Breast Imaging Flashcards
Where is the breast base?
2nd to 6th ribs, midclavicular line
Where is the breast located in relation to the deep pectoral and superficial fascia, and serratus anterior?
Anterior to deep pectora fascia, and enclosed in superficial
Lower part overlies serratus anterior
When is breast imaging needed?
Symptomatic patients or screening:
Lumps
Unilateral or blood-stained nipple discharge
Skin tethering or dimpling
Signs of inflammation
Axillary lumps
Not for pain, tenderness, symmetrical nodularity
What is the 1-5 grading in the triple assessment?
1 Normal 2 Benign 3 Atypical, probably benign 4 Suspicious 5 Malignant
When would breast pain be imaged?
Only if associated focal asymmetric nodularity, to exclude underlying mass
Mammography, US or both
What imaging should be used to initially investigate a mass?
US <40yo
XRM +- US >40yo
Why is mammography used?
Cost effective, non invasive
Reproducible, easy to document
Only technique that reliably visualises microcalcifications (<0.5mm)- assoc. with approx 30% of invasive cancer, almost all screen detected DCIS
When is digital mammography used?
Replaces film/screen combination
Various image detectors
Excellent contrast resolution
Better in dense breasts, younger women
What do LNs look like on the normal mammogram?
Oval/horseshoe with a fatty hilum
25% have intramammary nodes (UOQ)
What do calcifications look like on the normal mammogram?
Bright white
Can be arterial, sebaceous glands (polo mints), oil cysts (eggshell curvilinear)
What are the views in a mammogram?
Mediolateral oblique (MLO)
Craniocaudal (CC)
Extended CC
Others
What is the best single view, with the last foreshortening?
MLO (45’ off vertical, xray bean perpendicular to long axis of breast)
What does a CC view show?
Nipple in profile
Shows medial and most of lateral tissue, not axillary tail
Visualisation of retromammary fat
Describe paddle (localised compression) views
Very film localised compression
Less scatter, more contrast
Demonstration of borders of mass
Harder to differentiate between lesion and shadow
What are magnified views good for?
Microcalcification
What views can be magnified?
CC and lateral
x1.2-2.0
What are BIRADS parenchymal patterns?
A: nearly all fat
B: scattered fibroglandular densities (25-50%)
C: heterogeneously dense (51-75%)
D: extremely dense (>75% glandular)
What are the features of malignant calcification?
Distribution- cluster or segmental vs scattered of diffuse (benign)
Cluster shape/size- rhomboid forms
Individual particle shape- linear/branching/Y shaped forms
Pleomorphic nature- size/density
What are the indications for US?
Characterisation of mammographic findings- cystic/solid lesions
Palpable lesions- women <40yo
Nipple discharge
Breast implants or augmentation
Other- inflammatory conditions (abscesses)
Evaluation of response to chemo
What are the radiological characteristics of benign nodules?
Circumscribed Hypoechoic/hyperechoic Wider than tall Homogenous Peripheral/no vascularity Often multipe
What are the radiological characteristics of malignant nodules?
Poorly circumscribed Hypoechoic Heterogenous Taller than wide Spiculate Oedema/peritumoral fat
What can be used in vacuum assisted biopsy?
Mammotome
SUROS- hand held, light weight, adaptable for XRM/US/MRI
EnCor- hand held with offset needle, different cutting prevents blunting
Why is MRI very accurate in breast imaging?
Visualisation of morphological and temporal pattern
What can MRIs allow you to assess to aid in diagnosis?
Enhancement, and rate of enhancement (ROIs)
What are the absolute and relative contraindications of MRI in breast imaging?
As for any MRI- pacemaker, renal impairment etc
Pregnancy, lactation (contrast effect, increased background breast enhancement)
What are the indications for MRI in benign disease?
Implants (integrity) Problem solving (lesion characterisation)
What are the indications for MRI in malignant disease?
Diagnosis (occult 1' breast cancer) Staging and treatment planning Residual disease post WLE Response assessment- chemo Recurrent disease- breast, reconstructed breast, axilla Screening- high risk groups
What is MRI more accurate for than XRM/US in breast imaging?
Tumour size, chest wall involvement
m/f and m/c disease
Occult contralateral disease
What are the high risk groups that require screening?
Previous irradiation (HL, mantle XRT)
BRCA 1,2 or TP53 mutations (Li Fraumeni)- >60% lifetime risk
PHx of breast cancer
