CORE - Mammo Flashcards
1
Q
Screening women from 40-49 is classified as ___ by USPSTF
A
Class C - based on individual factors
2
Q
MLO imaging plane
A
40-60 degrees from the axial plane; parallel to the pectoralis major; may exclude superior-medial tissue
3
Q
“Dashes but not dots”
A
secretory calcifications (plasma cell mastitis); typically bilateral
4
Q
Cigar-shaped calcifications
A
secretory calcifications (plasma cell mastitis); typically bilateral
5
Q
Large rod-like calcifications
A
secretory calcifications (plasma cell mastitis); typically bilateral
6
Q
Popcorn calcifications
A
fibroadenoma
7
Q
Eggshell or rim calcifications
A
oil cyst
8
Q
“Breast within a breast”
A
hamartoma
9
Q
Powdered sugar calcifications
A
amorphous
10
Q
Coarse heterogeneous calcifications
A
irregular, >0.5 mm (but smaller than dystrophic calcifications); may be assoc. with malignancy; biopsy is warranted
11
Q
Dot-dash calcifications
A
fine pleomorphic (<0.5 mm)
12
Q
Most suspicious type of calcifications
A
fine linear-branching (BR-4c) > fine pleomorphic (BR-4b)
13
Q
Suspicious calcification distributions
A
segmental (most suspicious) > linear > grouped
14
Q
BI-RADS for suspicious calcification types
A
BR-4, unless other suspicious findings are identified on mammo/US (e.g. an associated mass)
15
Q
Suspected dermal calcifications
A
tangential view to prove skin location
16
Q
Tattoo sign
A
dermal calcifications; fixed relationship between calcifications across different views
17
Q
Regional distribution of calcifications
A
distributed over >2 cm; malignancy less likely
18
Q
Grouped distribution of calcifications
A
> 5 small calcifications within <2 cm; suspicious
19
Q
Bilateral flame shaped subareolar masses (male)
A
gynecomastia
20
Q
Shrinking breast
A
ILC
21
Q
Fat-fluid level
A
galactocele
22
Q
Rapidly-growing fibroadenoma
A
phyllodes tumor
23
Q
Mastitis refractory to antibiotics
A
inflammatory breast cancer
24
Q
Architectural distortion with calcifications
A
IDC + DCIS
25
Architectural distortion without calcifications
ILC
26
Type of DCIS associated with highest rate of recurrence
micropapillary
27
Snowstorm appearance on US
extracapsular silicone
28
Stepladder sign on US
intracapsular rupture
29
Linguine sign on MRI
intracapsular rupture
30
Calcifications in lumpectomy bed
must exclude residual or recurrent disease
31
Biopsied calcifications absent from mammo but not in core specimen
likely milk of calcium calcifications; use polarized light
32
Nipple enhancement on MRI
normal
33
Darkening of areola
normal with puberty and parity
34
Breast tenderness peak during cycle
day 27-30
35
Most comprehensive breast cancer risk model
Tyrer Cuzick (does not include breast density); Gail model is the worst (does not include genetics)
36
BRCA type most assoc. with male breast cancer
BRCA2
37
BRCA type more likely to have triple negative cancer
BRCA1
38
Surgical scars should get lighter over time
If getting darker or focal nodular, consider local recurrence
39
Silicone in a lymph node on US - NEXT STEP
MRI to evaluate for implant rupture
40
Biggest risk factor for implant rupture
age of implant
41
Invasive lobular carcinoma represents ____ of breast cancer
5-10%
42
Tumor invasion of dermal lymphatics
inflammatory breast cancer
43
Prognosis for ER/PR positive cancers
good prognosis (better than negative types)
44
Most common pathogen causing of mastitis
S. aureus; seen in nursing mothers and diabetics
45
Mondor disease + treatment
thrombophlebitis of a superficial vein; tender; Tx NSAIDs + warm compresses
46
BI-RADS 3
<2% chance of malignancy; gets 2 year diagnostic follow-up (6-6-12)
47
BI-RADS 4
2-95% chance of malignancy; benign path result is ok
48
BI-RADS 5
>95% chance of malignancy; CANNOT accept a benign path result
49
BI-RADS 6
biopsy-proven malignancy
50
Women with extremely dense breasts have a ____ increased risk of cancer compared with almost entirely fatty breasts
5x
51
Lesion movement based on location - CC => MLO => ML
"Muffins rise, lead falls." Medial lesions will move up from CC to lateral. Lateral lesions will move down.
52
New mass on screening mammogram (any characteristics) - NEXT STEP
ultrasound; cannot call any mass benign on screening mammo alone
53
Pathologic nipple discharge
unilateral; clear or bloody; often spontaneous
54
Non-pathologic nipple discharge
bilateral; green, brown, or milky
55
Most common cause of pathologic nipple discharge
papilloma
56
Clustered microcysts
due to apocrine metaplasia or fibrocystic changes; BR-3 (if no solid component)
57
ILC (compared to IDC)
more often multifocal and bilateral
58
Most common type of lymphoma involving the breast
B-cell lymphoma
59
Non-mammo finding in Poland syndrome
ipsilateral syndactyly; more common in males; often absence of breast tissue as well
60
Definition of focus on MRI
focal enhancement <5 mm, round/oval, well-circumscribed; no mass effect, no pre-contrast correlate
61
Normal enhancement at a lumpectomy site can be seen up to
6-18 months, due to granulation tissue; enhancement should not recur after it subsides
62
Post-radiation therapy increased breast density and skin thickening should peak at...
6 months; beyond 12 months post-radiation it should be considered recurrence until proven otherwise
63
Eklund view (mammo)
implant-displaced view
64
Implant type with a valve
saline
65
Implant type that is semi-lucent
saline
66
US-guided core biopsy needle characteristics
14G, spring-loaded
67
Standard breast biopsy needle advances approximately ___ when fired
2 cm
68
US-guided cyst aspiration needle characteristics
18G or 20G needle (FNA)
69
Cyst aspirate should be sent for cytology if...
bloody; may discard clear, green, grey, yellow, or cloudy fluid (benign)
70
Complex cystic mass biopsy - FNA or core
core needle biopsy
71
Stereotactic biopsy needle characteristics
11G, vacuum-assisted
72
Components of the mammographic report
history/indication/risk factors, comparison studies, breast composition, findings, impression/BI-RADS/recommendation
73
Required annotation for US image
side (left/right), clock face position, distance from nipple, orientation of probe
74
Indications for breast MRI
high risk screening (>20-25% lifetime risk), extent of disease, axillary mets with unknown primary, diagnostic dilemmas, suspected silicone implant rupture, evaluate for recurrence, evaluate for margins after resection, follow response after neoadjuvant chemo
75
Triple negative cancers
ER, PR, and her2/neu negative; aggressive, bad prognosis; may show paradoxically benign features
76
Bilateral axillary lymphadenopathy DDx
collagen vascular disease, lymphoma, leukemia, rheumatoid arthritis, HIV
77
Multiple intraductal papillomas
tend to occur in younger patients than solitary papillomas; not typically assoc. with nipple discharge; increased risk of breast cancer
78
Multiple skin masses DDx
neurofibromas (NF1), steatocystoma multiplex
79
Angiosarcoma MRI characteristics
T2 hyperintense, intense enhancement
80
Mets to the breast
most frequently from melanoma > RCC; also consider contralateral breast cancer if that is an option on multiple choice
81
Contraindications to stereotactic needle biopsy
<3 cm breast tissue when compressed, far posterior or subareolar location, inability to be positioned on table, uncontrolled coagulopathy
82
Complicated cyst
contains low-level echoes or layering debris; can perform aspiration or follow with US (BR-3)
83
Complex cyst
cystic and solid components; solid component needs to be biopsied (BR-4)
84
Sclerosing adenosis
benign; diffusely scattered microcalcifications
85
Tail of Spence
axillary extension of breast tissue
86
Quadrant most breast cancers arise from
upper-outer (most densely populated with fibroglandular tissue)
87
Regions of breast with least fibroglandular tissues
lower-inner and retroglandular regions ("danger zones" = areas where cancer hides)
88
Breast asymmetry
normal, but consider a "shrinking breast" (ILC)
89
Where do most breast cancers start?
TDLU
90
Lactiferous sinus
dilated portion of major duct just deep to nipple
91
Major blood supply to the breast
internal mammary artery (medial)
92
Major lymphatic drainage of the breast
axillary (97% of drainage)
93
Level 1 axillary nodes
inferior-lateral to pectoralis minor
94
Level 2 axillary nodes
deep to pectoralis minor
95
Level 3 axillary nodes
superior-medial to pectoralis minor
96
Rotter nodes
between pectoralis major and minor
97
Sternalis muscle
5% of population, usually unilateral; seen on CC view only
98
Most common location for ectopic breast tissue
axilla > inframammary fold
99
Most common location for polythelia
axilla > inframammary fold
100
Best time in cycle for mammogram and MRI
day 7-14 (follicular phase); lowest BPE for MRI
101
Increased breast density - when?
luteal phase, 3rd trimester, HRT, prolactinoma, antipsychotics, weight loss, hypothyroidism, young age, diabetic mastopathy
102
Lipoma appearance on US
appears isoechoic relative to fatty breast tissue
103
Mets to internal mammary node
consider a medial breast cancer
104
Peak time for breast pain and cyst formation (during life)
perimenopause
105
Risk of breast biopsy while lactating
milk fistula; must stop breast feeding if fistula forms
106
Technical adequacy
posterior nipple line touches pectoralis on MLO and within 1 cm on CC, no blur, nipple in profile on 1 view, inframammary fold should be seen
107
Indications for LMO view
pacemaker/central line, pectus excavatum, kyphosis
108
Which view includes the most breast tissue?
MLO
109
Collimation on spot compression views?
leave the collimator open (for wide FOV)
110
Choosing between an ML vs. LM view
last letter (detector side) should match lesion location on screening study; lateral => ML, medial => LM
111
Skin thickening + trabecular thickening DDx
edema (CHF, renal failure, liver failure), radiation, mastitis, lymphatic obstruction, inflammatory breast cancer
112
Recall rate benchmark
10%
113
PPV1 benchmark
cancers in patients called back (BR-0, BR-3, BR-4, or BR-5); 4%
114
PPV2 benchmark
cancers in patients recommended for biopsy (BR-4 or BR-5); 25%
115
PPV3 benchmark
cancers in patients who underwent biopsy; 31%
116
BI-RADS 4a
low suspicion for malignancy, >2 to ≤10%
117
BI-RADS 4b
moderate suspicion for malignancy, >10 to ≤50%
118
BI-RADS 4c
high suspicion for malignancy, >50 to <95%
119
Multiple bilateral masses + NEXT STEP
BR-2; at least 2 in one breast and 1 in the other breast; do not need to US unless palpable
120
Findings that can be BR-3 (mammo)
classic appearance for fibroadenoma, focal asymmetry, grouped punctate round calcifications; must be on baseline exam (NOT new)
121
Breast composition (mammo)
entirely fat, scattered fibroglandular, heterogeneously dense, extremely dense
122
Shape (mammo)
ROI - round, oval, irregular
123
Margins (mammo)
COMIS - circumscribed, obscured, microlobulated, indistinct, spiculated
124
Density (mammo)
fat density, hypodense, isodense, hyperdense; relative to breast parenchyma
125
Global asymmetry
asymmetric amount of breast tissue density in only one breast; must involve >1 quadrant
126
Developing asymmetry
focal asymmetry that is new or increased in size; at least BR-4 if it persists on compression and no benign US correlate
127
Shape (US)
ROI - round, oval, irregular
128
Margins (US)
CAMIS - circumscribed, angular, microlobulated, indistinct, spiculated
129
Orientation (US)
parallel or anti-parallel
130
Echo pattern (US)
anechoic, hypoechoic, isoechoic, hyperechoic, complex (cystic & solid), heterogeneous; relative to subcutaneous fat
131
Posterior features (US)
none, shadowing, enhancement, combined pattern
132
Background parenchymal enhancement (MRI)
minimal, mild, moderate, marked; based on first post-gad sequence
133
NME - distribution (MRI)
focal, linear, segmental, regional, multi-regional, diffuse
134
NME - enhancement pattern (MRI)
homogeneous, heterogeneous, clumped, clustered ring
135
Mass - shape (MRI)
ROI - round, oval, irregular
136
Mass - margins (MRI)
CIS - circumscribed, irregular, spiculated
137
Mass - enhancement (MRI)
homogeneous, heterogeneous, rim enhancement, dark internal septations
138
High density foci in axilla
deodorant
139
Parallel linear calcifications
vascular calcifications
140
DDx for amorphous calcifications
fibrocystic change, sclerosing adenosis, DCIS (low grade), columnar cell change
141
DDx for coarse heterogeneous calcifications
fibroadenoma, papilloma, fibrocystic change, DCIS (low to intermediate grade)
142
DDx for fine pleomorphic calcifications
DCIS (high grade), fibrocystic change, fibroadenoma, papilloma
143
Enlarging lipoma - NEXT STEP
biopsy
144
Steatocystoma multiplex
multiple oil cysts (intradermal)
145
Do fat-containing lesions (on mammo) get an US?
no
146
Benign myofibroblastic hyperplasia
a.k.a. PASH; well-circumscribed, solid mass
147
Fibroadenoma MRI characteristics
T2 bright, dark internal septations, type I enhancement
148
Breast mass that mets hematogenously
phyllodes tumor; 10% chance of malignant degeneration
149
IDC subtype associated with radial scar
tubular (presents as a small spiculated mass)
150
IDC subtype that is T2 bright
mucinous (a.k.a. colloid)
151
IDC subtype that is complex cystic and solid
papillary; 2nd most common subtype (IDC NOS is 1st)
152
IDC subtype associated with BRCA1
medullary; 25% have BRCA1
153
Multifocal breast cancer
within same quadrant or within 5 cm
154
Multicentric breast cancer
different quadrants AND >5 cm apart
155
3 ways to show DCIS
fine linear branching or fine pleomorphic calcifications, NME on MRI, or multiple intraductal masses on galactography
156
Architectural distortion without a central mass DDx
ILC, radial scar, surgical scar, IDC-NOS
157
Inflammatory breast cancer
bad prognosis; dermal biopsy if not identifiable mass; Tx chemo/radiation before surgery
158
Paget's disease of the breast association
high-grade DCIS; NOT T4 (despite nipple involvement)
159
Indications for MRI screening
BRCA mutation, 1st degree relative with BRCA but untested, lifetime risk >20-25%; radiation to chest b/w 10-30 y/o (>20 Gy), Li Fraumeni/Cowden/Bannayan-Riley syndrome + 1st degree relatives
160
Reduction mammoplasty
nipple moves superiorly, glandular tissue moves inferior (with swirling)
161
Age to start screening for BRCA patients
25-30 years old (varies based on guidelines)
162
Age to start screening for patient with 1st degree relative with breast cancer
10 years before relative developed cancer or age 30, whichever comes LATER
163
Age to start screening after chest radiation (b/w 10-30 y/o)
8 years after radiation treatment or at 25 y/o, whichever comes LATER
164
Clinical symptoms worrisome for breast cancer
skin dimpling, focal skin thickening, nipple retraction
165
Bilateral skin thickening
CHF, renal failure, liver failure
166
Unilateral skin thickening
inflammatory breast cancer, prior radiation, lymphatic obstruction, mastitis/abscess
167
Risk factors for mastitis
breastfeeding, smoking, diabetics
168
Causes of milky discharge
thyroid issues, prolactinoma, antidepressants/neuroleptics/reglan
169
Most common cause of benign nipple discharge in postmenopausal women
ductal ectasia; dilated ducts in subareolar region
170
Contraindications to galactography
active infection, unable to express discharge at time of exam, contrast allergy, prior surgery to nipple-areola complex
171
BI-RADS for architectural distortion
BR-4 (or BR-5 if other suspicious findings, e.g. mass); always biopsied
172
Suspicious mass identified on US - NEXT STEP
scan the remainder of the radian and the axilla
173
Indications for lymph node biopsy
cortical thickness of 3 mm or greater, loss of fatty hilum, irregular cortex or focal bulge, round shape
174
High density material in lymph nodes
gold (prior TB Tx), tattoo, sarcoidosis, nodal met
175
Most common pattern of gynecomastia
nodular (flame-shaped); others are dendritic and diffuse glandular
176
Most common palpable findings in men
gynecomastia > lipoma
177
Risk factors for male breast cancer
BRCA, Klinefelter's, cirrhosis, chronic alcoholism
178
Most common complication of implants
capsular contracture; contraction of fibrous capsule => cosmetic deformity; most common in pre-pectoral implants
179
Gel bleed
"leakage" of silicone through implant (not ruptured); seen as snowstorm in a lymph node
180
Keyhole sign
intracapsular implant rupture
181
Mastopexy
breast lift (removal of skin)
182
Peak time for recurrence after resection
4 years; occurs in 6-8% of patients following breast conservation therapy (higher without radiation)
183
Specimen radiograph evaluation
1. Are the mass/calcifications present? 2. Are the mass/calcifications at the edge?
184
Breast cancer T-staging
T1 = <2 cm, T2 = 2-5 cm, T3 = >5 cm, T4 = any size with chest wall fixation, skin involvement, or inflammatory carcinoma
185
Most important predictor of overall survival in breast cancer
axillary node status at diagnosis
186
Most common met to breast
melanoma
187
Contraindications to breast conservation therapy (lumpectomy + radiation)
inflammatory carcinoma, large size relative to breast, multicentric disease, prior radiation to same breast, contraindication to radiation (connective tissue diseases), early pregnancy, positive margins after reasonable surgical attempt
188
Breast cancer types that present as a well-circumscribed mass
papillary, mucinous, medullary ("Peanut M&M's")
189
Causes of gynecomastia
hormone-producing tumor (especially testicular), cirrhosis, marijuana, spironolactone, pituitary hormone dysfunction, anti-depressants
190
New mass on MRI
BR-4 or BR-5 depending on characteristics => MR-guided biopsy
191
New NME on MRI
BR-4 => MR-guided biopsy
192
Second-look US
use US to search for finding identified on MRI prior to proceeding to MR-guided biopsy; US-guided biopsy preferred to MR-guided biopsy
193
Amount of chest radiation between 10-30 y/o to justify MRI screening
20 Gy
194
Effect of tamoxifen on breast MRI
decreased BPE, with rebound increased BPE after cessation
195
Timing of early phase of enhancement (MRI)
within the first 2 minutes; slow, medium, rapid
196
Timing of delayed phase of enhancement (MRI)
2-6 minutes; persistent (type I), plateau (type II), washout (type III)
197
Enhancement kinetics warranting biopsy
type II or III
198
Most predictive feature of malignancy (MRI)
spiculated margins
199
Bilateral disease is more common with...
BRCA, ILC, multicentric disease
200
Patient on HRT needing breast MRI
discontinue HRT for 1-3 months prior
201
Multiple foci (MRI)
report as BPE (not a separate finding)
202
ACS screening guidelines
annually from 45-55 y/o, every 2 years starting at 55 y/o; should continue while in good health and life expectancy is >10 years
203
USPSTF screening guidelines
every 2 years starting at 50 y/o; continue until 74 y/o
204
ACR screening guidelines
annually starting at 40 y/o; continue until life expectancy is less than 5-7 years
205
BI-RADS meaning
Breast Imaging Reporting And Data System
206
BRCA1 chromosome
17; most common type of BRCA
207
BRCA2 chromosome
13
208
Men should be evaluated with US before age...
25 y/o; mammo for older males
209
Women should be evaluated with US before age...
30 y/o; mammo or US for women 30-39 y/o; mammo for women 40+ y/o
210
Paget disease represents what histologically?
DCIS
211
HER2/neu-specific treatment agents
trastuzumab, lapatinib
212
Granulomatous mastitis
occurs after childbirth, non-infectious inflammation
213
Periductal mastitis
a.k.a. plasma cell mastitis; produces secretory calcifications in post-menopausal women
214
Diabetic mastopathy
sequelae of insulin-dependent diabetes; ill-defined, asymmetric increased density
215
Definition of a mass (mammo)
space-occupying lesion with convex borders seen on two different projections
216
BI-RADS for diffusely distributed punctate calcifications
BR-2
217
Reduced compression view
for far posterior lesions that "slip out" of view with full compression
218
Superficial cysts
epidermal inclusion cyst, sebaceous cyst; located completely within the echogenic dermis, may communicate with skin surface
219
Findings that can be BR-3 (US)
complicated cyst, clustered microcysts, mass with fibroadenoma characteristics, hyperechoic mass with central hypoechogenicity (fat necrosis)
220
Fibroadenolipoma
a.k.a. hamartoma
221
Known lymphoma diagnosis + new breast mass
primary consideration is still breast cancer
222
Male with clinical gynecomastia - NEXT STEP
nothing; no imaging required
223
Benign lesions with type 3 kinetics
lymph nodes, adenosis, papillomas
224
Rim enhancement
descriptor for masses in MRI; highly suspicious; benign mimics include peripheral enhancement of inflammatory cyst or fat necrosis
225
Most common NME distribution of DCIS
segmental (triangular-shaped pointing towards nipple)
226
Most common NME internal enhancement of DCIS
clumped (cobblestone pattern or "bunch of grapes"), especially in a linear or segmental distribution
227
Susceptibility artifact on T1
calcifications, biopsy clips
228
BI-RADS for mass or NME with benign morphology and enhancement kinetics (MRI)
BR-3
229
Mass adjacent to vessel with type II or III enhancement kinetics
likely an intra-mammary lymph node (reniform shape)
230
Syndromes assoc. with a high risk of breast cancer
BRCA 1/2, Li Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba, ataxia telangiectasia
231
Lay report due within...
30 days
232
MQSA requirements - CME
15 credit hours with last 3 years, 960 studies during the last 2 years
233
MQSA requirements - initial certification (residency)
240 studies within a 6 month period during the last 2 years, 12 weeks of formal training, 60 hours of education
234
Needle angle for US-guided biopsy
parallel to chest well
235
Negative stroke margin + NEXT STEP
insufficient tissue thickness for stereotactic biopsy (<3 cm); next step is needle localization for excisional biopsy
236
Breast phantom characteristics
50% glandular, 4.2 cm thick, 6 fibers/5 masses/5 specks
237
Biopsy samples obtained - NEXT STEP
place marker clip then obtain orthogonal views to verify clip position
238
Gad or no gad for MRI-guided biopsy?
almost always requires gadolinium
239
Best approach for needle localization
shortest approach should be used
240
Amount of contrast used in galactography
0.2-0.3 cc
241
IDC subtype with best prognosis
tubular
242
Digital mammo is superior to film screen for which patient groups?
women <50 y/o, women with dense breasts, peri-menopausal women
243
Abscess treatment
aspiration + antibiotics
244
Stuff males do NOT get
ILC/LCIS/ALH, fibroadenoma, phyllodes
245
Complex sclerosing lesion definition
radial scar >1 cm
246
Palpable diagnostic mammography views
CC + MLO + spot tangential, then US
247
Minimum ultrasound probe frequency
10 MHz
248
Benefits of tomosynthesis
decreases recall rate, increases sensitivity for small masses
249
Stroke margin (definition)
distance from image receptor to tip of needle (post-fire); negative stroke margin => needle loc for excision
250
Breast cancers detected from screening
2-8 cancers per 1000 women screened
