4. Breast p136-140 (Symptomatic Breast, Architectural Distortion, Nodes)

Question 1

Breast pain (4)

Answer 1

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)

Question 2

Worrisome symptoms for cancer (3)

Answer 2

Skin dimpling,
focal skin thickening,
nipple retraction

Question 3

Non-focal skin thickening/breast oedema (2)

Answer 3

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

Question 4

Breast inflammation (2)

Answer 4

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

Question 5

Mastitis/abscess (4)

Answer 5

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

Question 6

Inflammatory breast cancer (5)

Answer 6

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)

Question 7

Discharge (4)

Answer 7

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.

Question 8

Milky discharge (2)

Answer 8

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)

Question 9

Causes of discharge (not milky) (4)

Answer 9

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

Question 10

Ductal ectasia (2)

Answer 10

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

Question 11

Galactography (8)

Answer 11

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.

Question 12

Architectural distortion (2)

Answer 12

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.

Question 13

Architectural distortion vs summation artefact

Answer 13

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

Question 14

Surgical scar vs pathology (2)

Answer 14

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

Question 15

Work up of AD (3)

Answer 15

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

Question 16

US trivia (AD) (4)

Answer 16

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.

Question 17

Architectural distortion trivia (7)

Answer 17

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

Question 18

Unilateral vs bilateral nodes

Answer 18

Unilateral lymphadenopathy is more worrying for cancers on that side.

Question 19

When to biopsy lymph nodes (3)

Answer 19

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

Question 20

Staging trivia (nodes) (3)

Answer 20

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

Question 21

Gold therapy (2)

Answer 21

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

Question 22

Snow storm nodes (2)

Answer 22

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