Clin Med: GUT Radiology Women's Health Mammography Flashcards
Halsted’s Principles or Tenets
Gentle Handling of Tissues
Strict Aseptic Technique before and during surgery
Sharp Anatomic Dissection of Tissue
Careful Hemostasis to decrease bleeding, limit infection and deadspace
Obliteration of deadspace and adequate removal of material
Avoidance of tension
Importance of rest
Describe the Breast Anatomy
-Note Lymphatic Drainage and Axillary Tail
- Apical axillary nodes
- central axillary nodes
- Lateral axillary nodes
- Pectoral axillary nodes
- Parasternal nodes
-Lymphatic and venous drainage passes from lateral and superior part of the breast into axilla
Breast Anatomy:
- Chest wall
- _____ Muscle
- Lobes and ______ (glandular tissue)
- Nipple
- Areola
- Ducts
- Fatty tissue
- Skin
- pectoralis
- lobules
**Breast tissue is made up of:
- Fibroglandular Tissue
- Fibrous CT
- Glandular tissue
- Fat
Breast CA:
-List non-modifiable risk factors–>
- Female sex
- Age
- Genetic Susceptibility
- Germline Mutation p53 -autosomal dominant
- -Li-Fraumeni Syndrome 50% by age 50, 90% by age 60
- Cowden Syndrome
- **endogenous Estrogen exposure
Describe Genetic Susceptibility in non-modifiable risk factors
(hint: specific genes?)
**BRCA 1 and 2 –autosomal dominant - Impaired DNA repair
-50-80% Ovarian Cancer 25%
Early onset, bilateral, male
Ex’s of increased susceptibility to endogenous Estrogen exposure:
- Early menarche- before 11 yrs,
- Late menopause
Ex’s of Decreased susceptibility to endogenous Estrogen exposure: (protective factor)
Early pregnancy, Breast feeding, Ovarian ablation
Breast Cancer: Modifiable Risk Factors
(list Ex’s)
- Hormone Replacement:Therapy HRT
- -Can be Combined Estrogen and Progesterone (opposed) or Estrogen alone (unopposed) – Controversial
- Radiation/Radiation Therapy 6X
- Obesity 3X in postmenopausal
- Alcohol
Quadrant-wise there is more breast tissue is in the ____ _____ quadrant.
upper outer**
Breast tissue changes as the patient ages: going from dense, fibroglandular tissue in younger women (difficult to evaluate) to predominantly _____ tissue in older women (relatively easier to evaluate). There is a wide variety in the appearance of normal mammograms between normal women. In a given patient, the breast tissue is usually _______
fatty
-symmetrical.
Breast Cancer usually arises from _______, lobar, lobular and/or ductal tissue. Inflammatory cancers can also occur, an aggressive malignancy infiltrating breast and skin.
parenchymal
Benign Breast masses are very common and include cysts, fibroadenomas, fibrocystic changes, ______, _____, and lymph nodes.
lipomas, fat necrosis
Lymphatic Drainage of the Breast:
-____% of drainage is to Axillary Nodes
-Remainder to Infraclavicular, pectoral, or parasternal (internal thoracic) nodes
75% **
Solitary “blue dome” cyst=
fibrocystic disease of the breast
fibroadenoma of the breast=
are common benign (non-cancerous) breast tumors made up of both glandular tissue and stromal (connective) tissue
Mastitis=
inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis MC affects women who are breast-feeding (lactation mastitis
Breast CA guidelines 2020
Guidelines differ between medical organizations and change over time.
Considerations in the differences between Guidelines
Psychological harms
Balance between benefits and harms
Unnecessary Imaging tests and biopsies.
Inconvenience
Overdiagnosis
Smaller net benefit based on numbers needed to screen.
Radiation dose effects
Viewpoint and experience
Screening Mammography=
-**Asymptomatic women
Recommendations/Guidelines: NCI, HHS, ACS, AMA, ACR
Diagnostic Mammography=
**Symptomatic women: Signs/Symptoms/Positive Screening
Computer Aided Detection: ?
Ultrasound: ?
- Density, Masses, Calcifications
- Cyst versus Solid
MRI: ? False Positive rate ?
CT: Helpful in evaluating ?
- High resolution contrast studies helpful in detection
- -False Positive rate= high.
- -High sensitivity, low specificity
-and monitoring spread
Benign breast conditions: (list)
Cysts Fibroadenoma Fibrocystic Changes Lipoma Fat necrosis Galactocele Hamartoma Intramammary lymph node
Malignant breast conditions- there are many forms (list)
- *Lobular
- *Ductal
- *Inflammatory
On mammography:
-Malignancies tend to have ____
**irregular and spiculated margins, solid
On mammography:
-benign densities tend to have ______
sharp, complete margins
-Very low densities tend to be seen in benign lesions: cysts, lipoma, galactocele, oil cyst
Benign calcifications tend to be=
larger, coarser, round, smooth
Malignant calcifications tend to be=
smaller, finer, pleomorphic, grouped
False Positive Mammograms:
-__% of screening mammograms require additional tests (ie diagnostic mammography or US)
-10%
-about 85% of these will be normal or benign after further workup
-about 2% of all Screening Mammograms are shown to be abnormal and will require biopsy.
Approximately 80% of those biopsied are benign, 20% malignant
Estimates are that for women having yearly mammograms between 40 and 49, there is a __% chance of having a false positive study and a 7-8% chance of having a breast biopsy within the 10 year period of time
The estimate for false positive mammograms is ___% for women 50 or older.
30%
-25%
Mammography:
False negative rate is ____%
8-10%
with aging, the dense tissue in breasts is replaced with _____ _____
fatty tissue
**much easier it is to see tumors in fatty breasts
Bi-RADS Evaluation SystemBreast Imaging Reporting and Data System:
-compostion: A,B, C, D
a- breasts almost entirely fatty
b- Scattered areas of fibroglandular tissue
c- heterogenously dense obscuring
small masses
d- extremely dense
Mass= space occupying lesion (anything irregular tends to be malignant)
-high level of concern w/ architectural distortion
Popcorn fibroadenoma and dystrophic lesions are ______ calcifications (benign or malignant?)
benign**
Malignant Calcifications (list ex’s)
- fine linear branching
- Amorphous (DCIS)
- fine pleomorphic
Malignant:
-associated features?
- skin retraction
- nipple retraction
- skin thickening >2mm
- architectural distortion
- calcifications (when seen in ductal CA may indicate DCIS**
Note spiculated
mass and micro-
calcifications=
think invasive ductal carcinoma!!
is a fibroadenoma of the breast benign?
yes, but must surgically excise and bx to prove benign
MRI of the Breast is being used more commonly**
-describe this technique?
- Multiple thin slices are obtained and reconstructed into a “three dimensional image” that is evaluated.
- Contrast is used to show increased vascularity in malignancies
3-D Tomosynthesis=
far more accurate than 2D!! but more radiation
=essentially a thin section CT of the breast
If we take a random group of 1000 50-year-old women, how many will be expected to die of breast cancer in the next 10 years. If we screen those 1000 women every two years for a decade, how many fewer women might be expected to die of breast cancer?
about five (5) are likely to die of breast cancer in the next ten years. If we screen every two years for a decade with mammograms, we prevent one of them from dying of breast cancer. We need to regularly screen 1,000 women in this way to prevent one breast cancer death. Studies have shown both men and women over-estimate their risk from diseases and benefits of screening.
**Know : with mammography we’re going to sav about 20-30% of the ppl who would get breast cancer
A recent study found that 0.5 percent of women ages 50 to 69 have breast cancer. One woman in that age group goes in for a screening mammogram. She gets a call that it’s ”positive” and needs to come back for a further workup. After that positive screen, what is the percent chance that she really has breast cancer, and what’s the percent chance that she does not?
Pre-mammogram, there is a 99.5% chance that she does not have breast cancer. Based on test characteristics, once she has had a “positive” screening mammogram, she then has a 4 percent chance of having breast cancer. She still has a 96 percent chance of not having breast cancer, even after the positive screen. People think that many screening tests are more accurate than they are.
Breast CA considerations
Evidence is accumulating that many breast cancers are being “overdiagnosed”.
“Overdiagnosis refers to detection of a neoplasm that will never cause symptoms or death (become clinically apparent = occult) during a patient’s lifetime”
These are cancers that either grow so slowly that the patient dies of other causes or the cancer lies dormant or regresses.
Overdiagnosis may occur in a significant percentage of cancers found, ie over 15-20%. One study says one cancer in three are overdiagnosed.
The Problem is to distinguish which are “bad” cancers and which are not going to harm or kill the patient. Currently this is not possible, thus all patients with a cancer found are treated.
Autopsy prevalence of occult cancers (undetectable clinically):
- ___% for invasive CA
- ___% for ductal carcinoma of
- 3% for invasive cancer
8. 9% for Ductal carcinoma in situ (DCIS)
**Characteristics of DCIS:
- **30-50% will progress to invasive breast cancer
- Invasive potential is impossible to predict for a given patient at this time
Thus, patients who have potentially non-invasive DCIS are being treated if DCIS is found clinically and/or mammographically.
