Breast: Radiology and Cytology Flashcards by Dua Khan

What imaging techniques are used to look at the breast?

Mammography -Ultrasound
Image guided techniques
MRI
Nuclear Medicine
Breast Screening Programme

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What view are used in mammography?

-ML oblique and craniocaudal mainly

Additional views

Coned view
Magnification view
True lateral
Extended CC

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Who undergoes mammography?

Over age 40

- Under 40 if strong suspicion of cancer or family history risk greater than 40%

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What is the radiation dose in mammography?

1mSv

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What are signs of breast disease of mammography?

Dominant mass
Asymmetry
Architectural distortion
Calcifications

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What are the features of malignant soft tissue masses on mammography?

Irregular, ill-defined
Spiculated
Dense
Distortion of architecture

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What are the features of benign soft tissue masses on mammography?

Smooth or lobulated
Normal density
Halo

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What is US used for in the breast?

Differentiate

Solid from cystic mass
Solid benign from malignant

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What is the first line imaging used in the <40s?

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What are the advantages of US?

No ionising radiation

- Improves specificity of imaging

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How do solid benign lesions appear on ultrasound?

Smooth outline
Oval shape
Acoustic enhancement

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How do malignant lesions appear on US?

Irregular outline
Interrupting breast architecture
Acoustic shadowing and anterior halo

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What is the triple assessment for breast pathology?

Clinical examination
Imaging
FNA cytology

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What is the sensitivity and specificity of the triple assessment for breast cancer?

Sensitivity 97-100%

- Specificity 98-100%

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What are the 2 basic types of image guided biopsy?

- Core biopsy

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How can image guided biopsy be carried out?

Stereotactic
-Upright or prone table

Ultrasound 
-Guided or freehand

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What are the indications for MRI of the breast?

-Recurrent disease -Implants -Indeterminate lesion following triple assessment -Screening high risk women

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What is the sensitivity and specificity of MRI?

Sensitivity 94-98% for all breast density

- Specificity is poor

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What are the disadvantages of MRI?

Claustrophobic
Noisy
Lengthy
IV contrast
Expensive

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How is sentinel node sampling performed?

Peritumoral injection of 99m Tc sulphur colloid ± isosulphan blue dye
Lymphoscintigraphy
Intraoperative Gamma probe
Single Lymph node removal

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How accurate is sentinel node sampling?

97% accurate at identifying the sentinel node

What is the breast screening programme?

Women 50-70 invited every 3 years for mammography -Mammograms detect 5 cancers/1000 screened
Uptake is 80%
Recall for further investigations is 5-10%

What is the aim of the breast screening programme?

To detect cancers at DCIS stage or less than 15 mm is size while still impalpable

What is cytology?

Microscopic examination of a thin layer of cells on a slide?

How can cells be obtained for cytology in breast disease?

- Fine Needle Aspiration - Direct smear from nipple discharge - Scrape of nipple with scalpel

What is the role of cytology in the symptomatic clinic?

Patient presents with symptoms and undergoes “triple assessment” by surgeon, radiologist and cytopathologist

What is the role of cytology in breast screening?

-Asymptomatic women invited for mammographic examination mostly get core biopsy and FNA of axillary nodes/ satellite lesions)

What may be palpable in someone who is symptomatic?

Discrete mass - Cystic - Solid Diffuse thickening Nipple lesion - Discharge - Eczematous skin

What equipment is needed for FNA?

- 23G needle - 10ml syringe +/- Cameco holder - Alcohol swab - Cotton wool, sticking plaster - Glass slides, pencil - +/-Vial with saline for needle washings

What is the technique for FNA?

- Ensure patient comfortable - Examine to locate lump - Swab area - Localise lump between fingers - Insert needle (45o) and aspirate using in and out action applying negative pressure on syringe - Release pressure and remove needle (nb. Non- aspiration technique) - Apply cotton wool to ensure haemostasis - Spread material onto glass slides - fix, air dry

What patient considerations are there for FNA?

- Informed of procedure - Comfort - Chaperone

What safety considerations are there for FNA?

- Wear gloves/ handwashing - Dispose of needle - Care handling fresh material/ infection risk

How do benign lesions appear on cytology?

- Low/moderate cellularity - Cohesive groups of cells - Flat sheets of cells - Bipolar nuclei in background - Cells of uniform size - Uniform chromatin pattern

How doe malignant lesions appear on cytology?

- High cellularity - Loss of cohesion - Crowding/overlapping of cells - Nuclear pleomorphism - Hyperchromasia - Absence of bipolar nuclei

What type of malignant diagnosis does cytology usually provide?

Usually non specific e.g. adenocarcinoma NOS Occasional feature may suggest - Cytoplasmic vacuoles (lobular carcinoma) - Cells arranged in tubes (tubular carcinoma)

What is the cytology scoring system?

- C1 Unsatisfactory - C2 Benign - C3 Atypia (probably benign) - C4 Suspicious (probably malignant) - C5 Malignant

What is the curative treatment for cysts?

Aspiration

Fluid from cysts is discarded unless..

- Fluid is bloodstained | - There is residual mass

What are the advantages of FNA cytology?

- Simple procedure - can be done at clinic - Well tolerated by patients - Inexpensive - Immediate results

What are the disadvantages of FNA cytology?

ACCURACY NOT 100% - False Negatives - False Positives - Invasion cannot be assessed - Grading cannot be done

What sampling limitations of FNA cytology are there?

- Small lesions | - Small tumour in a larger area of thickening

What technical limitations of FNA cytology are there?

- Difficult to examine cells | - Suboptimal smears (blood, thick, cells smeared)

What are the possible complications of FNA?

- Pain - Haematoma - Fainting - Infection - Rare (pneumothorax)

What is indicative of a nipple lesion?

Bloody discharge from single duct

What can be seen on cystoscopy of nipple discharge of duct ectasia?

Macrophages only

What can be seen on cystoscopy of nipple discharge intraduct papilloma?

Benign cells in papillary groups

What can be seen on cystoscopy of nipple discharge intraduct carcinoma (DCIS)?

Malignant cells

What can be seen on cystoscopy of a nipple scrape of Paget's disease?

Squamous cells and malignant cells

What can be seen on cystoscopy of a nipple scrape of eczema?

Squamous cells from epidermis only

When is core biopsy carried out?

- All cases with clinical OR radiological OR cytological suspicion - Breast screening – especially architectural distortion and microcalcification - Pre-operative classification

How is a core biopsy obtained?

- Using a 14G needle to extract an intact tissue strand | - Fixed in formalin

What is core biopsy used for?

- Confirm invasion - Tumour typing and grading - Immunohistochemistry – receptor status