50%, and men over 65.
Considered pathological if aged 13-65, associated with:
- Spironolactone
- Marijuana
- Alcoholic cirrhosis
- Testicular cancer
3 main patterns, nodular is most common.
Flame shaped, behind the nipple, asymmetric, can be painful.
Not being gynaecomastia suggested by not being behind the nipple, eccentric location and calcification

115
Q

Patterns of gynaecomastia (3)

A

Nodular
Dendritic
Diffuse glandular

116
Q

Nodular gynaecomastia (3)

A
  • Commonest
  • Flame shaped, centred behind the nipple, radiating posterior as it blends into fat.
  • Breast is often tender, lasts less than a year
117
Q

Dentritic gynaecomastia (3)

A

Resembles a branching tree
Usually chronic fibrotic pattern.
Usually not tender

118
Q

Diffuse glandular (2)

A

Mammogram looks like woman’s breast (diffuse increase in density).
Seen in men receiving oestrogen treatment

119
Q

Pseudogynaecomastia (2)

A

Increase in fat tissue of the breast, not glandular tissue
No discrete palpable findings, mount of tissue is not concentric to the nipple

120
Q

Lipoma

A

Second commonest palpable mass in a man

121
Q

Male breast cancer (9)

A

Rare, especially in younger men (average age 70).
1 in 4 have BRCA mutation, 2 is more common.
Other risk factors
- Klinefelter
- Cirrhosis
- Chronic alcoholism
Classically eccentric but near the nipple.
Almost always IDC-NOS type.
DCIS can occur, rare in isolation.
Mammography/US: looks like breast cancer. That said, nodular gynaecomastia can look sus on US.

122
Q

Suspicious features for male breast cancer (5)

A

Eccentric to nipple.
Unilateral.
Abnormal lymph nodes
Calcifications
Looks like breast cancer

123
Q

Calcifications in male breasts (2)

A

Micro-calcifications alone are uncommon.
If seen, tend to be less numerous, coarser and associated with mass (25% of male breast cancers have calcifications).

124
Q

Screening for male breast cancer (2)

A

Controversial, but only Klinefelters patients approach the level of risk to make screening worthwhile.
Males with gynaecomastia from gender reassignment, on hormone therapy, are not high risk enough for screening mammograms.

125
Q

Implants - overview (8)

A

2 main kinds, silicone and saline.
Saline is less significant if it ruptures, and doesn’t form a capsule so can’t have intracapsular rupture.
Follow up with mammogram and primary care/plastics.
Silicone can have intracapsular and extracapsular rupture.
Can only see extracapsular rupture on mammogram.
Extracapsular creates snowstorm appearance on US. Intracapsular creates a “step ladder” appearance on US and a Linguine sign on MRI.
MRI: Fat Sat T2 to look at implants.

126
Q

Implant rupture types (silicone) (3)

A

Can have isolated intracapsular.
Cannot have isolated extracapsular (always with intra).
Silicone in lymph node needs MRI to evaluate for intracapsular rupture.

127
Q

Implant location - types (2)

A

Subglandular (retromammary): implant behind breast tissue, anterior to pectoral muscle.
Subpectoral (retropectoral): Implant between pec major and minor.

128
Q

Silicone implants (3)

A

Body will form a shell around the implant, allowing intra and extracapsular rupture.
25% will get calcifications around the fibrous capsule.
Implants are NOT a contraindication for core needle biopsy, nor do they increase risk of cancer.

129
Q

Saline implants (6)

A

Also subglandular or subpectoral types.
Can see through it, differentiating from silicone.
Implant folds and valves can be seen.
If ruptured, saline is absorbed into the body with little clinical significance.
Can be easily burst by biopsy.
Some say physical exam is the best test for saline rupture.

130
Q

Screening mammogram for women with implants (3)

A

4 views of each breast:
- CC, MLO, Implant displaced CC and Implant displaced MLO
Obviously sensitivity is decreased in women with implants.
Implants are easier to displace if subpectoral.

131
Q

Capsular contracture (4)

A

Commonest complication of implants, occurs due to contraction of the fibrous capsule.
Causes cosmetic deformity.
Seen more commonly in subglandular silicone implants.
Mammogram: rounding or distortion of the implant

132
Q

Gel bleed (2)

A

Silicone molecules can pass through semi-permeable implant shell, which is different to rupture.
Silicone in the axillary nodes is seen.

133
Q

Rupture (5)

A

Top risk factor for rupture is age of implant.
Can occur without trauma. Rupture due to compression mammography is rare.
Saline
- Usually obvious (deflated breast).
- Only of cosmetic significance.
- “wadded up” plastic wrapper on mammogram. No need for US or MRI

134
Q

Silicone rupture (6)

A

Isolated intracapsular
- Occult on physical exam, mammo and possibly US.
- May see stepladder on US but MRI is more sensitive
Intracapsular with extracapsular rupture
- Obvious on mammogram (dense silicone seen outside the capsule). Normal implant is smooth outlined.
- Silicone outside the implant can go into nodes.
- US: Snow storm” pattern (echogenic with no posterior shadowing). May show lymph node with snowstorm on US.
- MRI: extracapsular silicone is T1 dark, T2 bright.

135
Q

Radial folds (3)

A

Mimics rupture.
Normal infoldings of the elastomer shell. Usually mimics linguine sign of intracapsular rupture.
Radial folds always connect with the periphery of the implant, rupture folds won’t.

136
Q

Post op breasts (6)

A

Mammoplasty is done to reduce breast size.
Mastopexy is done to “lift” the breasts, essentially removing skin.
Normal findings post mastopexy
- Swirled appearance affecting inferior breast.
- Fat necrosis/oil cysts
- Isolated islands of breast tissue

137
Q

Keyhole incision (2)

A

Done for mastopexy and mammoplasty,
Creates swirled appearance in the inferior aspect of MLO

138
Q

Surgical terminology (3)

A

Lumpectomy - sugical removal of cancer (palpable or not)
Excisional biopsy - Surgical removal of entire lesions
Inclusional biopsy - Surgical biopsy of a portion of the lesion

139
Q

Post biopsy changes (5)

A

Distortion and scarring are worse within 6-12 months and improve thereafter.
US: Scars should be thin and linear. Focal mass like thickening in a scar is suspicious.
Fat necrosis and benign dystrophic calcifications may evolve over 1-2 years, these are main mimics of recurrence.
Fat necrosis on MR: T1/T2 bright, reduced on fat sat.

140
Q

Risk of recurrence/residual disease - trivia (5)

A

Local recurrence occurs 6-8% with breast conserving therapy.
Peak time of recurrence is 4 years (most between 1-7).
Without radiation, local recurrence is around 35%.
Early recurrence (<3 years) is usually in the original tumour bed. Later recurrences more likely in a different location.

141
Q

What gets recurrent disease? (6)

A

Risk of recurrence is highest in premenopausal women (possible underlying genetic issue).
Other risk factors are
- Extensive inarticulate component.
- Tumour with vascular invasion.
- Multicentric tumours
- Positive surgical margins
- Tumour not adequately treated in the first place

142
Q

Residual vs new calcifications (4)

A

Residual calcifications are not good. Residual calcs near or in the lumpectomy bed correlate with 60% local recurrence rate.
New calcifications:
75% of DCIS will come back as calcifications.
Benign calcifications tend to occur early (2 years) whilst malignant ones occur later (4 years)

143
Q

Sentinel node failure (2)

A

Sentinel node biopsy is 95% effective, so 5% will have negative sentinel node biopsy with abnormal armpit node.

144
Q

Tissue flap (2)

A

Cancer will come from residual breast tissue or along the skin scar line.
Screening of the flaps is therefore contraversial, some say not necessary.

145
Q

Specimen radiography (4)

A

Path reports mentioning “close margins” or “positive margins” mean a very high chance of cancer still in the breast.
Specimen radiographs - look out for 2 things
- is the mass/calcification on the sample
- Is the mass/calcification near the edge of the sample or touching the edge.
Is at the edge, the chance of incomplete excision is around 80% and surgeon needs to be informed.

146
Q

Post radiation changes (5)

A

Pre-radiation mammogram is important. If you can see residual disease on it, the patient has many more treatment options.
If you discover residual disease after radiation therapy is given, surgery becomes the next option.
Post radiation changes:
Skin thickening and trabecular thickening, normal post radiation, should peak on first post radiotherapy mammogram.
If it gets worse, suggestive of recurrent disease.

147
Q

Breast cancer staging (5)

A

T1 = <2cm
T2 = 2-5cm
T3 = >5cm
T4 = Any size with invasion (chest wall fixation, skin involvement or inflammatory breast cancer).
Axillary status is most important predictor of overall survival in breast cancer.
Melanoma is most common met to breast

148
Q

Contraindications to breast conservation (5)

A

Inflammatory cancer
Large cancer size relative to breast
Multicentric (multiple quadrants)
Prior radiation therapy to same breast
Contraindication to radiation therapy (collagen vascular disease)

149
Q

Breast MRI - technique (4)

A

Patient lies on stomach, breasts hanging through holes in the table.
Sequences include T2, pre and post dynamic contrast fat sat T1.
Fat sat is important, as breasts contain a lot of it.
Dynamic imaging done to look at washout curves, like prostate MRI.

150
Q

Breast MRI - reading basics (6)

A

Assess background uptake
- Hormone changes with menstrual cycle change how much contrast is taken up, less early and more later on
Look for masses
- MIP is helpful, like looking for lung nodules.
- Most T2 things are benign (nodes, cysts, fibroadenoma)
- If not T2 bright, is it spiculated, a mass, is it new?
Washout curve
- Malignant morphology is more important than benign curve
New masses get biopsy. non mass like enhancement gets biopsy if new.
T2 bright is benign.

151
Q

MRI - parenchymal enhancement (4)

A

It’s normal.
Commonest in posterior breast, upper outer quadrant, during the lateral part of the menstrual cycle (luteal phase, day 14-28).
Reduced by performing MRI during days 7-14.
Tamoxifen decreases background parenchymal uptake, then causes a rebound

152
Q

MRI - Foci (3)

A

Defined as round or oval, circumscribed and <5mm.
Usually not high risk, 2-3% malignant.
Ill defined borders or suspicious enhancement should be biopsied.

153
Q

NMLE (non mass like enhancement) (3)

A

Not a mass, a clump of tissue enhancement.
Can be segmental (triangular, pointing at the nipple, indicates single branch), regional (bigger triangle) or diffuse.
Heterogenous enhancement of NMLE is most sus.

154
Q

Masses on MRI (3)

A

Defined as 5mm or larger.
Irregular shape, spiculated margins, heterogenous or rim enhancement are concerning and need biopsy.
Morphology is more important than kinetics.

155
Q

Kinetics (MRI) (5)

A

2 portions of kinetics graph
1 - initial upstroke (first 2 mins, can be rapid, medium, slow)
2 - washout portion (2-6 mins), graded either continued rise (type 1), plateau (type 2) or rapid washout (type 3).
RIsk of cancer
- Type 1: 6%
- Type 2: 7-28%
- Type 3: 29% +

156
Q

Classic looks on MRI (4)

A

Fibroadenoma: T2 bright, round, non-enhancing septa, type 1 curve
DCIS: Clumped, ductal, linear or segmental NMLE. Kinetics usually not helpful.
IDC: Spiculated irregular masses, heterogenous enhancement, type 3 curve.
ILD: doesn’t always enhance

157
Q

T2 bright lesions on MRI (2)

A

Usually T2 bright = benign. Cysts, Lymph nodes, Fat necrosis, Fibroadenoma.
Exception is Colloid cancer and mucinous cancer which can be T2 bright.

158
Q

Breast Ca MRI trivia (2)

A

Known breast Ca: 0.1-2% have contralateral Ca on mammogram. 3-5% on MRI.
Spiculated margins = 80% malignancy. Single most predictive feature of malignancy.

159
Q

Oestrogen related risk (6)

A

More oestrogen exposure = more breast cancer risk. E.g.
- Early menarche
- Late menopause
- Late first pregnancy/no children
- Obesity
- Alcohol
- Hormone replacement

160
Q

Other breast cancer risk factors (4)

A

Any of the high risk lesions mentioned earlier (ADH, ALD, LCIS, Radial scar, Papilloma) will increase risk
Density - medium risk, dose dependent (denser breasts = more risk)
Chest wall radiation: Usually in lymphoma patients. Big risk, especially in young age.
- Risk peaks around 15 years post treatment.
- If child has >20Gy to the chest, qualifies for annual screening MRI (from age 25 or 8 years after exposure, whichever is later)
Relatives with cancer: First degree relative increases lifetime breast cancer risk from 8% to 13%. 2 first degree relatives = 21%

161
Q

Breast cancer mutations (6)

A

BRCA 1 - chromosome 17, more common than BRCA 2. Increased risk for breast, ovary, various GI cancers
BRCA 2 - Chromosome 13, male carriers have higher risk. Increased risk of breast, ovary, various GI cancers.
Li Fraumeni - p53 doesn’t work, high risk for many rare cancers
Cowden syndrome - Risk of breast cancer, follicular thyroid cancer, endometrial cancer and Lhermitte-Duclos (a brain hamartoma)
Bannayan-Riley Ruvalcaba - associated with developmental disorders at young age
NF-1 - moderate risk of breast cancer

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