Breast Imaging Flashcards
Name 3 risk factors for breast abscess
Lactational mastitis
Smoking
Older women with chronic RA or DM
Name 2 mammographic features of sclerosing adenosis
Architectural distortion
Amorphous microcalcifications
What is complex sclerosing adenosis associated with?
Radial scar associated with DCIS and tubular carcinoma (30%)
What is breast papillomatosis?
Multiple papillomas in more than 1 duct system
Pre-malignant condition
Intra-ductal papilloma: US appearance and management?
Dilated ducts and well-defined intraductal mass with vascular stalk
Surgical excision needed to exclude malignancy
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
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%)
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
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
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
Name 3 features if DCIS
Simple mass or asymmetric density
50-75% have calcifications
Microlobulated hypoechoic mass
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)
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
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
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.
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
CAD in screening mammography
Single reader + CAD= dual reader
CAD is good for mass and microcalcifications
CAD struggles with architectural distortion
Linear array transducer in breast US: refraction artefact
Refraction artefact commonly seen at margins of cysts
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)
Lesion more echogenic than fat: benign or malignant?
Benign (most likely lipoma)
Fibroadenoma vs cyst on MMG
Similar density (can be indistinguishable)
Prevalence of breast cancer on 1st round screening?
6-10 per 1000 (prevalence screening)
Incidence screening (repeated attendance): 2-4 per 1000
Name 4 differentials for uniformly increased density and skin thickening.
Under-exposed film
Inflammatory breast cancer
Mastitis/ breast abscess
XRT
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!
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
