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Breast Flashcards

1
Q

What is the sensitivity of screening mammo?

A

68-90%

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2
Q

What is the sensitivity of diagnostic mammo?

A

93%

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3
Q

When should breast US be used?

A

Adjunct imaging modality, not used for screening.

Characterization of mammo findings, first-line evaluation of breast abnormality in young (<30), pregnant, or lactating woman, guidance for intervention, and evaluation of breast implants.

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4
Q

When should MRI be used?

A

Screen in high-risk patients (greater than 20% lifetime risk of developing breast cancer), evaluation of extent of disease with newly diagnosed cancer, evaluate neoadjuvant chemotherapy response, assessment for residual disease after positive surgical margins, eval for tumor recurrence, and eval for occult breast cancer in patient with axillary metastases.

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5
Q

What is the progression of ductal breast cancer?

A

Normal - Flat Epithelial Atypia (FEA) - Atypical Ductal Hyperplasia (ADH) - DCIS - IDC

Flat epithelial atypia and atypical ductal hyperplasia are considered NON-OBLIGATORY precursor lesions = indicator of higher risk of developing breast cancer. Not obligatory precursor towards invasive cancer.

14% of FEA are upstaged to DCIS at excision
18% of ADH are upstaged.

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6
Q

Risk of developing invasive carcinoma with DCIS?

A

30-50% of patients with DCIS will develop invasive carcinoma w/in 10 years.

~43% of DCIS diagnosed by US-guided core biopsy is upstaged to invasive carcinoma upon surgical excision.

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7
Q

What are the risk factors for developing breast cancer?

A

Age and female sex are two most important.

BRCA 1 or 2
First degree relative.
Prior chest radiation
Long-term estrogen exposure - early menarche, late menopause, late first pregnancy, nulliparity, or obesity.
Prior biopsy results of high risk lesions in lobular neoplasia spectrum - including atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS)

ALH and LCIS are not surgically excised - high risk lesions in lobular neoplasia spectrum.
Arise from the TDLU, can be distributed diffusely throughout the breast and considered a marker for increased risk rather than a precursor to invasive carcinoma.

Women with LCIS have 30% risk of developing invasive cancer (usually invasive ductal), which may occur in either breast.

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8
Q

How are atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) handled?

A

ALH and LCIS are not surgically excised - high risk lesions in lobular neoplasia spectrum.
Arise from the TDLU, can be distributed diffusely throughout the breast and considered a marker for increased risk rather than a precursor to invasive carcinoma.

Women with LCIS have 30% risk of developing invasive cancer (usually invasive ductal), which may occur in either breast.

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9
Q

What is tubular carcinoma?

A

Low grade cancer - small speculated mass.

May be difficult to distinguish on path between radial scars/complex sclerosing lesions and tubular carcinoma.

Radial scar may be a precursor to tubular carcinoma.

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10
Q

What is Mucinous Carcinoma?

A

Low-density circumscribed mass that can mimic a fibroadenoma on US.

T2 hyperintense on MRI.

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11
Q

What is Medullary Carcinoma?

A

Younger women with BRCA 1, rare variant.

Locally aggressive, but better prognosis than IDC.

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12
Q

What is Pappillary Carcinoma?

A

Malignant form of intraductal papilloma.

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13
Q

What is Adenoid Cystic Carcinoma?

A

Very rare breast cancer that presents as a palpable firm mass.

Prognosis is excellent with complete resection.

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14
Q

What is Paget Disease of the Nipple?

A

DCIS that infiltrates the epidermis of the nipple

Erythema, ulceration, and eczematoid changes of the nipple.

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15
Q

What is fibrocystic change?

A

Normal pattern of breast physiology.

Cyclical breast pain - sometimes with a palpable lump. Premenopausal women

No a Dx made on imaging - can cause cysts and calcifications- can mimic DCIS

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16
Q

What is Sclerosing Adenosis?

A

Benign proliferative lesion caused by lobular hyperplasia and formation of fibrous tissue that distorts the glandular elements.

Can mimic DCIS like fibrocystic change.

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17
Q

What is Granulomatous Mastitis?

A

Idiopathic noninfectious cause of breast inflammation that occurs in young women after childbirth.

Associated with breast feeding or OCPs.

May mimic cancer - biopsy.

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18
Q

What is Periductal Mastitis?

A

Plasma cell mastitis - irritating contents of intraductal lipids.

Post-menopausal women and produces large, rod-like secretory calcifications.

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19
Q

What is Diabetic Mastopathy?

A

Sequela of long-term insulin-dependent diabetes.

Autoimmune reaction to matrix proteins from chronic hyperglycemia - causes firm and sometimes painful mass.

Ill-defined, asymmetric density w/o microcalcifications.

Hypoechoic mass or regional acoustic shadowing, mimicking the appearance of scirrhous breast cancer.

Biopsy required.

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20
Q

What is Mondor Disase?

A

Thrombophlebitis of superficial vein of the breast - MC the Thoracoepigastric vein.

Pain and tenderness with a cordlike, elongated superficial mass.

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21
Q

What is the goal of screening mammo?

A

Detect pre-clinical breast cancer in asymptomatic women.

Detects 2-8 cancers per 1,000 women screened. Mortality decreasing 2.2% per year.

Start at 40 or 10 years younger than first degree relative with breast cancer.

Stop at 70.

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22
Q

What are the indications for diagnostic mammography?

A

Annual mammo in an asymptomatic women with past history of breast cancer

Short interval f/u (following BIRADS 3 lesion)

Evaluation of an abnormality found on screening mammo.

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23
Q

What are the classifications for breast density?

A

Almost entirely fat (<25% glandular)

Scattered fibroglandular (25-50% glandular)

Heterogeneously dense (51-75%)

Extremely dense (>75%) - 5x relative risk.

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24
Q

What is BIRADS 3?

A

<2% risk of malignancy

Need to conduct a complete diagnostic evaluation using diagnostic views and/or US before assigning a probably benign (3).

NEVER APPROPRIATE FOR SCREENING

Action required: Short interval f/u - 6 months. If 2 years of stability, can be considered benign (BIRADS 2). Any interval change is suspicious and may warrant biopsy.

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25
Q

What is BIRADS 4?

A

Suspicious of malignancy (>2% and <95%)

All recommendations for breast interventional procedures must be at least BIRADS 4, including cyst or abscess aspiration.

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26
Q

Causes bilateral and unilateral interval increase in fibroglandular density

A

Bilateral - usually benign - hormonal effects or breast edema.
Edema- bilateral trabecular blurring and skin thickening.
Hormone therapy - increase in fibroglandular density w/o skin thickening. Proliferation of cysts and fibrocystic change can be seen.

Unilateral - Worrisome for lymphatic obstruction.

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27
Q

BIRADS terms for mammo margins?

A 
Circumscribed
Microlobulated
Obscured
Indistinct
Spiculated
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28
Q

What to describe mass on mammo?

A

SMD

Shape - round, oval, lobular, irregular
Margins - circumscribed, obscured, microlobulated, indistinct, speculated
Density - radiolucent, low density, equal density, high density

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29
Q

BIRADS terms for density?

A

Compared to surrounding fibroglandular tissue

Radiolucent
Low density
Equal density
High density

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30
Q

BIRADS terms for shape?

A

Round
Oval
Irregular

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31
Q

What are associated features to look for in mammo?

A

Architectural distortion - Radiating linear densities emanating from a central point w/o definite mass visible - tethering of normal fibroglandular tissue and is highly concerning for cancer.

Microcalcifications

Skin retraction

Nipple retraction - should not be confused with inversion which may be developmental, bilateral, and is not necessarily a sign of malignancy.

Trabecular thickening - thickening of the fibrous septa of the breast - edema or radiation

Axillary adenopathy- replacement of the fatty hilum

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32
Q

What are the benign calcifications (BIRADS 2)?

A 
Skin 
Vascular
Coarse or "popcorn"
Large rod-like
Milk of calcium
Sutural
Dystrophic
Round
Punctate
Lucent-centered
"Eggshell" or "rim"
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33
Q

What are the intermediate concern calcifications (BIRADS 4)?

A

Amorphouse or indistinct - too small or hazy. Diffuse scattered are usually benign. In a clustered, regional, linear, or segmental distribution are more suspicious and warrant biopsy.

Coarse Heterogeneous - Irregular calcifications larger than 0.5 mm but smaller than dystrophic calcs - may be associated with malignancy = biopsy.

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34
Q

What are the higher probability of malignancy calcifications (BIRADS 4 or 5)?

A

Fine pleomorphic - “dot-dash appearance” - vary in size and shape. Highly suspicious - MC with DCIS or IDC.

Fine linear or fine-linear branching

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35
Q

What are the distribution patterns of calcium on mammo?

A

Diffuse/scattered - usually benign. Punctate and amorphous calcs are usually benign in this distribution - fibrocystic change or sclerosing adenosis.

Regional - large volume (>2 cc) not conforming to a ductal distribution - most of a quadrant or more than a single quadrant - less likely malignancy.

Linear - suspicious for malignancy

Segmental - in a ductal system - worrisome. Can be benign if secretory (rod-like). When intermediate-suspicion (amorphous) or typically benign (such as round or punctate) in a segmental distribution - concern for malignancy.

Grouped or clustered - at least 5 small calcs in <1 cc of tissue. Suspicous for malignancy - biopsy.
Clustered = worrisome = biopsy
Grouped = BIRADS 3 and followed.

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36
Q

What to describe calcs on mammo?

A

Morphology and distribution

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37
Q

What BIRADS can be used on a screening mammo?

A

0, 1, or 2

38
Q

What situations should BIRADS 3 be used?

A

Circumscribed, benign-appearing solid mass - round, oval , or lobulated, and its margins circumscribed. Must lack suspicious calcs. Must undergo US which should also be benign - follow for 2 years.

Cluster of tiny round calcifications - must be CLUSTER

Focal asymmetry - non-palpable lesion in two projections - does not have outwardly convex margins - usually interspersed with fat. No US correlate = BIRADS 3.
Developing asymmetry is a focal asymmetry that has increased in size = suspicious = further workup.

39
Q

What does parenchymal breast fat look like on US?

A

Hypoechoic

Elsewhere in the body it is echogenic.

40
Q

What are the scanning planes in US?

A

Radial - US probe oriented longitudinally away from the nipple - scan in circle around nipple

Anti-radial - oriented transversely away from the nipple - scan longitudinally away from nipple

Transverse- Probe parallel to ground and scan cranial-caudal

Longitudinal- Probe oriented cranial-caudal and scan horizontally.

41
Q

What are the things that need to be described on US for breast lesions?

A

SOME BP

Shape
Orientation
Margins
Echogenicity
Boundary
Posterior acoustic features
42
Q

What are the shape descriptors for US?

A

Oval
Round
Irregular

43
Q

What are the margin descriptors for US?

A

Indistinct - no clear boundary b/t mass and surrounding tissue

Angular - Sharp corners

Microlobulated - Serrated appearance

Spiculated- linear projections emanating from the mass.

44
Q

What is internal echo pattern compared to on US?

A

Surrounding fat.

Anechoic - simple cyst
Hypoechoic - complicated cyst or fibroadenoma
Isoechoic
Hyperechoic
Complex - combination of internal echogenicity - such as complex mass or necrotic tumor.

45
Q

What are the lesion boundary descriptors in US?

A

Abrupt interfact - clean demarcation b/t lesion and surrounding tissue

Echogenic halo - seen in cancer or abscess.

46
Q

What are the posterior acoustic features used in US?

A

Enhancement - non-specific, simple cyst

Shadowing - associated with fibrosis, such as from a neoplastic desmoplastic reaction or surgical scar.

47
Q

What are the US features of a benign mass?

A

Cannot have a single malignant feature

Marked hyperechogenicity (relative to fat)
Circumscribed margins
Parallel orientation to the skin
Ellipsoid shape
Few gentle macrolobulations
Thin echogenic pseudocapsule
48
Q

US features of a malignant mass?

A 
Spiculated margins - most specific
Non-parallel orientation - taller than wide - 2nd most specific sign
Angular or microlobulated margins
Posterior shadowing
Markedly hypoechoic echotexture
Associated calcifications
Wide zone of transition.
49
Q

What are the indeterminate mass features on US?

A

Lesion size
Iso or mild hypoechogenicity
Posterior acoustic enhancement
Heterogeneous or homogeneous texture

50
Q

What are the BIRADS 3 US lesions?

A

Complicated cyst or clustered microcysts

Oval, hypoechoic, circumscribed, parallel mass - consistent with fibroadenoma.

51
Q

What are the fat-containing circumscribed breast lesions?

A

Hamartoma (fibroadenolipoma)- fat and glandular tissue elements - “breast w/in a breast” which displaces normal breast tissue - typically has a pseudocapsule

Galactocele- well circumscribed, macrolobulated mass containing mixed high density and fat - fat-fluid level on the lateral view.

Intramammary Lymph Node - Should be in the lateral, upper outer breast - if looks like a LN, but medially, should be evaluated and considered suspicious.

52
Q

What is a fibroadenoma?

A

Benign neoplasm in young women - MC palpable mass. Firm, mobile mass.

Mammo: oval or lobular equal density circumscribed mass - nonspecific. Hyalinizing fibroadenoma (older women) - “popcorn” calcification

US: oval, circumscribed mass with homogeneous hypoechoic echotexture. Can have suspicious features on US including irregular borders, heterogeneous internal echotexture, or shadowing, promoting biopsy.

Is benign, but often either followed (BIRADS 3) or biopsied (BIRADS 4)- depending on imaging characteristics or clinical context.

53
Q

What are the variants of fibroadenoma?

A

Complex - proliferative elements and internal cysts - slightly increased risk of breast cancer.

Juvenile - Adolescents - very rapid growth

Giant - Greater than 8 cm in size. Can appear identical to Phyllodes.

54
Q

What is an Intraductal papilloma/papillary carcinoma?

A

Benign tumor of lactiferous ducts - 30-50.

MC cause of pathologic (blood, serous, or serosanguinous) nipple discharge. Grows on a fibrovascular staok and torsion of the stalk can cause pain and bleeding.

DCIS can also present with bloody nipple discharge.

Mammo: round or oval, circumscribed or irregular mass - subareolar region. Can do galactography to show filling defect.

US: Solid round or oval mass. When causing nipple d/c, papilloma may be evident as a mass in a fluid-filled duct.

Papillomas are excised b/c papillary carcinoma may appear identical on imaging.

55
Q

What is Pseudoangiomatous Stromal Hyperplasia (PASH)?

A

Unknown etiology composed of stromal and epithelial proliferation - thought to be under hormonal control

Mammo: Ill-defined, round or oval mass. May be circumscribed.

US: hypoechoic or mixed echogenicity, oval or irregular mass.

May mimic low-grade angiosarcoma on pathology, so excisional biopsy is usually performed if diagnosed as PASH and shows interval growth.

56
Q

What can medullary and mucinous carcinoma look like?

A

Can be circumscribed round mass on mammo and hypoechoic mas on US - can mimic a benign cyst, but has internal vascularity.

57
Q

What is a Phyllodes Tumor?

A

Rapidly growing tumor - older population - 40-50.

Majority are benign, about 25% malignant, and 20% metastasize - excise.

Large, oval or lobular circumscribed mass.

US: smoothly marginated mass with heterogenous internal echotexture.

DDx: large fibroadenoma or cancer.

58
Q

What is a Lactational Adenoma?

A

2nd or 3rd trimester of pregnancy or postpartum period

Freely mobile mass, may be tender if rapidly enlarged.

Benign and does not need excision. Will regress when no longer lactating.

59
Q

What are multiple intraductal papillomas?

A

Younger patients compared to solitary papillomas. More peripheral in location and bilateral - infrequently associated with pathologic nipple discharge.

Increased risk of cancer.

Multiple well-circumscribed masses located in the peripheral breast.

Papillomatosis: microscopic foci of intraductal hyperplasia with a papillary architecture - pathologic diagnosis.

Juvenile Papillomatosis: rare cause of a mass that resembles a fibroadenoma in adolescents or younger women up to age 40.

60
Q

What is Steatocytoma Multiplex?

A

Multiple intradermal oil cysts.

When skin over breasts is involved, mammography shows innumerable fat-density masses.

61
Q

What is a complicated cyst?

A

Cyst that contains low-level echoes or layering debris.

Considered benign, but risk of malignancy is not zero.

When new, typically BIRADS 3 or aspirated - if clear, white, or yellow = benign. If bloody - send for cytology.

62
Q

What is a complex mass?

A

Cyst with any complex feature, including thick walls or septations, or any solid or nodular element.

BIRADS 4 = biopsy. 36% will be cancer.

Malignant: Intracystic carcinoma, intracystic papilloma, cystic phyllodes tumor, and a solid cancer with central necrosis.

Benign: Hematoma, abscess, fat necrosis, galactocele, and benign cyst with adherent debris.

63
Q

What are clustered microcysts?

A

Apocrine metaplasia or fibrocystic change. Several adjacent tiny 2-5 mm cystic spaces separated by thing (<0.5 mm) septae.

BIRADS 2

64
Q

Differences between invasive ductal carcinoma and invasive lobular carcinoma

A

IDC: MC - high density, speculated mass. Malignant-type (pleomorphic or fine linear branching) calcs are often present w/in the mass.

ILC: 10% - Spread in an infiltrating pattern - challenge to diagnose, variable appearance. Rarely contains microcalcifications. More often multifocal or bilateral compared to IDC.

65
Q

What is Tubular Carcinoma?

A

Slow-growing cancer. Typically a small, speculated mass. May remain stable across several prior mammograms.

Radial scar may be a precursor to tubular carcinoma.

66
Q

What is a Radial Scar?

A

Complex sclerosing lesion - benign lesion of uncertain etiology.

Appears as a speculated mass or architectural distortion.

Adenosis, hyperplasia, and central atrophy resulting in pulling-in of adjacent tissue and formation of a speculated mass and architectural distortion.

Can look identical to cancer - spiculated mass or architectural distortion on mammo and hypoechoic shadowing mass on US.

May be associated with tubular carcinoma and high-risk lesions such as atypical ductal hyperplasia and lobular carcinoma in situ.

Surgically resect.

67
Q

What is Sclerosing Adenosis?

A

Benign proliferative breast lesion caused by lobular hyperplasia. Fibrous tissue envelopes and distorts the glandular elements with sclerosis of the affected tissue. Microcalcs may be present.

68
Q

Suspicious findings of lymph nodes

A 
Round shape
Thickened (>3 mm) cortex
Eccentrically thickened cortex
Focal outwards cortical bulge
Hilar indentation or obliteration of the hilum by thickened cortex
69
Q

What is primary breast lymphoma caused by?

A

Diffuse large B-cell lymphoma. Palpable mass with axillary LAD.

If known diagnosis of lymphoma with new breast mass, primary consideration remains breast cancer. Histologic sampling is essential as lymphoma is chemoradiation, not surgery.

70
Q

What is Angiosarcoma of the breast?

A

May be primary or secondary to prior breast conservation therapy with radiation therapy.

Hyperintense on T2 and demonstrates intense enhancement.

71
Q

Mets to breast?

A

RCC and melanoma

Multiple new masses in a non-ductal distribution are especially worrisome for hematogenous metastases.

72
Q

What are the enhancement patterns with MRI?

A

Early: Slow, medium and rapid

Delay: Persistent (I - 10% increase), plateau (II - w/in 10%), and washout (III - >10% decrease).

73
Q

What false positive lesions can show washout kinetics?

A

LN, adenosis, and papillomas

74
Q

MRI terminology for mass shape

A

Round
Oval
Lobular
Irregular

Same as mammo

75
Q

What is the most predictive MR feature?

A

Margin of the enhancing mass - smooth are more suggestive of benignity. Irregular or spiculated are more suspicious for malignancy.

Characteristics are more important than enhancement characteristics.

76
Q

MRI terms for mass margin

A

Smooth
Irregular
Spiculated

77
Q

What needs to be evaluated on breast MR

A

Shape
Margins
Enhancement

78
Q

Categories of internal enhancement on MRI

A

Homogeneous - benign
Heterogeneous - non-uniform enhancement is suspicious, especially with rim-enhancement
Rim-enhancement - highly suspicious
Enhancing internal septations and central enhancement
Dark internal septations = fibroadenoma

79
Q

Dark internal septations on MRI

A

Fibroadenoma

80
Q

What is an enhancing focus on MRI?

A

Small dot of enhancement <5 mm in size that does not have any mass effect or correlate to any abnormality on precontrast images.

Too small for accurate assessment of margins or internal enhancement characteristics.

Suspicion for malignancy depends on multiplicity and menstrual status.

81
Q

What needs to be described for non-masslike enhancement on MRI?

A

Distribution - linear/ductal, segmental, focal area, regional, multiple regions, diffuse

Internal Enhancement - Heterogeneous, homogeneous, clumped, stippled/punctate, reticular/dendritic

82
Q

Distribution types of non-masslike enhancement

A

Linear/ductal - 26% malignant, typically seen with a clumped enhancement morphology

Segmental- triangular shaped points towards nipple - suggests ductal etiology - MC distribution of DCIS

Focal- <25% of a quadrant and contains interspersed fat/glandular tissue

Regional- >25% of a quadrant

Multiple regions- at least 2 regions

Diffuse- uniform throughout the breast

83
Q

Enhancement pattern most associated with DCIS

A

Clumped segmental

84
Q

Internal enhancement patterns of non-masslike enhancement

A

Heterogeneous- confluent and non-uniform

Homogeneous - uniform, more suggestive of benign lesion

Clumped- cobblestone, “bunch of grapes” - most suggestive of DCIS - especially in a linear/ductal or segmental distribution.

Stippled/punctate- tiny round dots -associated with benignity

Reticular/dendritic- strand-like - may be associated with inflammatory carcinoma

85
Q

When should MRI be used for screening?

A

High-risk patients - 20% or greater lifetime risk of developing breast cancer

No data to support screening breast MRI in women at average risk for breast cancer, even with dense breasts.

86
Q

What is the significance of an enhancing lesion in the contralateral breast with cancer?

A

Low PPV for malignancy.

87
Q

When should enhancement of a lumpectomy site be expected and when abnormal?

A

Normal for 6-18 months due to granulation tissue.

Beyond 18 months may no longer be normal, especially after the initial postoperative enhancement has subsided.

88
Q

Contraindications to stereotactic biopsy?

A

Very thin breasts measuring <3 cm compressed
Far posterior or subareolar location
Inability to be positioned on the stereotactic table
Uncontrolled coagulation abnormality.

Routing ASA and Plavix are not contraindications.

89
Q

What is BIRADS 2 on MRI?

A

Bilateral stippled foci of enhancement w/o a dominant mass or suspicious focal NME.

90
Q

What is BIRADS 3 on MRI?

A

Mass or NME with benign morphology and enhancement kinetics, and negative targeted US - can only have benign features on MRI for f/u to be appropriate (rather than biopsy).

91
Q

What is BIRADS 4 on MRI?

A

Mass or NME with type I kinetics and benign morphology - Solitary, dominant, or asymmetric NME in a high risk patient -

Mass or NME with type II or III kinetcs and benign morphology
Exception is a benign LN which is typically in the lateral breast adjacent to a vessel and is reniform in shape.

Mass or NME with type I kinetics and malignant morphology

Mass or NME with type II-III kinetics and malignant morphology is BIRADS 4 or 5.

92
Q

What modality has the highest correlation with pathology for lesion size?

A

MRI

US and mammo underestimate.

Breast (3 decks)

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