Breast Flashcards
Asymmetric breast should make you think of ….
Shrinking breast of invasive lobular breast cancer.
Major blood supply and lymphatics of breast
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.
Axillary lymph node level
Level 1: Lateral to pec minor Level 2: Under Pec Minor Level 3: medial to Pec Minor Rotter node: between pec major and minor
Sternalis muscle
Non functional muscle next to the sternum, can stimulate a mass. It is only seen on CC view and never on MLO
Most common location for ectopic breast tissue
Axilla and inframammary fold.
Breast changes during HRT:
Breast gets more dense- breast pain may occur. Fibroadenoma may grow.
Breast changes during: Follicular phase: Day 7-14 Luteal phase: Day 15-30
Follicular phase: Oestrogen dominant- best time to have mammo and MRI Luteal phase: Progesterone dominant- breast tenderness. Increased breast density.
Breast changes during: Menopause Perimenopause
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.
Breast changes during pregnancy
Tubes and ducts proliferate. Breast gets denser- more hypo echoic on USS.
Most cancers start in…
TDLU: terminal duct lobule unit
Mammography and breast MRI IS BEST PERFORMED IN…. phase
Follicular phase ( day 7-14)
Fibroadenomas will degenerate in menopause with … calcification
POPCORN
Galactocele
benign fat containing lesion. Usually seen on cessation of lactation. Location: subareolar FAT- FLUID level.
mets to internal mammary nodes are uncommon- it is seen in which type of cancer?
seen in medial cancers
When to get LMO view of breast?
Kyphosis Pectus excavatum To avoid medial pacemaker/central line.
When using spot compression views: - Collimator open: - Small paddle : - Large paddle:
Collimator open: large FOV. Small paddle : better focal compression. Large paddle: Good visualisation of land marks.
Which views are obtained when using magnification views?
CC and ML ( true lateral) ML as opposed to MLO to help catch milk of calcium.
Name the artefacts: Coopers too thick for normal skin.
Blur artefact Thick coopers ligament: - Is the skin thickened? oedema - Is the skin normal? Blur artefact
When would you see blur artefact?
- Patient moved 2. Exposure too long 3. Exposure was too short
When would you NOT use grid in mammography?
No grid on magnified view.
Re localising a lesion: A lesion that is medial on CC will become more…. on MLO and even more … on ML
A lesion that is medial on CC will become more SUPERIOR on MLO and even more SUPERIOR on ML. M for Muffin RISE
Re localising a lesion: A lesion that is lateral on CC will become more…. on MLO and even more … on ML
A lesion that is lateral on CC will become more INFERIOR on MLO and even more INFERIOR on ML L for Lead SINKS
Localising lesion only seen on CC view: What would you do?
Rolled CC view.
How would you interpret rolled CC view?
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
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?
Dermal calcification You would do a tangential view.
Big calcification towards the nipple. Usually bilateral. BUZZWORD: - cigar shaped with lucent centre or - Dashes but no dots. 10-20 years after menopause
Secretory calcfication
Egg shell calcification
fat necrosis from any trauma- if they are big: liponecrosis macrocystica
Irregular in shape calcification with lucent centre
dystrophic calcification after radiation, trauma, or surgery
- What is milk of calcium? 2. What is it due to?
- 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.
How is milk of calcium viewed?
with polarised light to assess birefringence
Ddx amorphous Ca
Fibrocystic change- most likely Sclerosing adenosis Columnar cell change DCIS- low grade
Ddx coarse heterogenous Ca: (4)
FIBROADENOMA PAPILLOMA FIBROCYSTIC CHANGE DCIS- LOW-INTERMEDIATE GRADE
Ddx Fine pleomorphic Ca Countable, sharp tip, < 0.5mm, different shapes and sizes
Fibroadenoma Papilloma Fibrocystic change DCIS- High grade
Fine linear branching Ca
DCIS or atypical look for secretory calc or vascular calcs
Puff of smoke or warning shot sign?
calcification associated with focal asymmetry/mass
What is the diagnosis? thromboses vein presenting as a tender palpable cord.
Mondor disease- You don’t anticoagulant for it, its not a DVT. Treatment: NSAID and warm compresses.
BUZZWORD for breast hamartoma
Breast within breast on mammo Difficult to see on USS
Breast lipoma
radiolucent with no calcification. Enlargement of a lipoma is criteria for biopsy.
Pseudoangiomatous Stromal Hyperplasia- PASH
Benign myofibroblastic hyper plastic process. Usually big, oval shaped with well defined borders. Annual F/U is the recommendation
Phyllodes
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.
Distinguishing features of phyllodes tumour:
- Rapid growth
- Haematogenous mets
- Middle aged to older women
- Mimics fibroadenoma.
Leaflike pattern of growth.
Majority of Male breast cancer is of this type:
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.
IDC subtypes:
- Mucinous 2. Tubular 3. Medullary 4. Papillary
This types of IDC is associate with BRCA1 mutation.
Medullary: 25% will have BRCA 1 mutation Axillary nodes can be large even in the absence of mets.
This type of IDC is associated with a radial scar. The contralateral breast will have cancer 10-15% of the time
Tubular IDC
This type of IDC is complex cystic and solid
Papillary IDC
Multifocal vs multi centric breast cancer:
Multifocal : Multiple primary in the same quadrant Multi centric breast cancer: Multiple primaries in different quadrant
When would the risk of bilateral disease is increased?
It is increased in infiltrating lobular types and multi centric types.
What is the diagnoses? On USS: Microlobulated mildly hypo echoic mass with ductal extension and normal acoustic transmission
DCIS
Typical features of DCIS (3)
- Suspicious calcification- fine linear and fine pleomorphic 2. Non mass like enhancement on MRI 3. Multiple intraductal masses on galactography
What is the diagnosis? Architectural distortion without a central mass on CC view ONLY- dark star
ILC- Invasive lobular carcinoma.
BUZZWORD for ILC (2)
Shrinking breast Dark star Shadowing without a mass
Ddx for dark star
ILC- Lobular carcinoma Radial scar Surgical scar IDC NOS
ILC vs IDC
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.
ILC MRI curve
Washout is less common than with IDC
What is the diagnosis? Skin thickening on mammography, Swollen red breast
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.
What is breast Pagets disease? What is it associated with? Next step?
- 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.
Tubular IDC and DCIS are associated with this high risk lesion
Radial scar- Associated with DCIS +/- IDC 10-30% and tubular carcinoma
ADH- Atypical Ductal Hyperplasia
This is DCIS but lacks the quantitative definition by histology < 2 ducts involved
Lobular carcinoma in situ - LCIS
BUZZWORD: incidental finding. can be a precursor to ILC
Atypical Lobular Hyperplasia- ALH
Similar to LCIS LCIS: lobule distention with ALH you don’t
Lesion? Intraductal mass , may present with blood discharge. Classic location subareolar region. Dilated duct and filling defects on galactography
Papilloma
Staging trivia:
Level 1 and 2 are treated the same. Rotter nodes are treated as level 2. Level 3 and supraclavicular nodes are treated the same.
How would the LN of a Pt with rheumatoid arthritis treated with chrysotherapy look like?
Gold therapy: Very dense calcification within the nodes.
Name the condition: Snow storm node
Silicone infiltration from either leakage or rupture
Conditions causing gynaecomastia
Spironolactone Psych meds Marijuana Alcoholic cirrhosis Testicular cancer.
What are the three patterns of gynaecomastia?
- Nodular- most common type 2. Dendritic- branching tree 3. Diffuse glandular- looks like women’s breast
What are the typical appearances of nodular gynaecomastia?
Flame shaped, behind nipple, bilateral but asymmetrical. Can be painful.
Define pseuodogynaecomastia:
This is increase in fat tissue of the breast and not the glandular tissue.
Re Male breast cancer: - Mutations? - RF? Most common type?
- BRCA 2 mutation - RF: Klinefelter syndrome Cirrhosis Chronic alcoholism - Most common type IDC NOS
Rupture implant signs on: - USS - MRI, what sequence would you use?
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
Implant locations:
- Subglandular: anterior to pectoral muscle, behind breast tissue 2. Subpectoral: between pectorals major and minor.
How can you tell an implant is saline based?
You can see through them on mammo
Fat necrosis on MRI
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.
Staging:
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
Most common cancer to metastasise to breast
melanoma
Contraindication for breast conservation
Inflammatory cancer Large cancer size, relative to breast Multi centric Prior radiation to the same breast Contraindication to radiation therapy eg collagen vascular disease
Indications for Breast MRI: (5)
- High risk screening
- extent of disease- known cancer
- axillary mets with unknown primary
- diagnostic dilemma
- Implant rupture
Ddx for T2 benign bright masses:
- Cyst
- Fibroadenoma
- Lymph node
- Fat necrosis
Ddx for T2 malignant bright masses:
- Colloid and
- mucinous cancers
What does tamoxifen do to parenchymal enhancement?
It will decrease background parenchyma uptake and then it causes rebound.
which type of cancer is more suspicious for cancer?
Type 3, with rapid washout.
Re fibroadenoma Which kinetic curve?
Type 1 carve with persistent uptake. T2 bright round with non enhancing septa
Re IDC Which type of curve?
Type 3 with rapid washout
Oestrogen related risk of breast cancer:
More exposure to oestrogen increases the risk of breast cancer: - Early menarche and late menopause - HRT - Obesity - Alcohol - Late age of first pregnancy
20Gy of radiation to chest wall when your are a child, buys you annual MRI screening at …….
25 years old or 8 years after exposure, whichever is longer
BRCA1 and BRCA2
BRCA1: Chromes 17, more common in female BRCA2: Chromosome 13: More common in men. Both cause Breast, ovaries and GI cancers
Li Fraumeni
P53 does not work- rare cancers
Cowdens syndrome
- Bowel hamartoma
- Follicular thyroid cancer
- Lhermitte Duclos
- Breast cancer
Bannayan Riley Ruvalcaba
Associated with developmental disorders at a young age.
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.
Phyllodes
In this condition the risk of male breast cancer increases by 20 fold
Kleinfelters - XXY
Mammography:
Focal spot?
Grids?
Compression benefits?
- 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.
In mammography, magnification views are used been and what projections? And what is the purpose?
It is performed in CC and lateral projections
They integrate areas of microcalcification and they can show teacups with benign calcification
…. 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.
Papilloma
This condition is associated with multiple hamartoma
Cowden syndrome: associated with multiple hamartomas
Radial scar (sclerosing ductal hyperplasia) is a mimicker of ….
scirrhous breast carcinoma.
