Breast Flashcards
US –> first line eval for breast abnormality –> who? (3)
- <30yo
- pregnant
- lactating
MRI –> breast screen –> who?
high risk pt (>20% lifetime risk of breast CA)
MRI breast –> indications? (6)
- screen in high risk pt
- breast CA –> new dx –> eval extent of dz
- eval neoadjuvant ctx response
- positive surgical margins –> assess residual dz
- eval tumor recurrence
- axillary mets –> eval occult breast CA
invasive ductal breast CA –> stepwise progression?
1) flat epithelial atypia
2) atypical ductal hyperplasia
3) ductal carcinoma in situ (DCIS)
4) invasive ductal carcinoma
flat epithelial atypia (FEA) & atypical ductal hyperplasia (ADH) –> obligatory or non-obligatory precursor lesion for breast CA?
non-obligatory –> inc risk
breast CA –> RF? (7) which are most important RF?
- # 1 F
- # 1 age
- BRCA1/2
- 1st deg relative
- chest radiation
- long-term estrogen exposure (early menarche, late menopause, late first preg, nullipartiy, obesity)
- bx high risk lobular lesion (ie atypical lobular hyperplasia, lobular CA in situ)
breast CA –> MC type?
invasive ductal CA (IDC) not otherwise specified
breast CA –> invasive ductal CA (IDC) –> MC clinical presentation?
palpable mass
breast CA –> invasive ductal CA (IDC) –> classic mammo appearance?
- spiculated mass
- architectural distortion
- pleomorphic calcs
ductal breast CA –> subtypes? (5)
- invasive ductal, not otherwise specified
- tubular
- mucinous (colloid/mucoid/gelatinous)
- medullary
- papillary
invasive ductal CA vs other ductal breast CA –> better prognosis –> T/F?
F –> other ductal breast CA have better prognosis than invasive ductal
breast CA –> tubular CA –> mammo appearance?
small spiculated mass
breast CA –> mucinous (colloid/mucoid/gelatinous) CA –> US appearance? T2 MRI?
- US: low density circumscribed mass –> mimic fibroadenoma
- T2 –> hyper
breast CA –> medullary CA –> epidemiology?
young F –> BRCA1
breast CA: invasive lobular CA –> mammo appearance?
architectural distortion –> “dark star”
breast CA: what is inflamm CA?
tumor invasion of dermal lymphatics
breast CA: inflamm CA –> clinical presentation?
breast:
- erythema
- edema
- firm
breast CA: inflamm CA –> mammo appearance?
- breast –> lrg, dense
- trabecula thick
- skin thick
what is Paget dz of nipple?
form of DCIS –> infiltrate nipple epidermis
Paget dz of nipple –> clinical appearance?
nipple:
- erythema
- ulcer
- eczematoid changes
breast CA –> prognosis –> most important factor?
axillary LN status
breast CA –> axillary LN involvemt –> how to detect?
sentinel LN bx
breast CA –> surgical axillary LN dissection –> indication? (2)
sentinel LN:
- positive
- not ID
estrogen receptor (ER) & progesterone receptor (HR) –> positive –> longer disease free survival –> T/F?
T
ER, PR, HER2/neu negative –> triple neg CA –> poor prognosis –> MC epidemiology?
BRCA1
triple neg CA –> MC mammo appearance? MC location?
breast –> posterior –> round –> smooth margin –> no calcs
DCIS –> prognosis –> key factor?
presence of necrosis
DCIS –> which subtype gets sentinel LN bx?
DCIS w necrosis –> high grade
high grade DCIS –> MC mammo appearance?
calcs:
- pleomorphic
- fine linear branching
breast –> fibrocystic change –> epidemiology? clinical presentation?
pre-menopause:
- cyclic breast pain
- sometimes –> palpable lump
breast –> fibrocystic change –> imaging dx –> T/F?
F
sclerosing adenosis –> mammo appearance?
microcalcs –> can mimic DCIS
mastitis –> MC org?
Staph aureus
mastitis –> 2 MC epidemiology?
- nursing
- diabetes
mastitis –> clinical presentation?
breast:
- pain
- induration
- erythema
mastitis –> imaging (mammo/US) appearance?
- skin thicken –> focal/diffuse
- edema
- adenopathy
breast abscess –> MC location?
subareolar
breast abscess –> mammo appearance?
irreg mass –> mimic carcinoma
breast abscess –> tx?
- US-guide aspiration
- abx
what is granulomatous mastitis? epidemiology?
young F –> after childbirth –> rare idiopathic –> breast inflamm –> noninfx
granulomatous mastitis –> assoc RF? (2)
- breastfeed
- OCP
granulomatous mastitis –> mammo/US finding? –> next step? why?
mimic breast CA –> bx
periductal mastitis (plasma cell mastitis) –> epidemiology?
post-menopause
periductal mastitis (plasma cell mastitis) –> MOA? classic mammo appearance?
intraductal lipids –> irritating –> large rod-like calcs
diabetic mastopathy –> MOA?
long term diabetes –> chronic hyperglycemia –> autoimmune rxn to matrix proteins –> firm mass –> can be painful
diabetic mastopathy –> mammo appearance? calcs?
- ill-defined asymm density
- no microcalcs
diabetic mastopathy –> US appearance? next step?
- hypoechoic mass
- regional acoustic shadow
–> mimic scirrhous breast CA –> bx
what is Mondor thrombophlebitis?
breast –> superficial V –> thrombophlebitis
Mondor thrombophlebitis –> MC vein?
thoracoepigastric V
Mondor thrombophlebitis –> clinical presentation?
- superficial mass –> cordlike/elongated
- pain/tender
Mondor thrombophlebitis –> US appearance?
dilated tubular struct –> “bead-like” –> no color flow
cleavage view –> purpose?
image medial breast tissue of both breasts
what is exaggerated CC (XCC) view?
pull lat/med tissue into image detector
what is online screening?
screen mammo –> pt wait for final read
online vs offline screen –> cons? (2)
online:
- more imaging
- more false pos
- same cancer detection rate
image quality –> how determine if CC and MLO view have imaged adequate tissue?
posterior nipple line –> w/in 1 cm
image quality –> nipple?
nipple should be in profile in at least 1 view
mammo signs of malig? (4)
- mass
- calc
- architectural distortion
- asymm
BI-RADS categories?
- 0: need additional imaging
- 1: neg
- 2: benign
- 3: prob benign
- 4: suspicious
- 5: highly sugg malig
- 6: known bx-proven malig
BI-RADS 3 –> next step?
short interval fu –> usu 6mo
screen mammo –> BI-RADS 3 –> T/F?
F
can only be categorized 3 after dx mammo
BI-RADS 3 –> %malig?
<2%
BI-RADS 4 –> %malig?
2-95%
BI-RADS 4 –> next step?
bx or aspiration
breast abscess –> BIRADS?
4
BI-RADS 5 –> % malig?
> 95%
BI-RADS 5 –> next step?
- bx
- surg
fibroglandular density –> categories? (4)
- almost entirely fatty
- scattered
- heterogeneous
- extremely dense
almost entirely fatty vs extremely dense fibroglandular tissue –> which has inc risk of breast CA?
extremely dense fibroglandular –> 5x more risk –> than almost entirely fatty
inc fibroglandular density –> bilat –> ddx? (2)
benign:
- hormone
- edema
inc fibroglandular density –> unilat –> ddx? (1)
malig –> lymph obstruct
skin thickening –> benign cause? (3)
- radiation
- acute mastitis
- fluid overload (CHF, renal fail, liver fail)
what is “mass”?
2 projections –> space occupying lesion –> convex borders
asymm –> seen on how many views?
1
mass –> margins? (5)
- circumscribed
- microlobulated
- obscured
- indistinct
- spiculated
margin –> circumscribed –> % margin that must be well-defined?
75%
mass –> densities? (4)
- radiolucent (fat)
- low density
- equal density
- high density
mammo: mass –> shape? (3)
- round
- oval
- irreg
mammo vs US –> preferred terminology for location?
- mammo: quadrants
- US: clockface
mammo –> quadrants? (4)
- upper outer
- upper inner
- lower outer
- lower inner
assoc features? (7)
- architectural distortion
- microcalc
- skin retraction
- nipple retraction
- skin thick
- trabecular thick
- axillary LN
what is architectural distortion? concerning for CA?
radiating linear densities –> no definite mass
highly concerning for CA
skin retraction –> ddx? (2)
- postsurg
- desmoplastic tumor rxn
calcs –> indeterminate or susp for malig –> require what view?
spot compression –> mag
skin calcs –> mammo appearance?
MC medial location:
- punctate
- lucent center
calcs –> how to determine if skin calcs?
tangential view
popcorn calc –> dx?
involuting fibroadenoma
large rod-like calc –> dx?
plasma cell mastitis (duct ectasia)
milk of calcium –> etiology
fibrocystic change
milk of calcium calc –> mammo appearance?
- CC view: fuzzy round amorphous
- lat: semilunar/crescent shape
what is suture calc?
suture material –> calcium (usu after radiation)
dystrophic calc –> etiology? (4)
sequela:
- surg
- bx
- trauma
- rad
punctate calc –> shape? size (mm)?
round –> <0.5mm
lucent-center calc –> size?
<1mm - >1cm
eggshell (rim) calc –> ddx? (2)
- fat necrosis
- cyst –> calc wall
benign calcs (BI-RADS 2)? (11)
- skin
- vascular
- suture
- popcorn
- lrg rod-like
- milk of Ca
- dystrophic
- round
- punctate
- lucent-center
- eggshell (rim)
interm concern calcs (BI-RADS 4)? (2)
- amorphous/indistinct
- coarse heterogeneous
amorphous calc –> appearance?
too small or hazy to ascertain morphology
amorphous calc –> diffuse vs focal –> benign vs suspicious?
- diffuse –> benign
- focal –> susp
coarse heterogeneous calc –> appearance?
- irreg
- >0.5mm but smaller than dystrophic calc
higher prob of malig (BI-RADS 4-5) –> calcs? (2)
- fine pleomorphic
- fine linear (branching)
fine pleomorphic calc –> appearance?
vary in shape & size –> “dot-dash” appearance
fine pleomorphic calc –> ddx? (2)
- DCIS
- invasive ductal CA
calc –> distribution? (5) which are usu benign? more suspicious?
usu benign:
- diffuse/scattered
- regional
more suspicious:
- linear
- grped/cluster
- segmental
calc –> what is regional distribution?
lrg vol (>2cc) breast tissue –> not conform to ductal distribution
calc –> grped/cluster –> definition?
at least 5 calc in <1cc of breast tissue
what is rolled view? purpose?
CC view –> roll top breast med (RCCM) or lat (RCCL) –> localize lesion seen only on CC –> lesion mv med on RCCM –> in sup breast
what is reduced compression view? purpose?
reduced compression –> image far post lesions that slip out when full compression applied
true lat view –> when LM preferred over ML?
medial lesion –> LM –> lesion closer to detector
MLO –> lesion –> superior on lat view –> lesion is located med or lat?
med (Medial: Muffins rise)
MLO –> lesion –> inf on lat view –> lesion is located med or lat?
lat (Lat: Lead sinks)
punctate or round calc –> grp/cluster –> BI-RADS?
3
amorphous calc –> cluster –> next step?
indeterminate –> bx
what is focal asymm?
nonpalpable non-mass lesion –> seen on 2 projections
focal asymm –> US –> no correlate –> BI-RADS?
3
what is developing asymm? benign or suspicious?
focal asymm –> inc in size
suspicious
epidermal inclusion cyst –> US appearance?
circumscribed –> variable internal echotexture –> anechoic to heterogeneous
breast lesion –> dermis + hypodermis –> findings that dermal origin? (2)
- claw of dermal tissue –> wrap around lesion
- lesion –> tract to epidermal surface
what is mammary zone? contains what tissue/structures?
zone bw subcutaneous & retromammary:
- ducts/TDLU
- fat
- fibrous tissue
- Cooper’s lig
ultrasound: mass –> shape? (3)
- round
- oval
- irreg
ultrasound: mass –> orientation? (2)
- parallel
- non-parallel
ultrasound: mass –> margin? (5)
- circumscribed
- indistinct
- angular
- microlobulated
- spiculated
ultrasound: mass –> what is lesion boundaries? 2 types?
transition bw mass & surrounding tissue:
- abrupt interface
- echogenic halo
ultrasound: mass –> echogenic halo –> ddx? (2)
- CA
- abscess
ultrasound: mass –> posterior acoustic features? (4)
- no post acoustic feature
- enhancemt
- shadowing
- combined pattern
ultrasound: mass –> posterior acoustic shadowing –> ddx? (1)
fibrosis:
- neoplastic desmoplastic rxn
- surg scar
ultrasound: mass –> internal echo pattern? (5)
- anechoic
- hypoechoic
- isoechoic
- hyperechoic
- complex
benign mass –> ultrasound features? (5)
- internal echo pattern
- margin
- orientation
- shape
- marked hyperechoic
- circumscribed –> thin echogenic pseudocapsule
- parallel
- oval/few gentle macrolobulation
malig mass –> ultrasound features? (7) which 2 are most specific for malig?
- # 1 spiculated
- # 2 non-parallel
- angular, microlobulated
- post shadow
- marked hypoechoic
- assoc calcs
- wide zone of transition
lipoma vs oil cyst –> margin?
- lipoma –> no peripheral cacl
- oil cyst –> peripheral calc
lipoma –> should be eval by US prior to dx –> T/F?
F
can be dx w mammo alone
oil cyst –> MOA?
trauma or surg –> fat necrosis
what is hamartoma (fibroadenolipoma)?
benign mass –> fat & glandular tissue
hamartoma (fibroadenolipoma) –> classic mammo appearance?
breast w/in breast –> displace normal breast tissue
hamartoma (fibroadenolipoma) –> should be eval by US prior to dx –> T/F?
F
mammo almost always diagnostic
what is galactocele?
lactating –> cystic collection of milk –> palpable mass
galactocele –> mammo appearance?
- circumscribed
- macrolobulated
- mixed high density + fat
- true lat view –> fat-fluid level
intramammary LN –> MC location?
lat –> upper outer quad –> adj to vessel
medial breast –> lesion that look like intramammary LN –> benign or suspicious?
suspicious
fibroadenoma –> mammo XR –> density?
equal density
fibroadenoma –> US –> density?
- hypoechoic
- central hyperechoic band
fibroadenoma –> BI-RADS?
3
fibroadenoma –> variants? (3)
- complex
- juvenile
- giant
complex fibroadenoma –> characteristics? (2)
- prolif elements & internal cysts
- inc risk of breast CA
juvenile fibroadenoma –> characteristics? (2)
- adol
- very rapid growth
giant fibroadenoma –> characteristic? (1)
> 8cm
fibroadenoma –> ddx? (1)
phyllodes tumor
what is intraductal papilloma? epidemiology?
30-50yo –> benign tumor of lactiferous ducts
intraductal papilloma –> clinical presentation?
nipple discharge:
- bloody
- serous
- serosanguinous
bloody nipple discharge –> ddx? (2)
- intraductal papilloma
- DCIS
intraductal papilloma –> mammo XR –> shape? margin? MC location?
- round/oval
- circumscribed/irreg
- subareolar
intraductal papilloma –> galactography appearance?
intraductal filling defect
intraductal papilloma –> US –> appearance? solid/cyst? shape?
- solid
- round/oval
- mass in fluid-filled duct
intraductal papilloma –> dx by mammo/US alone –> T/F?
F –> dx by bx
bx –> intraductal papilloma –> next step? why?
surg excise
papillary CA may appear same
what is pseudoangiomatous stromal hyperplasia (PASH)?
hormone –> stromal & epithelial prolif
pseudoangiomatous stromal hyperplasia (PASH) –> mammo appearance?
mass:
- circumscribed
- oval/irreg
pseudoangiomatous stromal hyperplasia (PASH) –> US appearance?
mass:
- hypoechoic/mixed echogenicity
- oval/irreg
pseudoangiomatous stromal hyperplasia (PASH) –> demonstrate slow growth –> next step? why?
excisional bx
PASH can mimic low-grade angiosarcoma
mammo –> circumscribed round mass –> breast CA ddx? (2)
- medullary
- mucinous
phyllodes tumor –> epidemiology?
40-50yo
phyllodes tumor –> benign or malig?
- most benign
- 25% –> malig
lactational adenoma –> epidemiology?
- 2nd-3rd trimester
- postpartum
lactational adenoma –> benign or malig?
benign
lactational adenoma –> tx?
none –> regress when stop lactating
mult intraductal papillomas –> epidemiology?
younger
mult intraductal papillomas –> location?
bilat breasts –> peripheral
mult intraductal papillomas –> inc risk of breast CA –> T/F?
T
what is steatocystoma multiplex?
AD –> mult intradermal oil cysts
simple cyst –> BI-RADS?
2
new –> complicated cyst –> next step?
- BIRADS 3
- aspiration
complicated cyst –> aspiration –> fluid is white/clear/yellow –> next step?
discard fluid
complicated cyst –> aspiration –> fluid is bloody –> next step?
send fluid to cytology
what is complex mass?
cyst w complex feature:
- thick wall
- septation
- solid/nodular compont
complex mass –> BI-RADS?
4
complex mass –> cancer ddx? (4)
- intracystic CA
- intracystic papilloma
- cystic phyllodes tumor
- solid CA w central necrosis
what is intracystic CA?
cyst wall –> CA
complex mass –> benign ddx? (5)
- hematoma
- abscess
- fat necrosis
- galactocele
- benign cyst w adherent debris
what is clustered microcyst?
apocrine metaplasia or fibrocystic change –> several tiny 2-5mm cystic spaces separated by thin septae
clustered microcyst –> BI-RADS?
2
MC breast CA?
invasive ductal CA (IDC)
invasive ductal CA (IDC) –> typical mammo appearance?
- spiculated mass –> high density
- often: pleomorphic or fine linear branching calcs
invasive lobular CA –> differences from invasive ductal CA (IDC)? (3)
invasive lobular:
- rare calc
- more often multifocal
- more often bilat
tubular CA –> typical mammo appearance?
small spiculated mass –> slow growing
possible precursor lesion to tubular CA?
radial scar
what is radial scar?
uncertain etiology –> dense fibrosis around ducts –> spiculated mass or architectural distortion
what is complex sclerosing lesion?
radial scar –> >1cm
radial scar/complex sclerosing lesion –> tx?
surg excision
postsurgical scar –> can get larger over time –> T/F?
F
what is sclerosing adenosis?
benign –> lobular hyperplasia –> fibrous tissue envelop & distort glandular elements –> sclerosis –> breast lesion –> maybe microcalcs
what is diabetic mastopathy?
long-term insulin-dep diabetes –> inflamm lymphocytes & fibrosis –> large painless firm mass
diabetic mastopathy –> mammo appearance? US?
- mammo: ill-defined mass or asymm density
- US: hypoechoic shadowing mass
benign breast fibrosis conditions? (2)
- sclerosing adenosis
- diabetic mastopathy
LN metastasis –> suspicious US features? (5)
- round
- thick cortex >3mm
- eccentric thick cortex
- focal outward cortical bulge
- thick cortex –> indent or obliterate hilum
1ary breast lymphoma –> MC etiology?
diffuse lrg B-cell lymphoma
breast lymphoma –> calcs or no calcs?
no calcs
known lymphoma –> new breast mass –> most likely mets or breast CA?
breast CA
2ary angiosarcoma of breast –> etiology?
prior breast conservation –> rtx
2ary angiosarcoma of breast –> T2 appearance? enhancemt?
- T2 hyper
- intense enhance
new mult masses –> non-ductal distribution –> dx?
hematogenous mets to breast
mets to breast –> what 1ary cancers? (2)
- melanoma
- RCC
what is asymm?
1 view –> prominent breast tissue
asymm –> MCC?
superimposed gland tissue
what is global asymm?
1 breast –> majority (>1 quad) –> asymm density
global asymm –> MCC?
greater vol of parenchyma in 1 breast
what is focal asymm?
abnormality –> 2 views –> <1quad –> concave contour
what is sternalis muscle?
<10% –> access parasternal chest wall muscle
sternalis muscle –> MC location?
unilat –> med –> far-post –> only see on CC view
access nipple (polythelia) –> mammo appearance?
mammo crest –> round mass
what is Poland synd? (3)
congenital:
- unilat –> pect major absent
- ispilat breast absent
- syndactyly
access (ectopic) breast tissue –> MC location?
axillary tail
breast MRI –> enhancemt kinetics –> enhancemt curve –> 2 parts (time)?
- early (2min) phase
- delayed
breast MRI –> early enhancemt –> 3 categories?
- slow
- med
- rapid
breast MRI –> delayed enhancemt –> 3 categories?
- type 1 persistent
- II plateau
- III washout
breast MRI –> delayed enhancemt –> what is type 1 persistent? assoc w benign/suspicious/malig?
continuous inc enhance (>10%)
83% –> benign
breast MRI –> delayed enhancemt –> what is type II plateau? assoc w benign/suspicious/malig?
level off (w/in 10%)
susp –> PPV 64-77%
breast MRI –> delayed enhancemt –> what is type III washout? assoc w benign/suspicious/malig?
> 10% dec in enhancemt
malig –> PPV 87-92%
breast MRI –> delayed enhancemt –> type III washout –> benign ddx? (3)
- LN
- adenosis
- papilloma
morphology vs enhancemt kinetics –> which is more important to determine if lesion is benign or suspicious?
morphology
breast MRI –> internal enhancemt? (4)
- homogeneous
- heterogeneous
- rim enhance
- dark internal septations
breast MRI –> dark internal septations –> highly specific for what condition?
fibroadenoma
breast MRI –> what is focus?
<5mm dot of enhancemt –> too small for accurate assess:
- no mass effect
- no correlate on precontrast seq
what is non-masslike enhancemt?
enhancing region –> not mass or focus
non-masslike enhancemt –> distribution? (6)
- linear/ductal
- segmental
- focal
- regional
- mult region
- diffuse
non-masslike enhancemt –> what is focal distribution? regional?
- focal: <25% quadrant
- regional: >25% quadrant
non-masslike enhancemt –> internal enhancemt? (4)
- homogeneous
- heterogeneous
- clumped
- clustered ring
non-masslike enhancemt –> int enhancemt –> clustered ring –> ddx? (2)
- DCIS
- invasive ductal
non-masslike enhancemt –> stippled/punctate enhancemt –> assoc w benign or malig?
benign
mass –> enhancing portion –> T2 hyper –> highly sugg benign or malig?
benign
breast MRI: type I kinetic curve + benign morphology –> BI-RADS? (3)
- 2
- 3
- 4
breast MRI: type II kinetic curve + benign morphology –> BI-RADS? (1)
4
breast MRI: type III kinetic curve + benign morphology –> BI-RADS? (1)
4
breast MRI: type I kinetic curve + malig morphology –> BI-RADS? (1)
4
breast MRI: type II/III kinetic curve + malig morphology –> BI-RADS? (2)
- 4
- 5
high risk for breast CA –> definition?
> 20% lifetime risk of develop breast CA
what is breast conservation therapy?
lumpectomy + rtx
status post lumpectomy –> enhancemt at lumpectomy site –> can be normal for how long?
6-18mo
MRI –> evaluate silicone or saline implants?
silicone
how differentiate silicone vs saline implant on screen mammo?
saline:
- valve
- wall is denser than center
silicone:
- uniformly dense
- no valve
breast implant –> screen mammo –> special view?
Eklund (implant-displaced) view
saline implant –> rupture –> clinical presentation?
sudden collapse –> instant dec breast size
silicone implant –> rupture –> clinical presentation?
- subtle change in implant contour
- no change in size or shape
silicone implant –> rupture –> MRI sign?
linguine
silicone implant –> rupture –> US appearance?
snowstorm
reduction mammoplasty –> mammo findings? (2)
lower breast:
- skin thick
- curvilinear architectural distortion
gynecomastia –> clinical presentation?
subareolar palpable abnormality
gynecomastia –> mammo appearance?
subareola –> flame/triangle-shape density
male –> breast mass –> benign features –> benign or suspicious?
male –> any breast mass –> susp
breast bx –> path discordant –> next step?
repeat bx –> core or excision
benign-appearing cyst –> aspirate –> bloody –> next step?
send to cytology
benign-appearing cyst –> aspirate –> cloudy –> next step?
discard fluid
benign-appearing cyst –> aspirate –> clear –> next step?
send to cytology
benign-appearing cyst –> aspirate –> green –> next step?
discard fluid
calc –> MC bx technique?
stereotactic-guided core
stereotactic bx –> CI? (5)
- thin breast –> <3cm compressed
- far post location
- subareolar location
- pt can’t be positioned on stereotactic table
- unctrl coag abnormal
breast –> asymmetric in size –> ddx? (1) buzzword?
“shrinking breast” –> invasive lobular breast CA
axillary lymph node drainage –> order?
level 1 (lateral) –> 2 –> 3 (medial) –> thorax
what are Rotter nodes?
nodes bw pec minor & major
Rotter nodes –> at same level as which axillary LN?
level 2
sternalis M –> seen only on what view?
CC
MC location for ectopic breast tissue?
axilla
CA –> MC quadrant?
upper outer
CA –> start in what unit?
terminal duct lobular unit (TLDU)
majority (60%) of blood flow to breast –> which vessel?
internal mammary
singular mets to internal mammary nodes –> common or uncommon?
uncommon
singular mets to internal mammary nodes –> indicate what about the CA?
medial location
sternalis M –> usu unilat or bilat?
unilat
breast tenderness –> greatest at day ___?
day 27-30 (near end of luteal phase - progesterone dominates -> lobules prolif –> breast density inc slightly)
mammography & MRI –> best performed in what phase of the breast/menstrual cycle?
follicular phase (day 7-14)
never bx a prepubescent breast –> T/F? why?
T –> can damage breast developmt
cyst formation –> greatest in pre/peri/post menopause?
perimenopause
breast pain –> greatest in pre/peri/post menopause?
perimenopause
fibroadenoma –> degenerate in pre/peri/post menopause?
(post)menopause
secretory calcs (rod-like) –> dev in pre/peri/post menopause?
10-20 yrs post menopause
lactating breast –> mammogram vs US –> which is more sensitive? why?
lactating breast –> more dense –> US more sensitive for mass
bilat breasts –> inc density –> ddx? (2)
- pituitary prolactinoma
- meds –> ie antipsych
lactating breast –> bx –> comp?
milk fistula
lactating breast –> bx –> milk fistula –> tx?
stop breastfeeding
galactocele –> aunt minnie finding?
fat-fluid level
galactocele –> typical seen when? typical location?
- cessation of lactation
- sub-areolar
lactating adenoma –> fu recommendation?
4-6mo postpartum/postdelivery/cessation of lactation –> US
lactating adenoma –> natural progression of dz?
stop lactation –> rapid regress
lactating adenoma –> usu single or multiple?
mult
when get LMO view? (3)
- kyphosis
- pectus excavatum
- avoid medial pacemaker/central line
which view contains most breast tissue?
MLO
spot compression view –> collimate or not?
leave collimator open –> larger FOV –> ensure get what you wanted
mag view –> which positional views are obtained?
- CC
- ML (true lat)
screener –> lat breast –> microcalcs –> mag view –> ML or LM view?
ML
screener –> med breast –> microcalcs –> mag view –> ML or LM view?
LM
screener –> MLO only –> suspicious finding –> additional views –> ML or LM view? why?
ML view –> most (70%) breast cancers occur laterally
what is “camel nose”?
MLO –> breast not pulled up and out –> looks saggy
advantage of CC view over MLO?
maximize visualization of post medial tissue
advantage of MLO view over CC?
maximize visualization of axillary & post tissue
adequate technique: MLO –> pectoral muscle –> should be seen at level of what struct?
level of nipple or below
adequate technique: MLO –> pectoral muscle –> should be convex or concave?
convex
CC view –> lack adequate coverage of post lat tissue –> next step?
exagg lat CC view (XCCL)
ML view –> which is closer to the detector –> medial or lat breast?
lat
mass seen only on CC view –> next step?
rolled CC
mass in far post medial breast –> next step?
cleavage view (CV)
breast implants –> what views?
Eklund view (implant displaced) –> MLOID, CCID
Cooper’s ligaments appear thick –> ddx? (2)
- blur
- edema
mammo –> blur –> etiology? (3)
- motion (breathing, inadeq compression)
- exposure –> too long
- exposure –> too short
mag view –> use grid or no grid?
no grid
lesion seen only on MLO –> ML view –> how know if lesion is in med vs lat breast?
“Lead Sinks, Muffins Rise”:
- inf on ML view –> lat breast
- sup on ML view –> med breast
screeners –> PPV? (anything other than BR1/2)
4% –> 3-8 cancers per 1000 mammos
mammo –> bilat –> mult circumscribed similar appearing masses –> BI-RADS?
2
grped round calcs –> BI-RADS?
3
screening mammo –> BI-RADS options?
- 0
- 1
- 2
diagnostic mammo –> BI-RADS options?
- 2
- 3
- 4
- 5
focal asymm –> compress –> less dense –> looks like breast tissue –> BI-RADS?
3
MRI –> background parenchymal enhancemt –> categories? (5)
- none
- minimal
- mild
- mod
- marked
MRI –> mass –> shape –> categories? (3)
ROI:
- round
- oval
- irreg
MRI –> mass –> margin –> categories? (3)
- circumscribed
- irreg
- spiculated
MRI –> mass –> T2 hyperintense signal –> categories? (3)
- grter than parenchyma
- grter than or equal to fat
- grter than or equal to water
MRI –> non mass enhancmt (NME) –> distribution –> categories? (6)
- focal
- linear
- segmental
- regional
- mult regions
- diffuse
complex cystic & solid mass –> BI-RADS?
4
complicated cyst (cyst w debris) –> BI-RADS?
2 or 3
calc –> “cigar shaped w lucent center” –> dx?
secretory (rod like) calcs
calc –> “dashes but no dots” –> dx?
secretory (rod like) calcs
milk of Ca –> bx –> no calcs visualized –> how to assess for milk of Ca?
view w polarized light –> birefringence
amorphous calc –> ddx? (4)
- # 1 fibrocystic change
- sclerosing adenosis
- columnar cell change
- DCIS (low grade)
coarse heterogeneous calc –> ddx? (4)
- fibroadenoma
- papilloma
- fibrocystic change
- DCIS (low-interm grade)
fine pleomorphic calc –> ddx? (4)
- fibrocystic change
- fibroadenoma
- papilloma
- DCIS (high grade)
Mondor dz –> tx?
- NSAID
- warm compress
lipoma –> enlrg –> next step?
bx
bx –> pseudoangiomatous stromal hyperplasia (PASH) –> fu?
12mo
young F –> MC palpable mass?
fibroadenoma
MRI –> fibroadenoma –> T2 signal? enhance?
- T2 bright
- type 1 enhance (progressive enhance)
phyllodes tumor –> epidemiology?
middle age to older F
phyllodes tumor –> recommend sentinel node bx –> T/F?
F
if mets –> hematogenous –> lung & bone
phyllodes tumor –> rapid growth –> T/F?
T
ductal CA –> medullary subtype –> assoc finding?
lrg axillary LN (not necessarily mets)
ductal CA –> papillary subtype –> mass appearance?
complex cystic & solid
ductal CA –> #2 MC type?
papillary
breast CA –> multifocal vs multicentric?
- multifocal: same quad –> <4-5cm apart
- multicentric: mult quad
DCIS –> comedo vs non-comedo –> which is more aggressive?
comedo
galactography –> mult intraductal masses –> ddx? (1)
DCIS
Pagets dz of breast –> topic therapy –> skin lesion still not resolve –> next step?
wedge bx
invasive lobular CA –> US appearance?
ill-defined area of shadowing –> “shadowing w/o mass”
prognosis: IDC vs ILC –> which is better?
similar prognosis
ILC –> often only seen on CC view –> T/F?
T
ILC –> common to get axillary mets –> T/F?
F
axillary mets is less common –> instead, like to go to strange places ie peritoneum
architectural distortion wo central mass (“dark star”) –> ddx? (4)
- ILC
- IDC-NOS
- radial scar
- surgical scar
breast –> red, swollen, thick skin –> next step?
US
eval for focal lump to help target US
breast –> red, swollen, thick skin –> US –> no focal mass –> next step?
- punch bx
- abx –> see if it gets better (if IBC, will improve but not resolve)
compare: inflamm breast CA vs locally advance breast CA
- rapid/prolonged onset
- age of presentation
- mets at presentation
inflamm breast CA:
- rapid onset
- younger (mid 50s)
- 30% mets at presentation
LABC:
- prolonged onset
- older (mid 60s)
- 10% mets at presentation
inflamm breast CA (IBC) –> tx? why?
1) ctx –> high chance of positive margins
2) mastectomy –> for local ctrl
bx –> 5 classic high risk lesions?
- radial scar
- atypical ductal hyperplasia
- atypical lobular hyperplasia
- LCIS
- papilloma
MCC bloody nipple discharge?
papilloma
1ary breast lymphoma –> what type of lymphoma?
non-Hodgkin (diffuse lrg B-cell)
1ary breast lymphoma –> require what type of stain to confirm dx?
IHC
1ary breast lymphoma –> mammo appearance?
hyperdense mass
2ary breast lymphoma –> typical mammo appearance?
inflamm thickening wo mass
inflamm breast CA –> painless or painful?
painless
nipple discharge –> suspicious features? (4)
- spontaneous
- bloody
- serous
- from a single duct
nipple discharge –> milky –> possible etiology? (3)
- thyroid dz
- pituitary adenoma –> prolactinoma
- meds (ie antidep, neuroleptic, reglan)
nipple discharge –> suspicious –> possible etiology? (2)
- intraductal papilloma
- DCIS
nipple discharge –> benign –> possible etiology? (2)
- fibrocystic change
- ductal ectasia
galactography –> contraindication? (4)
- active infx (mastitis)
- unable to express discharge at time of galactogram
- contrast allergy
- prior surg to nipple-areola complex
architectural distortion + calcs –> ddx? (1)
IDC + DCIS
architectural distortion, no calcs –> ddx? (1)
ILC
mammo –> architectural distortion –> no correlate on US –> next step?
bx
dx mammo –> suspicious spiculated mass –> US –> same thing –> next step?
US for axillary mets
axillary LN –> suspicious features? (3) which is most specific?
- # 1 specific –> loss of central fatty hilum
- cortical thick >2.3mm
- irreg outer margins
male –> gender reassignmt –> hormone tx –> gynecomastia –> should get screening mammo –> T/F?
F
mammo –> dense LN –> US –> snowstorm appearance –> next step?
US –> eval for breast implant rupture
silicone breast implant –> intracapsular rupture –> US fiding?
“step ladder” appearance
breast implant –> contraindication for core needle bx –> T/F?
F
breast implant –> inc risk of breast CA –> T/F?
F
saline implant –> dx of rupture –> test of choice?
physical exam
breast implant –> MC comp?
capsular contracture
breast implant –> what is capsular contracture?
fibrous capsule –> contract –> cosmetic deformity
breast implant –> capsular contracture –> MC with…
- silicone/saline?
- subglandular/subpectoral?
subglandular silicone
silicone in axillary LN –> ddx? (2)
- breast implant rupture
- gel bleed (not a rupture)
breast implant rupture –> #1 RF?
age of implant
saline breast implant –> what imaging modality to see implant rupture?
mammo
bx –> excisional vs incisional?
- excision: remv entire lesion
- incision: bx portion of lesion
breast CA –> recurrence –> peak time? (yr)
4yr
breast CA –> breast conserving tx –> radiation vs no radiation –> %recurrence?
- radiation: 6-8%
- no radiation: 35%
breast CA –> lumpectomy –> immediate postop mammo demonstrates residual calcs –> Ok or not ok?
not ok
residual calcs –> assoc w 60% local recurrence
DCIS –> lumpectomy –> new calcs –> benign vs recurrence –> timeline (yr)?
- benign calc –> 2 yr
- recurrent calc (DCIS) –> 4yr
breast CA –> radiation tx –> comp? (1)
2ary angiosarcoma
breast CA –> radiation tx –> 2ary angiosarcoma –> classic clinical presentation?
red plaques/skin nodules
MC CA that mets to breast?
melanoma
breast conservation tx –> contraindications? (5)
- inflamm CA
- lrg cancer size relative to breast
- multicentric
- prior rtx to same breast
- CI to rtx (ie collagen vascular dz)
breast MRI –> focus –> size criteria?
<5mm
breast MRI –> tamoxifen –> what happen to background parenchymal enhancemt?
dec –> then rebound
child –> chest radiation –> how much rad (Gy) for inc risk of breast CA?
20gy
child –> chest radiation –> 20gy –> when start screening mammo?
whichever is later:
- 25yo
- 8yr post exposure
Cowden synd –> synd? (4)
- breast CA
- follicular thyroid CA
- bowel hamartoma
- Lhermitte-Duclos (brain hamartoma)
breast CA risk models –> all current risk models underestimate lifetime risk –> T/F?
T
breast CA risk models –> which is most comprehensive?
Tyrer-Cuzick
what meds that reduce incidence of ER/PR+ cancer? (2)
- tamoxifen
- SERMs (raloxifene)
BRCA1 vs BRCA2 –> which is more common?
BRCA1
men w BRCA1 vs BRCA2 –> who gets more CA?
BRCA2
> 20% lifetime risk of breast CA –> when start screening?
- 25-30yo
- 10yr before 1st deg relative
