breast Flashcards
1
Q
What is the most common and effective screening tool for breast?
A
mammo
used for screening and diagnostic purposes
2
Q
what are some limitations of mammo?
A
dense breast tissue cant differentiate cystic vs solid lesions limited localization malignant vs benign features human error
3
Q
what are some advantages of breast us?
A
painless low cost non-ionizing can differentiate cystic vs solid able to localize masses assists in biopsy guidance
4
Q
what are limitations of breast us?
A
operator and equipment dependent
benign vs malignant features
microcalcs detection
5
Q
explain what the anatomy of the breast is and what can play a role in composition
A
is an exocrine gland with the primary function to produce milk
made of glandular, fatty and fibrous connective tissues, vessels, lymphatics and nerves
age and hormonal status can play a role in composition
6
Q
what is the function of the glandular elements? stromal elements?
A
- function to produce and convey milk
- consist of fat, fibrous connective tissues, blood vessels, lymph and nerves
7
Q
what is precocious puberty?
A
development of both breasts before 8yp
8
Q
list some developmental anomalies
A
congenital nipple inversion polythelia (extra nipple, most common) polymastia - complete extra breast hypoplasia or hypertrophy amastia amazia - absence of breast tissue but nipple is present
9
Q
explain what coopers ligaments are
A
suspensory ligaments that provide support to the breast and enclose the fat lobules
10
Q
explain the breast lymphatics
A
drainage starts in the lobules near the lactiferous ducts, flows through the intramammary nodes and lymph vessels into a subareolar plexus
intramammary nodes are located mostly in the UOQ near the axilla
11
Q
what types of lymph nodes are in the breast?
A
axillary (75% of drainage)
internal mammary
supraclavicular
12
Q
what are the 3 breast layers
A
premammary (subcutaneous fat)
mammary (parenchymal)
retromammary layer (fat layer)
13
Q
what does the mammary layer consist of? (what little pieces of anatomy)
A
15-20 overlapping nodes in a radial pattern
- each lobe containing 20-40 terminal ductolobular units (TDLUs)
- composed of a lobule and an extralobular terminal duct
14
Q
explain what a TDLU is
A
the functional units of the breast
- ductules turn into acini during pregnancy (smallest functional units of the breast, produce milk)
terminal duct continues into the lobule becoming an intralobular terminal duct
15
Q
explain the pathway out of the breast from the acini thru the nipple
A
acini - intralobular duct - extralobular duct - lactiferous ducts - major lactiferous duct - lactiferous sinus - nipple
16
Q
what is seen in the premammary layer
A
coopers ligaments fat lobules (separated by coopers ligaments
17
Q
wat is seen in the mammary layer
A
possibly major lactiferous ducts (<2mm usually)
glandular tissue
is the layer where sonographic appearances vary the most
18
Q
briefly explain the male breast
A
consists mostly of fatty tissue, small amounts of fibrous connective tissue
thicker skin and larger muscles
the most significant breast conditions in men are gynecomastia and cancer
19
Q
what are standard mammo screening views?
A
craniocaudal (CC) and medial lateral oblique (MLO)
20
Q
which mammo view shows greatest amount of UOQ breast tissue and axillary tail?
A
MLO
-masses appear higher or lower on this view than in reality due to the oblique angle (45* +/- 15*)
21
Q
what is the term used to describe where masses might actually lie in the breast compared to the mammo image
A
“muffins rise, lead falls”
- Medial masses can lie HIGHER in the breast than shown on MLO
- Lateral masses may actually be LOWER in the breast than shown on MLO
22
Q
what are the most common causes of breast lumps in women 35-50yo
what are most related to
A
benign simple cysts
true cysts - epithelial lined fluid filled masses
most are related to fibrocystic change (FCC)
23
Q
what is the mammo appearance of a simple cyst
A
round/oval, smooth margins, water density masses may have slightly higher density than surrounding parenchyma
24
Q
explain fibrocystic change (FCC)
A
is the most common benign diffuse breast condition, most symptomatic during ages 35-55
hormone imbalances affect the ducts, lobules and connective tissues of the TDLUs
25
what are the key features of FCC
s/s?
epithelial hyperplasia, adenosis, stromal fibrosis and cyst formation
tenderness, pain, fullness, nodularity
typically bilat
nipple discharge
26
sonographic appearance of FCC?
multiple cysts in both breasts (occasionally complicated)
tiny echogenic foci
increased echogenicity of parenchyma
solid nodules may be seen
nodular adenosis can appear mass like
sclerosing adenosis can be difficult to differentiate from cancer
27
what is the most common benign mass in lactating patients?
| what can it become if it persists beyond the lactation period
galactocele
- milk cyst from an obstruction of a lactiferous duct
subaerolar location is common, can persist beyond the lactation period and become a lipid cyst
- may become infected and can rupture
28
ultrasound findings of a galactocele?
```
round, oval, circumscribed
uni or multiloculated
internal echoes or completely anechoic
fluid fat levels
no internal vascularity
possible rim calcs in older lesions
```
29
what causes a sebaceous/epidermal inclusion cyst?
from obstructed sebaceous glands or hair follicles
contains sebum or keratin
superficial in location
30
ultrasound findings of sebaceous cysts and epidermal inclusion cysts?
```
round/oval
thin walls and circumscribed
within the dermis or just beneath and projecting into the fat
focal skin thickening at the cyst
low-medium level internal echoes, fluid fat levels, or completely anechoic
posterior enhancement
no internal BF
may develop wall calcs over time
```
31
what are 3 benign inflammatory conditions?
mastitis, abscess or Mondor disease
32
when is mastitis most common?
| what are the etiologies?
most common in pregnancy and lactation but can affect all women
non-lactational women: infected/ruptured cyst or a duct, post sx infection, periductal inflammation, granulomatous conditions
peurperal mastitis: related to lactation, is the most common cause of acute mastitis
33
ultrasound appearance of mastitis?
dilated infected ducts appearing as thick walls and internal echoes from congealed milk
calcs can develop
look for abscess formation
CD may show increased vascularity along duct wall
34
explain a breast abscess and the signs/symptoms
localized area of pus and necrotic tissue
subareolar is most common location but can occur anywhere
signs of infection, pain, redness and skin thickening, pus/discharge, palpable mass, enlarged tender nodules
35
ultrasound appearance of abscesses
```
variable depending on the stage
thickened or hyperemic skin
increased echogenicity of subcutaneous fat from edema*
dilated lymph vessels
interstitial fluid
hyperemic surrounding tissue
```
36
what does an organized abscess look like?
complex, complicated fluid collection with internal echoes, septations and possible layered debris
walls can be thick, irregular or indistinct
37
explain Mondor disease
| think veins
rare in both females and males
is acute thrombophlebitis of superficial veins of breast/chest wall
most common location: lateral thoracic, thoracoepigastric, superior epigastric veins
38
signs and symptoms of Mondors?
tender, palpable, superficial cord like mass
| thickened skin, redness and warmth
39
sonographic appearance of mondor disease?
dilated tubular vein with internal echoes from clotted blood
incomplete compressibility
absent blood flow if fully occluded
increased echogenicity and thickness or surrounding tissues and skin
40
list benign trauma related masses
hematomas
seromas
fat necrosis
post sx scars
41
what are some s/s of hematomas?
bruising
skin thickening
tenderness
palpable mass
42
what is the sonographic appearance of a hematoma
```
appearances vary depending on the stage
round, oval or irregular
may be anechoic, complicated with internal echoes, echogenic clot, septations, fibrous strands
absence of internal BF
posterior enhancement is variable
```
43
what is a seroma?
| s/s? is the patient febrile or afebrile?
a collection of serum
palpable mass at sx site
afebrile
large may cause pain and stretching of the skin
44
what is the sonographic appearance of a seroma?
fluid collection of variable appearance
typically conforms to the sx cavity right behind the scar
obvious posterior enhancement
absence of internal vascularity
45
explain fat necrosis of the breast
| consists of what? what can it turn into?
an inflammatory ischemic process due to trauma
consists of necrosis, liquefaction, and hemorrhage to a focal area of fat due to disruption of blood supply
may turn into a lipid cyst or a fibrous sclerotic mass
46
what are the s/s of fat necrosis of the breast?
*can mimic cancer so clinical hx is important
| palpable area in the area of the injury, skin thickening, dimpling and nipple retraction that is usually painless
47
what is the sonographic appearance of fat necrosis?
variable
early stage: increased echogenicity of fat @ the area of trauma with a hypo/anechoic area
can evolve into a solid, suspicious appearing lesion due to fibrosis and granuloma formation (fibrotic fat necrosis*)
no internal vascularity
48
what is the mammo appearance of fat necrosis?
```
variable
oil cyst with egg shell calcs around the cyst
fat density (benign feature)
fibrotic changes may mimic cancer
```
49
when can a post surgical scar form?
| what are the s/s?
following involution of a hematoma, seroma, or abscess
can also occur post radiation
sometimes can be palpable
abundant scarring can cause skin thickening, firmness and retraction
50
what is the mammo appearance of a post surgical scar?
radiodense, changes appearance on different views
architectural distortion, focal asymmetry, spiculated with dystrophic calcs
decreasing size of sequential mammograms
51
sonographic findings of a post sx scar?
```
hypoechoic area with acoustic shadow
skin thickening/retraction is common
changes appearance in different planes
pressure can flatten the scar and reduce shadowing
no vascularity
diminish over time
```
52
what % of breast biopsy return benign results?
80%
53
```
when is a mass minimally assigned birads 1?
birads 2 (benign) or birads 3 (probably benign)
birads 4?
```
- if one or more findings is present
- if no suspicious findings are present, but specific benign findings are present
- if benign findings are not present (nodule is classified as indeterminate with low suspicion of malignancy, bx is recommended)
54
what are benign findings of a solid mass?
oval shaped
macrolobulation - 3 or less gentle lobulations
wider than tall
thin echogenic pseudocapsule
55
what are hard findings of solid masses associated with invasion?
spiculation
angular margins
acoustic shadowing
56
what are mixed findings of solid masses associated with invasion?
microlobulation
taller than wide
marked hypoechogenicity
57
what are soft findings of solid masses associated with invasion?
microcalcs
duct extension - tumor projection from mass into a single duct directed toward the nipple
branch pattern - tumor projection into multiple small ducts away from the nipple
58
what are some benign solid breast masses?
```
fibroadenoma
adenoma/secretory adenoma
phyllodes tumor
hamartoma
lipoma
intraductal papilloma, intracystic papilloma, papillomatosis
```
59
```
what is the most common benign solid breast tumor?
explain it (what induces it, growth rate etc)
```
fibroadenoma
- an estrogen induced tumor in ages 15-35yo
- slow growing, usually <3cm, growth can be accelerated due to hormone stimulation
- single or multiple, uni or multilateral
- can undergo involution, hyalinization and calcification
60
explain juvenile type/giant fibroadenomas
quickly growing from adolescence
accounts for up to 10% of fibroadenomas in females under 20
can grow very large and usually solitary
61
what are the sonographic appearances of a fibroadenoma
```
oval, circumscribed, homogenous
iso/hypoechoic compared to fat
solid, gentle lobulations
wider than tall
some vascularity
may calcify
```
62
what is the mammo appearance of a fibroadenoma?
```
water density
circumscribed
oval/round
thin radiolucent halo is a benign feature
older may have calcs
```
63
what is the most common breast sarcoma?
| explain it
phyllodes tumor (phylloides)
- fibroepithelial tumor
- leaf shaped pattern
- appears similar to fibroadenoma but contains thin, cyst like clefts
- typically unilateral and can grow rapidly and large
- may undergo malignant transformation with potential to metastasize*
64
what is the sonographic appearance of a phyllodes tumor?
| mammo appearance?
similar to fibroadenoma but with the addition of cystic spaces
```
radiopaque
circumscribed
oval
polylobulated
*calcs are not typical*
```
65
what is a hamartoma?
| where is it located?
benign tumor like malformation of varying amounts of normal/dysplastic fibrous, epithelial and fatty tissue
located in the mammary zone, represents a focal malformation of breast development
66
what are the s/s of of a hamartoma?
```
usually unilateral and often >3cm when diagnosed
painless, palpable mass
soft, rubbery consistency
smooth lobulated surface
compressibility varies with tissue comp
```
67
what are the sonographic appearances of a hamartoma?
| shape, echo pattern
circumscribed oval mass
variable appearance usually with a mixed echo pattern
thin echogenic pseudo-capsule of compressed breast tissue
may appear as heterogenous lipoma or fibroadenoma
68
what is the mammo appearance of a hamartoma?
smooth, lobulated encapsulated lesion
mixed radiolucent and radiodense areas
calcs are occasionally present
*mammo is better at differentiating fat within a lesion than u/s*
69
what is a lipoma?
(size, growth etc)
s/s?
```
adipose tissue surrounded by a thin connective tissue capsule
2-10cm in size
slow growing
typically unilateral
susceptible to fat necrosis when large
```
presents as a painless, palpable, mobile soft compressible mass
70
what is the sonographic appearance of a lipoma?
smooth thin walls
iso/hyperechoic compared to normal fat
homogenous or multiple fine linear echoes with mild posterior enhancement
compresses with pressure
71
what is the mammo appearance of a lipoma?
oval or round
| circumscribed radiolucent nodule surrounded by thin radiopaque capsule
72
what is the most common mass within the milk ducts of the breast?
intraductal papillomas
-typically develops centrally, beneath or close to the areola within a major lactiferous duct
usually solitary and too small to palpate
73
why is excision of a papilloma recommended?
presence slightly increases the risk of developing breast cancer
74
explain an intracystic papilloma and what can occur when one is present?
a projection that can obstruct the duct causing a cyst to form that envelopes the solid lesion
-torsion/infarction of the stalk can occur and cause bleeding into the cyst
75
what is a peripheral papillomatosis?
form of epithelial hyperplasia causing small papillary growths in the small ducts of a TDLU
less common than large duct papillomas
has a higher risk for developing cancer than central papillomas
76
what is juvenile papillomatosis?
| what does it show? what is it a marker of?
rare process that affects teens/young women who usually have a fm hx of breast cancer
juvenile form shows papillomatosis with possible severe atypia, extensive cyst formation and sclerosing adenosis
serves as a marker for increased breast cancer risk
77
what are the s/s of intraductal papillomas?
can be asymptomatic
most commonly nipple discharge (bloody/watery)*
benign papilloma is the #1 cause of spontaneous nipple discharge from a single breast duct
78
what is the mammo appearance of intraductal papillomas?
| think fruit
suspicion raised by presence of asymmetrically dilated subareolar duct
solitary can appear as subareolar soft tissue nodule that may have a "raspberry like" microlobulated appearance
occasionally microcalcs
79
what is the sonographic appearance of intraductal papillomas?
dilation of the duct
soft tissue mass in the duct that may extend into branches
vascularity in the stalk
sono cannot tell benign from malignant in this case to bx/excision is necessary
80
what is the sonographic appearance of intracystic papillomas?
what BIRADS classification is it assigned?
ultrasound can see both the solid and cystic components of the lesion
soft tissue mass extending into the cyst
vascularity in mass
real intracystic mass = BI-RADS4 with biopsy or excision to exclude intracystic cancer
81
what is the sonographic appearance of juvenile papillomatosis?
think food
focal ill-defined heterogenous mass with several small peripheral calcs
"swiss cheese appearance"
82
What is the second most leading cause of cancer related deaths in women over 50yo?
breast carcinoma
83
what % of breast cancers are genetically linked?
5-10%
| highest change of developing in the UOQ
84
what is grade 1 cancer?
grade 2?
grade 3?
1- cancer cells that resemble normal cells and are not growing rapidly
2- cancer cells that dont look like normal cells but growing faster than normal cells
3- cancer cells that look abn and may grow or spread more aggressively
85
what are risk factors for breast cancer in females?
```
advancing age
personal and/or fam hx
gene mutation
early menarche and late menopause
nulliparity
exogenous estrogen use
high dose radiation exposure
```
86
what does the TNM system mean?
T- tumor size
N- nodal status
M- evidence of distal mets
87
what is non-invasive cancer also termed?
| what are the types?
carcinoma in situ
- malignant cells confined within boundaries of the duct and/or lobule and have not extended into adjacent tissue
lobular carcinoma in situ (LCIS)
ductal carcinoma in situ (DCIS)
88
explain LCIS
```
abn cells in the small ducts
often multifocal (more than 1 distinct tumor in same quadrant) or multicentric (multiple tumors in different quadrants) and can be bilateral
not treated as a true cancer
```
89
explain DCIS
s/s?
"intraductal carcinoma"
most common noninvasive cancer, average age of detection 50yo
-stage 0 disease that can progress to invasive cancer
atypical ductal hyperplasia is a precursor to developing DCIS
s/s: nipple discharge
90
what is the earliest form of cancer than be detected on imaging?
what is the mammo appearance
DCIS
appears as a suspicious calcifications
microcalcs can be found in groups
focal mass is less common
91
sonographic appearance of DCIS?
can go undiagnosed especially without duct distention or a focal mass
microcalcs
distended duct
hypoechoic mass, microlobulations
92
what is Paget disease?
an uncommon cancer of the epidermis of the nipple
| can affect more men than women
93
what are the s/s of Paget disease?
eczema like crusting of the nipple/areola, redness or ulceration
nipple discharge and itching
diagnosis is made by bx
94
what is the most common breast cancer?
IDC: invasive ductal carcinoma, aka: infiltrating ductal carcinoma or invasive ductal carcinoma of no specific type (NST/NOS: not otherwise specified)
IDC NOS prognosis is typically worse than for other invasive tumors
-these incite vigorous desmoplastic response
95
what are the s/s of IDC?
hard and fixed when palpable
most commonly in UOQ
unilateral bloody or serosanguineous nipple discharge
skin dimpling, nipple retraction or breast contour changes
96
what is the mammo appearance of IDC?
asymmetric irregular and radiodense mass with spiculated margins
clustered microcalcs are common
thick/straight coopers ligaments
97
what is the sonographic appearance of IDC?
```
irregular shape, hypoechoic/heterogenous
indistinct, angular, microlobulated or spiculated margins
microcalcs
shadowing
sometimes taller than wide
```
- a subset of IDC NOS can appear circumscribed with increased sound transmission
- a necrotic IDC may appear as a complex, cystic and solid mass
98
what is the second most common invasive breast malignancy?
what type of pattern does this malignancy follow?
ILC: invasive lobular carcinoma
- diffuse growth pattern: higher rates of being multifocal, multicentric and bilat than IDC
cells tend to follow a more linear pattern rather than forming a solitary mass
desmoplastic response is uncommon*
99
what are the s/s of ILC?
can present as a hard, fixed mass
| may also feel like an area of nonspecific thickening
100
what is the mammo appearance of an ILC?
can be missed in early stages due to diffuse infiltrative nature
suspicious calcs are uncommon
architectural distortion and asymmetrical density
sometimes may present as a mass with spiculated or obscured margins
101
what is the sonographic appearance of ILC?
irregular, ill-defined hypoechoic solid area with acoustic shadowing
architectural distortion
102
what are the special type invasive ductal carcinomas?
medullary
colloid
papillary
tubular
103
explain medullary carcinoma
| what age does it develop before? what does it compress?
an uncommon breast cancer, tends to develop earlier that other breast cancers (before age 50)
well circumscribed, occasionally multiple or bilat
compress peripheral tissues as they grow
104
what are the s/s of medullary carcinoma?
discrete round, somewhat soft, mobile palpable mass
rapid growth
mostly in UOQ
105
what is the mammo appearance of medullary carcinoma?
round or lobulated, radiodense
circumscribed or partially circumscribed
appearance mimics benign lesions
calcs are not common
106
what is the sonographic appearance of a medullary carcinom?
```
round/oval solid mass
circumscribed
markedly hypoechoic
lobulations
prominent vascularity
central necrosis can cause a complex appearance
```
107
what is a colloid carcinoma?
| think snot
```
a mucinous carcinoma
rare, circumscribed
tumor cells spread out in pools of mucin
pure mucinous tumors are more common in elderly women
slow growing, can get large
```
108
what are the s/s of a colloid carcinoma?
soft feeling mass when palpable
may feel like an area of thickening
if large, may be fixed to skin/chest wall
109
what is the mammo appearance of a colloid carcinoma?
low-high density round/oval/lobulated circumscribed mass
110
what is the sonographic appearance of a colloid carcinoma?
```
round/oval/lobulated circumscribed mass
iso/hypoechoic to fat
homogenous/mildly heterogenous
sound enhancement is normal/enhanced
may mimic a fat lobule to lipoma
```
111
explain papillary carcinoma
(what it is, age incidence, rarity, how does it grow)
what are the s/s?
solid papillary and intracystic papillary carcinomas tend to occur in older women
rare
can occur from malignant transformation of a large duct papilloma or within a peripheral TDLU, slow growing
bloody nipple discharge
112
what is the sonographic appearance of a papillary carcinoma?
| size, BF
has an overlap of benign and malignant features*
malignant intraductal papillary lesions tend to be larger, extending greater distances or branch into adjacent ducts
prominent blood flow/vascular stalk usually with multiple feeding vessels
113
explain tubular carcinoma
| rarity, approx size, prognosis, where do they often develop from
rare, usually present around age 50
small and slow growing
very well defined, incites prominent reactive fibrosis
has good prognosis
often develop within TDLUs in peripheral breast and can arise from a radial scar
114
what are the signs and symptoms of tubular carcinoma?
fixed if palpable
| skin dimpling
115
what is the mammo appearance of a tubular carcinoma?
small, irregular
radiodense with long spicules
(white star appearance)
116
what is the sonographic appearance of tubular carcinoma?
small, irregular, centrally hypoechoic mass
obvious spiculation
thick/straight coopers ligaments (related to skin retraction)
117
when does inflammatory carcinoma occur?
| rarity and prognosis
occurs when highly invasive cancer infiltrates the lymphatics of the skin
often high grade IDCs
aggressive but rare (1-5%)
with poor long term prognosis
118
what are signs/symptoms of inflammatory carcinoma?
| what can it mimic?
```
red, warm, edematous skin
orange peel skin
painful and hard breast
palpable axillary lymph nodes
can mimic acute mastitis
```
119
what is the mammo appearance of inflammatory carcinoma?
discomfort and swelling makes compression hard for photos
skin thickening
edema increases breast density which reduces vis
120
what is the sonographic appearance of inflammatory carcinomas?
thick, echogenic skin (from inflammation)
dilated lymph vessels and veins
hypervascular surrounding tissues
edema
121
what are the routes for metastatic cancer?
where is the first site of mets from a primary breast cancer?
what lymph node is most at risk for mets?
where are the most frequent sites for mets from primary breast cancer?
- lymphatic channels, blood or direct extension
- ipsilateral axillary lymph nodes
- sentinel node
- bone, liver, lung, brain
122
what is the sonographic appearance of suspicious lymph nodes (related to metastatic cancer)
```
nodal enlargement
rounded shape
markedly hypoechoic or heterogenous
asymmetrical cortical thickening
loss of fatty hilum
indistinct margins
```
123
what is the rarity of mets TO the breast and how does it spread?
what is the most common source of mets to the breast?
second most common?
very rare, spreads through lymphatics or blood
primary cancer in the contralateral breast via primary lymphatics
melanoma that typically spreads by blood
124
what are the most common male breast conditions?
gynecomastia
| male breast cancers
125
what is the most common male breast anomaly?
| explain the anomaly
gynecomastia: benign male breast enlargement
abn proliferation of ductal and stromal tissues
associated with increased estrogen-testosterone ratio
uni or bilateral
126
what does pseudogynecomastia refer to?
male breast enlargement caused by excessive fat deposits without subareolar ductal proliferation
127
what are the signs and symptoms of gynecosmastia
soft-mildly firm
mildly tender
area of firmess
nodularity beneath areola
128
what is the mammo appearance of gynecomastia?
subareolar density
| may extend deeper into the breast and possible extension into UOQ
129
what are the sonographic appearances of gynecomastia?
| early changes vs
need to rule out a subareolar mass
early changes: hypoechoic nodular/triangular area beneath areola, increased vasc
diffuse gynecomastia may appear similar to female glandular tissue
130
what is the incidence of male breast cancer?
what is it strongly associated to?
what increases the risk?
which is the most common?
rare*
Klinefelter syndrome
elevated estrogen to androgen ratio
IDC
131
what are the signs and symptoms of male breast cancers?
unilateral, often painless and hard, subareolar or periareolar
bloody nipple discharge, retraction, ulceration of the nipple or skin
palpable axillary nodes
132
what is the mammo appearance of male breast cancer?
radiodense
round, oval or irregular
suspicious features similar to ones found in females
133
what are the sonographic findings of male breast cancers?
| secondary features?
variable
well circumscribed vs complex
vascularity
secondary features of skin thickening, nipple retraction
