Breast Flashcards
what % of DCIS found as calcs on mammo?
90%
when are round calcs not benign?
linear/segmental
new
% DCIS visible on USS
50%
management of atypical ductal hyperplasia
excision
what kind of papilloma gets excision
papilloma w/ atypia
which breast cancer lacks e-cadherin
lobular neoplasia (ILC & LCIS)
which kind of lobular carcinoma in situ should get excised?
pleomorphic
where are cancers found in radial scars?
periphery
recommendation of radial scar & radial sclerosing lesion
scar - f/u image
lesion - excision
which is more likely to have LN mets in same size lesion? invasive lobular or ductal carcinoma?
invasive lobular
management of breast pain
- <30 start with US
- 30-35 image with US or mammogram
>35 start with mammo - if N no further imaging, if abN do USS
subtypes of invasive ductal carcinoma
- NOS (not otherwise specified)
- tubular –> slow grow spiculated
- medullary –> fast grow smooth
- mucinous
- papillary
‘circumscribed’ subtypes of ductal carcinoma
mucinous
medullary
papillary
slow growing subtypes of ductal carcinoma
tubular
mucinous
papillary
breast cancer T2 bright
mucinous carcinoma
invasive ductal
Compared to invasive ductal carcinoma, invasive lobular carcinoma is more likely to:
infiltrative pattern of ILC =
- tends to be larger at diagnosis
- present as distortion without or with a mass
- result in a false negative FNA
- result in mastectomy
compared with IDC.
What is the most common intra-cystic breast carcinoma?
Papillary carcinoma aka “encapsulated” carcinoma
- behaves like DCIS unless an invasive component extends outside of cyst wall
An apparent decrease in size of one breast is most typical of:
“shrinking breast” - typical of invasive lobular
- affected breast does not compress as well on mammo
56 yo F dx’ed w/ malignant phyllodes tumor. The next step in staging is sentinel lymph node biopsy? True/False
False - Malignant phyllodes tumor behaves like a sarcoma with hematogenous spread rather than lymphatic spread. A chest CT would be more appropriate for staging than axillary sampling.
what modifier do you use after neoadj chemo in TNM staging?
yTNM
DCIS calcification types & grade
fine, linear, fine linear branching (high grade)
fine pleomorphic (high grade)
amorphous (low grade)
why do you get posterior acoustic shadowing in birads5 masses
desmoplastic changes in mass
breast mets by subtype
luminal A - bone
HER 2+ - brain & liver
Triple negative - brain & viscera
breast ca w/ best outcome
ER/PR+, regardless of HER2+
most common invasive breast cancer subtype
luminal A (ER/PgR+)
more likely to be multicentric/focal - luminal A or B
luminal B (53%)
inflammatory breast carcinoma needs tumor cells where?
dermal lymphatics
breast MRI kinetic enhancement curves
type 1 - benign - initial slow uptake and persistent enhancement
type 2 - indeterminate - plateau
type 3 - malignant - initial fast uptake with washout
axillary lymph node levels
level I: lateral to pec minor
level II: behind pec minor
level III: medial & superior to pec minor
LCIS on biopsy - next step
sx referral (ALH/cLCIS) excision (pLCIS)
most common MALE palpable lump
gynecomastia
birads for biopsy proven cancer
birads 6
PASH
pseudoangiomatous stromal hyperplasia
- benign prolif STROMAL lesion consisting of myofibroblasts
- responds to hormonal stimulus, usu premenopausal or postmeno on HRT
- present as mass or asymmetry, NOT calcs
interval breast cancer
clinically detected cancer during interval btwn recommended screenings
- can be mammographically occult, missed on prior mammography, or a new mammographic finding
- more often in dense breasts
- more commonly high grade & triple negative
- > 50% incr risk of death cf. screen-detected cancer
nonpuerperal mastitis and subareolar abscess associated with…
heavy smoking
- results in squamous metaplasia of lactiferous ducts with resulting duct ectasia, stasis, and recurrent infection
the goal for recall rate for screening mammography examinations should be less than or equal to…
10%
Radiology 2007
modality to diagnose saline implant rupture
mammography (+ physical exam)
US and MRI not needed
multifocal vs multicentric breast cancer
multifocal: disease in the same quadrant or within 5 cm of each other
- may be removed by a lumpectomy if breast large enough
multicentric: disease in separate quadrants or separated by >5 cm
- requires mastectomy
modified radical mastectomy involves removal of…
complete breast
level I and II axillary nodes
(pectoral muscles remain intact)
TRAM flap vs DIEP flap
both autologous flaps using abdominal skin, subcutaneous fat & adjoining vasculature (for breast reconstruction post-mastectomy)
DIEP: deep inferior epigastric perforator
transverse rectus abdominis MYOcutaneous flap:
- also uses rectus abdominis muscle
deep inferior epigastric perforator flap:
- does not use rectus abdominis muscle
- fewer complications, faster return to activity
Imaging: atrophied rectus abdominis muscle in the reconstructed breast = TRAM
contraindications for breast conservation
inflammatory cancer large cancer size relative to breast multicentric (multiple quadrants) prior radiation to the same breast contraindication to radiation therapy (collagen vascular disease)
most common tumour met to breast
melanoma
most important predictor of overall survival in breast ca
axillary status
breast cancer T staging
T1 = <2cm
T2 = 2-5 cm
T3 = >5cm
T4 = any size with chest wall fixation, skin involvement, or inflammatory breast ca
Paget’s is carcinoma in situ of nipple epidermis, NOT T4
mammo findings of extracapsular silicone rupture
silicone granulomas
dense lymph nodes
patterns of gynecomastia
early nodular (most common)
- flame shaped behind nipple, radiating posterior blending into fat
- tender
late dendritic (branching tree)
- chronic fibrosis & hyalinization; irreversible
- usu not tender
diffuse glandular
- diffuse incr in density (mammo looks like woman’s breast)
- men receiving estrogen treatment
punctate and amorphous high-density foci within axillary node
gold therapy
ipsilateral arm/chest tattoos
NPV of combined negative mammography and targeted US for focal breast pain
100%
idiopathic granulomatous mastitis
benign noninfective granulomatous inflammation in parous women that mimics malignancy
- lobulocentric, noncaseating granulomas
painful mass +/- draining sinus
50% resolve spontaneously, most resolve on oral steroids +/- intermittent relapse
US: large, ill-defined areas of hypoechogenicity
function of BRCA 1 and 2 genes
regulate DNA-damage response and repair in the cell
most likely cause for symmetric, regional, heterogeneous non-mass enhancement in the upper outer breast quadrants with persistent enhancement kinetics on MR
normal variant inflow phenomenon
- this pattern is most typical during luteal phase of menstrual cycle (days 14-28)
- why MR is best performed between days 6-12 of menstrual cycle to decrease background enhancement
TNM of inflammatory breast ca
classified as T4d; at least stage IIIB
if N3 disease, then stage IIIC: many (>10) axillary LNs, an ipsilateral internal mammary LN with 1 or more positive level I or II axillary LNs, or an ipsilateral supraclavicular LN
if distant lymph nodes or organs (M1), then stage IV
fine linear or fine linear branching calcs - % likelihood of malignancy
70%
BIRADS 4C (>50% to <95%)
fine pleomorphic calcs - % likelihood of malignancy
30%
BIRADS 4B (>10% to <50%)
coarse heterogeneous calcs - % likelihood of malignancy
<15%
BIRADS 4B (>10% to <50%)
amorphous calcs - % likelihood of malignancy
20%
BIRADS 4B (>10% to <50%)
HER2/neu positive breast cancer treatment
targeted therapy with trastuzumab (Herceptin)
- HER2/neu specific antibody shown to be effective against HER2 positive breast cancer in metastatic, adjuvant, and neoadjuvant settings
- relative risk of recurrence is decreased by 50% in early stage breast cancer after treatment with trastuzumab
what is the desired cancer detection rate for 1000 screening mammograms?
5
which breast MRI sequence is misregistration artifact seen on?
subtraction
secondary to motion causing movement of breast tissue between fat suppressed enhanced T1 and fat suppressed unenhanced T1 weighted sequences
during an upright stereotactic breast biopsy, when adjusting for depth, which coordinate does not change?
the X coordinate is the only coordinate that does not change when moving the needle to the target on stereotactic upright biopsy
the Y changes ever so slightly because the needle is angled slightly
the Z has the most significant change as it is the depth and as you dial to the lesion, the Z approaches 0
BIRADS for known CLL, bilateral axillary lymphadenopathy, and otherwise negative/normal mammogram
BIRADS 2
report also should indicate presence of lymphadenopathy and known underlying disease
e.g. negative or benign followed by “with bilateral axillary lymphadenopathy presumed due to the patient’s known lymphoma”
when is a focus on breast MRI concerning?
new
washout
near a cancer
Inflammatory breast cancer stage
Stage 3B
High risk lesions (5)
Radial scar ADH ALH LCIS Papilloma
Contraindications to breast conservation
Inflammatory cancer Large cancer size relative to breast Multi centric Prior radiation to same breast Contraindication to radiation (collagen vascular disease)
Washout kinetic types & risk of cancer
Type I: persistent, 6% risk
Type II: plateau 7-28%
Type III: washout =>29%
male breast lacks?
- terminal lobules and acini
- cooper’s ligaments
internal enhancement pattern of NME on MR most predictive of cancer?
clustered ring C+ (87% PPV)
clumped 30-40% PPV
