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Radiology > Breast > Flashcards

Breast Flashcards

1
Q

Anatomy/Physiology Trivia

A

Nipple enhance on C+ MRI
Most Ca upper outer quadrant, starts in TDLU (terminal duct lobule unit)
60% blood flow IMA, mets to IM nodes uncommon
Axillary LNs lat to med 1,2,3 plus Rotter node inbetween Pecs
Sternalis muscle unilateral seen on CC only
Breast tenderness max day 27-30
MRI best in follicular phase day 7-14
Perimenopause peak time for breast pain and cysts
fibroadenomas degenerate in menopause (popcorn)
secretory calcs 10-20 years post menopause

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2
Q

CC and MLO

A

CC
nipple in profile and pointing straight
posterior nipple line is straight back

MLO
nipple in profile
posterior nipple line straight back to pec
pec should be convex ad should see inframammary fold
pull breast up and out

Posterior nipple lines shouldnt differ by more than 1cm

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3
Q

LMO, LM and ML

A

LMO
patient with kyphosis or pectus
avoid pacemaker/central line

ML
90 degree view
lateral breast in better detail

LM
90 degree view
medial breast in better detail

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4
Q

Next view

A

Nodule in CC - rolled CC (superior lesion moves in direction you roll, inferior lesion opposite)
Nodule in skin - Tangential view TAN
Nodule milk of calcium - true lateral
Nodule far posteromedial - cleavage view CV
Implants - implant displaced MLOID CCID
Calcs - mag view (no grid)
Architectural distortion - spot compression

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5
Q

Artifacts on mamm

A

BLUR
breathing/px moved
inadequate compression
exposure too long/short

GRID LINES
mamms all have grid except mag
horizontal line

Check Coopers lig should be thin unless edema or artifact

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6
Q

Localization

A

Medial breast on CC not well seen on MLO
Posteroinferior breast n MLO not well seen on CC

medial nodule on CC superior on MLO (muffins rise)
lateral nodule on CC inferior on MLO (lead sinks)
PNL (posterior nipple line) on frontal view is upper inner down to lower outer

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7
Q

BIRADS

A

Breast image reporting and data system

BR0 - incomplete technical or needs further view
BR1 - normal
BR2 - benign (cyst/lipoma/secretory calc etc)
BR3 - <2% chance cancer, probable benign (fibroadenoma)
BR4 - 2-95% cancer (BR4a/b/c), needs biopsy
BR5 - >95% cancer
BR6 - proven cancer

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8
Q

Mammogram description

A

SHAPE (ROI)
round, oval, irregular

MARGIN (COMIS)
circumscribed, obscured, microlobulated, indistinct, spiculated

DENSITY
Fat, low, equal, high

ASYMMETRY
asymmetry, global, focal, developing

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9
Q

USS description

A

SHAPE (ROI)
round, oval, irregular

ORIENTATION
W>T or parallel
T>W or antiparallel

MARGIN
circumscribed, indistinct, angular, microlobulated, spiculated

ECHO
anechoic, hypo, hyper, iso, complex

POSTERIOR
none, enhancing, shadowing

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10
Q

MRI description

A 
Background parenchymal enhancement
Lesion analysis
describing masses (shape/margin/enhancement)
T2 signal
Non-mass enhancement distribution
kinetic curves
associated findings
implants
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11
Q

Benign calcifications

A

Dermal calcs (skin folds/sweat)
vascular calcs (parallel/linear)
popcorn (degenerating fibroadenoma)
secretory (rod like, involuting ducts post meno)
eggshell (fat necrosis)
dystrophic (radiation/trauma/surgery)
round (in lobules, scattered, bilateral - fibrocystic change)
milk of calcium (tea cupping, fibrocystic change, may need polarized light to assess birefringence)

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12
Q

Suspicious calcs

A

AMORPHOUS
fibrocystic change, sclerosing adenosis, columnar cell change, low grade DCIS

COARSE HETEROGENOUS
fibroadenoma, papilloma, fibrocystic change, intermediate DCIS

FINE PLEOMORPHIC
fibroadenoma, papilloma, fibrocystic change, high grade DCIS

FINE LINEAR BRANCHING
DCIS (maybe secretory or vascular)

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13
Q

Fat containing lesions

A

All benign

HAMARTOMA - breast within breast
GALACTOCOELE - fat fluid level, can form abscess
OIL CYST/FAT NECROSIS - random/post trauma/post surgery/egg shell calc
LIPOMA - radiolucent, no calcs
INTRAMAMMARY LN - tissue along pec

Mondor disease - thrombosed vein presents as tender palpable cord.

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14
Q

Benign lesions

A

PSEUDOANGIOMATOUS STROMAL HYPERPLASIA (PASH)
- benign myofibroblastic hyperplastic process. Big/solid/overall/well defined

FIBROADENOMA
Common, oval/circumscribed/homogenous hypoechoic/popcorn calc degenerate

PHYLLODES
10% malignant degeneration, can met to lung and bone.
Need resection with wide margin. Rapid growth, mimics fibroadenoma, middle age to older, will met haematogenously

NF1
Numerous skin nodules. classically periareolar but are usually everywhere

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15
Q

Invasive Ductal Carcinoma IDC

A

Most common invasive breast cancer 80-85% cases.
Hard, non-mobile, painless mass. Irregular and high density with spiculate margins and pleomorphic calcs. Antiparallel shadowing mass with echogenic halo.

Most common subytpe is IDC NOS 65%

Other subtypes are
TUBULAR, MUCINOUS, MEDULLARY, PAPILLARY

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16
Q

Multi cancer

A

MULTIFOCAL
multiple primaries in same quadrant, classically same ductal system les than 4-5cm from another

MULTICENTRIC
multiple primaries in diff quadrants.

SYNCHRONOUS BILATERAL
2-3% women on mamms, a further 3-6% on MRI
risk increased with infiltrating lobular and multicentric

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17
Q

DCIS

A

Earliest form of breast ca. Confined to duct. Low, intermediate or high grade.
10% will go onto have invasive component at time of biopsy. 25% will go from core to have invasive at time of surgery. 8% present as a mass without calcs.

USS shows microlobulated mildly hypoechoic mass with ductal extension and normal acoustic transmission.
Mamm can have fine linear branching or pleomorphism. Non mass enhancement on MRI

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18
Q

Pagets

A

carcinoma in situ of nipple epidermis. 50% of time patient will have palpable finding associated with skin changes.
96% associated with high grade DCIS. SKin involvement does not upstage disease

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19
Q

Lobular ILC

A

Second most common after IDCNOS
5-10% breast ca
Cell decides to be ca, loses e-cadherin, cells dont stick to eachother and infiltrate breast. No desmoplastic reaction so just has eventual architectural distortion without mass on mamm. ‘dark star’ appearance on CC

USS shows ill defined shadowing without mass
Buzzword is ‘shrinking breast’ - doesnt compress as much

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20
Q

ILC high yield

A

presents later than IDC
occurs in older popn
often only seen on CC (compresses better)
calcs less common
mammo buz words ‘shrinking breast’ and ‘dark star’
USS buzzword ‘shadowing without mass’
washout less common on MRI
prognosis of ILC and IDC is similiar
more often multifocal and bilateral (up to 1/3).

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21
Q

Inflammatory breast ca IBC

A

bad prognosis (30% mets at presentation)
hot swollen red breast developed rapidly.
‘peau d’ orange’
no focal palpable mass
mamm buzzword ‘skin thickening’ due to tumour emboli obstructing lymphatics
IDC most common subtype to result in IBC

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22
Q

IBC vs LABC (locally advanced breast ca)

A

IBC
rapid onset, younger (mid 50s), 30% mets at presentation.

LABC
prolonged onset, older (mid 60s), 10% mets at presentation

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23
Q

High risk lesions

A

RADIAL SCAR
high risk, must come out. associated with DCIS and/or IDC 10-30% time. Associated with tubular carcinoma

ATYPICAL DUCTAL HYPERPLASIA (ADH)
DCIS burden underestimated when this is present. 30% time surgical path will be upgraded to DCIS

LOBULAR CARCINOMA IN SITU (LCIS)
Occult on mamm. Can be precursor to ILC. Pleomorphic LCIS worse than regular LCIS

ATYPICAL LOBULAR HYPERPLASIA (ALH)
Similar to LCIS - lobule distended with LCIS, not with ALH. Milder than LCIS. risk of ca 4-6x with ALH, 11x with LCIS. Would excise

PAPILLOMA
most common intraductal mass lesion, most common cause of bloody discharge.Age late 50s. Classically subareolar within 1cm from nipple in 90%. Mamm often normal. USS well defined smooth walled hypoechoic mass, duct dlatation often.

PHYLLODES
malignant degeneration risk of 10%. fast growing mass. Older age group than fibroadenomas

24
Q

Lymphoma in breast

A 
PRIMARY BREAST LYMPHOMA
Non Hodgkin (DIffuse large B cell). usually hyperdense mass (architectural distortion rare). IHC staining to confirm.

PRIMARY LYMPHOMA
Less common. Usually solitary, large and palpable. Cystic on USS

SECONDARY LYMPHOMA
More common. Inflammatory thickening without a mass. Can look like anything.

25
Q

Breast pain

A

Common, cyclical (worse during luteal phase). Cyclical pain in both breasts doesnt need evaluation but focal non cyclical pain does.

Worrisome symptoms are:
skin dimpling, focal skin thickening and nipple retraction.

26
Q

Non-focal skin thickening

A

CCF, renal failure. Usually bilateral unless slept on one side.

Mamm see trabecular thickening favouring dependent portions of breast

27
Q

Breast inflammation

A

MASTITIS/ABSCESS
Swollen painful red breast. Patient s usually very sick. Associated with breast feeding. Smokers and diabetics. Abscess can develop (staph a)

INFLAMM BREAST CA
Bad prognosis. If no response to ABs needs punch biopsy. Usually 40-50s. Enlarged red breast with peau d’ orange. Usually not painful. Diffuse skin thickening. Chemo/radio first then surgery

28
Q

Nipple discharge

A

Usually benign 90%. Spontaneous bloody discharge form single duct is most suspicious. Serous discharge also suspicious

Milky discharge is not suspicious but can be secondary to thyroid issues or pituitary adenoma (prolactinoma) or any medication that messes wth dopamine

MULTIPLE DUCTS
Benign

SINGLE duct
Maybe malignant. Papilloma vs DCIS

29
Q

Nipple discharge

A

BENIGN
Premeno - fibrocystic change
Post meno - ductal ectasia

WORRISOME
Intraductal papilloma 90% (single intraductal mass near nipple)
DCIS 10% multiple intraductal masses

Ductal ectasia:
Most common benign cause of nipple discharge in postmeno. See on galactography dilated ducts near subareolar region

Papilloma:
Most common cause of bloody discharge. Single or multil and carry small malignant risk 5%

30
Q

Architectural distortion AD

A

Distortion of normal architechture without visible mass. Focal retraction, distortion of edge of parenchyma, radiation of normal thin lines into a focal point.

Summation of normal vessels/ducts/ligaments much more common but these should not radiate to single point.

Surgical scars get progressively lighter and harder to see. Check priors. If new, get spot compression views and USS.

31
Q

Architechtural Distortion quick facts

A

Radiating lines to single point is AD
Ad + calcs = IDC + DCIS
AD without calcs = ILC
Even without MR or USS correlate, AD gets biopsy
Never BR3 AD (<2%)
Still needs work up even if been there a while
ILC can grow slowly
Surgical scars should get less dense with time

32
Q

Lymph Nodes in Breast Ca

A

Cortical thickness over 3mm gets biopsy
Loss of central fatty hilum gets biopsy
Irregular outer margins gets biopsy

Level 1 and 2 LNs treated the same (Rotter treated as level 2)
Level 3 and supraclavicular LN treated the same

LN with very dense calc = gold therapy
Snow storm LN on USS = silicone in LN

33
Q

Male breast

A

No elongated or branching ducts, or proliferated lobules.

Men do not get lobule based pathology (lobular carcinoma, fibroadenoma or cysts)

34
Q

Gynacomastia

A

Non-neoplastic enlargement of epithelial and stromal elements in a mans breast. 50% adolescent boys and men over 65. Can be spironolactone, psych meds, marijuana, alcoholic cirrhosis, testicular cancer). Flame shaped, behind nipple, bilateral but asymmetric, can be painful

NODULAR (MOST COMMON)
flame shaped, behind nipple, radiating posterior as it blends with fat, tender. Lasts 1 year.

DENDRITIC
Resembles branching tree. Chronic fibrotic. Not tender.

DIFFUSE GLANDULAR
Diffuse increase density looks like womens breast. Men receiving estrogen treatment.

35
Q

Male palpable mass

A

Gynacomastia then lipoma

Pseudogynacomastia is increase in fat tissue with no palpable findings, wont be concentric to nipple

36
Q

Male breast ca

A

Uncommon in men and very uncommon in younger men, average age around 70.

1/4 affected males will be BRCA positive (BRCA 2 more common). Other risks are Klinefelters, cirrhosis, chronic alcoholism. Eccentric but near nipple, almost always IDCNOS. DCIS can occur but rare

Eccentric to nipple, unilateral, abnormal LNs, calcs, looks like breast ca

37
Q

Implants

A

SALINE
No biggie if rupture, follow clinically.
Does not form a capsule - cant have intracapsular rupture.
Can see through it. Implant folds and valves can be seen

SILICONE
Can have intra and extracapsular rupture. Extra has snow storm appearance on USS, intra has step ladder appearance on USS and linguine appearance on MRI
body forms shell around implant which allows for both intra and extracapsular rupture. Can see calcs 25% around fibrous capsule

IMPLANTS
can be subglandular/retromammary or subpectoral/retropectoral (inbetween pecs).
No increased risk of cancer and not a contraindication to biopsy

38
Q

Implant complication

A

CAPSULAR CONTRACTURE
Most common comp. Contraction of fibrous capsule, terrible cosmetic deformity. Silicone and saline. Most common subglandular

GEL BLEED
Silicone molecules can/do pass through the semipermeable implant shel coating. Does not mean implant rupture. Silicone in axillary LN (snow storm - bright with no shadowing).

RUPTURE
Biggest risk for rupture is age. Can be spontaneous. Rupture with compression mamm is rare.
Saline rupture obvious (deflated), saline is reabsorbed and mamm shows wadded up plastic wrapper (dont need USS or MRI)
Silicone rupture has isolated intracapsular or intra/extra. Isolated is occult on exam/mamm and USS. Might see stepladder on USS but need MRI. Intra/extra has dense silicone outside implant

RADIAL FOLDS
Normal in foldings of elastomer shell. Mimic of linguine sign but will connect with periphery. Allow implants to be partially compressible

39
Q

Mastopexy

A

MASTOPEXY (BREAST LIFT)
Removal of skin to address ptotic breasts. See swirled appearance inferior breast with fat necrosis/oil cysts, isolated islands of breast tissue.

40
Q

Post surgical change

A

First post op mamm at 6 months usually. DIstortion and scarring maximal on this film but will regress. Scars should be fine and linear. Focal mass like thickening within scar makes you think local recurrence. Fat necrosis and benign dystrophic calcs over first year or 2.

Local recurrence 6-8% in breast conserving rx. Peak time 4 years. Without radiation local recurrence closer to 35%. Early recur in tumour bed, late recur elsewhere. Risk of recurrence highest in premeno, tumour with vascular invasion, multicentric tumour, positive margins. Residual calcs not good, local recurrence 60%. Benign calcs occur early 2 years, bad calcs come back 4 years.

Sentinel node only 95% accurate so 5% time will have node negative biopsy with an abnormal axillary LN. Tissue flaps in surgery cancer can spread from edges into flap.

41
Q

Specimen radiography

A

CLose margins or positive margins has very high chance theres cancer still in breast. In test, is there mass/calc in specimen and is there mass/calc near periphery

42
Q

Post radiation changes

A

skin and trabecular thickening which will improve over time. If doesnt improve, question recurrence

43
Q

Secondary angiosarcoma

A

Seen after breast conservation/raditherapy. Takes around 6 years to develop. Red plaques or skin nodules. Thickening due to the cancer is often confused with post therapy skin thickening. T2 bright

44
Q

Staging/planning

A

T1 <2cm
T2 2-5cm
T3 >5cm
T4 and size with chest wall fixation, skin involvement or inflammatory breast Ca (Pagets not included)

Axillary status is most important predictor of overall survival.

Melanoma most common met to breast

45
Q

Contraindications to breast conservation

A 
Inflammatory cancer
Large cancer size relative to breast
multicentric
prior radiation therapy to same breast
contraindication to radiation such as collagen vascular disease
46
Q

Breast MRI indications

A 
high risk screening (lifetime risk >25%)
extent of disease with known cancer
axillary mets with unknown primary
diagnostic dilemmas
possible silicone implant rupture

Breast coil, px prone breast through holes. T2, pre and post fat sat T1

47
Q

Reading breast MRI

A

Look at background uptake (hormone changes with cycles changes appearance)
Look for masses. Use MIPS. T2 bright benign mostly.
Washout curve
Apply Birads. NMLE gets BR4

48
Q

BREAST MRI

A

PARENCHYMAL ENHANCEMENT
Normal. Seen in upper outer and in late cycle (do MRI early d7-14). Tamoxifen decreases uptake.

FOCI
Define. If <5mm usually benign unless ill defined and suspicious enhancement.

NON MASS ENHANCEMENT
Clump of tissue enhancment. Segmental, regional, diffuse. Heterogenous most suspicious

MASSES
>5mm. Bad if ill defined, heterogenous enhacement, rim enhancement

KINETICS
Initial upslope (slow medium fast) then washout portion (continuous plateau rapid).
Rapid with rapid washout is high risk

49
Q

Classic MRI looks

A

FIBROADENOMA
T2 bright, round, nonenhancing, fast continuous curve (type 1)

DCIS
Clumped, ductal, linear, segmental NME

IDC
Spiculated, irregular shaped mass heterogenous enhancement and rapid rapid curve (type 3)

ILC
Doesnt always enhance

T2 BRIGHT
Usually benign. cysts/LN/fat necrosis/fibroadenoma
BUT colloid cancer and mucinous cancer can be bright

50
Q

Breast ca risk including estrogen

A 
Early menstruation
late menopause
late age of first pregnancy or no kids
being fat
being alcoholic
hormone replacement with estrogen

ADH, ALH, LCIS, radial scar, papilloma increase risk

Density of breast increases risk in dose dependent manner

Chest wall radiation (lymphoma) increases risk

Relatives with cancer increase risk

Early maturation of lobules lowers risk (getting pregnant young)

51
Q

Syndromes

A

BRCA 1
c17, more common than BRCA 2, increased risk for breast/ovary/various GI

BRCA 2
c13, male carriers have high risk with BRCA 2, increased risk for breast/ovary/various GI

LI FRAUMENI
p53 doesnt work, high risk for many rare cancers

COWDEN
increased risk for breast, follicular thyroid, endometril, Lhermitte Duclos (brain hamartoma)

BANNAYAN RILEY RUVALCABA
developmental disorders young age

NF1
moderate risk breast ca

52
Q

High yield risk facts

A

Estrogen increases risk
BRCA 1 more common than BRCA 2 in women
Men with BRCA 2 get more cancer than men with BRCA 1
Breast density is independent risk
20 Gy radiation to chest as kid gets you screening MRI at age 25 or 8 years after exposure whichever is later
Cowden syndrome - bowel hamartoma, follicular thyroid cancer, Lhermitte Duclos (dysplastic cerebellar gangliocytoma), breast cancer
All current risk models underestimate lifetime risk
Tyrer Cuzick is most comprehensive risk model but doesnt include breast density
Exercise reduced risk of breast cancer
Tamoxifen and Raloxifene (SERMs) reduce incidence of ERPR positive cancers

53
Q

Screening

A

HIGH RISK
BRCA, chest radiation, >20-25% risk

MEDIUM RISK
Personal history breast cancer, ALH, ADH, 15-20% risk

AVERAGE RISK
<15% lifetime risk

54
Q

Stereotactic biopsy

A

Preferred move for calcs.
Specimen xrayed following biopsy
Vacuum assisted device used for calcs
Performed in compression with slightly less pressure than normal mamm, breast should not be less than 20mm - if it is then do wire localization for excisional biopsy
Clip placed following - do orthagonal mamm to check position, clips can move

55
Q

Helpful videos

A

BREAST PATHOLOGY
https://www.youtube.com/watch?v=I2pa7KzGmQY

MORE BREAST PATH
https://www.youtube.com/watch?v=yZ1AEQBweDQ

Radiology (16 decks)

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