Breast Review Flashcards by Jason Halpern

What structures comprise the TDLU?

Terminal Duct Lobule Unit - Lobule is the exocrine gland

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What does MQSA of 1998 stand for and mean?

Mamo. Quality Standard Act. Applies to docs, physicists, rads technologists

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ACS guidelines for breast screening?

Qyear at age 40

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ACS guidelines for breast BSE and CBE

CBE should be done at 20-39 q3 years. BSE should be taught about BSE and limitations but can start at 20yo.

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What is screening mamo for?

Healthy adult with no symptoms of BC

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What is a diagnostic mamo for?

Done under supervision of radiologist for patient with signs or symptoms related to breast. Lump, focal, discharge, etc.

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What is the sens/spec of mammography for detection?

Sens 80-90, spec 80-95%

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What are the two standard views?

MLO, CC

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What are 8 special views, additionally?

Spot compression, mag views, true lateral, axillary tail, cleaavage view, rolled, exaggerated CC, implant displaced.

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How old should a comparison mammo study be?

2 years old! Because good to evaluate slow growing tumors.

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Indications for BUS?

solid/cystic? biopsy planning. Evaluation of mass in woman under 30 years old. Staging.

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What is ultrasound NOT good for detecting?

Calcifications

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What two nuclear medicine studies detect breast cancer?

Tc-99m sestamibi, FDG PET

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Four methods for getting samples of a breast lesion?

CNB, needle loc with surg bx, FNA, surgical excision of palpable mass.

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What are the indications for a CNB?

Birads 5 and 4, and 3 if patient is anxious.

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BIRADS

0 - needs additional imaging
1 - negative
2 - Benign - stable mass, cyst, calcs, 0% chance of malig
3 - Probably benign - round calcs, 90% chance
4 - Suspicious abnormality - 2%-90% chance of malig (35% biopsy positive)
5 - Highly suggestive of malig - >90% chance (99% biopsy positive)
6 - Known active malignancy

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What are the three terms used to describe a mass in BIRADS lexicon?

Shape, Margin, density

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What are the three most common palpable masses?

Fibroadenoma (young), cyst, carcinoma (older)

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Lexicon words to describe benign lesions?

Round, oval, macrolobulated, circumscribed margin, radiolucent, or low dencity.

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Lexicon words to describe malignant lesions?

Irregular mass shape, spiculated margin, high density, architectural distortion, enlargement over time

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List a differential for a well defined mass

Cyst, fibroadenoma, phylloides, carcinoma, mets, papilloma, hematoma, hamartoma, lipoma, lymph node (intramammary), abcess, oil cyst, galactocele.

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List a differential for a ill defined mass

Carcinoma, abcess, hematoma, radial scar, fibrocystic change, myoblastoma

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List a differential for a lucent lesions

lymph node, lipoma, hamartoma, oil cyst, galactocele

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What are DIRECT signs of malignancy?

Mass, spiculated, malignant calcs, assymetry, neodensity, architectural distortion

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What are INDIRECT signs of malignancy?

Architectural distortion, skin thickening, nipple retration, lymphadenopathy, breast edema

What is "taller than wide" a sign of?

Bad sign

BUS sign of cystic lesion?

Anechoic, parallel orientation, increase through transmission

BUS sign of fibroadenoma?

Oval or macrolobulated, parallel, circumscried, iso/hypo echoic

BUS sign of carcinoma?

Irregular, spiculated, hypoechoic, NONPARALLEL

What are the stages of enhancement on MRI?

Type1a: persistent (likely benign), Type1b: bowing (typically benign), Type2: plateau (intermediate), Type 3: washout (bad sign)

What type of cancer only enhances 50% of the time?

DCIS

What calcifications are typically benign?

Diffuse/scattered, large, popcornlike, rodlike, smooth, round, stable

What calcifications are typically malignant?

Grouped/clustered, linear, micro (<0.5mm), pleomorphic/heterogeneous, increasing in number

What are ductal casts?

Can be a sign of malignany - these are necrotic debris or secretions that calcify in the ducts. They cand be sandlie or granular

What are two lesions that are almost always associated with calcifications?

DCIS and IDC

What causes PLEOMORPHIC or HETEROGENOUS calcs?

DCIS, fibrocystic change, fibroadenoma, papilloma

What causes AMORPHOUS calcs?

DCIS, fibrocystic change, sclerosing adenitis

What causes LINEAR BRANCHING calcs?

DCIS, VASCULAR, secretory

What causes LUCENT calcifications

fat necrosis, skin cals

What does a vascular calcification look like?

Tram-track

Appearance of fibroadenoma calc?

Popcornlike

Appearance of fibrocystic change calc?

scattered round or amorphous

Appearance of oil cyst calc?

lucent centereed

Appearance of plasma cell mastitis?

needle like calcs along orientation of ducts

Appearance of vascular calc?

tram tracks

Appearance of artifactual calcs of deodorant, talc?

distribution

Appearance of silicone, or foreign body calcs?

bizarre...

Milk of magnesium calcs?

Looks like tea cups on laterals and pearls on CC.

What can cause benign skin thickening?

Inadequate compression, irradiation or surgery, mastitis, cardiac failure, renal failure, liver or hypoalbuminemia, Mondor's disease, SVC thrombus

What can cause malignant thickening?

Locally advanced cancer, recurrent cancer, lymph obstruction, inflammatory breast cancer

What can cause a dialted duct?

Obstruction: DCIS, papilloma, adenoma, debris, duct ectasia

Risk factors for developing breast cancer?

Female, family history, previous BC, early menarche and late menopause, nulliparity, BRCA, prior radiation therapy

What are the histologic types of breast cancer?

Invasive ductal (65), DCIS (15), invasic lobular (10), medullary (3), mucinous (3), tubular (1), phyloides, pagets, inflammatory, papillary.

Keys for ductal carcinoma

could be palpable or discrete, usually spiculated in mammo

Keys for lobular carcinoma

Usually spiculated, usually mammographically occult, which is bad!

Keys for inflammatory carcinoma

Red swollen painful, peau d'orange.

Keys for phylloides tumor

Usually 70 or older, can be round, circumscribed, and look like fibroadenoma, BUT you have to be very suspicious in an old woman.

Keys for Paget's disease of the breast

Thickening of the nipple, can look normal

TNM staging

0: DCIS (nearly 100% survival) I: Invasive tumor less than 2cm, no nodes. (96% survival) II: Invasive tumor less than 5cm, not fixed to chest wall and w/wo local nodes (81% survival) III: Invasive tumor of any size, fixed to chest wall, with nodes, but NO distant (52% survival) IV: Distant mets (18% survival)

What is the most prognostic factor in patients with primary breast cancer?

Axillary nodes

Levels of lymph nodes related to what muscle

All in relation to pec minor

What are the levels?

I is lateral, II is over the muscle, III is medial to the muscle

Does ER positive status portend favorable or bad outcome?

Better outcome

What does a Halstead radical remove?

All breast tissue, pect major/minor, all lymph nodes

What does a modified radical remove?

Everything that the Halstead does minus the musclulature.

What does the total (simple) remove?

Modified minus the nodes

What does a subcutaneous mastectomy remove?

removal of most of the tissue but preservation of nipple, etc.

What is the difference between LCIS and DCIS?

LCIS is being debated to whether it is the precursor to ICS. Whereas 35% of DCIS progresses.

What is a cause of bloody discharge?

Papilloma

How could you try to diagnose this?

Ductogram

What does a radial scar look like radiographically?

Usually spiculated, may have black star (central lucency) appearance, whereas malignancy usually looks like a white star.

Are radial scars associated with cancers?

Yes. Tubular carcinoma. There is often atypia associated so excision is recommended.

How does a simple breast cyst develop?

Dilation of the TDLU!

What gives the appearace of a breast within a breast?

Hamartoma

What appears well circumscribed and entirely radiolucent?

Lipoma

What cystic lesion is caused by a sudden cessation of breast feeding?

galactocele

What is Mondor's disease?

Superficial thrombophlebitis of the veins of the breast.

What does fibrocystic change look like?

Mammo: increased glandular tissue, microcalcifications that are scattered or milk of calcium.

What does fibrcystic change look like on US?

macrocysts or microcyst <3 mm.

What would an abnormal lymph node look like?

dense, not fatty hilum.

When is nipple discharge worrysome?

Blood or serous.

When is nipple discharge not worrysome?

Bilateral, brown, green, milky

What is a study that's useful for evaluating discharge?

Galactogram (ductogram)

What are the two types of rupture?

Intracapsular, extracapsular

How does a breast react to an implant?

Fibrous capsule

What is the best method for evaluating breast implant rupture?

MRI

What is the linguine sign?

Lines in an implant may represent collapse of the capsule

What are radial folds?

NORMAL reduntant retaining capsule

What do crenelated margins indicate?

capsular contracture

What does a focal bulge in implant represent?

Possible herniation through a defect in the fibrous capsule

Breast density categories

Fatty, scattered, heterogenous, dense