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Radiology > Breast > Flashcards

Breast Flashcards

1
Q

Diagnosis?

Composition?

Increased risk of malignancy?

A

Hamartoma (fibroadenolipoma).

Glandular and fatty tissue.

No.

Typically painless.

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2
Q

Diagnosis?

Mammographic features?

A

Fibroadenoma. By ultrasound, oval or gently lobulated hypo to iso-echoic mass. Parallel orientation.

Oval, round, or macrolobulated. Low/isodense to the breast parenchyma. Can calcify.

(Tubular adenoma would also be on the differential for this US appearance, but higher density on mammo)

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3
Q

Composition of fibroadenoma?

Age?

A

Fibroepithelial tumor with stromal and epithelial elements.

Premenopausal. Or in postmenopausal woman taking hormones. Responds to hormones by changes in size and tenderness.

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4
Q

When to worry about fibroadenoma? Why?

A

Growing >20% in 6 months. Biopsy to rule out phyllodes tumor (often more complex by US).

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5
Q

DIagnosis?

A

Popcorn calcs in a degenerating fibroadenoma.

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6
Q

MRI features of fibroadenoma?

A

Lobulated margins, nonenhancing internal septations, progressive enhancement pattern.

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7
Q

Definition of a complicated cyst?

What BiRADS?

A

Cyst with internal echoes. No thick walls, septations, mass, or solid component.

If asymptomatic and incidental - Birads 3 (follow).

If symptomatic, enlarging, or new solid component - Birads 4 (biopsy).

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8
Q

Diagnosis?

Mammo/US appearance?

Malignant potential?

A

Fat necrosis.

Mammo: lucent areas, may develop coarse calcifications (can be years after). May present as oil cysts, spiculated lesion, focal mass. US: complex solid or cystic mass with no blood flow. Masses should decrease over time, calcs can increase.

No.

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9
Q

Steatocystoma multiplex?

A

Autosomal dominant disorder manifested as multiple hamartomatous malformations of the pilosebaceous junction. Get mutliple fat-containing masses in the chest and axilla.

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10
Q

What are eggshell calcifications associated with?

Biopsy?

A

Oil cyst. Form of fat necrosis- round lucent masses with progressive rim calcifications.

Avoid biopsy - contents can be irritating and cause local inflammatory reation.

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11
Q

Diagnosis?

A

Secretory calcifications (thick, rodlike, ductal pattern). Premenopausal: plasma cell mastitis. Post menopausal: duct ectasia.

No treatment or intervention. Note- late nipple retraction can occur.

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12
Q

Tram-track calcifications are?

A

Vascular (breast arterial calcifications).

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13
Q

“Tea cup calcification” goes with?

A

Milk of calcium. Also called layering or crescent shaped.

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14
Q

Cause of milk of calcium (breast)?

Typical appearance on CC view?

A

Fine powdery calcifications that precipitate in dilated lobules, microcysts, or macrocysts.

On CC view, often appear amorphous. Layer on true lateral.

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15
Q

Typical calcifications in sclerosing adenosis?

A

Smudgy amorphous. Do not change from CC to lateral view. Can also be punctate.

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16
Q

Sclerosing adenosis is?

Appearance on mammo/us?

Differential?

BiRADS?

A

In the spectrum of proliferative breast disease/fibrocystic change. Combination of stromal sclerosis and proliferative adenosis (of ductules and lobules of the terminal ductal lobular unit).

Amorphous or punctate calcifications, focal or diffuse. Can also present with/as architectural distortion or focal mass.

Differential: Radial scar, cancer.

4- biopsy. Associated with increased RR of cancer (2-7).

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17
Q

Differential diagnosis for nodular sclerosing adenosis?

A

Fibroadenoma. Mass presentation of sclerosing adenosis (“nodular”) and fibroadenoma can not be differentiated on imaging.

Sclerosing adenosis most commonly presents as a cluster of calcifications, but can also cause architectural distortion or focal mass.

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18
Q

Most common age at presentation- sclerosing adenosis?

A

Pre or perimenopausal. This is a proliferative lesion.

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19
Q

What is a tubular adenoma?

Age at presentation?

Can they grow?

A

Benign breast tumor- pure adenomas.

Young women (<35).

Yes.

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20
Q

Mammo/US appearance of tubular adenoma?

Differential?

A

Mammo: high-density, circumscribed mass. Can calcify: round, punctate, or irregular microcalcifications uniformly sized, tightly packed, and located within dilated acini.

US: homogeneous hypoechoic mass. Internal blood flow.

Similar appearance to fibroadenoma (but calcs will look different).

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21
Q

What is PASH (pseudoantiomatous stromal hyperplasia)?

Increased risk of malignancy?

A

Localized stromal proliferation of unknown etiology. Most common in premenopausal women, range from 1-10 cm in size. Common incidental finding in breast biopsies performed for other reasons.

No.

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22
Q

Mammo/US appearance of PASH (pseudoangiomatous stromal hyperplasia)?

A

Mammo: Mass (often circumscribed or partially), can be mass with indistinct margins, or a focal asymmetry. Equal density to surrounding breast tissue. No calcs.

US: often circumscribed mass, hypoechoic, slightly heterogenous. Can look like fibroadenoma.

MRI: nonspecific, often non-mass enhancement.

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23
Q

Diagnosis? Exam?

A

Intraductal papilloma.

Galactogram. Filling defect within a duct, described by location: central (70-90%) or peripheral.

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24
Q

Intraductal papilloma US appearance?

Differential?

A

Well-defined, smooth-walled, solid, hypo-echoic mass or a lobulated, smooth-walled, cystic lesion with some solid components. May see internal flow, vascular stalk. A dilated duct can be frequently visible sonographically.

Pappilary carcinoma- usually presents as an intracystic mass or mural nodules within a cystic mass. More likely to have an irregular shape.

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25
Q

Which ducts are typically dilated with an intraductal papilloma- proximal or distal to the lesion?

Common presentation?

Management?

A

Distal (the ones b/t the lesion and the nipple) due to secretions from the lesion.

Nipple discharge- clear or bloody (bloody may be from infarction).

Controversial b/c 12-14% of lesions diagnosed on core needle biopsy get upgraded to carcinoma on excision. Excise all papillomas with atypia.

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26
Q

What is a sclerosing papilloma of the breast?

Imaging appearance?

A

A subtype of papilloma- a papilloma that has undergone extensive sclerosis and hyalinization. Benign.

Imaging- mass ranging from oval to spiculated. Hypoechoic on ultrasound has internal vascularity.

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27
Q

Increased risk of breast cancer in a patient with intraductal papilloma?

A

Yes, 2-3x. Risk is bilateral and long-term.

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28
Q

Clustered amorphous calcifications go with?

A

Atypical ductal hyperplasia

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29
Q

Pleomorphic calcifications go with?

A

DCIS. Also associated with fine linear.

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30
Q

Atypical ductal hyperplasia is?

Age?

Risk of malignancy in these patients?

Management?

A

Histologically borderline lesion that has some, but not all the features of ductal carcinoma in situ (DCIS).

More common after age 40.

Risk of cancer 4-5x increased in both breasts.

Always excised. 10-25% upgrade rate of ADH to carcinoma.

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31
Q

Radial sclerosing lesion- appearance on mammo, MRI.

A

Mammo: areas of architectural distortion with long spicules, central lucency, and no overlying skin changes (vs cancer usually more dense centrally). May be associated with calcs (30-50%).

MRI: spiculated appearance on T1, isointense on T2, enhances (vs possurgical scar- doesn’t enhance).

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32
Q

Differential diagnosis?

A

Radial scar, invasive carcinoma, sclerosing adenosis, postsurgical scar.

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33
Q

Increased risk of cancer with radial scar?

Management?

A

Yes, 2x in both breasts. If ADH too, 4-5x.

If any associated atypia (atypical ductal or lobular hyperplasia, LCIS), excise.

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34
Q

Differential for an asymmetry seen on a single view?

A

Radial scar.

Tubular carcinoma.

Lobular carcinoma.

35
Q

Differential differential diagnoses of coarse heterogeneous calcifications:

A

Fibroadenoma/fibroadenomatoid change, stromal fibrosis, fat necrosis, ductal carcinoma in situ (usually linear or segmental distribution), and invasive ductal carcinoma.

36
Q

What is Gardner syndrome?

A

A polyposis syndrome, characterized by:

  • FAP (familial adenopolyposis)
  • multiple osteomas (esp mandible, skull, long bones)
  • Epidermal cysts
  • Fibromatoses
  • Desmoid tumors of abdominal wall
  • Papillary thyroid CA
37
Q

What are the birads calcifications and what do they go with?

A

Punctate: < 0.5 mm, round shape. Scattered, diffuse typically benign: Adenosis. Grouped on baseline: BI-RADS 3New group: BI-RADS 4; 11% malignant among Ca++ biopsied.

Coarse heterogeneous: > 0.5 mm irregular Ca++. Calcifying FA, fibrosis, fat necrosis. 13% malignancy rate when biopsied.

Amorphous: Too small or hazy to define morphology. 21% rate of malignancy, usually low-grade DCIS.

Fine pleomorphic: ≤ 0.5 mm irregular Ca++, vary in size and shape. 28-41% risk of malignancy among lesions biopsied.

Fine linear/branching: Thin linear, irregular, or curvilinear Ca++; suggests filling of a duct lumen irregularly involved by tumor. 70% risk of malignancy, often high-grade DCIS.

38
Q

Has grown 50% in 6 months. Diagnosis?

Mammo and US appearance?

A

Phyllodes tumor.

Mammo: high density, circumscribed, oval or macrolobulated. Calcs rare.

US: inhomogeneous, solid-appearing mass is most common. May contain cystic spaces (more common when malignant), have posterior acoustic enhancement. Solid components usually have flow.

39
Q

What is a phyllodes tumor?

Average age at presentation?

Benign vs malignant?

A

A fibroepithelial tumor that arises from the periductal stroma.

Older than for fibroadenoma (40-52 years).

40-80% are benign. Tumors > 3 cm more likely malignant. Mets in 6-22% (lung, bone, liver). Both benign and malignant recur if not completely excised.

40
Q

Most common presentation of low grade DCIS? Versus intermediate, high grade, and invasive?

Differential diagnosis for this presentation?

Chance to progress to invasive carcinoma over 10-30 years if untreated?

A

1) Clustered fine amorphous calcifications. Can also present as a solid mass (uncommon). Pleomorphic calcs more common of intermediate grade, linear calcifications more suggestive of high-grade DCIS. Invasive ductal carcinoma usually presents as an irregular mass or asymmetry +/- calcs- presenting as only calcs is uncommon.
2) Sclerosing adenosis, atypical ductal hyperplasia (ADH).
3) 30-60%.

41
Q

Appearance of DCIS on MRI?

A

Clumped linear or ductal enhancement.

42
Q

Pathologically, what is high grade DCIS?

A

Poorly differentiated DCIS with central necrosis in duct lumens (comedonecrosis). This is where the calcs form.

Extent of high-grade DCIS is more reliably predicted on imaging than low or intermediate grade.

43
Q

What is the difference between stage 0 and stage 1 DCIS?

A

Dependent on the presence of microinvasive disease (<1 mm). Stage 0 is pure DCIS, stage 1 (T1mic) has microinvasive disease).

44
Q

What is the Van Nuys prognostic index?

A

Used to assess for the probability of recurrence of DCIS with and without radiation. HIgher score = worse prognosis. Prognostic indicators are histology (nuclear grade and necrosis), tumor size, and margin status.

Younger patients with DCIS, greater risk of local recurrence. >1/2 of recurrences are invasive carcinoma.

45
Q

Most common form of breast cancer?

Features on mammo/US?

A

Invasive ductal carcinoma.

Most common presentation on mammo- spiculated mass. US- irregular hypoechoic mass with angular margins. Angular margins- 60% PPV of malignancy, Echogenic halo- 70% PPV of malignancy.

46
Q

Imaging and histologic differences in low and high grade breast cancers?

A

Invasive ductal carcinoma- high grade more likely to have mass WITH calcifications.

US- high grade tumors more likely to have posterior accoustic enhancement, be isoechoic.

High grade- more likely to be ER/PR negative (worse prognosis, more early recurrences- vs ER/PR+ tend to recur late).

47
Q

Invasive ductal vs lobular breast cancer… which is more likely to:

1) Have calcs?
2) Be multifocal/multicentric/bilateral?
3) Better prognosis?
4) Not be seen on mammo?
5) Be more advanced at presentation?

A

1) Ductal more likely to have calcs.
2) Lobular more likely to be multifocal- MRI useful for eval for other sites of disease.
3) Lobular- slightly better prognosis.
4) Lobular- up to 19% false neg rate on mammo. Can also present as a one-view finding.
5) Lobular, because of it’s insidious presentation.

48
Q

MRI appearance of invasive lobular carcinoma?

Mammo?

A

May not demonstrate classic rapid enhancement and washout that is sean with IDC. May have delayed enhancement, and may not exhibit washout. Morphology is important.

Mammo- typical presentation is as a focal asymmetry or irregular mass. Spiculated mass is less common.

49
Q

Classic findings of tubular carcinoma?

How is the prognosis?

A

Small (<1 cm), spiculated, asymptomatic mass, presenting in a patient over 50. Up to 50% have associated amorphous or pleomorphic microcalcifications. MRI can be negative (low to mild enhancement) due to hypovascularity.

Excellent prognosis- 95-98% 5-year survival.

50
Q

What is tubulolobular breast carcinoma?

Mammographic appearance?

A

Has features of tubular and lobular carcinoma. Wide age range at presentation. Intermediate prognosis (b/t tubular and lobular).

Mammo- Dense spiculated mass, generally small (<2 cm).

51
Q

What is mucinous breast carcinoma?

Appearance on mammo, US, MRI?

A

Uncommon sub-type of invasive ductal carcinoma. Tends to present in older women. Slow growing, paucity of cellularity.

Tends to have benign imaging features. Equal density mass on mammo, isoechoic to fat on US. May be well circumscribed, posterior accoustic enhancement. On MRI, may only have rim enhancement (can be confused with complicated cyst).

52
Q

What is medullary breast carcinoma?

Imaging appearance?

A

Uncommon, often younger women, arises from supporting stromal cells. Typically triple negative, but better prognosis than invasive ductal carcinoma NOS. Clinically feel soft, may be mistaken as benign.

Partially circumscribed (the “circumscribed carcinoma”) and lobulated, with posterior accoustic enhancement and internal vascularity on US. Calcifications uncommon. May have central necrosis. Characterized by rapid growth. Locally aggressive. Can present with enlarged axillary lymph nodes without involvement.

53
Q

Diagnosis? Diagnostic features?

Presentation?

A

Intracystic papillary carcinoma. (can also see solid papillary carcinoma when no cyst present.) Mural nodules in a cyst with blood flow.

May present with no symptoms, palpable mass, or bloddy nipple discharge. Mean age at diagnosis 63-67 years.

54
Q

Possibe cause of a nonresolving “bruise?”

A

Angiosarcoma

55
Q

Is there an increased risk of breast cancer in patients treated with radiation therapy for Hodgkin lymphoma? If yes, when?

A

Yes, but only in patients who get radiated <30 years old. Peak incidence of this breast cancer is 15 years after radiation treatment.

Baseline mammogram is recommended at 8-10 years after radiation (not younger than 25), then every 2-3 years until 40.

56
Q

Diagnosis?

Differential?

A

Inflammatory breast cancer. Thickened skin, dense breast.

VS. Mastitis- mastitis imaging features are similar, but should improve on Abx (IBC may show minimal improvement initially).

57
Q

What is inflammatory breast cancer?

Clinical symptoms?

Age involved?

A

Aggressive form of invasive breast cancer- from any breast cancer subtype (invasive ductal most common).

Red, swollen, warm breast. Peau d’orange appearance due to cancer infiltration of the skin/lymphatics.

Younger- mean age 55. More common in African American women.

58
Q

Differential diagnosis for new nipple retraction?

A

Duct ectasia, periductal mastitis, tuberculosis, malignancy.

59
Q

Typical appearance for dermal calcifications?

Location?

A

Lucent-centered with a thin rim.

Medial, inferior, periareolar, and in the axilla. They are within the sebaceous glands.

60
Q

Diagnosis?

Other areas of involvement?

A

Neurofibromatosis, probably type 1 (greater skin involvement- nodules and cafe au lait lesions).

Also can see: hamartomas, optic nerve gliomas, bone dysplasia, and spinal cord neurofibromas.

61
Q

Diagnosis?

A

Sternalis muscle. Normal variant seen in 3-5%, more common unilateral than bilateral. Thin muscle running along the lateral border of the sternum.

62
Q

Causes of bilateral axillary adenopathy on mammo? BIRADS?

Unilateral?

A

Bilateral- Lymphoproliferative diseases (lymphoma, leukemia), collagen vascular diseases (RA, scleroderma, SLE), granulomatous diseases (sarcoid, TB), HIV. If cause known, BI-RADS 2. If unknown, 0.

Unilateral- cancer, infection/inflammation, mets (breast, lung, melanoma), silicone from implant leak.

63
Q

Diagnosis?
Complications?

A

Free silicone injections.

Infection, fibrosis, lymphadenopathy, silicone migration.

64
Q

Appearance of silicone on ultrasound?

A

Hyperechoic with “snowstorm” shadowing- highly specific.

65
Q

Signs of intracapsular silicone implant rupture?

A

Linguine sign (collapsed shell), keyhole sign (silicone between radial folds of the shell), subcapsular line sign (silicone between the shell and fibrous capsule), water in the implant. This is the more common type (80%), is not seen on mammo.

66
Q

Mammographic findings at a lumpectomy scar?

A

Architectural distortion with entrapped fat, increased density, trabecular thickening, skin thickening/retraction, fat necrosis. Often dicrease over time and become stable in 2-3 years. Scars tend to change in appearance between projections.

67
Q

Cause of dystrophic calcifications in the breast?

Timeframe?

A

Some form of trauma (iatrogenic or physical).

Form 6 mo - 2 years after insult.

68
Q

Incidence of seroma following lumpectomy?

US appearance?

A

Seen in 50% of patients in the 4 weeks following. Most resolve within the first 2 years.

Cystic masses with septations, thickened walls, or echogenic nodules. Do not aspirate if asymptomatic (will reaccumulate, risk of infection).

69
Q

1) 51 year old female diabetic with palpable firm breast mass with skin induration. Diagnosis?
2) Cause?
3) Clinical presentation? Treatment?
4) Mammo, US, MRI appearance?

A

1) Diabetic mastopathy (need to rule out cancer with biopsy).
2) Stromal fibrosis unique to longstanding insulin-dependent diabetics (>20 years).
3) Clinical presentation- firm, palpable mass (2-10 cm). Commonly bilateral. Self-limited. No increased risk of malignancy, doesn’t need to be excised.
4) Mammo: area of homogeneous dense parenchyma. US: hypoechoic area with indistinct margins, posterior shadowing, NOT hypervascular. MRI: heterogeneous progressive enhancement.

70
Q

Most common metastases to the breast?

Typical imaging features?

A

In declining order: lymphoma, melanoma, lung (25-40% of small cell CA- breast is first metastatic site), ovarian, soft tissue sarcomas.

More commonly circumscribed, oval/round (vs spiculations, calcs, architectural distortion breast Ca), mets tend to be more superficial.

71
Q

Mammogram and US appearance of lymphoma in the breast?

A

Multiple (new) round-oval masses. On ultrasound, they are hypoechoic to anechoic. No posterior accoustic enhancement or shadowing, mild increased vascularity.

72
Q

Cause of gynecomastia?

Increased risk of breast cancer?

Mammographic patterns?

A

Stromal proliferation and ductal hyperplasia. Many causes: hormonal, drugs (antihypertensives, alcohol, marijuana), genetic (klinefelter), systemic (cirrhosis), idiopathic.

No.

Nodular, dendritic, and diffuse. Must emenate from the nipple. Can be unilateral or bilateral, asymmetric or symmetric.

73
Q

Most common type of male breast cancer?

Prognosis?

Age at presentation?

Genetics?

A

Invasive ductal carcinoma, then DCIS. Invasive lobular uncommon (no lobules in male breasts unless on estrogen).

Same prognosis as stage matched females, but often present later.

Mean 60-70, older than in women. Androgen receptor expression has a worse prognosis.

High incidence of BRCA-2 mutation. Increased prevalence in African Americans, Native American, men of Jewish ancestry.

74
Q

Most common organisms for mastitis and breast abscess?

A

Staph epi and staph aureus, strep.

Both have findings similar to inflammatory breast cancer- short term follow up to make sure it resolves on abx.

75
Q

What does it mean when an invasive ductal carcinoma has “extensive intraductal component?”

How does this change prognosis?

A

An infiltrating tumor composed of at least 25% DCIS present in the adjacent tissues, either as a direct extension or as a separate foci.

Makes achieving surgically negative margins difficult, higher risk of local recurrence after breast conservation therapy. Extent of calcification important.

76
Q

What is the difference between multifocal and multicentric breast cancer?

A

Multifocal: cancers within the same quadrant of the breast or within 4 cm of one another.

Multicentric: in different quadrants of the breast.

-More common in women under 45, higher recurrence rate.-

77
Q

Differential diagnosis for a circumscribed mass on mammogram?

A

Simple or complicated cyst. Oil cyst, epidermal inclusion, sebaceous cyst.

FA, phyllodes tumor, lymph node, hamartoma.

Lactating adenoma, galactocele.

Invasive ductal (high grade), medullary, mucinous, or encapsulated papillary carcinoma.

Metastases to breast, sarcoma.

78
Q

Differential diagnosis for a fat containing mass on mammogram?

A

Lipoma, fibroadenolipoma (hamartoma), fat necrosis, galactocele (fat-fluid level on 90° lateral view mammogram), intramammary lymph node.

79
Q

Differential diagnosis for a high density mass on mammogram?

A

Invasive ductal carcinoma (IDC) not otherwise specified (NOS): most common high-density malignancy.

Mucinous, medullary carcinoma. Papillary carcinoma.

Metastases to breast: Melanoma, lymphoma, lung.

Metastatic intramammary or axillary lymph node.

Abscess, hematoma/seroma.

80
Q

Differential diagnosis for amorphous calcifications?

A

20% malignant (90% DCIS, 10% IDC- often associated mass).

20% high-risk lesions (ADH, FEA, ALH, LCIS).

60% benign (FCC, sclerosing adenosis)

Associated circumscribed mass suggests papilloma, fibroadenoma, or sclerosing adenosis.

When in lymph node: Consider metastatic ovarian carcinoma, sarcoid, or gold injections (rheumatoid arthritis) mimicking Ca++.

81
Q

Type of calcs?

A

Amorphous

82
Q

Type of calcs?

A

Pleomorphic

83
Q

Differential diagnosis for fine pleomorphic calcifications?

A

DCIS ± invasive ductal carcinoma.

Fibrocystic change.

Fibroadenoma or fibroadenomatoid change.

Pleomorphic LCIS.

Radiology (11 decks)

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