Breast Imaging Flashcards by Raj Sohawon

Name 3 risk factors for breast abscess

Lactational mastitis

Smoking

Older women with chronic RA or DM

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Name 2 mammographic features of sclerosing adenosis

Architectural distortion

Amorphous microcalcifications

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What is complex sclerosing adenosis associated with?

Radial scar associated with DCIS and tubular carcinoma (30%)

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What is breast papillomatosis?

Multiple papillomas in more than 1 duct system

Pre-malignant condition

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Intra-ductal papilloma: US appearance and management?

Dilated ducts and well-defined intraductal mass with vascular stalk

Surgical excision needed to exclude malignancy

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Name 2 types of DCIS

Comedo (60%): large cell and more aggressive

Non-comedo (40%)- small cell and less aggressive: papillary, cribriform, intracystic papillary carcinoma in situ etc

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Name the top 5 subtypes of IDC

IDC NOS (65%)- scirrhous and worst Px

Tubular carcinoma (7-8%): best Px and cured by excision

Medullary carcinoma (2%): fast growing

Mucinous or colloid carcinoma (2%): slow-growing

Papillary (1-2%)

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Name 3 features of mucinous breast cancer

More common in 70-75 years: slow growing

Well defined lobular mass. Calcifications rare.

Mixed solid/cystic components with acoustic enhancement

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Name 3 features of medullary breast carcinoma

Young women (35 years)- fast growing

Rounded mass with ill-defined margins. No calcifications.

Homogeneously hypoechoic on US

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Name 3 features of tubular breast carcinoma

Non-palpable and 50% associated with DCIS

Small, spiculated with calcifications (15% multifocal)

Hypoechoic mass with posterior acoustic shadowing

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Name 3 features if DCIS

Simple mass or asymmetric density

50-75% have calcifications

Microlobulated hypoechoic mass

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Name 3 features of LCIS

Pre-menopausal women (80-90%)

MMG: usually normal or non-specific calcifications

Need excisional biopsy (15-30% develop IDC or ILC)

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Name 3 features of ILC

Seen on only 1 view (usually CC)- 16% occult

Similar risk of contralateral breast cancer to IDC (5-10%)

May need further assessment with MRI

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Name 3 features of papillary carcinoma

Post-menopausal women: 65 years

50% in retro-areolar or sub-areolar region

Complex, solid-cystic mass with internal vascularity. Better Px than other IDC

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Describe 3 features of Phylloides

Peak incidence 45 years

Large rounded mass with radiolucent halo. May have coarse calcifications

Can be benign, borderline or malignant. Histologically resembles FA but has increased cellularity and mitoses.

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What are the features of benign, indeterminate and malignant breast lesions on MRI?

Benign: no enhancement or slow-gradual enhancement

Indeterminate: rapid initial enhancement followed by gradual late enhancement

Malignant: rapid initial enhancement followed by plateau or washout

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CAD in screening mammography

Single reader + CAD= dual reader

CAD is good for mass and microcalcifications

CAD struggles with architectural distortion

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Linear array transducer in breast US: refraction artefact

Refraction artefact commonly seen at margins of cysts

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Breast density in different phases of menstrual cycle

Breast density is greater in luteal (secretory) phase compared to follicular (proliferative) phase

Women should have mammography in follicular phase (1st 2 weeks of cycle)

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Lesion more echogenic than fat: benign or malignant?

Benign (most likely lipoma)

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Fibroadenoma vs cyst on MMG

Similar density (can be indistinguishable)

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Prevalence of breast cancer on 1st round screening?

6-10 per 1000 (prevalence screening)

Incidence screening (repeated attendance): 2-4 per 1000

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Name 4 differentials for uniformly increased density and skin thickening.

Under-exposed film

Inflammatory breast cancer

Mastitis/ breast abscess

XRT

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Flamed shaped changes in the retro-areolar tissue in a man. Dx?

Gynaecomastia

If there’s no mass, do not perform US as it can be confusing and lead to unnecessary biopsy!

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DDx for bloody nipple discharge

Benign: intra-ductal papilloma Paget's disease of the nipple (usually DCIS) Breast carcinoma

Name 3 proliferative disease without atypia

Epithelial hyperplasia Sclerosing adenosis: increased number of acini (adenosis) + stromal fibrosis (sclerosis) Papilloma: growth within a dilated duct (nipple discharge)

Name 3 components of complex sclerosing adenosis

Also called radial scar: mimics IDC on radiology and gross histology. But, NON-PALPABLE! No dilated lymphatics. Central fibroelastic core Dilated ducts Epithelial and myoepithelial cells

Name 3 features of juvenile papillomatosis

2/3 less than 20 years Ductal hyperplasia and epithelial proliferation with cyst formation Benign but marker for familial breast cancer and concurrent breast ca

What is Paget disease of the breast?

DCIS from ductal system extends into nipple skin without crossing the basement membrane Tumour cells disrupt nipple epithelial barrier resulting in scaling Risk of progression to invasive ca is 1% (lumpectomy and XRT) 50-60% have underlying invasive ca (rest have DCIS only)

Name 3 features of LCIS on histology

Loss of E-cadherin expression Small, dyscohesive cells Mucin-positive signet ring cells often present

What cancer is more common in women with BRCA 1?

Medullary carcinoma (10-15% associated with BRCA)

Lymphocytic infiltrate and pushing border (non-infiltrative) border on histology. Dx?

Medullary carcinoma

Papillary carcinoma vs papilloma

Absence of myoepithelial cells

3 features of ILC on histology

Dyscohesive tumour cells arranged in indian file Signet ring cells common (mucin) No tubule formation

Name 4 features that affect grading of breast ca

Tubule production (glandular differentiation) Mitotic count Nuclear pleomorphism Necrosis

Nodal disease and 10 year disease-free survival

No nodes: 70-80% 1-3 nodes: 35-40% More than 10 nodes: 10-15 %

What is the significance of ER, PR and HER2/ neu expression?

ER and PR positive means better Px HER2/ neu over-expression has poorer survival

Name the top 3 stromal breast tumours

Intralobular stroma: phylloides and FA Interlobular stroma: PASH

Describe 3 features of PASH

Circumscribed palpable mass Stromal proliferation of fibroblasts and myofibroblasts Can mimic phylloides or mucinous tumour on FNA. Core biopsy is diagnostic- conservative management

Breast cancer stages

Stage I: T1N0 or T0N1mi Stage II: T1N1 or T2N0 or T3N0 Stage III: T4N0-2 or T3N1-2 or T2N2 or T1N2 Stage IV: any T and any N and M1

Apart from breast and ovarian ca, what other tumours do BRCA1 and BRCA2 predispose to?

Prostate ca Colon ca

DCIS- micropapillary subtype

Extends well beyond mammographic abnormality

DCIS- cribriform subtype

Neoplastic cells pack the distended duct: cookie-cutter like appearance

LCIS pre-malignant?

No, indolent lesion which does NOT usually progress to ILC (unlike DCIS). However, increased risk of ipsilateral and contralateral invasive cancer (both ductal and lobular).

Pleomorphic variant of LCIS?

More aggressive behaviour- more radical therapeutic approach

When would you biopsy a lesion that looks like a fibroadenoma?

If more than 25 mm to exclude a phylloides tumour

What drug associated with FA?

Cyclosporin

Digital vs film mammography

20-30% increased sensitivity in 40-50 year-old women (dense breasts)

Most common presentation of ILC

Spiculated mass

Is sclerosing adenosis associated with microcalcifications?

YES 47% have punctate or amorphous calcifications

Edge and shadow artefact in breast US?

Edge artefact: cyst Shadow artefact: fibrous tissue

Name 2 appearances of breast papilloma on MMG

Dilated ducts or well defined mass Non specific calcifications

Name 2 malignancies associated with radial scar

30% associated with DCIS and tubular carcinoma

Fibroadenoma on MRI?

Slow initial enhancement with persistent delayed enhancement Non-enhancing septae

From MLO to lateral, what happens to a lesion?

Lateral lesion goes lower Medial lesion goes higher

Triple negative (ER, PR and HER) breast cancer?

Medullary breast cancer (especially BRCA-1 associated) Poorly differentiated IDC

Non proliferative breast disease

FCC: cysts, fibrosis and adenosis

Name 5 proliferative breast disease without atypia (RR 1.5-2.0)

Epithelial hyperplasia Sclerosing adenosis: acini distorted by fibrosis. Calcifications Papilloma: growth within dilated duct. Nipple discharge 80% Juvenile papillomatosis: ductal hyperplasia and cyst formation. Marker for familial and concurrent breast ca Radial scar

Invasive papillary ca vs papilloma

Invasive papillary ca: absence of myoepithelial cells

Micropapillary ca vs invasive papillary ca

Micropapillary has worse Px due to LN involvement

Name 2 features of complex FA

Cysts more than 3 mm Mild increased cancer risk

Male breast cancer- Px when matched for grade?

SAME prognosis when matched for grade Most cases are IDC

What anode and filter for non-obese female?

Mo-Mo with 28 kVp filter Note: Rh anode produces more penetrating radiation for use in dense breasts (Rh-Rh) Mo-Nb for thin breasts

Most common cause of bloody nipple discharge?

Papilloma

Most common presentation for PASH?

Circumscribed mass with NO calcifications Biopsy needed to distinguish from phylloides

Name four B3 (indeterminate lesions)?

ADH, ALH, LCIS, radial scar