Breast Imaging

Question 1

what is a mammogram?

Answer 1

X ray

mainstay of breast imaging

Question 2

views on mammogram?

Answer 2

oblique and Craniocaudal (CC)

Question 3

where do most cancers occur?

Answer 3

upper outer quadrant

Question 4

how does breast density change across lifetime?

Answer 4

density reduces as you get older

Question 5

how does density affect risk of breast cancer?

Answer 5

more dense = higher risk?

Question 6

advantages of mammography?

Answer 6

images whole of both breasts
sensitive for detecting DCIS and invasive cancer
only screening known to reduce population mortality

Question 7

calcification on mammogram?

Answer 7

fine bright white specks

Question 8

drawbacks of mammography?

Answer 8

ionising radiation (can induce a cancer)
can be uncomfortable

Question 9

what is tomosynthesis?

Answer 9

3D mammography (many slices, almost like a CT of the breast)
increased sensitivity

Question 10

conrast enhanced spectral mammography?

Answer 10

shows contrast enhancement in the breast after IV iodine contrast
low energy image
high energy image
subtraction image (take 1 away from the other so only the parts that are enhancing are left behind)

Question 11

breast US is best used in which cases?

Answer 11

symptomatic cancer (palpable lump)
can further investigate lesion shown on mammogram
image guided biopsy
breast inflammation/abscesses (can be used in draining)
breast problems in pregnancy

Question 12

advanatages of US?

Answer 12

no ionising radiation
not uncomfortable
good sensitivity and specificity for invasive cancer
cant show DCIS
quick
can differentiate cystic from solid
cheap and easy

Question 13

advanced US technologies?

Answer 13

contrast enhanced

Question 14

elastography?

Answer 14

medical imaging modality that maps the elastic properties and stiffness of soft tissue. The main idea is that whether the tissue is hard or soft

Question 15

problems with strain elastography?

Answer 15

non-quantitive

poor reproducibility

Question 16

shear wave elastography?

Answer 16

strain produced by the US probe (shear waves)

….

Question 17

why are breast cancers stiff?

Answer 17

collagen in stroma around the tumour

• organised in normal
• disorganised and poorly aligned in cancerous

Question 18

stiffness in types of breast cancer from most to least?

Answer 18

lobular > ductal > papillary > tubular

Question 19

MRI in breast cancer?

Answer 19

most sensitive imaging for breast cancer diagnosis and sizing
(contrast enhanced = 95% sensitive)

Question 20

problems with MRI?

Answer 20

almost too good
will show tiny foci away from main lesion which will have to be biopsied and will result in a mastectomy when a wide local incision would otherwise be sufficient (other systemic cancer treatments would actually mop up these tiny foci but if they’re seen they have to be taken out)

Question 21

when is MRI used?

Answer 21

lobular cancers
if cancer cant be seen on mammography
if cancer is thought to be bigger than shown on other imaging
pagets disease of the nipple
down sizing of tumour with neoadjuvant chemotherapy (before surgery)
good at showing that the tumour is gone
positive axillary node biopsy but normal mammogram and US
breast implant integrity (intracapsular rupture etc)
screening in very high risk women

Question 22

pagets?

Answer 22

invasion of the nipple by DCIS

Question 23

which type of curve on MRI enhancement (Kuhl enhancement) indicates cancer?

Answer 23

type 3 “washout pattern”

has a relatively rapid uptake and shows reduction in enhancement towards the latter part of the study

Question 24

types of biopsy?

Answer 24

FNA (rarely used anymore)
core needle (most common)
vacuum
stereotactic biopsy (mammogram guided, type of core?)

Question 25

commonest causes of breast lump by age?

Answer 25

<30 = fibroadenoma
30-50 = cyst
>50 = cancer

Question 26

why cant menopausal women get cysts?

Answer 26

need oestrogen in system to form cysts

Question 27

best imaging modality to assess breast mass?

Answer 27

US

• greyish = solid
• black hole = cyst

Question 28

spiculate masses are likely to be what?

Answer 28

cancer

Question 29

when is axillary US done?

Answer 29

can show metastases in breast cancer

abnormal nodes identified by cortical thickness and shape

Question 30

how is breast cancer staged?

Answer 30

only local staging for operable breast cancer
use CT (chest, abdo and pelvis) to look for mets in locally advanced disease

Question 31

when is nipple discharge worrying?

Answer 31

unilateral single duct

bloody etc

Question 32

what can cause breast abscess/infection?

Answer 32

lactation

duct ectasia

Question 33

when is screening done?

Answer 33

every 3 years in women aged 50-70

Question 34

who gets screening?

Answer 34

annual mammogram in women over 40 who have a moderate family history
MRI done in people with BRCA gene or with risk equal to BRCA gene