Breast Flashcards
1
Q
Mammography characteristics of radial scar
A
Spiculated lesion with long curved spicules
Central lucency
Variable appearance on different projections
May have calcifications
No skin thickening or retraction
2
Q
True or false: US and MRI are useful in evaluation of radial scar
A
False. Indistinguishable from cancer
3
Q
What is abnormal size for axillary lymph node?
A
Cortex >3mm. Total size does not matter.
4
Q
What is a solitary papilloma of the breast
A
Benign intraductal lesion
5
Q
Ddx intraductal papilloma
A
Intracystic papillary carcinoma Atypical ductal hyperplasia Ductal carcinoma in situ Duct ectasis with debris Nipple adenoma
6
Q
What is phyllodes tumor
A
Locally agressive stromal tumor with papillary growths. Can range from benign to malignant.
Rapidly growing circumscribed mass - looks like a fibroadenoma
7
Q
Rate of recurrence of phyllodes tumor post excision
A
21% in 2 years
8
Q
Ddx phyllodes tumor (3)
A
Fibroadenoma
Sarcoma
Invasive cancer
9
Q
Mammography appearance of tubular carcinoma
A
Small spiculated mass with dense center or architectural distortion.
Calcifications in up to 50% of cases. Can be stable for years.
Cannot be distinguished from radial scar or other type of cancer on imaging
10
Q
Breast fat necrosis appearance on mammography and US and MR
A
Circumscribed lucent mass with peripheral calcifications
Can be spiculated and dense, similar to cancer
US
Acute - increased echo
Subacute - complex cystic areas in mass
Chronic - hypoechoic
MR
High t1
Low t2 fat sat /w surrounding edema
Rim enhancement
11
Q
Hamartoma definition and mammo appearance
A
Focal developmental pseudotumor composed of normal breast tissue
Well circumscribed mass containing fat with a thin rim on mammography
12
Q
Ddx breast hamartoma
A
Fibroadenoma
Galactocele
Fat necrosis
Lipoma
Go look up other ddx
13
Q
What is PASH
A
Pseudoangiomatous stromal hyperplasia (PASH) is a benign, relatively uncommon form of stromal (mesenchymal) overgrowth within breast tissue that derives from a possible hormonal aetiology.
14
Q
What is the characteristic appearance of a radial fold? (breast implant)
A
they are blind ending within the implant, which allows differentiation from a capsule rupture.
They are also thicker than the curvilinear lines of a capsule rupture because they represent 2 lines adjacent to one another
15
Q
In breast MR, define type 1, 2 and 3 enhancement kinetics
A
type 1: persistent kinetics, degree of enhancement continues with delayed phase. most often benign.
type 2: plateau kinetics, degree of enhancement plateaus on delayed phase. indeterminate.
type 3: wash-out kinetics, degree of enhancement decreases in delayed phase. most often malignant.
enhancement kinetics cannot exclude benign vs malignant!
16
Q
What is the most common benign breast mass in lactating women (describe its appearance)
A
galactocele
cystic mass forms due to duct dilatation and contains fluid that resembles milk. variable imaging findings depends on content.
17
Q
what is the most common benign solid breast mass in young women (describe its appearance)
A
fibroadenoma
classically: circumscribed or gently lobulated, mildly hypoechoic, thinly encapsulated, elliptically shaped mass oriented parallel to the chest wall.
18
Q
popcorn calcifications in the breast are pathognomonic for which entity?
A
Degenerating/involuting fibroadenoma (benign)
19
Q
on mammography, linear distribution and linear, branching morphology are suggestive of a benign or malignant process?
A
highly suggestive of malignancy
20
Q
what is typical mammo/US appearance of a breast hamartoma
A
mammo: circumscribed margins with combination of fatty/soft tissue densities surrounding by thin radiopaque capsule or pseudocapsule. “breast within a breast” appearance.
US: circumscribed oval mass with heterogeneous internal echoes
21
Q
mammographic appearance of radial scar?
A
spiculated appearance similar to carcinoma but with a translucent low density center (“dark star” appearance)
microcalcifications rare
requires histological diagnosis to exclude carcinoma
22
Q
What is the difference between radial scar and complex sclerosing lesion?
A
They are differentiated by size. Radial scar 1cm
23
Q
Do you need to see the pectoralis on a CC view mammography?
A
No. Only for MLO
24
Q
What calcification morphology descriptors are suspicious for neoplasm according to BI-RADS?
A
Amorphous
Coarse heterogeneous
Fine pleomorphic
Fine linear/fine linear branching
25
Describing a finding with the descriptor "complex" implies what minimum BI-RADS score?
BI-RADS 4
Using the term complex implies that a biopsy should be performed
VP
26
What are the ACR indications for breast MRI
```
High risk screening
New diagnosis of breast cancer
Breast implants
Assessing extent of disease
Recurrence
Positive margins post lumpectomy
```
Refer to ACR guidelines for all indications and details
27
Most common intraductal breast mass?
Papilloma
28
What is the best time in the menstrual cycle to perform a breast MRI?
day 8-14: follicular phase of differenciation. Contrast uptake in normal tissue is at its lowest at this time.
29
TRUE OR FALSE
On breast MRI, enhancement kinetics are more important in the evaluation of a mass than its morphology.
FALSE
Suspicious morphology is more important than kinetics. More specifically, its margins.
As far as enhancement is concerned, early enhancement is most important.
30
What are the categories of findings that need to be present in a breast MRI report?
```
1- Amount of Fibroglandular Tissue
2- Background Parenchyma Enhancement
3- Focus
4- Masses
5- Non-mass Enhancement
6- Other (lymph node, skin, associated findings)
7- Location of Lesion
8- Kinetic Curve (initial and delayed)
```
31
According to ACR lexicon, on breast MRI, what is the definition of a focus?
Unique punctate enhancing dot <5mm
32
On breast MRI, what are the features of malignancy of a focus?
Unique/dominant
no fatty hilum
washout kinetics
change from prior
33
According to ACR lexicon, on breast MRI, what is the definition of a mass?
3D space occupying structure with convex-outward contour.
```
You should describe
size
shape: oval, round, irregular
contour: circumscribed, irregular, spiculated
internal enhancement characteristics
```
34
According to ACR lexicon, on breast MRI, describe the internal mass enhancement characteristics lexicon
homogeneous, heterogeneous, rim enhancement, dark internal septations
35
What is the typical T2 signal of a fibroadenoma on breast MRI?
Fibroadenoma
Can be hypointense on T2 or have dark internal septations if it is sclerotic or contains bands of dense connective tissue
Non-enhancing
36
On breast MRI, what lesions can be T2 hyperintense?
```
fibroadenoma
cyst
lymph node
fat necrosis
mucinous carcinoma
intraduct carcinoma with necrosis
```
37
According to ACR lexicon, on breast MRI, what is the definition of an area of non-mass enhancement?
It is neither a focus nor a mass. The internal enhancement is a pattern discrete from the normal background parenchyma.
It is described by distribution and internal enhancement pattern.
38
On breast MRI, what malignant neoplasms present as non-mass enhancement?
DCIS (65%)
| lobular carcinoma
39
On breast MRI, what benign pathologies present as non-mass enhancement?
Fibrocystic changes
Stromal fibrosis
Papilloma
Sclerosing adenosis
40
Most common benign breast lesion in men?
lipoma
41
TRUE OR FALSE
Fibroadenomas are amongst the most common benign breast lesions in men
FALSE. Men do not have TDLUs, therefore fibroadenomas are extremely rare (case reports).
42
TRUE OR FALSE
A non subareolar abnormality cannot be gynecomastia
true
43
What is the most common location of breast cancer in men?
65-95% present as a painless SUBAREOLAR mass
44
What is the lifetime risk of breast cancer is a non high-risk woman in north america?
10-11%
45
What is the most common breast mass in adolescent girls?
fibroadenoma
46
What is Mondor disease?
Mondor disease is a rare benign breast condition characterized by thrombophlebitis of the superficial/subcutaneous veins of the chest wall.
47
What is the DDx of pleomorphic calcifications on mammography?
```
Fibrocystic changes
papilloma
fibroadenoma
DCIS - intermediate to high grade
ADH
```
48
What is the DDx of amorphous calcifications on mammography?
Fibrocystic changes
sclerosing adenosis
DCIS - low grade
ADH
lower PPV of malignancy than pleomorphic calcification
49
What distribution of calcifications on mammography is worrisome for malignancy?
Linear
Groups/clustered
Segmental - most worrisome
50
What is the Ddx of spiculated mass on mammography?
```
IDC
- tubular
- low grade
fat necrosis
scars (decrease over time)
radial scar
```
51
What is the Ddx of a lesion with indistinct margins on mammography?
```
IDC
- any grade
many benign histologies
abscess
hematoma
```
52
What is the ddx of a lesion with architectural distortion on mammography?
intraductal/intralobular carcinoma
radial scar/complex sclerosing lesion
scar
fat necrosis
53
What is the ddx of developping asymmetry on mammography?
```
Fibrosis
PASH
Fibrocystic changes
trauma
infection
radial scar
intraductal carcinoma
```
54
What is the size of needle typically used for fine needle aspiration in breast pathology?
22-18 gauge hypodermic needle
55
When biopsying an axillary lymph node, where should you direct your needle?
You want to biopsy tissue from the cortex of the lymph node, not the hilum
56
What should you do at the end of every breast biopsy?
Leave a clip in the location of the biopsy
57
What is the main indication for stereotactic core needle biopsy of the breast?
To biopsy microcalcifications since they cannot be visualized on ultrasound
58
What is Ddx of a complex solid and cystic mass on breast ultrasound?
```
Papillary lesion (papilloma +++, papillary carcinoma)
Fibrocystic changes
aprocine metaplasia
intraductal carcinoma with necerosis
abscess
hematoma
```
59
What % of core biopsies with flat epithelial hyperplasia are upstaged to DCIS+ on surgical excision? % of atypical ductal hyperplasia?
14% of patients with a core needle biopsy of FEA will be upstaged to DCIS or invasive carcinoma upon surgical excision.
Approximately 18% of ADH diagnosed by core needle biopsy will be upstaged to either invasive carcinoma or DCIS upon surgical excision.
60
BREAST
What % of ductal carcinoma in situ will progress to invasive ductal carcinoma within 10 years?
Between 30% to 50% of patients with DCIS will develop invasive carcinoma within 10 years.
61
What % of patients diagnosed with DCIS by ultrasound guided core needle biopsy are upstaged to invasive carcinoma upon surgical excision?
Approximately 43% of DCIS diagnosed by ultrasound-guided core needle biopsy is upstaged to invasive carcinoma upon surgical excision.
62
What are the risk factors for developping breast cancer?
Female gender
Increasing age
BRCA1/BRCA2 mutation (50-80% chance by 80yr)
First degree relative with breast cancer
Prior chest radiation for lymphoma
Long-term estrogen exposure (early menarche, late menopause, late first pregnancy, nulliparity, obesity)
• Prior biopsy result of a high risk lesion in the lobular neoplasia spectrum, including atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). Women with LCIS have a 30% risk of developing invasive cancer (usually invasive ductal), which may occur in either breast.
63
What is the most common type of breast cancer?
The most common type of breast cancer is invasive ductal carcinoma (IDC), representing 70–80% of cases
64
BREAST
What are the subtypes of (invasive) ductal carcinoma?
```
ductal carcinoma NOS
Tubular carcinoma
Mucinous carcinoma
Medullary carcinoma
Papillary carcinoma
Adenoid cystic carcinoma
```
65
What is Paget disease of the nipple?
Paget disease of the nipple is a form of DCIS that infiltrates the epidermis of the nipple.
66
In non-metastatic breast cancer, what is the most important prognostic factor?
In non-metastatic breast cancer, axillary lymph node status is the most important prognostic factor, with the absence of nodal involvement offering the highest likelihood of cure
67
In the assessment of axillary lymphadenopathy in breast cancer, what is the sensitivity of surgical sentinel lymph node biopsy?
93%
68
TRUE OR FALSE
Triple negative breast cancer often appears as a round mass with smooth margins on mammography/ultrasound
TRUE
On imaging, triple-negative cancers may show benign features on mammography and ultrasound despite their aggressive nature. They are often round with smooth margins, without spiculations and calcifications, and are located posteriorly in the breast.
69
A sentinel lymph node biopsy will be performed in cases of DCIS if what findings are present? (2)
Necrosis
| Microinvasive disease
70
On mammography, what types of calcification suggest the presence of a high grade DCIS (necrosis)?
On mammography, the typical manifestation of high-grade DCIS is pleomorphic or fine linear branching calcifications, which are caused by calcification of necrotic debris in the duct lumen.
71
What is granulomatous mastitis?
Granulomatous mastitis is a rare idiopathic noninfectious cause of breast inflammation that occurs in young women after childbirth.
May be associated with breast feeding or oral contracetives.
The mammographic and sonographic features of granulomatous mastitis may mimic breast cancer and biopsy is usually warranted.
72
What is periductal mastitis?
Also known as plasma cell mastitis
Caused by the irritating contents of intraductal lipids. It is seen in post-menopausal women and produces the classic mammographic appearance of large, rod-like secretory calcifications.
73
BREAST
How are rolled views obtained?
Rolled views are obtained by moving the top and bottom of the breast in opposite directions. Rolled views are helpful to localize a lesion that is seen on the CC view only.
• Two rolled views are typically obtained. A view is obtained with the top of the breast rolled medially (RCCM) and a second view with the top rolled laterally (RCCL).
If a lesion moves medially with an RCCM view, then it’s in the superior breast. If a lesion moves laterally with an RCCM view, then it’s in the inferior breast.
74
What mammographic view allows the localization of a mass seen only on MLO views?
True lateral
If the lesion rises on the lateral compared to the MLO, the lesion is located in the medial breast (medial:muffins rise); If the lesion sinks, it is lateral (lateral:lead sinks).
75
What BIRADS scores can be used for a screening mammogram?
BIRADS 0, 1 or 2.
| Other categories require diagnostic mammography beforehand
76
True or false
A mass with any suspicious feature either on mammogram or US should be biopsied.
True
Even if it appears benign on 1 study, if it appears suspicious on another a biopsy is required.
77
Name the three situations where a BIRADS 3 score is appropriate for a mammographic finding
Group of tiny round calcifications
Circumscribed benign appearing solid mass
Focal asymmetry: non-palpable lesion seen on 2 views, without convex borders. A developing asymmetry (growth over time) however requires biopsy
78
TRUE or FALSE
A breast lesion limited to the dermis and hypodermis can be confidently diagnosed as benign
FALSE
A lesion limited to the echogenic dermis can be confidently diagnosed as benign (epidermal inclusion or sebaceous cyst), but if the hypodermis is involved, then the DDx is wider and includes malignancy.
79
On US, what 2 clues allow you to determine that a lesion is localization in the dermis and therefore benign?
Two clues can be helpful to establish dermal origin:
1) Visualization of a claw of dermal tissue wrapping around the lesion.
2) Visualization of a tract connecting the lesion to the epidermal skin surface.
80
What anatomic structures are located in the mammary zone?
The mammary zone is the site of most breast pathology, and includes ducts and terminal ductal lobular units (TDLUs), fat, fibrous tissue, and Cooper’s ligaments.
81
What are the terms used according to the BIRADS lexicon to describe the shape of a mass on ultrasound?
Oval
Round
Irregular
82
Why is a non-parallel breast mass on US suspicious for malignancy?
Malignant lesions have a propensity to violate tissue planes, which are oriented longitudinally in the breast, therefore a mass that is taller than wide is suspicious for malignancy.
83
What are the terms used according to the BIRADS lexicon to describe the margins of a mass on ultrasound?
Circumscribed
Indistinct: No clear boundary between the mass and its surrounding tissue.
Angular: Featuring sharp corners.
Microlobulated: Serrated appearance of the margins.
Spiculated: Linear projections emanating from the mass.
84
On breast US, the echogenicity of a mass is determined in comparison to what tissue?
Surrounding breast fat
85
When assessing a breast lesion on US according to BIRADS, what should be described?
```
Size
Position
Orientation
Margin
Internal echo pattern
Lesion boundary
Posterior acoustic features
```
86
What is diabetic mastopathy?
Diabetic mastopathy is a sequela of long-term insulin-dependent diabetes. An autoimmune reaction to matrix proteins from chronic hyperglycemia causes a firm and sometimes painful mass.
Requires biopsy because imaging appearance mimics breast cancer
87
What is Mondor disease?
Mondor disease is thrombophlebitis of a superficial vein of the breast, most commonly the thoracoepigastric vein.
88
What is the characteristic ultrasound finding of diabetic mastopathy?
Irregular hypoechoic masses with marked posterior acoustic shadowing.
Sometimes sonographic features can mimic more sinister pathology such as breast malignancy
89
What is the age range for screening mammography?
50-69 years
90
What is the risk of malignancy from BIRADS 3 to 5?
```
BIRADS 3 <2%
BIRADS 4A 2-10%
BIRADS 4B 10-50%
BIRADS 4C 50-95%
BIRADS 5 >95%
```
91
TRUE OR FALSE
BIRADS 0 is only appropriate for screening studies
TRUE
All diagnostic studies must conclude with BIRADS 1-6 result.
92
TRUE OR FALSE
BIRADS 3 can be appropriate for screening studies
FALSE
It is necessary to conduct a complete diagnostic imaging evaluation using diagnostic views and/or ultrasound before assigning a probably benign (Category 3) assessment. Category 3 is never appropriate for screening mammography.
93
What is the usual interval period for follow up of a BIRADS 3 finding?
6 months
94
TRUE OR FALSE
All recommendations for breast interventional procedures are at least BIRADS 4
TRUE
This includes aspiration of cysts and abscesses
95
Name the categories for fibroglandular density on mammography
Almost entirely fat (<25% fibroglandular)
Scattered fibroglandular density (<25-50%)
Heterogeneous fibroglandular density (50-75%)
Extremely dense (>75%)
96
What is the relative risk of breast cancer of a woman with extremely dense breasts compared to a woman with almost entirely fatty breasts?
A woman with extremely dense breasts has a 5x relative risk of breast cancer compared to a woman with almost entirely fatty breasts.
97
BREAST
| A unilateral increase in fibroglandular density is worrisome for what underlying process?
A unilateral increase in fibroglandular density is worrisome for lymphatic obstruction, which may be malignant.
98
BREAST
| Name causes of bilateral increasing fibroglandular density
Bilateral interval increase in fibroglandular density is usually benign and may be caused either by hormonal effects or breast edema.
```
Edema from systemic causes such as CHF
Hormone therapy
Pregnancy
Lactation
Weight loss
```
99
```
BREAST
Name benign (5) causes of skin thickening
```
BENIGN:
Radiation therapy
Acute mastitis
CHF (fluid overload)
Renal failure (fluid overload 2nd protein wasting)
Liver failure (fluid overload 2nd hypoalbuminemia)
100
```
BREAST
Name malignant (3) causes of skin thickening
```
Inflammatory carcinoma
Locally advanced carcinoma
Lymphatic obstruction from axillary lymphadenopathy
101
According to BIRADS lexicon, what is the difference between mass and asymmetry on mammography?
A mammographic mass is a space-occupying lesion with convex borders seen in two different projections.
An asymmetry is seen in one view only.
102
According to BIRADS lexicon, what terms should be used to describe the margins of a mammographic mass?
```
Circumscribed
Microlobulated
Obscured
Indistinct
Spiculated
```
103
BREAST
| What is the difference between circumscribed and obscured mass on mammography?
In a circumscribed mass, at least 75% of the margin must be well defined. In obscured, more than 25% of the margin is obscured by overlying/adjacent normal tissue.
104
BREAST
| When should you use the term obscured mass vs indistinct mass on mammography?
Obscured implies that the border is felt to be circumscribed, but obscured by overlying/adjacent normal tissue
Indistinct is used when a poorly defined margin of the mass raises concern that the lesion may be infiltrating
105
TRUE OR FALSE
A spiculated mass on mammography is malignant until proven otherwise
TRUE
106
List the BIRADS lexicon for density of a mass on mammography
Radiolucent (fat density)
low density
Equal density
High density
107
List the BIRADS lexicon for shape of a mass on mammography
Round
Oval
Lobular
Irregular
108
BREAST
Describe architectural distortion on mammography
Radiating linear densities emanating from a central point without a definite mass visible.
Architectural distortion is caused by tethering of the normal fibroglandular tissue and is highly concerning for a cancer, although there are some benign causes. If there is no history of surgery or trauma, biopsy is appropriate.
109
What mammographic calcifications are typically benign according to BIRADS classification? (9)
```
Skin calcifications
Vascular calcifications
Coarse/popcorn calcifications
Large rod-like calcifications
Milk of calcium calcifications
Sutural calcifications (surgical suture)
Dystrophic calcifications
Round calcifications
Rim calcifications
```
110
BREAST
| What imaging study should be performed to confirm the presence of skin calcifications?
Mammogram with tangential view. A BB marker is should be placed over the calcifications, and on tangential view they will be seen in the dermis immediately deep to the BB.
111
BREAST
| What is the sequence of calcification within a fibroadenoma (involuting)?
Starts as peripheral calcification and progresses to chunky popcorn-like appearance
112
BREAST
| How do you confirm the presence of milk of calcium calcifications?
By performing both CC and lateral views, the calcium particles will change shape from one view to the next because they represent floating calcium in tiny benign cysts.
113
BREAST
| Name potential etiologies of dytrophic calcifications
Associated with fat necrosis. May occur as sequela of:
Surgery
Biopsy
Trauma
Irradiation
114
According to BIRADS, what distribution of calcification on mammography is usually benign?
Diffuse
| Regional
115
BREAST
On mammogram, punctate and amorphous calcifications in a diffuse or scattered distribution are typically associated with what pathology? (2)
Usually benign, often bilateral
Fibrocystic change
Sclerosing adenosis
116
BREAST
| Describe regional calcifications
Regional calcifications are distributed in a large volume (>2 cc) of breast tissue not conforming to a ductal distribution. Involves most of a quadrant or more than a single quadrant.
117
What are the ultrasound features of a malignant breast mass?
* Spiculated margins, which is the most specific sign of malignancy.
* Non-parallel (taller-than-wide) orientation, the second most specific sign.
* Angular or microlobulated margins.
* Posterior shadowing.
* Markedly hypoechoic echotexture.
* Associated calcifications (visible on sonography as echogenic foci).
* Lesion boundary with wide zone of transition.
118
On breast ultrasound, what are the 2 most specific signs of malignancy?
Spiculated margins
| Taller than wide (non-parallel orientation)
119
What are the ultrasound features of a benign breast mass?
Lack of any malignant findings: If even a single malignant feature is present then a lesion is indeterminate or suspicious and should be biopsied
• Marked hyperechogenicity (relative to fat)
• Circumscribed margins
• Parallel orientation to the skin (wider-than-tall; width:height >1.4)
• Ellipsoid shape
• Few gentle macrolobulations
• Thin echogenic pseudocapsule.
120
TRUE OR FALSE
Posterior acoustic enhancement is an indeterminate feature on breast ultrasound and does not help differentiate benign from malignant masses
TRUE
The indeterminate features on breast ultrasound are the following:
Lesion size
Iso- or mild hypoechogenicity
Posterior acoustic enhancement
Heterogeneous or homogeneous texture
121
How can you differentiate a lipoma from an oil cyst (post fat necrosis) on mammogram?
Although they are both radiolucent masses with thin rims, a lipoma will not have calcification of its wall, whereas that is a typical feature of an oil cyst.
122
TRUE OR FALSE
All fat containing circumscribed breast masses are benign
TRUE. If there is macroscopic fat, it is a BIRADS2 lesion.
123
What are the mammographic features of a hamartoma?
"Breast within a breast"
Well circumscribed heterogeneous round/oval mass containing fat and glandular tissue with a thin pseudocapsule.
124
What are the mammography/US findings of a galactocele?
MAMMOGRAM:
Well circumscribed macrolobulated mass with variable heterogeneous appearance (hypo and hyperdense components of varying degrees).
On the true lateral view, a fat-fluid level may be seen (very specific).
ULTRASOUND:
Also variable. Appears as a cyst-like mass, with cystic/multicystic, mixed solid/cystic or completely solid appearance.
125
What is the typical quadrant of an intra-mammary lymph node?
The vast majority are in the upper outer quadrant. If a lesion that looks like an intra-mammary lymph node is located in the medial aspect of the breast, it should be carefully evaluated for suspicious features.
126
What is the age range of fibroadenoma of the breast?
They usually occur in women between the ages of 10 and 40 years. It is the most common breast mass in the adolescent and young adult population. Their peak incidence is between 25 and 40 years. Incidence decreases after 40 years.
127
What ultrasound features, when met, allow you to classify a presumed fibroadenoma as BIRADS 3?
Ovoid shape, parallel orientation with an width to height ratio of >1.4 (wider-than-tall).
All margins circumscribed.
Not highly hypoechoic.
Core Radiology
128
What is a complex fibroadenoma?
A complex fibroadenoma contains proliferative elements and internal cysts, and confers a slightly
increased risk of breast cancer.
129
What is the size criteria for giant fibroadenoma?
>8cm
130
What is the typical age range of an intraductal papilloma?
30-50 years
131
What is the most common cause of pathologic nipple discharge?
intraductal papilloma
However DCIS can also present with bloody nipple discharge
132
Typically mammographic and ultrasound features of intraductal papilloma?
MAMMOGRAM
Round or oval
Circumscribed
usually in subareolar region
ULTRASOUND
Solid round or oval mass
Can be seen within a dilated fluid filled duct
133
What malignancy can appear identical to intraductal papilloma on imaging?
papillary carcinoma
134
What is PASH?
Pseudoangiomatous stromal hyperplasia (PASH) is a rare benign breast disease composed of stromal and epithelial proliferation, thought to be under hormonal control.
135
What rapidly growing mass can look identical to fibroadenoma on imaging?
Phyllodes tumor
136
TRUE OR FALSE
The majority of Phyllodes tumors are benign
TRUE
25% are malignant
137
What is the management of phyllodes tumors? Why?
Wide surgical excision
Imaging cannot differentiate benign from malignant phyllodes tumor. Incomplete excision leads to recurrence.
138
What are the most commonly encountered breast masses during pregnancy and lactation?
Galactocele - most common benign breast mass in lactating patient
Fibroadenoma - usually present prior, but increases due to hormonal effects.
Lactating adenoma - most commonly third trimester
Intraductal papilloma - bloody nipple discharge, can also be caused by intraductal carcinoma
139
TRUE OR FALSE
Multiple intraductal papillomas confer an increased risk of breast cancer
TRUE
140
What is steatocystoma multiplex?
Steatocystoma multiplex is a rare, autosomal dominant disease of multiple intradermal oil cysts.
They usually appear during adolescence and progress with age.
Can appear anywhere in the body. When the skin over the breasts is involved, mammography shows innumerable fat-density masses.
141
When a new complicated breast cyst is identified, what is the birads score and management?
They are classified as either BIRADS 3 or BIRADS 4A, requiring followup or aspiration.
142
According to BIRADS criteria, when should you give the diagnosis of "complicated cyst"?
Complicated cysts contain debris, which often manifest as homogeneous, low-level echoes. There is no discrete solid component, and the cyst has an imperceptible wall.
The echoes visible within a complicated cyst should be homogeneously low-level echoes throughout, with no mural nodules, thick septa, thick walls, or any other suggestion of a solid component.
143
How should you describe a cyst with thick septations on breast ultrasound?
complex cystic and solid mass
Complex cystic and solid masses include those with a thick wall, thick septations, intracystic or mural mass, and predominantly solid masses with cystic spaces
144
What are the malignant causes of a complex cystic and solid breast mass?
Intracystic carcinoma
Intracystic papilloma
Cystic phyllodes tumor
Solid cancer with central necrosis
145
What are the benign causes of a complex cystic and solid breast mass?
```
Hematoma
Abscess
Fat necrosis
Galactocele
Benign cyst with adherent debris
```
146
What is the BIRADS category for clustered microcysts?
BIRADS 2 when clearly composed of simple cysts and non-palpable.
If these criteria are not met, BIRADS 3 is appropriate.
147
TRUE OR FALSE
Calcifications are often present in invasive ductal carcinoma, whereas they are rare in invasive lobular carcinoma
TRUE
pleomorphic or fine linear branching calcifications are often present in invasive ductal carcinoma, whereas the presence of internal calcifications is rare in invasive lobular carcinoma.
148
Between invasive ductal carcinoma and invasive lobular carcinoma, which is more like to be multifocal?
Invasive lobular carcinoma is more likely to be multifocal or bilateral than invasive ductal carcinoma.@
149
Which type of breast cancer is known to progress very slowly?
tubular carcinoma, can be stable across multiple mammograms.
150
What is diabetic mastopathy?
Diabetic mastopathy is a condition characterized by the presence of benign tumour like breast masses in women with long-standing type 1 or type 2 insulin-dependent diabetes. The condition has also been reported in men.
151
What are the imaging findings of diabetic mastopathy?
The most common mammographic findings are ill-defined masses or asymmetric densities. Such lesions are often masked by dense glandular tissue, making mammographic evaluation difficult.
Ultrasound often reveals the most characteristic imaging findings of the disease: irregular hypoechoic masses with marked posterior acoustic shadowing. Sometimes sonographic features can mimic more sinister pathology such as breast malignancy.
152
What are the sonographic features suspicious for axillary lymph node metastasis (breast cancer)
```
Round shape
thickened cortex (>3mm)
Eccentrically thickened cortex
Focal outward cortical bulge
Hilar indentation/obliteration of the hilum
```
153
Most common type of primary lymphoma of the breast?
Diffuse large B-cell lymphoma
154
What are the MRI features of invasive ductal carcinoma of the breast?
T1
isointense to parenchyma
hypointense to fat
T2
iso to hypointense to parenchyma
hyperintense edematous zone
T1 C+ (Gd)
ring enhacement with centripetal progression
dilated veins draining the tumor
155
Which primary breast carcinoma is typically T2 hyperintense?
mucinous carcinoma, rare.
156
What is the BIRADS definition of a mass on mammogram?
A mass is 3-dimensional and occupies space. It is seen on two different mammographic projections. It has completely or partially convex-outward borders and (when radiodense) appears denser in the center than at the periphery.
157
According to BIRADS lexicon, define global asymmetry on mammogram
Global asymmetry is a real finding (visible on two different mammographic projections), involving a large portion of the breast that is defined as at least a quadrant.
158
What is the BIRADS classification of global asymmetry?
In the absence of a palpable correlate, global asymmetry usually is a normal variant or due to contralateral excision of a large volume of dense fibroglandular tissue and is assessed as benign (BI-RADS category 2) with a recommendation for routine
screening.
159
According to BIRADS lexicon, define focal asymmetry on mammogram
An abnormality on 2 views without a clear 3 dimensional appearance (concave contours). A focal asymmetry differs from global asymmetry only in the volume of the breast involved, occupying less than a quadrant.
160
BIRADS classification of a focal asymmetry?
BIRADS 3
Focal asymmetry is of more concern than global asymmetry because a small focal asymmetry may be nonpalpable yet malignant.
There is a 0.5%–1% likelihood of malignancy for a solitary focal asymmetry identified at screening, with no associated architectural distortion, microcalcifications, or underlying mass identified at subsequent diagnostic mammography and US.
161
What is BIRADS classification of a developping asymmetry?
BIRADS 4
If no history of surgery, trauma or infection at the site of the finding, needs to be further assessed.
Unless charcteristically benign on further workup, requires tissue diagnosis.
162
What is the characteristic location and appearance of the sternalis muscle on mammography?
It is either triangular or rounded in shape and seen only on the CC view medially at far-posterior depth. It is more commonly unilateral
163
What degree of enhancement differentiates persistent from plateau kinectics in the delayed phase on breast MR?
A type I (persistent) curve shows continuously increasing (>10%) enhancement in the delayed phase.
A type II (plateau) curve has an early rise in enhancement, but levels off (within 10%) in the delayed phase
164
TRUE OR FALSE
On breast MR, type II kinetic curve is more suspicious than type 1
TRUE
Type 1 curve is benign in 83% of cases, type 2 curve is benign in 64-77% of cases.
165
What is the PPV of type 3 kinetic curve on breast MR for malignancy?
87-92%
166
TRUE OR FALSE
Most breast malignancies show type 3 kinetic curve on breast MR?
FALSE. Type 3 curve is seen in 21% of malignant lesions.
167
What benign lesions can show washout kinetics (type 3) on breast MR?
lymph nodes
adenosis
papillomas
168
What is the BIRADS definition of a mass on MR?
A mass is defined as a space-occupying lesion that displaces normal breast parenchyma, with convex borders.
169
What is the most predictive MRI imaging feature for breast malignancy?
Evaluation of the margin of an enhancing mass is the most predictive MRI imaging feature.
Margins are: smooth, irregular, spiculated
170
What are the BIRADS terms to describe the enhancement pattern of a breast mass on MRI?
Homogeneous
Heterogeneous
Rim enhancement
Dark internal septations
171
On breast MR, dark internal septations are highly specific for which pathology?
Fibroadenoma (>95% PPV)
172
What is the most suspicious enhancement pattern of a mass on breast MRI?
enhancing internal septations, PPV for malignancy >95%
173
According to BIRADS lexicon, what are the terms used for distribution of non mass-like enhancement on breast MRI?
```
Focal
Linear
Segmental
Regional
Multiple regions
Diffuse
```
174
According to BIRADS lexicon, what are the terms used for enhancement pattern of non mass-like enhancement on breast MRI?
Homogeneous
Heterogeneous
Clustered ring
Clumped
175
What is the difference between an intracapsular and extracapsular breast implant rupture?
A breast implant has an implant wall and a surrounding fibrous capsule. An intracapsular rupture involves the implant wall but is limited within the fibrous capsule, whereas an extracapsular rupture extends beyond the fibrous capsule.
176
BREAST
Describe the linguine sign
Finding in intracapsular silicone breast implant rupture. It describes the fragmented elastomer shell that is freely floating within the silicone contained within the fibrous capsule.
177
TRUE OR FALSE
A benign breast mass in a male is very rare
TRUE
Any breast mass in a male should be regarded with suspicion (even if round and circumscribed).
178
What is the preferred needle size for ultrasound guided core needle biopsy of a breast mass?
14 gauge
179
What is the preferred needle size for ultrasound guided aspiration of a breast cyst?
18-20 gauge needle
180
TRUE OR FALSE
Routine aspirine or clopidogrel use is not a contraindication for stereotactic guided biopsy of the breast
TRUE
181
What is the reported reduction of breast cancer mortality associated with routine screening?
30% according to the Swedish Two-County trial (130k women over 25 years)
182
What is the lifetime risk of breast cancer in a patient with atypical ductal hyperplasia?
4x relative risk of developping breast cancer.
| 25-30% risk of breast cancer over 25 years post-biopsy (cleveland clinic)
183
What lifetime risk % of breast cancer is an indication for mammography + breast MRI screening?
20+%
184
By what degree (odds ratio) does the presence of dense breasts increase the risk of breast cancer in comparison to mostly fatty breasts?
the risk of breast cancer is four times higher in dense breasts.
