Breast Imaging Flashcards
what are the 4 ways to image breasts
- Mammography (standard digital xray or 3D)
- Breast US
- Breast MRI
- PET/CT - tool for staging cancer
At what age does annual breast cancer screening start for patients with normal risk
40
At what age does annual breast cancer screening start for patients with first degree relatives dx with cancer before 40
10 years younger than relative’s diagnosis
*typically no mammogram done before age 30
What is screening mammogram for?
patients without breast complaints or findings
What is a call back?
- When a finding is noted on screening mammogram that needs further imaging
- pt is recommended to come back for dx workup
Diagnostic mammography is used when?
- abnormal finding on screening mammography
- patient has a breast complaint (lump, nipple inversion or discharge, skin changes, focal breast pain)
What does diagnostic imaging of the breasts consist of?
- mammogram
- US (usually after mammogram)
- MRI
*this is different than a screening mammogram, pts might be confused why need a second mammogram when get a callback from a screening mammogram
2D mammogram
- how does it work
- what are the views
- x-ray to obtain 2 static pictures of each breast
- craniocaudal (CC) and mediolateral obliquie (MLO)
Tomosynthesis 3D mammography
- describe
- X-rays at multiple angles to create a cine imagine of breast tissue
- better for dense breasts and breast lesions
- overall results in fewer callbacks: can isolate layers to better analyze tissue
Breast US
- used as starting for w/u on pts <30 yo
- used in conjunction with mammography to w/u abnormality on screening mamm/pt complaint
- evaluates axilla for abnormal lymph nodes
Breast MRI
- when used
- what is evaluated
- used as screening to evaluate high risk patients
- used for women dx with cancer or who have unresolved findings
- looks for add’l suspicious lesions
- evaluates contralateral breast
- evaluates lymph nodes
Breast MRI
- two downsides
- one pro
- downside: uses contrast, problem with kidney issues. Also can’t use with a heart pacer
- pro: can evaluate implants
Two main tissues in the breast (dumbed down)
- fat
- glandular “working” tissue: where cancers arise
What are the two most common types of breast cancer
- DCIS: ductal carcinoma in situ
2. IDC: invasive ductal carcinoma
What are two additional (less common) types of breast cancer
- LCIS: lobar carcinoma in situ
2. ILC: invasive lobar carcinoma
DCIS
- non-invasive cancer precurser. “respects” the boundary of the duct walls.
- can be aggressive “high grade” or non-aggressive “low grade”
- picked up on mammogram
IDC
- cancer cells break through duct and can infiltrate lymphatics and vasculature.
- does not “respect” boundary of duct walls,
LCIS
Not a true premalignant lesion but associated with cancer
ILC
invasive cancer which originated from lobule
Three additional types of cancer
- Paget’s disease
- Inflammatory breast cancer
- Phyllodes (not as important to know well)
Paget’s disease
Skin changes of areola and/or nipple with underlying DCIS and IDC
(dont’ just call it eczema!!) (and be wary of too much Frankincense)
Inflammatory breast cancer
- erythematous, edematous, warmth of skin
- looks like mastitis
- secondary to aggressive fast growing ca that back up the lymphatic system of the breast
Non-malignant breast pathology
- 2 findings
- Benign, no further w/u needed
- Benign but still needs to be removed
Examples of non-malignant breast pathology that needs no further workup
- ductal hyperplasia
- columnar cell changes
- fibrocystic change
- adenosis
- sclerosis
- apocrine metaplasia
Examples of non-malignant breast pathology that need further workup
- atypical ductal hyperplasia
- flat epithelia atypia
- radial scars
- LCIS
**the risk of these things becoming cancer or harboring cancer is high enough to warrant removal
Benign breast lesions (4)
- Mastitis: nursing women. Erythematous, edematous, tender, warm. Usually with fever
- Fibroadenoma: benign, in young women
- Fibrocystic change: monthly pain and cysts. approx 50% of women have this
- Cysts
Where do breast cancers most commonly spread?
lymph nodes of the chest:
- axilla
- internal mammary chain
- intramammary lymph nodes
Distant mets:
- bone
- liver
- lung
- brain
How do phyllodes tumors spread?
hematogenously
Genetics of breast cancer
- percentage hereditary vs. sporadic
- what two populations at greater risk
- 20% hereditary
- 80% sporadic
- ashkenazi jews and AA
Known breast cancer genes
- BRCA 1 and BRCA2
- PALB2, BARD1, etc. etc.
what other cancers are BRCA1 and 2 associate with?
- melanoma
- ovarian ca
- pancreatic ca
- prostate ca
- GI ca
Does absence of BRCA1/2 gene on 23ANDme test mean there is not a BRCA mutation?
no - just tests for 3 of the many snips
What are the breast cancer risk factors
- Age (greatest factor)
- Hormonal state in early life (onset of menstruation, children, breast feeding, onset of menopause)
- Fam hx
- breast density
What should you make suspicious about breast cancer
- relative dx with breast or ovarian cx younger than 50
- multiple breast and/or ovarian ca on one side of family
- fam hx of bilateral breast ca
- fam hx of triple negative breast ca
- fam hx of male breast cancer
What are current breast health recommendations for women >35 with normal breast cancer risk?
- Clinical encounter 6-12 months
- Annual screening mammogram (consider 3D)
- Breast awareness: be aware of breasts and promptly report changes
What are current breast health recommendations for women with a lifetime risk >20% of breast cancer
- clinical encounter 6-12 months
- annual screening mammogram (starting 10 years prior to youngest fam member’s dx age but no earlier than 30)
- Consider annual breast MRI
- breast awareness
- most high risk programs alternate mammogram with MRI/US every 6 months
What is effect of chest radiation? Who is at risk
- pts treated as child or teenager with radiation for lymphoproliferative disorders like lymphoma
- “mantle radiation”
- considered high risk breast cancer
- start screening 8 years after radiation or by age 25, whichever is later
What sort of clinical breast findings are there?
lumps
change in skin
change in nipple
nipple discharge
How to workup a breast lump
- <30 yo: breast US and possible mammogram
- > 30 yo: dx mammogram and US
- not always cancer, esp if young!
- always work up, believe the patient
How to workup a nipple retraction
- Is it congenital: is it new or old?
- If new, always work it up!
- less concerning if it is intermittently retracted
What causes nipple retraction in cancer
Cancer pulls on cooper ligaments and pulls nipple into breast
Peau d’orange
- describe
- when to workup
- skin dimpling
- sign of edema
- unilateral or bilateral
- unilateral: concern for cancer
- bilateral: more likely systemic cause like renal, liver failure or heart dysfunction
- always workup!!
Nipple discharge
- describe poss findings
- when is it concerning for cancer
- uni or bilateral
- multiple or single duct
- ca risk: spontaneous, unilateral, single duct discharge that is bloody or clear = aways work up
Workup of redness/rash
- causes
- when to be suspicious
- Paget’s of areola or nipple
- infection
- inflammatory breast cancer
- Beware of young women not lactating who has what looks like mastitis! If not gone in 1 week of abx, send to breast imaging!!
Breast pain workup
- common
- But not common presentation of cancer
- diffuse, cyclic pain is almost never associated with breast cancer
- if uncomfortable, send to breast imager
What are the 7 BI-RADS findings
0: need more w/u, “call back”
1: negative
2: benign
3: probably benign =< 2% cancer
4: suspicious
5: highly suspicious
6: known cancer
What three BI-RADS can screening mammography be assigned?
0: more workup needed
1: negative
2: benign
Why might screening mammography get a 0
- waiting on prior comparisons
- suspicious finding was found, pt needs to come in for add’l mammography views or US
BI-RADS 0
- the patient experience
- how often need a biopsy?
- scary!!! Remind pt that breast imagers are cautious, just want to ensure it is ok
- most will be benign
- 20% will need a biopsy but only 20% of those will be cancerous
Examples of BI-RADS 2 findings
(benign)
- vascular calcification
- dystrophic calcification
- Fat necrosis
- oil cyst
- secretory calcification
BI-RADS 3
- ca risk
- f/u protocol
(probably benign)
- <2% risk of ca
- f/u imaging in 6, 12, 24 months if there is not a change at each visit
- if there is a change, biopsy
BI-RADS 4
- ca risk
- f/u
(suspicious)
- 2-95% cancer risk
- biopsy always recommended
- if pathology is benign, return to routine or high risk screening as before
BI-RADS 5
- ca risk
- f/u
(highly suspicious)
- > 95% risk
- even if pathology shows benign, lesion should be sx excised
*would still biopsy to determine what type of ca which will help determine what to excise - lymph nodes, etc.
BI-RADS 6
This is for post-biopsy proven cancer
Other concerning finding on mammography
Unilateral skin thickening
- need to know what caused it if it is new
Does estrogen cause breast cancer??
NO. It might add some fuel to the fire but that ca was there regardless of hormone therapy
Estrogen receptor positive just means cell still has E receptor! Not that the E caused the cancer
What hormone is given as hormone replacement therapy for breast cancer survivors?
testosterone
Do you give breast cancer survivors estrogen therapy?
NO, never. Testosterone is prob ok though
What are the three receptors on teh cancer cell that are referred to in “triple negative”
- E
- P
- Her2neu (a gene actually not a receptor)
