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GU > Breast > Flashcards

Breast Flashcards

1
Q

Asymmetric breast should make you think of ….

A

Shrinking breast of invasive lobular breast cancer.

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2
Q

Major blood supply and lymphatics of breast

A

Internal mammary , the rest goes to the lateral thoracic and intercostal perforator. Nearly all 97% of lymph drains to axilla, the remaining goes to the internal mammary nodes.

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3
Q

Axillary lymph node level

A

Level 1: Lateral to pec minor Level 2: Under Pec Minor Level 3: medial to Pec Minor Rotter node: between pec major and minor

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4
Q

Sternalis muscle

A

Non functional muscle next to the sternum, can stimulate a mass. It is only seen on CC view and never on MLO

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5
Q

Most common location for ectopic breast tissue

A

Axilla and inframammary fold.

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6
Q

Breast changes during HRT:

A

Breast gets more dense- breast pain may occur. Fibroadenoma may grow.

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7
Q

Breast changes during: Follicular phase: Day 7-14 Luteal phase: Day 15-30

A

Follicular phase: Oestrogen dominant- best time to have mammo and MRI Luteal phase: Progesterone dominant- breast tenderness. Increased breast density.

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8
Q

Breast changes during: Menopause Perimenopause

A

Menopause: Lobules go down. Ecstatic ducts.Popcorn calcification of fibroadenoma. Perimenopause: Shortening of follicular phase - less oestrogen and more progesterone: more breast pain, more fibrocystic change, more cyst formation.

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9
Q

Breast changes during pregnancy

A

Tubes and ducts proliferate. Breast gets denser- more hypo echoic on USS.

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10
Q

Most cancers start in…

A

TDLU: terminal duct lobule unit

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11
Q

Mammography and breast MRI IS BEST PERFORMED IN…. phase

A

Follicular phase ( day 7-14)

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12
Q

Fibroadenomas will degenerate in menopause with … calcification

A

POPCORN

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13
Q

Galactocele

A

benign fat containing lesion. Usually seen on cessation of lactation. Location: subareolar FAT- FLUID level.

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14
Q

mets to internal mammary nodes are uncommon- it is seen in which type of cancer?

A

seen in medial cancers

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15
Q

When to get LMO view of breast?

A

Kyphosis Pectus excavatum To avoid medial pacemaker/central line.

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16
Q

When using spot compression views: - Collimator open: - Small paddle : - Large paddle:

A

Collimator open: large FOV. Small paddle : better focal compression. Large paddle: Good visualisation of land marks.

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17
Q

Which views are obtained when using magnification views?

A

CC and ML ( true lateral) ML as opposed to MLO to help catch milk of calcium.

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18
Q

Name the artefacts: Coopers too thick for normal skin.

A

Blur artefact Thick coopers ligament: - Is the skin thickened? oedema - Is the skin normal? Blur artefact

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19
Q

When would you see blur artefact?

A
  1. Patient moved 2. Exposure too long 3. Exposure was too short
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20
Q

When would you NOT use grid in mammography?

A

No grid on magnified view.

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21
Q

Re localising a lesion: A lesion that is medial on CC will become more…. on MLO and even more … on ML

A

A lesion that is medial on CC will become more SUPERIOR on MLO and even more SUPERIOR on ML. M for Muffin RISE

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22
Q

Re localising a lesion: A lesion that is lateral on CC will become more…. on MLO and even more … on ML

A

A lesion that is lateral on CC will become more INFERIOR on MLO and even more INFERIOR on ML L for Lead SINKS

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23
Q

Localising lesion only seen on CC view: What would you do?

A

Rolled CC view.

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24
Q

How would you interpret rolled CC view?

A

Superior tumours move in the same direction you ROLL. Inferior tumours move in the opposite direction you ROLL. Superior mass on CC –(roll medial)–> moves the cancer medially Superior mass –(roll lateral)–> moves lateral Inferior mass –(roll medial)–> Moves lateral Inferior mass– (roll lateral)–> Moves medial

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25
Q

Name the calcification: anywhere women sweat- they are groped like a bear. They stay in the same place on CC and MLO view- TATTOO sign What would you do to confirm your diagnoses?

A

Dermal calcification You would do a tangential view.

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26
Q

Big calcification towards the nipple. Usually bilateral. BUZZWORD: - cigar shaped with lucent centre or - Dashes but no dots. 10-20 years after menopause

A

Secretory calcfication

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27
Q

Egg shell calcification

A

fat necrosis from any trauma- if they are big: liponecrosis macrocystica

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28
Q

Irregular in shape calcification with lucent centre

A

dystrophic calcification after radiation, trauma, or surgery

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29
Q
  1. What is milk of calcium? 2. What is it due to?
A
  1. On CC: powdery and spread out calcification On MLO they may layer- on ML: tea cup appearance 2. It is fluid-fluid in a lobule- due to fibrocystic change.
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30
Q

How is milk of calcium viewed?

A

with polarised light to assess birefringence

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31
Q

Ddx amorphous Ca

A

Fibrocystic change- most likely Sclerosing adenosis Columnar cell change DCIS- low grade

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32
Q

Ddx coarse heterogenous Ca: (4)

A

FIBROADENOMA PAPILLOMA FIBROCYSTIC CHANGE DCIS- LOW-INTERMEDIATE GRADE

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33
Q

Ddx Fine pleomorphic Ca Countable, sharp tip, < 0.5mm, different shapes and sizes

A

Fibroadenoma Papilloma Fibrocystic change DCIS- High grade

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34
Q

Fine linear branching Ca

A

DCIS or atypical look for secretory calc or vascular calcs

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35
Q

Puff of smoke or warning shot sign?

A

calcification associated with focal asymmetry/mass

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36
Q

What is the diagnosis? thromboses vein presenting as a tender palpable cord.

A

Mondor disease- You don’t anticoagulant for it, its not a DVT. Treatment: NSAID and warm compresses.

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37
Q

BUZZWORD for breast hamartoma

A

Breast within breast on mammo Difficult to see on USS

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38
Q

Breast lipoma

A

radiolucent with no calcification. Enlargement of a lipoma is criteria for biopsy.

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39
Q

Pseudoangiomatous Stromal Hyperplasia- PASH

A

Benign myofibroblastic hyper plastic process. Usually big, oval shaped with well defined borders. Annual F/U is the recommendation

40
Q

Phyllodes

A

10% risk of malignant degeneration- They can mets to lung and bone (haematogenous mets)

It is typically a large, fast growing mass that forms from the periductal stroma of the breast.

Leaflike pattern of growth.

41
Q

Distinguishing features of phyllodes tumour:

A
  • Rapid growth
  • Haematogenous mets
  • Middle aged to older women
  • Mimics fibroadenoma.

Leaflike pattern of growth.

42
Q

Majority of Male breast cancer is of this type:

A

Invasive ductal carcinoma- IDC. This is usually retroareolar and hyperdense on mammography with irregular margins. Secondary features such as nipple retraction and skin thickening usually present.

43
Q

IDC subtypes:

A
  1. Mucinous 2. Tubular 3. Medullary 4. Papillary
44
Q

This types of IDC is associate with BRCA1 mutation.

A

Medullary: 25% will have BRCA 1 mutation Axillary nodes can be large even in the absence of mets.

45
Q

This type of IDC is associated with a radial scar. The contralateral breast will have cancer 10-15% of the time

A

Tubular IDC

46
Q

This type of IDC is complex cystic and solid

A

Papillary IDC

47
Q

Multifocal vs multi centric breast cancer:

A

Multifocal : Multiple primary in the same quadrant Multi centric breast cancer: Multiple primaries in different quadrant

48
Q

When would the risk of bilateral disease is increased?

A

It is increased in infiltrating lobular types and multi centric types.

49
Q

What is the diagnoses? On USS: Microlobulated mildly hypo echoic mass with ductal extension and normal acoustic transmission

A

DCIS

50
Q

Typical features of DCIS (3)

A
  1. Suspicious calcification- fine linear and fine pleomorphic 2. Non mass like enhancement on MRI 3. Multiple intraductal masses on galactography
51
Q

What is the diagnosis? Architectural distortion without a central mass on CC view ONLY- dark star

A

ILC- Invasive lobular carcinoma.

52
Q

BUZZWORD for ILC (2)

A

Shrinking breast Dark star Shadowing without a mass

53
Q

Ddx for dark star

A

ILC- Lobular carcinoma Radial scar Surgical scar IDC NOS

54
Q

ILC vs IDC

A

ILC : often multifocal- and bilateral ( up to 1/3 are bilateral) Less often mets to axilla- but likes funny places like peritoneal surfaces. More often has +ve margin and more often treated with mastectomies. Similar prognosis.

55
Q

ILC MRI curve

A

Washout is less common than with IDC

56
Q

What is the diagnosis? Skin thickening on mammography, Swollen red breast

A

Inflammatory breast cancer- mastectomy is done for local control. The inflammation can get better with antibiotics , but do NOT be fooled. A dermal biopsy is needed.

57
Q

What is breast Pagets disease? What is it associated with? Next step?

A
  • This is carcinoma in situ of the nipple epidermis. - This is associated with high grade DCIS - Wedge biopsy on any skin lesion that affects the nipple areolar complex that does not resolve with topical therapy - Pagets is NOT considered T4. The skin involvement does not up the stage in this setting.
58
Q

Tubular IDC and DCIS are associated with this high risk lesion

A

Radial scar- Associated with DCIS +/- IDC 10-30% and tubular carcinoma

59
Q

ADH- Atypical Ductal Hyperplasia

A

This is DCIS but lacks the quantitative definition by histology < 2 ducts involved

60
Q

Lobular carcinoma in situ - LCIS

A

BUZZWORD: incidental finding. can be a precursor to ILC

61
Q

Atypical Lobular Hyperplasia- ALH

A

Similar to LCIS LCIS: lobule distention with ALH you don’t

62
Q

Lesion? Intraductal mass , may present with blood discharge. Classic location subareolar region. Dilated duct and filling defects on galactography

A

Papilloma

63
Q

Staging trivia:

A

Level 1 and 2 are treated the same. Rotter nodes are treated as level 2. Level 3 and supraclavicular nodes are treated the same.

64
Q

How would the LN of a Pt with rheumatoid arthritis treated with chrysotherapy look like?

A

Gold therapy: Very dense calcification within the nodes.

65
Q

Name the condition: Snow storm node

A

Silicone infiltration from either leakage or rupture

66
Q

Conditions causing gynaecomastia

A

Spironolactone Psych meds Marijuana Alcoholic cirrhosis Testicular cancer.

67
Q

What are the three patterns of gynaecomastia?

A
  1. Nodular- most common type 2. Dendritic- branching tree 3. Diffuse glandular- looks like women’s breast
68
Q

What are the typical appearances of nodular gynaecomastia?

A

Flame shaped, behind nipple, bilateral but asymmetrical. Can be painful.

69
Q

Define pseuodogynaecomastia:

A

This is increase in fat tissue of the breast and not the glandular tissue.

70
Q

Re Male breast cancer: - Mutations? - RF? Most common type?

A
  • BRCA 2 mutation - RF: Klinefelter syndrome Cirrhosis Chronic alcoholism - Most common type IDC NOS
71
Q

Rupture implant signs on: - USS - MRI, what sequence would you use?

A

USS: snow storm sign for extra capsular rupture and step ladder for intra-capsular rupture. MRI: Linguini sign (intra-capsular). Sequence FS T2 T1 dark and T2 bright

72
Q

Implant locations:

A
  1. Subglandular: anterior to pectoral muscle, behind breast tissue 2. Subpectoral: between pectorals major and minor.
73
Q

How can you tell an implant is saline based?

A

You can see through them on mammo

74
Q

Fat necrosis on MRI

A

T1 and T2 bright, fat sat drops its out.

On mammo:

Typically seen as a radiolucent rounded mass of fat density +/- wall calcification, which if present typically appears as eggshell calcification. Lesions are usually well circumscribed with a thin capsule. Rarely, fat-fluid levels may be present.

75
Q

Staging:

A

T1: < 2cm T2: 2-5 cm T3: > 5 cm T4: Any size witchiest wall fixation, skin involvement or inflammatory breast cancer. Remember Paget is not T4

76
Q

Most common cancer to metastasise to breast

A

melanoma

77
Q

Contraindication for breast conservation

A

Inflammatory cancer Large cancer size, relative to breast Multi centric Prior radiation to the same breast Contraindication to radiation therapy eg collagen vascular disease

78
Q

Indications for Breast MRI: (5)

A
  1. High risk screening
  2. extent of disease- known cancer
  3. axillary mets with unknown primary
  4. diagnostic dilemma
  5. Implant rupture
79
Q

Ddx for T2 benign bright masses:

A
  1. Cyst
  2. Fibroadenoma
  3. Lymph node
  4. Fat necrosis
80
Q

Ddx for T2 malignant bright masses:

A
  1. Colloid and
  2. mucinous cancers
81
Q

What does tamoxifen do to parenchymal enhancement?

A

It will decrease background parenchyma uptake and then it causes rebound.

82
Q

which type of cancer is more suspicious for cancer?

A

Type 3, with rapid washout.

83
Q

Re fibroadenoma Which kinetic curve?

A

Type 1 carve with persistent uptake. T2 bright round with non enhancing septa

84
Q

Re IDC Which type of curve?

A

Type 3 with rapid washout

85
Q

Oestrogen related risk of breast cancer:

A

More exposure to oestrogen increases the risk of breast cancer: - Early menarche and late menopause - HRT - Obesity - Alcohol - Late age of first pregnancy

86
Q

20Gy of radiation to chest wall when your are a child, buys you annual MRI screening at …….

A

25 years old or 8 years after exposure, whichever is longer

87
Q

BRCA1 and BRCA2

A

BRCA1: Chromes 17, more common in female BRCA2: Chromosome 13: More common in men. Both cause Breast, ovaries and GI cancers

88
Q

Li Fraumeni

A

P53 does not work- rare cancers

89
Q

Cowdens syndrome

A
  1. Bowel hamartoma
  2. Follicular thyroid cancer
  3. Lhermitte Duclos
  4. Breast cancer
90
Q

Bannayan Riley Ruvalcaba

A

Associated with developmental disorders at a young age.

91
Q

10% risk of malignant degeneration- They can mets to lung and bone (haematogenous mets)

It is typically a large, fast growing mass that forms from the periductal stroma of the breast.

Leaflike pattern of growth.

A

Phyllodes

92
Q

In this condition the risk of male breast cancer increases by 20 fold

A

Kleinfelters - XXY

93
Q

Mammography:

Focal spot?

Grids?

Compression benefits?

A
  • High SR to detect microcalcification.
  • Short exposure time to reduce movement artefact
  • Small focal spot: 0.1 and 0.3 mm
  • Grids are used to reduce scatter and increase contrast
  • Low molybdenum provide high contrast
  • Breast compression:
    • reduces geometric and movement unsharpness
    • improves contrast and radiation dose.
94
Q

In mammography, magnification views are used been and what projections? And what is the purpose?

A

It is performed in CC and lateral projections

They integrate areas of microcalcification and they can show teacups with benign calcification

95
Q

…. may be seen as a well-defined solid nodule or intraductal mass which may either fill a duct or be partially outlined by fluid - either within a duct or by forming a cyst. Colour Doppler will demonstrate a vascular stalk.

A dilated duct can be frequently visible sonographically.

A

Papilloma

96
Q

This condition is associated with multiple hamartoma

A

Cowden syndrome: associated with multiple hamartomas

97
Q

Radial scar (sclerosing ductal hyperplasia) is a mimicker of ….

A

scirrhous breast carcinoma.

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