Breast Flashcards
What is the target recall rate for screening mammography (not including initial screens)?
The Canadian target is
DDx fat-containing lesions
Hamartoma LN Galactocele Fat necrosis Lipoma
What is the risk of cancer in BIRADS 3?
less than 2%
What is the risk of cancer in BI-RADS 4a?
2-10%
What is the risk of cancer in BI-RADS 4b?
10-50%
What is the risk of cancer in BI-RADS 4c?
50-95%
DDx for breast skin thickening
- Tumor (inflam BrCa, lymphoma/leukemia)
- Inflammation (mastitis, abscess, radiation, post surg)
- Lymphatic obstruction (spread of tumor to axilla, lung/breast cancer)
- Edema (right heart failure, central venous obstruction, nephrotic syndrome)
DDx for architectural distortion
- Cancer
- Radial scar
- Post-operative (scar from bx or surgery)
- Sclerosing adenosis
DDx bilateral axillary lymphadenopathy
- Granulomatous dz (sarcoid, TB)
- HIV
- Lymphoma
- Lymphoid hyperplasia
- Collagen vascular disease (SLE, RA)
- Silicone adenopathy
DDx fat-containing lesions
- Hamartoma
- LN
- Galactocele
- Fat necrosis
- Lipoma
If a patient has ADH or ALH, what is the increased risk for developing cancer?
5x (Primer)
Other sources say 4x for ADH and ALH and 2x risk for radial scar
What is the increased risk for developing cancer if you have sclerosing adenoma; hyperplasia, moderate or florid, solid or papillary?
2x (Primer)
What is the most common metastasis to the breast?
melanoma
Lobular neoplasia (formerly LCIS) is not considered malignant, but carries what percentage risk of developing breast cancer?
30% risk of breast cancer (15% in each breast)
-Primer
10x increased risk of developing subsequent invasive carcinoma
DDx shrinking breast
- Diffuse ILC
- Post-surgical
- Radiation tx
- Diabetic mastopathy
What is the recommended mgmt for flat epithelial neoplasia (FEA)?
Surgical excision. (Commonly co-exists with more significant lesions such as ADH, DCIS, tubular ca).
What is the recommended mgmt for a radial scar?
Surgical excision. 30-40% upgrade rate to DCIS or tubular carcinoma.
What is the increased risk of cancer in those with radial scar?
2x compared to normal population (Radiopaedia)
What is the recommended mgmt for pseudoangiomatous stromal hyperplasia (PASH)?
1 year f/u for definite benign cases. Not a/w incr’d risk of malignancy.
What is the recommended mgmt for sclerosing adenosis?
1 year f/u for definite benign cases. Not a/w incr’d risk of malignancy.
What is Mondor disease?
Mondor disease is a rare benign breast condition characterized by thrombophlebitis of the superficial/subcutaneous veins of the chest wall.
What is considered locally advanced breast cancer (LABC)?
-LABC: Stage III breast cancer, excluding inflammatory breast cancer (reported separately due to distinct clinical presentation/behavior)
+T3: Primary invasive tumor > 5 cm
+T4: Tumor any size direct extension to skin or chest wall; invasion of the dermis alone does not qualify as T4 (requires skin ulceration &/or skin nodules)
+N2: Matted axillary nodes; ipsilateral internal mammary nodes in absence of axillary metastasis
+N3: Ipsilateral metastatic infra- or supraclavicular nodes or clinically apparent (includes imaging) internal mammary nodes and axillary nodes
+Stage IIIA: T0-2 N2 M0 or T3 N1-2 M0
+Stage IIIB: T4 N0-2 M0
-Chest wall invasion: Intercostal muscle invasion; Pectoralis muscle invasion should be reported but is not classified as chest wall invasion
What is a level 1 LN?
Level I includes lymph nodes that are inferior to the inferolateral border of the pectoralis minor muscle
What is a level 2 LN?
lymph nodes that are posterior to and between the lateral and medial borders of the pectoralis minor muscle
What is a level 3 LN?
lymph nodes that are medial to the superior border of the pectoralis minor muscle (including infraclavicular nodes)
What is the limit for average glandular dose per mammogram?
-limited to 3 mGy (per view)
DDx for dystrophic calcifications
- recurrent malignancy
- fibroadenoma, fibroadenomatoid hyperplasia
- dermatomyositis, Ehlers-Danlos
DDx for intraductal mass
-Papilloma, benign or atypical
-DCIS +/- IDC
-Periductal inflammation, abscess
(BIRADS 4A usually, 8% malignancy rate)
What is the mgmt of clustered micro cysts on ultrasound?
Considered benign or probably benign in perimenopausal women. If this finding is new or enlarging in a postmenopausal woman not on HRT, bx should be considered.
DDx for clustered micro cysts on US
- Fibrocystic changes (38%)
- Apocrine metaplasia (38%)
- Papillary apocrine metaplasia
- DCIS, usually papillary
- IDC, mutinous carcinoma
DDx hypo echoic mass on US
- Malignant: DCIS, IDC, Lobular carcinoma, metastasis
- Atypical lesions: ADH, LCIS
- Benign: lactational changes, gynecomastia, FA, complicated cyst, papilloma, adenosine, fibrosis, fibrocystic changes, fat necrosis, abscess, post surgical changes, radial scar
DDx for fine pleomorphic calcifications
- DCIS +/- IDC
- Fibrocystic changes
- Fibroadenoma
- Pleomorphic LCIS
- (Overall risk of malignancy is moderate, 29%)
In the 50-69 year old age group, what is the reduction in mortality from screening mammography? (%)
about 30% (27%)
What are the current recommendations from the Canadian Task Force on Preventative Health on screening for breast cancer with mammography for average risk women?
- 40-49 years old: routine screening is not recommended
- 50-69 years old: routine screening every 2-3 years
- 70-74 years old: routine screening every 2-3 years
What are the odds that a Canadian woman will develop breast cancer in her lifetime?
1 in 9
What are the odds that a Canadian woman will die from breast cancer in her lifetime?
1 in 25
What are typical characteristics of dermal calcifications on mammography?
- lucent centres
- often spherical or polygonal in shape
- have a fixed relationship on multiple mammography views, a finding termed the “tattoo sign”
- Grouped dermal calls usually have a linear distribution on tangential views.
- Can project deep within the breast on multiple mammographic views. Tangential views are helpful to demonstrate that the lesions are superficial in location.
What is the upgrade rate for intraductal papilloma?
-6.5-10% for non-vacuum assisted core biopsy
-1% for vacuum-assisted core biopsy
(Radprimer)
At mammography, tubular carcinoma typically presents as a _____ mass
spiculated mass (not a well-circumscribed mass). They are slow growing and have an irregular shape and are spiculated.
At mammography, papillary carcinoma typically presents as a ______ mass
Most likely will present as a circumscribed mass. It is a relatively well-differentiated tumor with a better prognosis than ductal carcinoma, not-otherwise specified.
Which quality control test must be performed DAILY?
a) phantom image evaluation
b) repeat analysis
c) processor QC
d) darkroom fog
c) Processor QC should be performed daily at the start of the workday before any patient films are put through the processor.
Invasive lobular carcinoma accounts for what percentage of breast cancers?
Approx 10%
Second most common after IDC
When is the ideal time for performing breast MRI?
Days 7-14 of the cycle
At what time points are the contrast-enhanced breast MR images obtained?
Pre-contrast Ax T1 FS, 2 min post, 9 min post.
Subtraction sequences acquired.
The echogenicity of a breast lesion (iso, hypo, hyperechoic) is with respect to:
subcutaneous fat
DDx for high density material in axillary LNs
- metastatic disease (usually breast, thyroid, ovarian)
- chronic granulomatous disease (TB, sarcoid)
- gold tx for RA
- silicone from previous silicone injection or implant rupture
- high density material from ipsilateral arm or chest tattoo
What is multifocal vs. multi-centric breast cancer?
Multifocal breast cancer is defined as multiple (≥ 2) separate foci of breast cancer within 4 or 5 cm of each other, typically within the same quadrant, and usually along the same ductal system. MR is sensitive for depicting tumor extent. At least 75% of additional foci are multifocal; fewer than 25% are multicentric (foci separated by > 5 cm and/or in different quadrants).
-Radprimer
What are the goals (in terms of size detected and % node negative) of screening mammography in Canada?
75% of screened cancers less than 1 cm in size and 75% node negative (as per Dr. Seely)
->50% screen-detected invasive tumors
What is the most common source of metastases to the breast?
Melanoma
What is the expected cancer detection rate in
screened paIents?
5 per 1000 (Rosenberg et al. Radiology 2006)
What is the radiaIon dose from a mammogram?
glandular dose from standard 2 view, bilateral mammography must not exceed 3 mGy (equivalent to 7 weeks of background radiaIon)
Should women get screening mammograms when they are breastfeeding?
In women >40yrs, routine screening mammography should resume 3 months after cessation of lactation to allow the breast parenchyma to involute and return to baseline density
What are the CAR guidelines for screening mammography?
CAR recommendations
- 40-49yrs: Annual screening
- 50-74yrs: Every 1-2 years
- > 74yrs: Every 2 years
Axillary lymph nodes are considered abnormal when the cortical thickness measures above?
3 mm is the upper limit of normal for cortex thickness
List 3 worrisome features of nipple discharge
- bloody or clear
- spontaneous
- from a single duct orifice
What is the Canadian target for positive predictive value for screening mammography (e.g. those with an abnormal mammogram who go on to be diagnosed with invasive or in situ cancer)?
The Canadian target is ≥5% for first screens and ≥6% for subsequent timely screens.
-Public Health Agency of Canada
What is the Canadian target participation rate for screening mammography?
Aim for >70% of the eligible population
What is the recommended positive biopsy rate for a radiologist? (e.g. out of every 100 breast biopsies performed, how many should come back as cancer?)
- Target is 30% (applies to a screening population)
- If your rate is 10% then you are likely performing too many biopsies
- If your rate is 50%, then you are probably undercalling things and not performing enough biopsies.
When is breast cyst aspiration necessary?
a) When there is a possibility that it is solid
b) When the cyst is symptomatic
c) When a simple cyst is shown to have grown in size
d) a and b
e) all of the above
d) A and B: A cyst should be aspirated if there are internal echoes (ie. when it is unclear whether it is a cyst or solid) or if the patient seeks relief from symptoms
Cysts get larger and smaller, come and go. Enlargement of a simple cyst is not in and of itself an indication for aspiration.
What is the risk of DCIS developing into invasive cancer?
a) 1% per year develop into invasive cancer
b) 25% per year
c) 0.1% per year
d) 10% per year
a) DCIS is quoted to progress to invasive cancer at a rate of 1% per year if left untreated. The histologic grade of DCIS usually correlates with the histologic grade of invasive tumor.
The echogenicity of a breast lesion (iso, hypo, hyperechoic) is with respect to?
subcutaneous fat (Stavros 2003)
What is considered interval growth for a presumed BI-RADS 3 fibroadenoma?
If documented growth >20% in 6 months, biopsy or excision should be performed as findings may represent a phyllodes tumor.
What percentage of patients with inflammatory breast cancer will have metastases at clinical presentation?
20-40%
What is the likelihood of malignancy for a developing asymmetry identified at screening mammography?
13% (RadioGraphics 2016)
What is the lifetime risk of developing breast cancer in a women with the BRCA1 or BRCA2 gene? Express as a percentage.
50-85%
