Breast CTC Flashcards
What should asymmetric breast make you think about?
“Shrinking breast” of invasive lobular breast cancer.
If the size difference is new or the parenchyma looks asymmetrically dense, think cancer.
What is a Lactiferous Sinus?
Dilated portion of the major duct under the nipple.
Normal- not a mass.
What are the axillary lymph node levels?
Level 1: Lateral to pec minor
Level 2: Under pec minor
Level 3: Medial to pec minor
Rotter Node: Between pec major and minor
What is the Rotter Node?
Axillary LN between the pec major and minor.
How does breast tissue develop in response to hormones?
Enter puberty- ducts elongate and branch (estrogen effects), then their lobules proliferate (progesterone).
Biopsy a breast bud during development - damage and affect breast development.
What happens to breast during follicular phase?
Day 7-14 - estrogen dominates.
Best time to have both mammgram and MRI
What is the best time to have a breast MRI and mammogram?
Follicular phase - Day 7-14 - Estrogen dominates.
What happens to the breast during luteal phase?
Day 15-30 - Progesterone dominates.
When you get some breast tenderness (max at day 28-30). Breast density increases slightly.
What happens to breast during pregnancy?
Tubules and ducts proliferates. Breast gets a lot denser (more hypoechoic on US) and US may be your best bet if you have a mass.
What happens to breast during Perimenopausal period?
Shortening of follicular phase = breast gets more progesterone exposure.
More progesterone = more breast pain, more fibrocystic change, and more breast cyst formation.
What happens to breast during Menopause?
Lobules go down. Ducst stay but may become ectatic.
Fibroadenomas will degenerate (they like estrogen) and get their “popcorn” calcifications.
Secretory calcs will develop (15-20 years post menopause).
What happens to breast during hormone replacement therapy?
Breast will get more dense (even more so estrogen-progesterone combos).
Breast pain can occur, typically peaking the first year.
Fibroadenoma can grow.
When is breast tenderness max?
Day 27-30
What is a milk fistula?
Biopsy a breast that is getting ready to lactate/lactating.
Have to stop breast feeding to stop the fistula.
What chest wall radiation increases risk of breast cancer?
Child - more than 20 Gy to the chest for lymphoma.
Annual screening MRI at 25 or 8 years post exposure (whichever is later).
How does having a first degree relative with breast cancer increase your risk?
Increases from 8 to 13%.
Two first degree relatives increases to 21%.
What are the inherited causes of increased risk of breast cancer?
BRCA 1: Chromosome 17. More common than type 2. Increased risk for breast, ovary, and various GI cancers
BRCA 2: Chromosome 13. Male carriers have a higher risk with 2. Increased risk of breast, ovary, and various GI cancers.
LiFraumeni: p53 doesn’t work, high risk for all kinds of rare cancers.
Cowden Syndrome: Risk for breast cancer, follicular thyroid cancer, endometrial cancer, and Lhermitte-Duclos (a brain hamartoma)
Bannayan-Riley Ruvalcaba: Associated with developmental disorders at a young age.
NF-1: “Moderate risk” of breast cancer
What is Cowden Syndrome?
Risk for breast cancer, follicular thyroid cancer, endometrial cancer, and Lhermitte-Duclos (a brain hamartoma) - bowel hamartoma
What is Bannayan-Riley Ruvalcaba?
Associated with developmental disorders at a young age.
What are the breast cancer models and what do they take into account?
All underestimate lifetime risk.
Gail Model: Oldest and most validated breast cancer risk model; Focuses on person risk factors, biopsy of ADH, and family history; Doesn’t use genetics. Only validated for AAs
Claus, BODICEA, and BRCApro: Focuses on genetics; Does NOT include personal risk or breast related risk factors
Tyrer-Cuzick: “Most comprehensive”; Includes personal risk, biopsy with ADH or LCIS, Family history; Does NOT include breast density.
What does the Gail Model of breast cancer risk take into account?
Oldest and most validated breast cancer risk model
Focuses on person risk factors, biopsy of ADH, and family history
Doesn’t use genetics. Only validated for AAs
What do the Claus BODICEA, and BRCApro breast cancer models take into account?
Focuses on genetics
Does NOT include personal risk or breast related risk factors
What does the Tyrer-Cuzick breast cancer model take into account?
“Most comprehensive”
Includes personal risk, biopsy with ADH or LCIS, family history
Does NOT include breast density.
When do you get a LMO view?
Kyphosis or pectus excavatum
Avoid medial pacemaker or line.
When can you see a grid artifact?
Moves fast.
Can get if: Patient moved, exposure was too long, exposure was too short.
Goal numbers of screening mammogram?
Find 3-8 cancers per 1000 mammograms.
What areas are not seen on single views?
Medial breast on CC may not be seen on MLO.
Inferior posterior breast on MLO may be excluded from the CC.
Things you can call BIRADS 3?
Fibroadenoma
Focal asymmetry that looks like breast tissue (becomes less dense on compression)
Grouped on clustered round calcifications
What do you need to describe for a mass on mammo?
Shape: Round, oval, lobular, irregular
Margin: Circumscribed, microlobulated, obscured, indistinct, spiculated
Density (relative to breast parenchyma): Fat density (radiolucent), hypodense, isodense, hyperdense
What do you need to describe for a mass on US?
Shape: Round, oval, irregular
Orientation: Paralle (wider than tall), anti-parallel (taller than wide)
Margin: Circumscribed, indistinct, angular, microlobulated, spiculated
Echogenicity: Anechoic, hyperechoic, hypoechoic, isoechoic, or complex (both anechoic and echogenic components)
Boundary: Abrupt, echogenic halo (interface between mass and surrounding tissue is bridged by an echogenic zone)
Posterior Features: None, enhancement, shadowing.
What is the suspicious to benign distributions?
Segmental - Linear - Grouped/Clustered - Regional - Scattered
Characteristics of dermal calcifications
Look like paw of a bear or foot of a baby.
Stay in the same place on CC and MLO views. Tattoo sign.
Get tangential view.
What is liponecrosis macrocystica?
Large fat necrosis
What if you don’t see calcs on biopsy?
Milk of calcium needs to be viewed with polarized light to assess birefringence.
What are round calcifications?
Develop in lobules - usually scattered, bilateral, and benign.
When benign, going to due to fibrocystic change.
Usually bilateral and symmetric (and benign). If clustered together by themselves, or new they may need to be worked up, just like a mass.
If clustered round calcs on the first mammogram - BR3 them.
What are amorphous calcs?
Look like powdered sugar - not able to count each individual calcification.
Distribution is key - if scattered and bilateral, probably benign. If segmental = concerning.
What are course heterogeneous calcs?
Countable, but their tips are dull - not poke you.
Usually bigger than 0.5 mm.
Distribution and comparison to priors is always important.
Can be associated with mass (fibroadenoma, or papilloma).
What are fine pleomorphic calcs?
Countable, and their tips appear sharp - poke you.
Usually smaller than 0.5 mm.
Highest suspicion for malignancy.
DDx for amorphous calcs?
Fibrocystic change (most likely)
Sclerosing adenosis
Columnar Cell change
DCIS (low grade)
DDx for Coarse Heterogeneous Calcs?
Fibroadenoma
Papilloma
Fibrocystic Change
DCIS (low-intermediate grade)
DDx for fine pleomorphic calcs?
Fibroadenoma (less likely)
Papilloma (less likely)
Fibrocystic change
DCIS (high grade)
What is Pseudoangiomatous Stromal Hyperplasia (PASH)?
Benign myofibroblastic hyperplastic process.
Usually big, 4-6 cm, solid, oval shaped, with well defined borders.
18-50. F/u in 12 months is typical recommendation
What is a Fibroadenoma?
MC palpable mass in young women
Oval, circumscribed mass with homogenous hypoechoic echotexture and a central hyperechoic band.
T2 bright with type I (progressive) enhancement.
What is a Phyllodes Tumor?
Benign with malignant degeneration risk of about 5-25%.
Fast growing breast mass.
Older age group than fibroadenoma (40s-50s)
Distinguishing features of Phyllodes Tumor
Rapid Growth
Hematogenous Mets
Middle-age or older women
Mimics a fibroadenoma
What are the IDC types (other than NOS)
Tubular: Small spiculated slow growing mass, with favorable prognosis. Often conspicuous on US. Associated with radial scar. Contralateral breast will have cancer 10-15% of the time.
Mucinous: Round (or lobulated) and circumscribed mass. Uncommon. Better outcomes than IDC-NOS.
Medullary: Round or oval circumscribed mass, without calcs. Axillary nodes can be large even in absence of mets. Typically younger (40-50s). Better outcome in IDC-NOS.
Papillary: Complex cystic and solid. Axillary nodes are NOT common. Typically elderly, favors people who are not white and is 2nd MC (behind IDC-NOS)
What is Tubular Carcinoma?
IDC Type
Small spiculated slow growing mass, with favorable prognosis.
Often conspicuous on US. Associated with radial scar. Contralateral breast will have cancer 10-15% of the time.
What is Mucinous Carcinoma?
IDC Type
Round (or lobulated) and circumscribed mass.
Uncommon. Better outcomes than IDC-NOS.
What is Medullary Carcinoma?
IDC Type
Round or oval circumscribed mass, without calcs.
Axillary nodes can be large even in absence of mets. Typically younger (40-50s). Better outcome in IDC-NOS.
What is Papillary Carcinoma?
IDC Type
Complex cystic and solid.
Axillary nodes are NOT common. Typically elderly, favors people who are not white and is 2nd MC (behind IDC-NOS)
Difference between multifocal and multicentric breast cancer?
Multifocal: Multiple primaries in the same quadrant - classically same duct system
Multicentric: Multiple primaries in different quadrants.
Triva on DCIS
10% on imaging may have invasive component at time of biopsy
25% on core biopsy may have an invasive component on surgical excision.
8% will present as a mass w/o calcs
MC US appearance = microlobulated mildly hypoechoic mass with ductal extension, and normal acoustic transmission.
How will DCIS be shown?
Suspicious calcs (fine linear branching or fine pleomorphic)
Non mass like enhancement on MRI
Multiple intraductal masses on galactography.
How does ILC progress?
Cell loses “e-cadherin” - cells no longer stick to one another and begin to infiltrage the breast “like the web of a spider” - infiltrative pattern does not cause a desmoplastic reaction so it gets missed on multiple mammos - architectural distortion w/o a central mass, on CC view only - dark scar.
What is “shrinking breast”?
Buzzword for ILC
Breast isn’t actually smaller, just doesn’t compress as much
What is “Dark Scar”?
Distortion w/o a central mass
DDx: lobular carcinoma, radial scar, surgical scar, and IDC-NOS
ILC vs IDC
ILC is more often multifocal.
ILC less often mets to the axilla, likes to go to strange places like peritoneal surfaces.
ILC more often has positive margins and more often treated with mastectomy, although prognosis is similar to IDC.
Things to know about ILC
Presents later than IDC
Older population
Often seen only on 1 view - CC, it compresses better
Calcs are less common than with ductal cancers
Mammo buzzword = Dark scar
Mammo Buzzword = shrinking breast
US buzzword = shadowing without mass
MRI - washout is less common than with IDC
Axillary mets are less common
Prognosis of IDC and ILC are similar
More often multifocal (compared to IDC)
What is Paget’s Disease?
Carcinoma in situ of the nipple epidermis.
~50% of the time will have a palpable finding associated with skin changes.
Things to know about Pagets
Associated with high grade DCIS
Wedge biopsy should be done of any skin lesion that affect the nipple-areolar complex that doesn’t resolve with topical therapy
Pagets is NOT considered T4. Skin involvement does not up stage in this setting.
What are the 5 classic high risk lesions that must come out after biopsy?
Radial Scar Atypical Ductal Hyperplasia Atypical Lobular Hyperplasia LCIS Papilloma
What is a Radial Scar?
Not an actual scar, but looks like one on histology. Have a bunch of dense fibrosis around the ducts giving the appearance of architectural distortion (dark scar)
High risk and has to come out
Associated with DCIS and/or ICD
Associated with Tubular Carcinoma.
What is Atypical Ductal Hyperplasia?
DCIS but lacks quantitative definition by histology (<2 ducts involved)
Comes out b/c its high risk and b/c DCIS burden is often underestimated when its presents.
30% of the time, surgical path will be upgraded to DCIS.
What is LCIS?
Classically occult on mammogram - “incidental finding”.
Can be a precursor to ILC, but isn’t obligated to be. Risk of conversion to an invasive cancer is less when compared to DCIS to IDC.
What is Atypical Lobular Hyperplasia (ALH)?
Very similar to LCIS, but separated based if the lobule is distended or not - yes in LCIS, no in ALH.
Considered mild to LCIS (risk of subsequent cancer is 4-6x higher with ALH and 11x higher with LCIS).
Excision.
What do you need to call multiple masses?
Need multiple (at least 3) bilateral well circumscribed masses w/o suspicious features.
BIRADS 2.
Multiple unilateral masses won’t work- need to be bilateral.
What is treatment of inflammatory breast cancer?
Chemo and/or radiation, then surgery.
What is the most suspicous nipple discharge?
Spontaneous, bloody from a single duct.
Serous discharge is also suspicious.
Milky discharge is NOT suspicious, but can be secondary to thyroid issues or pituitary adenoma (prolactinoma). Any medication that messes with dopamine can stimulate prolactin production - antidepressants, neuroleptis, reglan.
Benign and Worrisome causes of non-milky nipple discharge?
Benign:
Pre-menopausal - fibrocystic change
Post-menopausal - ductal ectasia
Worrisome:
Intraductal papilloma - single intraductal mas near nipple
DCIS - multiple intraductal masses.
What is ductal ectasia?
MC benign cause of nipple discharge in a post menopausal woman.
Galactography will see dilated ducts near the subareolar region with progressive attenuation more posterior.
What does harmonics do to breast lesions?
Can make it easier to see some lesions, but can make you lose your posterior features, especially when they are soft to start with - like the shadowing of an ILC>
Harmonics can also make not so simple cysts look simple.
Things to know about architectural distortion
Radiating lines to a single point AD + calcs = ICD + DCIS AD without calcs = ILC Even if no US or MRI correlate = biopsy Never BIRADS 3 an area of AD ILC can grow slow Surgical scars should get less dense with time, not more dense.
How are axillary lymph nodes treated?
Level 1 and 2 are treated the same
Rotter nodes are treated as Level 2
Level 3 and supraclavicular nodes are treated the same.
What pathology can men NOT get?
No elongated and branching ducts or proliferated lobules that women have.
Do NOT get lobule associated pathology, lobular carcinoma, fibroadenoma, or cysts.
Patterns of gynecomastia
Nodular (MC)- Flame shaped centered behind the nipple, radiating posterior as it blends into fat. Breast is often tender. Usually lasts less than 1 year.
Dendritic - Resembles a branching tree. This is a chronic fibrotic pattern. Usually not tender.
Diffuse glandular - Looks like woman’s breast - diffuse increase in density. You see this in men receiving estrogen treatment.
Risk factors for male breast cancer
BRCA 2
Klinefelter Syndrome
Cirrhosis
Chronic alcoholism
Eccentric, but near the nipple.
Almost always ICD-NOS type. DCIS can occur, but very rare in isolation.
Should men get screening mammograms?
Controvercial. Only Klinefelter patients approach the screening range with regards to risk
Males with gynecomastia from gender reassignment on hormone therapy are not high enough risk for screening mammogram.
What is breast implant capsular contracture?
MC complication of implants. Secondary to contraction of the fibrous capsule, can result in cosmetic deformity - seen in both silicone and saline implants - MC in subglandular silicone implants.
On mammo, looks like rounding or distortion of the implant - comparisons show progression.
What is Gel Bleed with implants?
1 risk for rupture is age.
Silicone molecules can (and do) pass through the semi-permeable implant shell coating the exterior surface.
Does NOT mean the implant is ruptured.
Show you silicone in the axillary LN - does NOT mean rupture.
Signs of Intracapsular Implant Rupture
Stepladder Sign - Seen on US. Multiple parallel echogenic lines w/in the sonolucent silicone.
Linguine Sign - Seen on MRI. Curvy low signal line w/in the implant. Basically the shell floating in the silicone (with the fibrous shell holding the silicone together)
Keyhole Sign/Noose Sign/Inverted Teardrop Sign - Seen on MRI. Silicone on both sides of a radial fold - associated with Gel Bleed.
Salad Oil Sign - Seen on MRI. Caused by rupture of the inner lumen of a double-lumen implant (causes saline and silicone to rupture).
Subcapsular Line Sign - Seen on MRI. Silicone adjacent to both surfaces of the ruptured shell.
What are Radial Folds?
Normal infoldings of the elastomer shell. Primary mimic for linguine sign of intracapsular rupture.
Radial folds should always connect with the periphery of the implant - linguine sign does not.
When should the first mammogram be done after biopsy?
6-12 months
Distortion and scarring should be worst on this film and should progressively improve.
On US, scars are supposed to be thin and linear. If focal mass like thickening in the scar - call it suspicious.
Fat necrosis and benign dystropic calcs may evolve over the first year or two and are the major mimics of recurrence. Fat necrosis can be shown on MR (T1/T2 bright, and then fat sat drops it out).
Facts about local recurrence
Local recurrence occurs 6-8% of the time with breast conserving therapy- w/o radiation is closer to 35%.
Peak time is 4 years.
75% of DCIS will come back as calcs - Benign calcs tend to come back early (2 years) vs the cancer ones which come back around 4 years.
What are the T stages of breast cancer?
T1 = <2 cm T2 = 2-5 cm T3 = >5 cm T4 = any size with chest wall fixation, skin involvement, or inflammatory breast CA
Pagets is NOT T4.
Contraindications for Breast Conservation
Inflammatory Cancer Large cancer size relative to breast Multi-centric (multiple quadrants) Prior Radiation therapy Contraindication to radiation therapy (Collage-vascular disease)
Who gets a screening MRI?
Lifetime risk of 20-25%
Includes people who got 20 Gy of radiation to the chest as a child.
Estimated using risk of models that includes family history (NOT the Gail model)
Pick the Tyrer-Cuzick model
What does Tamoxifen do to parenchymal enhancement?
Will decrease background parenchyma uptake. Then cause it to REBOUND.
Classic for fibroadenoma on MRI
T2 bright, round, with “non-enhancing septa”, and a type 1 curve
Classic for DCIS on MRI
Clumped, ductal, linear or segmental non-mass like enhancement.
Kinetics are typically not helpful.
Classic for IDC on MRI
Spiculated irregular shaped masses with heterogeneous enhancement and a type 3 curve.
What type of cancer is T2 bright on MRI?
Colloid and mucinous cancer
Usually T2 bright = benign. Cysts, LN, fat necrosis, fibroadenoma.
Single most predictive feature of malignancy on MRI
Spiculated margins
If you have known breast cancer- find contralateral CA 0.1-2% via mammo and 3-5% by MRI.
Never BIRADS 0 an MRI.
Who makes the MQSA standards?
USDA
Medical audit and outcome analysis once per year.
F/u positive mammo and correlate pathology with biopsy results. Have to grade the biopsy with the risk category
MQSA recall rate
Less than 10%
Must provide written results in language they can easily understand.
Consumer complaint mechanism is required to be established.
Patients can obtain their original mammograms, not compies, when needed.
Trivia for Quality control
The “interpreting physician” is ultimately responsible for QC
Resolution = 13 lp/mm in anode to cathode direction and 11 lp in the left right direction
Pass: 4 fibers, 3 microcalc clusters, and 3 masses + “acceptable artifacts”
Dose to phantom is 3 mGy per image (+ grid)- 50% glandularity, 4.2 cm thick. NO PATIENT DOSE IN MAMMO- ONLY PHANTOM.
Typical average breast = compressed to 6 cm, glandularity of 15-20%.
Digital system generally use higher beam qualities which results in lower dosese.
Digital mammo does not use fixed dose (Screen-film); can use as much (or as little) radiation as deemed appropriate.
MQSA Processor QC
Daily
MQSA Darkroom cleanliness
Daily
MQSA Viewbox Conditions
Weekly
MQSA Phantom evaluation
Weekly
MQSA repeat analysis
Quarterly
MQSA compression test
Semi-annually
MQSA Darkroom Fog
Semi-annually
MQSA Screen-film contrast
Semi-annually
Medical audit numbers for recall rate, cancers/1000 screened, PPV for biopsy recommendations
Recall Rate = 5-7%
Cancers/1000 screened = 3-8
PPV for biopsy recommendations = 15-35%
What are PPV1, 2, and 3?
PPV 1: Screening
PPV 2: Diagnostic
PPV 3: Biopsy results
