Abnormal Development, Diagnosis and Imaging Flashcards
Poland syndrome
> > genetic disorder that presents as a unilateral variable loss of the breast tissue, pectoralis major and minor, and serratus anterior muscles as well as several ribs.
Accessory breast tissue (polymastia) and accessory nipples (supernumerary nipples)
> > result of persistence of the mammary ridge
Supernumerary nipples
> > usually rudimentary and occur along the milk line from the axilla to the pubis in males and females
True polythelia
> > more than one nipple serving a single breast, which is rare
Accessory breast tissue
> > is commonly located above the breast in the axilla.
> > The accessory mammary tissue may be removed surgically if it is large or cosmetically deforming or to prevent enlargement during future pregnancy.
Gynecomastia
- Hypertrophy of breast tissue
- Pubertal hypertrophy is generally treated by observation - Surgical excision if the enlargement is unilateral, fails to regress, or is cosmetically unacceptable
Drugs causing gynecomastia
- digoxin
- thiazides
- estrogens
- phenothiazines
- theophylline
- cannabis
> > hepatic cirrhosis, renal failure, or malnutrition.
Cancer Vs Gynecomastia
> > Carcinoma is not usually tender
asymmetrically located beneath or beside the areola,
may be fixed to the overlying dermis or to the deep fascia.
Nipple Discharge without a mass , any risk of cancer ?
In the absence of a palpable mass or suspicious findings on mammography, discharge is rarely associated with cancer.
The most common cause of spontaneous nipple discharge
- Single duct is a solitary intraductal papilloma (60%–80%)
- Subareolar duct ectasia (20%) > multiple ducts
Papilloma risk for cancer
- Papillomas that are located away from the nipple-areolar complex are at higher risk of malignancy (20%).
- A papilloma is the most common benign tumor to develop breast cancer, primarily DCIS.
Nipple discharge that is bilateral and comes from multiple ducts
is not usually a cause for surgery
Bloody discharge from a single duct, Tx ?
> > often requires surgical excision to establish a diagnosis and control the discharge
Bilateral bloody spontaneous discharge , Cause ?
> > is likely endocrine in nature and is associated with pregnancy and hypothyroidism.
Galactocele
- occurs after the cessation of lactation or when feeding frequency has declined
- may occur 6 to 10 months after breastfeeding has ceased
- Needle aspiration produces thick, creamy material that may be tinged dark green or brown.
Galactocele Tx?
> > Treatment is large bore needle aspiration, and withdrawal of thick milky secretion confirms the diagnosis
> > surgery is reserved for cysts that cannot be aspirated or that become infected
What is a clinic Sign specific for Malignancy
> > dimpling of the skin or nipple retraction is a sensitive and specific sign of underlying cancer
Hallmark for Inflammatory Carcinoma by clinical exam
- Peau d’orange
- tenderness
- warmth
- swelling
> > may be mistaken for acute mastitis.
What causes The inflammatory changes and edema
> > caused by obstruction of dermal lymphatic channels by emboli of carcinoma cells
Inflammatory cancer onset
> > rapid onset (less than 3 months) as compared to a similar presentation for locally advanced cancer, which may have been present for years and neglected.
Flattening or inversion of the nipple causes?
> > caused by fibrosis in certain benign conditions, especially subareolar duct ectasia.
Paget disease
- Commonly associated with an underlying breast cancer
- Carcinoma cells invade across the junction of epidermal and ductal epithelial cells and enter the epidermal layer of the skin of the nipple
- Paget disease originates on the nipple and secondarily involves the areola
FNA Role?
> > A limitation of FNA in evaluating solid masses is that cytologic evaluation does not differentiate noninvasive lesions from invasive lesions if malignant cells are identified.
> > If FNA demonstrates malignancy, a CNB is still required for definitive histologic diagnosis before surgical intervention.
When FNA needed ?
> > One clinical scenario in which FNA still has utility is in the evaluation of a second suspicious lesion in the ipsilateral breast of a patient with a known malignancy.
> > evaluation of lymph nodes that are suspicious on either physical examination or imaging
> > sensitivity of approximately 90% and a specificity of up to 100%
How to do FNA ?
- 22-gauge needle
- syringe
- alcohol preparation pad.
- The needle is repeatedly inserted into the mass while constant negative pressure is applied to the syringe.
- multiple areas of a mass could be sampled
- The fluid and cellular material within the needle are submitted in buffered saline or fixed immediately on slides in 95% ethyl alcohol
How to DO CNB ?
- trigger devices requiring multiple entries or with vacuum-assisted devices
- Size of a CNB ranges from 8 to 14 gauge
- under mammographic (stereotactic), ultrasound, or (MRI) guidance
- During stereotactic CNB, the breast is compressed, most often with the patient lying prone on the stereotactic CNB table
- After local anesthetic is injected
- a small skin incision is made,
- core biopsy needle is inserted into the lesion to obtain the tissue sample with vacuum assistance.
- A clip should be placed to mark the site
- specimens should be imaged
- A mammogram obtained after biopsy confirms that a defect has been created within the target lesion and that the marking clip is in the correct position
Image-guided localization and surgical excision are required if
> > the lesion cannot be adequately sampled by CNB
or
if there is discordance between the imaging abnormality and pathologic findings.
Indications for Excisional Bx ?
- Less than 10% of patients who undergo CNB have inconclusive results and require surgical biopsy for definitive diagnosis.
- Biopsy results that are not concordant with the targeted lesion (e.g., a spiculated mass on imaging and normal breast tissue on CNB) necessitate surgical excision.
- When ADH is found on CNB, surgical excision reveals DCIS or invasive carcinoma in 20% to 30% of cases because of the difficulty of distinguishing ADH and DCIS in a limited tissue sample.
- A finding of a cellular fibroadenoma on CNB requires excision to rule out a phyllodes tumor.
Screening vs diagnostic mammo
- On screening mammography, two views of each breast are obtained, mediolateral oblique and craniocaudal and ready at a later time usually in batches
- diagnostic mammography is indicated, which is read at the time of performance so additional views may be performed
Digital mammography
> > superior to traditional film-screen mammography for detecting cancer in younger women and women with dense breasts
mammo in younger than 30 and older women
> > women younger than 30 years, whose breast tissue is dense with stroma and epithelium, may produce an image without much definition.
> > As women age, the breast tissue involutes and is replaced by fatty tissue.
On mammography, fat absorbs relatively little radiation and provides a contrasting background that favors detection of small lesions.
Recommendation for Screening
> > recommended biennial screening mammography for women 50 to 74 years old
> > recommended against screening for women 40 to 49 years old or older than 75 years
> > the American Cancer Society continues to recommend annual screening mammography for women older than 40 years
Screening MRI ?
> > Younger women with a previous breast cancer
significant family history of breast cancer
histologic risk factors for breast cancer equal to a 20% lifetime risk
Tomosynthesis ( 3D )
Tomosynthesis acquired thin sections of tissue with its main advantage being to separate overlapping breast tissues, decrease callbacks, and find smaller significant disease
> > higher detection of breast cancer but a slightly higher false positive recall
excels in delineating small and multiple masses, microcalcifications, and distortion due to ducts and vessels
But has higher radiation
US for Screening ?
No
because operator Dependent
MRI ? When MRI is used for screening, it should be used in addition to screening mammography.
- Unknown Primary
- Axillary LN with no palpable mass in breast
- patients with Paget disease of the nipple without radiographic evidence of a primary tumor
- extent of the primary tumor, particularly in young women with dense breast
- extent of residual disease after lumpectomy with positive margins;
- presence of multifocal or multicentric cancer
- screening of the contralateral breast
- for evaluating invasive lobular cancers
- assessment of treatment response after neoadjuvant chemotherapy.
- used for assessing implant rupture or assessing the breast when silicone injections have been used.
- Younger women with a previous breast cancer
- significant family history of breast cancer
- histologic risk factors for breast cancer equal to a 20% lifetime risk
Women at High Lifetime Risk (Risk Criteria for Breast Magnetic Resonance Imaging Screening. ≈20%–25% or Greater) of Breast Cancer
- Known BRCA1 or BRCA2 gene mutation
- First-degree relative with BRCA1 or BRCA2 gene mutation, but have not had genetic testing themselves
- Lifetime risk of breast cancer of ≈20%–25% or greater
- Radiation therapy to the chest between the ages of 10 and 30
- Li-Fraumeni syndrome or Cowden syndrome or a first-degree relative with one of these syndromes
Women at Moderately Increased (15%–20%) Lifetime Risk
- Lifetime risk of breast cancer of 15%–20% according to risk assessment tools based mainly on family history
- Personal history of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia
- Extremely dense breasts or unevenly dense breasts when viewed by mammograms
probably benign lesions are designated BI-RADS 3
> > monitored with 6-month interval mammograms over a 2-year period.
> > Biopsy is performed only for lesions that progress during follow-up
Non Visible lesions even in US , What to do ?
- wire is used to localize the lesion, it is placed through an introducer needle and has a hook that engages within the breast parenchyma at or near the abnormality
- After excision, a specimen radiography confirms that the targeted lesion has been excised.
> > Patients who have a diagnosis of benign findings on excision should undergo new baseline mammogram 4 to 6 months after the surgical procedure
> > radioactive seed localization, which involves positioning a 4.5-mm 125I seed in the breast tissue
a gamma probe, which detects technetium-99m (99mTc), commonly used for sentinel lymph node dissection (SLND), and 125I can be used to guide the breast resection
- A newer technique, fluoroscopic intraoperative neoplasm or node detection
