breast Flashcards
breast danger zones
- medial/inferior (medial often seen on CC , not MLO and Infpst often on MLO/not CC)
- retroglandular
- where there is no dense fibroglandular tissue
where does nipple overlie?
4th IC space
retraction vs inversion
- inversion-nipple invaginate into breast
- retraction-nipple pulled back slightly
- both N if chronic
terminal duct lobular unit
-lobules (milk makers) + duct
-
order of lobule and duct system
TDLU (lobule + duct) –> major duct –> lactiferous sinus (dilated portion of major duct) –> nipple
-5-10 ductal openings at nipple
breast blood supply
- internal mammary-60%
- lateral thoracic
- intercostal perforators
lymphatic drainage
- axilla-97%
- internal mammary nodes-3%
axillary node levels
- pec minor=landmark
- 1) lat to pec minor
2) deep to pec minor
3) medal & above pec minor - rotter node: btw pec minor and major. Considered same as level 2
Rotter nodes
-btw pec minor and maj. “level 2 nodes”
mets to int mammary node
- medial cancer
- rare in isolation, ie: already in axilla
sternalis m
UL
CC view
ectopic breast tissue
- axilla-MC
- inframammary fold-2nd MC
milk streak
embryologic loc of normal breast and loc of ectopic breast tissue
estrogen vs progesterone effs on breast tissue during dev
- estrogen: duct elongation, branching
- prog: lobule prol
- don’t bx a breast bud/prepubescent breast
where do most cancers start?
- upper outer
- TLDU
maximum breast tenderness during menstrual cycle
day 27-30
peak time for breast pain/cyst formation: premen, men, perimeno, meno
perimenopause (50s)
when do fibroadenomas degenrate
menopause
when do secretary calcifications development?
10-20 yrs after menopaus
best time for mammogram or MRI?
- follicular phase
- for MR: estrogen cause contrast enh of benign br parenchyma in premenopausal women. greatest in wks 1 and 4. ie: 2nd wk best!
breast change during pregnancy
- tubes and ducts prol
- denser (during 3rd TM)–> hypoechoic
breast change during peri-menopause
shortening follicular phase/(-) estrogen –> (+) prog effs ==>. (+) pain, fibrocystic change, cyst formation
breast change during menopause
- lobules (-)
- ducts stay but ectatic
- FA degen (they like estrogen)
- secr Ca 15-20 yrs after
effects of antipsychotics
increased density
effects of prolactin
increased density
can you biopsy a lactating breast?
Yes=risk of milk fistula
mx=stop br feeding
-low risk of fistula superinfection
galactocele
- fat fluid level
- cessation of breast feeding
lactating adenoma
Circumscribed mass; many tightly packed, small lobules with lactational change and secretory hyperplasia
- ant, +/- multiple
- rapidly regress after lactation
- f/u 4-6 mos post partum, delivery or cessation of lactation (via US)
camel nose
-MLO that hasn’t been pulled up and out, ie: lift the breast on repeat
breast ideally convex or concave on mammo?
convex-pec m’s relaxed. More breast tissue
which view show most breast tissue?
MLO
when would you get an LMO?
kyphosis
- pectus pexcavatum
- avoid medial pacemaker/central line
Mag views
- CC
- ML (for milk of Ca)
spot compression views
- leave collimator open (large FOV)
- small paddles-focal compression
- large paddles-good visualization of landmarks
ML vs LM
90˚
- ML: lateral lesions.
- LM: medial lesions
ML or LM if see lesion on MLO but not CC?
-ML (70% breast cancers occur laterally)
where do motion artifact predominate and how to fix?
- inferiorly (less compression)
- “sweep up and out”
what do MLO and CC maximize?
- MLO: axillary and pst tissue
- CC: pst medial
next step: black adequate coverage at pstlat edge or ax tail on CC
XCCL
what’s next best view:
- lesion seen only in CC view
- lesion favored in skin
- lesion favored to be milk of Ca
- lesion in far pst medial breast
- br implants
- Ca
- rolled CC
- tangental
- true lateral
- cleavage view
- “eklund/implacnt displaced”
- mag
Routine and implant-displaced (ID) views standard
Implant pushed back (Eklund maneuver) and tissue pulled forward for ID views
DBT typically only performed on ID views
basic mammo artifacts
1) motion
2) grid lines
3) chin
4) deoderant
5) hair
6) jewelry
7) VP shunt
when is a grid not used in mammoth?
mag views
causes of motion artifact
- breathing or inadequate compression
1) pt moved
2) exposure too long
3) exposure too short
triangulation
muffins rising and lead sinking MLO –> CC
lesion only on CC view
rolled CC
- checks for sup or inf
- sup lesions move in dir you rolle
- inf lesions move in opp dir
BR score: bilateral well circumscribed, similar appearing masses
BR2
*don’t US unless palp
things you can BR3
- a baseline now called back
- require 2 yr f/u
- FA
- focal asymm
- grouped round Ca
BI-RADS divisions
0-incompl 1-N 2-benign 3-probably benign <2% change of CA 4-suspicious (2-95% chance of CA) 5-highly suggestive (>95% CA) 6) known biopsy proven
which BIRADS are allowed on screen?
0-2
“mass”
space occupying lesion seen in 2 different prj
- shape
- margin
- density
mass shapes
ROI
round
oval- 2-3 gentle lobulations
irreg (lobular is considered “irreg”!)
mass margin
COMIS
- circ-75%; rest “obscured”
- obscured-margin hidden by tissue but believed to be circumscribed
- microlobulated-short cycle undulations
- indisctinct-ill-defined, suggesting infiltration
- spiculated-radiating lines
mass densities
- rel to breast parenchyma
- high
- equal
- low
- fat
what is most reliable feature determining benign vs mal “mass”
margin
asymmetry
-non-mass like density
asymm vs global asymm vs focal asymm vs developing asymm
- asymm-only 1 view, not clearly 3D mass
- global-greater vol breast tissue than CL side in 1+ quadrants
- focal-2 prjs; needs compression
- developing asymm-new or progressed
Focal asymmetry: Small (< 1 quadrant) relatively discrete area of tissue density. Typically seen on both views.
Lacks discrete margins and conspicuity of true mass
Spot compression, US may reveal underlying mass
Normal variant usually has interspersed fat
Suspicious when new or larger (developing): 15% malignant across screening and diagnostic setting
describing mass on ultrasound
PEMOS
1) shape- round, oval, irreg
2) orientation-parallel, not parallel
3) margin-circus, indistinct, angular, microlobulated, spiculated (CAMIS)
4) echo-an, hypo, hyper, iso, complex
5) pst features-none, enh, shadowing
MRI focus vs mass
focus <5mm
mass >5mm
“background parenchymal enh”
- 1st post contrast sequence
- non, minimal, mild, moderate, marked
MRI lexicon “t2 signal”
1) greater than parenchyma (on T2)
2) greater than or equal to fat (on T2)
3) greater than or equal to water (on T2 fat sat)
Ca artifacts
1) on img receptor-doesn’t change position btw views
2) deoderant
3) zink oxide (collects in mold)
4) metallic- from electrocautery device; will be next to scar
Ca distribution in order of increasing suspicion
1) scattered/diffuse
2) regional-Scattered over area > 2 cm in diameter.
4% of Ca⁺⁺ biopsied; 30% malignant
3) grouped-≥ 5 Ca⁺⁺ in 1-cm span; more Ca⁺⁺ may be seen in area up to 2-cm span
4) linear
9% of Ca⁺⁺ biopsied; 59% malignant
5) segment
9% of Ca⁺⁺ biopsied; 48% malignant
dermal Ca
“tattoo sign”
- tangental view
- in folds
benign Ca types
1) dermal
2) vascular
3) popcorn
4) secretory (rod-like) Ca
5) eggshell Ca
6) dystrophic Ca
7) round
8) milk of Ca
pathophysiology of secretory/rod like Ca
duct involution
- 10-20 yrs s/p meno
- “cigar shaped w/ Lucent center”
- “dashes, no dots”
popcorn Ca pathophys
- involution FA
- per –> coalesce over mult imgs
liponecrosis macarycystica
massive eggshell Ca
where do round Ca dev and what do they rep?
- lobules
- fibrocystic change
etiology of milk of Ca
fibrocystic change
why would milk of ca not be seen on bx?
must be viewed with polarized light to assess birefringence
when are “round Ca” benign vs suspicious?
- BL and symm
- clustered, new,-need w/I
- grouped round Ca on first mammo-BR3
suspicious Ca
- amorphous
- coarse heterogenous->5mm, dull tip
- fine pleomoprhic-<5mm, sharp tips
- fine linear/fine linear branching
Ca most ass with malignancy
1) fine linear/fine linear branching=highest likelihood
2) fine pleomorphic-2nd highest
ddx amorphous Ca
- FC change (most likely)
- sclerosing adenosis
- columnar cell change
- DCIS (low grade)
ddx coarse heterogenous Ca
- FA
- papilloma
- FC change
- DCIS (low-intermediate grade)
“puff of smoke” sign or “warning shot”
susc Ca ass w/ density
- incr likelihood mal
- US next step
when is US useful in the setting of Ca?
1) ass w/ mass/asymm
2) palp finding
Mondor dx
- thrombosed v
- pres: palpable cord
- mx: NSAIDS, warm compress
Fat containing lesions
1) hamartoma
2) galactocele
3) oil cyst/fat necrosis
4) lipoma
5) intramammary LN
steatocystoma multiplex
hamartomas + mult oil cysts/fat necr
when would you bx a lipoma?
growing
when do you not US a palpable lesions?
-fat containing definite B2 on mammo
PASH
-pseudoangiomatous stromal hyperplasia
PASH
- pseudoangiomatous stromal hyperplasia
- myofibroblastic HP
- pre and postmen women on exogenous hormone rx
- f/u 12 mo (rec)
- low-grade angiosarcoma can mimic PASH on core bx==> excision bx recommended if mass grows!
most common palpable mass in young woman
fibroadenoma
fibroadenoma- classic US img in young and older woman
- oval, circumscribed mass
- homog hypoechoic
- CENTRAL hyperecho band
older: popcorn ca
fibroadenoma on MR
T2+
type 1 enh
phyllodes-mal pot
10%
- hematog to lung, bone. Bx of sentinel node not needed (met via lymph is SO rare!)
- wide margin on sx (recur if <2cm)
distinguishing features of phyllodes tumor
Fibroepithelial neoplasm with epithelial-lined hypercellular stroma creating leaf-like projections with intervening clefts
- rapid growth
- hematog mets
- middle-age to older woman
- mimicsc fA
- unresponsive to crx or rrx
Mammogram: High-density, oval/round or lobulated mass; coarse Ca⁺⁺ rare
US: Lobulated, heterogeneous mass, frequent fluid clefts/cystic spaces, ↑ vascularity
MR: Lobulated, heterogeneous mass with washout kinetics, cystic clefts/spaces ± hemorrhage, dark internal septations
classic distribution NF
peri-areolar
classic story IDC
-hard, painless, non-mobile mass
classic IDC img
- irreg, high density
- indis/spic margins
- pleo Ca
-anti-parallel shadowing mass + echogenic halo/rim
MC IDC type
-invasive ductal NOS
IDC subtypes
- invasive ductal NOS-mc
- tubular
- mucinous
- medullary
- papillary-2nd MC
mucinous IDC subtype
- uncommon
- round/lobulated, circumferential mass
- T2+
tubular IDC subtype
- small speculated slow growing mass
- “radial scar”
- favorable prognosis
contra laterality of tubular IDC subtype
-CL breast has cancer 10-15%
which IDC subtypes have better prognosis than NOS
mucinous, medullary
medullary IDC subtype
round/oval circ mass, no Ca
- large ax nodes (w/o mets)
- 40s-50s
- BRCA 1, 25%
papillary IDC subtype
- 2nd MC
- complex cystic/solid
- older
- no ax nodes
multifocal vs multi centric breast cancer
- multifocal-same quadrant, <4-5 cm apart. same duct system.
- multicentric-multiple primaries in different qudrants, discrete unrelated sites
synchronous BL breast cancer by modality and type
- mammo-2-3%
- MRI: 3-6%
-infiltrating lobular, multi-centric dx
earliest form of breast cancer
DCIS
DCIS subtypes
- comedo-more agg
- non-comed
DCIS histo divisions
- low (amorphous
- intermediate
- high (fine linear)
Mx DCIS
-wide local excision, >2mm (-) margins + XRT
DCIS change to invasiveness on bx, sx
- 10% DCIS on img have invasive comp at time bx is done
- 25% DCIS on core bx have inv comp on sx excision
how will DCIS appear
Clonal proliferation of malignant epithelial cells in terminal duct lobular unit without invasion of basement membrane
- US: microlobulated mildly hypo mass w/ ductal ext, normal acoustic transmission
- 8% mass w/o Ca
1) susp Ca
2) non mass enh
3) mult intraductal masses on galactography
pagets disease-path, pres, bx, ass, staging
Adenocarcinoma (Paget) cells within epidermis of nipple; associated with local inflammatory response, pruritus and excoriation
- CA in situ of nipple epidermis
- 50% palpable + skin change
- wedge bx of skin lesion
- ass: high grade DCIS 96%
- skin involvement does not upstage
Clinical: Erythema, flaking and ulceration of skin of nipple
Mammography: Include magnification views of suspicious Ca⁺⁺; thickening of nipple and areola may be only finding
US: Identify and biopsy any suspicious mass(es)
MR: Identify underlying malignancy and define extent for preoperative staging and treatment planning
ILC
interlobular carcinoma-2nd mc cancer
why is ILC missed on mult mambos?
-infiltrative pattern does not cause desmoplastic rxn
findings of ILC
- “dark star”-arch distortion w/o central mass seen on CC only
- US: shadowing w/o discrete mass
- “shrinking breast”
ILC vs IDC
*similar prognosis (except pleomorphic ILC :( )
ILC…
- multifocal, BL (1/3)
- met weird places (peritoneum, less met to axilla)
- positive margins
- mastectomy
- later pres
- older pop
- one view (CC, compresses better)
- Ca less common
- less w/o
dark star ddx
arch distortion w/o central mass
- lobular Ca
- radial scar
- surgical scar
- IDC-NOS
IBC mets at time of pres
30%
“peau d’orange”
IBC
IBC palp mass likelihood
no focal palpable mass
pathology of IBC skin thickening
-tumor emb blocking lymphatics
confirming dx of IBC requires:
1) tissue AND
2) clinical evidence
distinguishing mastitis from IBC
1) US:
complex cyst-drain/abx/culture & gram
solid mass susp features- bx
2) no mass?
1) abx-see if it gets better-not RESOLVED 1-2 wks=IBC
2) punch bx, consider MRI to better target
*IBC painless usually.
IBC resp to abx
-can improve but no resolve
what is MC subtype to result in IBC?
IDC (although any time can)
IBC stage
4
Poorly differentiated IDC > ILC, T4d (stage III); dermal lymphatic tumor emboli; lymphovascular invasion
IBC rx
- neoadjchemo or XRT –> mastectomy
* only breast cancer to do this
IBC vs locally advanced breast cancer
- IBC: rapid onset, mid 50s, 30% met at pres
- LABC: prolonged, mid 60s, 10%
IBC: Locally advanced breast cancer with rapid-onset (≤ 6 months) inflammatory skin change and breast swelling
Top Differential Diagnoses
Secondary skin invasion by breast cancer (T4b or T4c)
Mastitis ± abscess; granulomatous mastitis; edema
5 high risk lesions
*come out after bx
1) radial scar
2) atypical ductal hyperplasia
3) lobular carcinoma in situ
4) atypical lobular HP
5) papilloma
radial scar-app/img, ass
- dense fibrosis around ducts
- ass: DCIS & IDC 10-30%; tubular carcinoma.
Radial scar (RS): Benign proliferative lesion with central fibroelastosis and spiculated appearance radiographically and histologically
Complex sclerosing lesion (CSL): RSL > 1 cm in size
Radial sclerosing lesion (RSL): Refers to both RS & CSL
atypical ductal HP
- DCIS w/o quantitative definition by histo, ie: <2 ducts involved
- 30% upgraded at surgery
lobular carcinoma in situ
- classically occult on mammo, ie BW=incidental finding
- precursor to ILC, risk of conversion to invasive < DCIS to IDC
which ILC and LCIS subtype is worst?
pleomorphic
atypical lobular HP vs LCIS
atypical: lobule not distended on histo. subsequent risk CA 4-6x
- LCIS: lobule distended. CA 11x+
papilloma MCs
- intraductal mass lesion (subareolar, 1cm from nipple 90%)
- bloody discharge
papilloma-who, img, mult
- late repro/early meno yrs (50 yo)
- subareolar
- mammo-Ca. (often normal)
- US: well-define, solid, hypo echo. (may be cystic + solid). ass duct dil
- galactography-solid filling defect + dilation
-mult: per. mult mass OR no mass, just Ca
“multiple masses”
BL and 3+
1˚ lymphoma-type, img, what’s required for dx
- non hodgkin (DLBC)
- mammo: hyperdense mass, solitary, larger, usually palp
- US: cystic
- histo: ICH staining
*less common than 2˚
2˚ lymphoma-img
- most common 2˚/met to breast
- inflammatory thickening without mass (but can look like anything)
when to evaluate breast pain
focal, UL, non-cyclical
NPV mammo + US for focal breast pain
100%
if breast cancer found, it’s elsewhere
BL breast edema
CHF
renal fx
mc orgm breast abscess
staph aureus
RFs mastitis
- breast feeding
* incr in smokers, diabetics
how often is nipple discharge benign?
90%
when is nipple discharge suspicious
-spon’t, bloody discharge from single duct = mod suspicious feature combo
-serous
>60 yo
cancers related to nipple dc
- papilloma
- DCIS
causes of milky discharge
- prolactinoma
- antidepressants, neuroleptics, reglan
- thyroid issues
causes of non milky discharge-benign and worrisome
- B9: fibrocystic change (premenopausal), ductal ectasia (post meno)
- mal: intraductal papilloma (90%), DCIS (10%)
ductal ectasia
- MCC benign discharge in post-meno woman
- galactography: dilated ducts + progressive attenuation more pst
CI galactography
- active inf
- inab to express discharge at time of study
- contrast allergy
- prior sx to nipple areola complex
galactography procedure
- 27 or 30 g
- inj 0.2-0.3 cc contrast
- mammo (CC & ML)
- filling defect?-wire localization
architectural distortion vs summation
- summation-lines con’t past each other
- AD: lines radiate to a point
progression of surgical scar
-should get lighter, ~5-10yrs (lumpectomy scars > bx)
harmonic vs compound img
- harmonic-easier to see lesions (decrease reverberation)
- compound-lose pst features
AD + Ca vs AD w/o Ca
- ICD, DCIS
- ILC
how often are abN nodes ass w/ cancer?
1/3
recommending a bx on a node
- loss of fatty hilum-most spec
- cortical thickness 2.3 mm
- irreg outer margin
when staging LNs, which are treated the same?
- level 1 and 2 (+rotter)
- 3 and supraclavicular
v dense LNs
gold rx
patterns of gyenocmastia
1) nodular (MC)-flamae-shaped, tender, <1 yr
2) dendritic-branching tree, chronic fibrosis, tender
3) diffuse glandular-estrogen
“pseudogynecomastia”
“bitch tits”, ie: fat, no glandular tissue
which breast diseases are not in men?
those involving lobules: lobular CA, FA, cysts
male breast cancer-MC age, type, RFs
- 70 yo
- IDC-NOS
- BRCA (1/4), Klinefelter, cirrhosis, chronic EtOH
- eccentric, near nipple
palpable masses in man
1) gynecomastia = mc
2) lipoma=2nd mc
things that make you think male breast cancer (vs gynecomastia)
- eccentric to nipple
- UL
- abN LN
- Ca (25%)- less numerous, coarser and ass w/ mass
screening mammo in men
only klinefelter
working up gender reassignment breast on hormone therapy
- don’t meet screening criteria
- w/u if palp finding
implant types
1) silicone
2) saline
implant location
1) sub glandular (retromammary)
2) sub pectoral (retropectoral)-btw pec major and minor m’s
how often are Ca ass w/ fibrous capsule?
25%
do implants increase risk of cancer?
lymphoma
can you biopsy w/ implants?
yes but saline can burst w/ 25g FNA so be careful
modality of choice when evaluating implant
MRI T2 FS
complications associated with implants
1) capsular contracture-MC. sub glandular silicone
2) gel bleed-silicone. in LN
3) rupture
silicone rupture types
*cannot have isolated extra capsular rupture
1) isolated intracapsular-occult on physical exam.
- stepladder on US
- linguine sign on MRI
2) intracapsular w/ extracapsular rupture
- snowstorm- v echo w/o pst shadowing
- MR: T1 and T2 (-)
radial folds
-normal inholdings of esatomer shell, should always conn with periphery of implant, thicker (bc rep both layers)
reduction mammoplasty
smaller breasts
mastopexy
removing extra skin
- swirled, inf breast
- fat necrosis/oil cysts
- isolated islands of breast tissue
key hole incision
surgical approach for mammoplasty and mastopexy
-“swirled” appearance in inf asp MLO
lumpectomy
surgical removal of cancer (palpable or not)
excisional vs incisional bx
removing entire lesion vs portion of lesion
when to obtain first post-op img and what to expect
6-12 mo
- mammo: distortion/scarring worst on this film
- US: thin, linear
- if focal mass like/thickness-suspicious
fat necrosis on MR
T1/T2+ w/ w/o on FS
local recurrence-how often, when, who, where
- breast conservation w/o radiation 35%
- breast conservation w/ radiation 4-6%
-1-7 yrs after (peak ~4yrs)
- early recur: in org tumor bed, later=diff site
- comes from either residual breast tissue or along skin scar line
- premeno women (highest risk), extensive inarticulate component, vascular, multi-centric, positive sx margins, not adequately treated org
- residual Ca recurr rate 60%
new calcs s/p rx
- benign: ~2 yrs
- mal: ~4 yrs
lymph node failures rate
5%
chance of incomplete excision if mass at edge of specimen radiograph
80%
residual dx on pre and post radiation mammo
pre: more rx options
post: mastectomy
secondary angiosarcoma
- 6 yrs after breast conservation/radiation rx
- red plaques or skin nodules
- T2+
breast cancer staging
1) <2cm
2) 2-5 cm
3) >5 cm
4) any size + invasion (cw fixation, skin, inflammatory)
MI predictor overall survival in breast cancer
axillary status
mc tumor to met to breast
melanoma
CI for breast conservation
1) inflammatory cancer
2) large cancer size rel to breast
3) multi centric (mult quadrants)
4) prior radiation rx
5) CI to radiation (ex: collagen-vascular dx)
T2 bright things on MR
- benign (usually)
- cysts, LN, fat necrosis, fibroadenoma
exc:
- colloid cancer
- mucinous cancer
who gets MR screening? WHo’s not rec?
- lifetime risk >20-25%. Can consider for moderate (15-20%), not recommended for low (<15%)
- don’t use Gail model. Tyrer-Cuzick is best!
- 20 Gy radiation to chest as a child (FTC says hx radiation btw 10-30 yo.)
- peaks 15 yrs after
- 25 yo or 8 yrs post exposure-whichever is later!
- known genetic mets (incl BRCA1, BRCA2, PTEN)
- fam hx (2+ 1st degree w/ premenopausal br CA or fam hx breast or ovarian CA
not recommended: 15-20% lifetime risk -personal hx br ca -ADH, lobular neo -more limited family hx.
effect of tamoxifen on breast parenchymal enc
-decreases –> rebound
in determining suspicion, kinetics or morph?
morph > kinetics
are foci bad?
2-3% chance of mal
breast kinetics
- 2 parts:
1) upslope (~2 mins)-slow, medium, rapid
2) washout (2-6 mins) - type 1: curve 6%; fibroadenomas
- type 2: curve: 7-28%
- type 3: curve 29%+; high risk
type I curve: progressive or persistent enhancement pattern
typically shows a continuous increase in signal intensity throughout time
usually considered benign with only a small proportion of (~9%) of malignant lesions having this pattern
type II curve: plateau pattern
initial uptake followed by the plateau phase towards the latter part of the study
considered concerning for malignancy
type III curve: washout pattern
has a relatively rapid uptake shows reduction in enhancement towards the latter part of the study
considered strongly suggestive of malignancy
hereditary syndromes ass w/ breast cancer risk
1) BRCA 1
2) BRCA 2
3) Cowden Syndrome
4) Hereditary diffuse gastric cancer syndrome
5) Li-Faumeni Syndrome
“hereditary breast and ovarian cancer syndrome”
BRCA 1: chrom 17. Br cancer 72%, ov cancer 44%.
BRCA 2: chrom 13. Br CA 69%, ov CA 17%. Male breast cancer.
-triple neg
medullary subtype
-other cancers: Fallopian tube, pancr, colon
Cowden syndrome
hamartomas, facial/mouth bumps
- Br CA 77%, other br conditions
- thyroid (follicular) & benign thyroid dx-annula thyroid screening
- lhermitte-duclos (dysplastic gangliocytoma of cerebellum)
hereditary diffuse gastric cancer syndrome
- diffuse gastric cancer risk-70%
- lobular br cancer risk-40% (lobules look like poop)
- ppx gastrectomy
li fraumeni syndrome
- bad p53
- cancer everywhere
- high grade breast cancer in 30-40 yo
NF1 risk of breast cancer
moderate
Bannayan-Riley Rucalcaba
ass w/ developmental disorders at young age
estrogen related RFs
- early menstration
- late menopause
- late age first pregnancy/no kids
- obesity
- EtOH
- horm repl
does breast density increase risk of br cancer?
- > 75% br density have fivefold (+) risk. Not for those with dense breasts (>50%)
- dose-dep
- “medium risk”
increased risk of br cancer with family members
- 1st degree relative-13%
- 2+ 1st degree relative-21%
eff of SERMs on br CA
-reduce incidence of ER/PR+
sclerosis adenosis
Adenosis: Benign proliferation of lobular glandular elements with ↑ acini/ductules
Sclerosing adenosis (SA): Adenosis + intervening stromal fibrosis compressing and distorting acini
Microglandular adenosis (MGA): Extremely rare variant of adenosis with single epithelial cell layer infiltrative pattern
Best diagnostic clue
Microcalcifications: Grouped or scattered, amorphous ± punctate
Less common: Oval circumscribed mass ± Ca⁺⁺; architectural distortion
May be incidental finding on biopsy
Imaging findings vary among pathologic subtypes
Size
Masses usually small (average: 12-25 mm)
cancer detection rate
- number of cancers with positive initial interpretation (BI-RADS 0, 4, 5) per 1000 SCREENING mambos.
- benchmark >2.5/1000
definition of “False negative”
-tissue diagnosis of cancer w/I 1 yr negative exam
bi-rads 1, 2 for screening, 1-3 for dx
definition “FP 1”
no known tissue dx of cancer w/i 1 yr of positive screening exam.
definition “FP 2”
no known tissue dx of cancer w/i 1 yr after recommendation for tissue dx or surgical consultation on the basis of positive exam (bi-rads 4,5)
definition FP 3
concordant benign tissue dx (or discordant benign tissue dx and no known tissue dx) w/I 1 yr after rec for tissue dx on basis of (+) exam (BR 4, 5)
definition TP
tissue dx of cancer w/I 1 yr after positive exam
definition TN
no known tissue dx of cancer w/I 1 yr negative exam
compression plate and img receptor sizes, compression F, collimate to what?
- 18 x 24 and 24 x 30 cm
- 25-45 lb
- collimate to receptor
“abN interpretation rate” aka “recall rate” in screening mammography
percentage of exams interpreted as positive, ie: 0, 4, 5
“abN interpretation rate” aka “biopsy recommendation rate”
percentage of exams interpreted as positive, ie: BR 4,5)
-# BR 4, 5/total # dx mambos.
“cancer detection rate”
# of cancers correctly detected at mammo/1000 pts examined at mammo -# positive bx/total number screened
phase encoded directions axial and sag sequences
- axial: L to R
- sag: sup to inf
dose gadolinium for contrast enhanced MR
0.1 mmol/kg followed by saline flush
PPV 1-3
PPV1: TP/#positive screening exams
PPV2 (biopsy recommended): percentage of all dx (or rarely screening) exams recommended for tissue dx or surgical consultation that result in tissue dx in 1 yr
-TP/(# screening or dx exams recommended for tissue dx)
OR
-TP/ (TP+FP2)
PPV3 (bx performed): percentage of all known biopsies done as a result of positive dx exam that resulted in tissue dx of cancer w/I 1 yr
-aka “bx yield of malignancy” or “positive bx rate (PBR)
TP/# biopsies OR TP/(TP + FP 3)
birads US lexicon, tissue composition (Screening only)
1) homogenous background echotexture-fat
2) homogenous bg echotexture-fibroglandular
3) heterogenous bg echotexture
analysis of medical audit data: acceptable ranges of screening mammo
1) cancer detection rate/1000 exams: 2.5+
2) abN interpretation (recall) rate: 5-12%
3) PPV1 (abN interpretation): 3-8%
4) PPV2 (recommendation for tissue dx): 20-40%
5) sensitivity: 75%+
6) specificity: 88-95%
likelihood of Ca malignancy based on distribution
- diffuse distribution: 0%
- regional 26%
- grouped 31%
- linear 60%
- segmental 62%
suspicious Ca likelihood of malignancy based on morphology
- coarse heterog 13%
- amorphous 21%
- fine pleo 29%
- fine linear/fine linear branching 70%
DIEP vs TRAM
TRAM flap reconstruction: absence of atrophied rectus abdominis muscle and its vascular pedicle in the reconstructed breast differentiates a DIEP from a TRAM flap
Poland syndrome has increased incidence of which cancers?
- breast
- leukemia
- NHL
- lung
mx high risk lesions
- surgical excision
- 6 mo f/u’s
appearance TRAM
fatty dome shaped area in center of breast
in pts with TRAM, where do recurrences MC occur?
deep to TRAM
triple negative cancers
- resp to various management.
- Who?
- v aggressive
- no resp to hormone manipulation but responsive to crx
- 70% pt’s w/ BRCA-1 have triple (-)
- premeno, black, obese
- met to brain, lungs (not bones)
BRCA 1 vs BRCA 2
- BRCA 2= smaller, less aggressive, ER/PR (+).
- act more like sporadically detected cancers
“specificity”
TN/TN + FP. Probability of normal mammogram when no cancer is present
mammo exposure
~5-24 mSv
-1 Sv=200 mammos
what is the highest acceptable percentage of node positivity in cancers detected by mammo in a screening program?
25%
ie: in a well-administered screening mammography program, >75% of cancers should be node negative
risk of radiation induced cancer in screening
1/1000
IBC vs LABC
inflamm = shorter duration of syx’s
purpose of preoperative MRI
- look for additional lesions in same or CL breast
- if additional lesions-biopsy (usually under MRI guidance since lesions weren’t seen on other img)
portions of breast with met
non-glandular tissue
medullary CA- app, mlc markers, aggressive and local recurr
solid circumscribed mass
- young
- triple (-)-doesn’t resp to horm rx
- histo aggressive but sens to crx ==> survival :)
N staging
N1: IL axillary (if discrete)
N2: IL internal mammary discrete. matted axillary (clinical)
N3: IL supraclavicular, IL infraclavicular, combo of IL internal mammary w/ other IL ax
M1: CL
“locally advanced breast cancer” by definition
> 5 cm
or mass of any size that involves skin or chest wall
-skin detected via: nodules, ulcerations. *peau d’ orange alone is not enough
-chest wall: ribs, IC m, serrates ant m, ie: pec m not enough
salad oil sign
rupture of inner lumen double lumen implant on MRI
gel bleed not seen on…
not seen on US or mammo
critical sequence for MR evaluation of breast implant?
T2WI w/ fat sat
what complications of PM have been reported with mammo?
- lead damage and breakage
- NOT loss of pacemaker settings (which has been reported with CT chest).
- may obscure small lesions
benefits of compression:
1) (+) SR (via (-) thickness)
2) (+) CR (via spreading of tissue)
3) (-) dose
components of phantom, thickness, composition, and how often checked
(clusters, masses, fbrs)
- CMF 556 , 334 to pass
- 4.2 cm thick
- 50/50 fatty/glandular
- checked weekly
where do skin folds develop on MLO views?
lateral aspects
where and how do skin folds and pec major m appear on cc mammo views?
- inf/pst
- underexposed, ie: v bright/dense, sharply defined dark shadow trapped under breast
savi scout
- radar detector placed in breast lesion
- ninitol/nickel
- placed via 16g needle
savi scoutman’s breast
- radar detector placed in breast lesion
- ninitol/nickel
- placed via 16g needle
pathophys gynecomastia
*non-neo enlargement of ep & stromal elements
- physiologic in adolescents (aff 50%!)
- path (13-65 yo)- spironolactone, psyche meds, marijuana, EtOH cirrhosis, testicular CA)
what should make you think br CA in males (vs gynecomastia)
eccentric to nipple UL abN LNs Ca looks like br CA
Ca in males
rare. usually less numerous, courser and ass w/ mass
how many male Br CA have Ca
25%
