Breast Review Flashcards
What structures comprise the TDLU?
Terminal Duct Lobule Unit - Lobule is the exocrine gland
What does MQSA of 1998 stand for and mean?
Mamo. Quality Standard Act. Applies to docs, physicists, rads technologists
ACS guidelines for breast screening?
Qyear at age 40
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.
What is screening mamo for?
Healthy adult with no symptoms of BC
What is a diagnostic mamo for?
Done under supervision of radiologist for patient with signs or symptoms related to breast. Lump, focal, discharge, etc.
What is the sens/spec of mammography for detection?
Sens 80-90, spec 80-95%
What are the two standard views?
MLO, CC
What are 8 special views, additionally?
Spot compression, mag views, true lateral, axillary tail, cleaavage view, rolled, exaggerated CC, implant displaced.
How old should a comparison mammo study be?
2 years old! Because good to evaluate slow growing tumors.
Indications for BUS?
solid/cystic? biopsy planning. Evaluation of mass in woman under 30 years old. Staging.
What is ultrasound NOT good for detecting?
Calcifications
What two nuclear medicine studies detect breast cancer?
Tc-99m sestamibi, FDG PET
Four methods for getting samples of a breast lesion?
CNB, needle loc with surg bx, FNA, surgical excision of palpable mass.
What are the indications for a CNB?
Birads 5 and 4, and 3 if patient is anxious.
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
What are the three terms used to describe a mass in BIRADS lexicon?
Shape, Margin, density
What are the three most common palpable masses?
Fibroadenoma (young), cyst, carcinoma (older)
Lexicon words to describe benign lesions?
Round, oval, macrolobulated, circumscribed margin, radiolucent, or low dencity.
Lexicon words to describe malignant lesions?
Irregular mass shape, spiculated margin, high density, architectural distortion, enlargement over time
List a differential for a well defined mass
Cyst, fibroadenoma, phylloides, carcinoma, mets, papilloma, hematoma, hamartoma, lipoma, lymph node (intramammary), abcess, oil cyst, galactocele.
List a differential for a ill defined mass
Carcinoma, abcess, hematoma, radial scar, fibrocystic change, myoblastoma
List a differential for a lucent lesions
lymph node, lipoma, hamartoma, oil cyst, galactocele
What are DIRECT signs of malignancy?
Mass, spiculated, malignant calcs, assymetry, neodensity, architectural distortion
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
