Breast: Radiology and Cytology Flashcards
What imaging techniques are used to look at the breast?
- Mammography -Ultrasound
- Image guided techniques
- MRI
- Nuclear Medicine
- Breast Screening Programme
What view are used in mammography?
-ML oblique and craniocaudal mainly
Additional views
- Coned view
- Magnification view
- True lateral
- Extended CC
Who undergoes mammography?
- Over age 40
- Under 40 if strong suspicion of cancer or family history risk greater than 40%
What is the radiation dose in mammography?
1mSv
What are signs of breast disease of mammography?
- Dominant mass
- Asymmetry
- Architectural distortion
- Calcifications
What are the features of malignant soft tissue masses on mammography?
- Irregular, ill-defined
- Spiculated
- Dense
- Distortion of architecture
What are the features of benign soft tissue masses on mammography?
- Smooth or lobulated
- Normal density
- Halo
What is US used for in the breast?
Differentiate
- Solid from cystic mass
- Solid benign from malignant
What is the first line imaging used in the <40s?
US
What are the advantages of US?
- No ionising radiation
- Improves specificity of imaging
How do solid benign lesions appear on ultrasound?
- Smooth outline
- Oval shape
- Acoustic enhancement
How do malignant lesions appear on US?
- Irregular outline
- Interrupting breast architecture
- Acoustic shadowing and anterior halo
What is the triple assessment for breast pathology?
- Clinical examination
- Imaging
- FNA cytology
What is the sensitivity and specificity of the triple assessment for breast cancer?
- Sensitivity 97-100%
- Specificity 98-100%
What are the 2 basic types of image guided biopsy?
- FNA
- Core biopsy
How can image guided biopsy be carried out?
Stereotactic
-Upright or prone table
Ultrasound
-Guided or freehand
What are the indications for MRI of the breast?
-Recurrent disease -Implants -Indeterminate lesion following triple assessment -Screening high risk women
What is the sensitivity and specificity of MRI?
- Sensitivity 94-98% for all breast density
- Specificity is poor
What are the disadvantages of MRI?
- Claustrophobic
- Noisy
- Lengthy
- IV contrast
- Expensive
How is sentinel node sampling performed?
- Peritumoral injection of 99m Tc sulphur colloid ± isosulphan blue dye
- Lymphoscintigraphy
- Intraoperative Gamma probe
- Single Lymph node removal
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
