CORE - Mammo Flashcards
Screening women from 40-49 is classified as ___ by USPSTF
Class C - based on individual factors
MLO imaging plane
40-60 degrees from the axial plane; parallel to the pectoralis major; may exclude superior-medial tissue
“Dashes but not dots”
secretory calcifications (plasma cell mastitis); typically bilateral
Cigar-shaped calcifications
secretory calcifications (plasma cell mastitis); typically bilateral
Large rod-like calcifications
secretory calcifications (plasma cell mastitis); typically bilateral
Popcorn calcifications
fibroadenoma
Eggshell or rim calcifications
oil cyst
“Breast within a breast”
hamartoma
Powdered sugar calcifications
amorphous
Coarse heterogeneous calcifications
irregular, >0.5 mm (but smaller than dystrophic calcifications); may be assoc. with malignancy; biopsy is warranted
Dot-dash calcifications
fine pleomorphic (<0.5 mm)
Most suspicious type of calcifications
fine linear-branching (BR-4c) > fine pleomorphic (BR-4b)
Suspicious calcification distributions
segmental (most suspicious) > linear > grouped
BI-RADS for suspicious calcification types
BR-4, unless other suspicious findings are identified on mammo/US (e.g. an associated mass)
Suspected dermal calcifications
tangential view to prove skin location
Tattoo sign
dermal calcifications; fixed relationship between calcifications across different views
Regional distribution of calcifications
distributed over >2 cm; malignancy less likely
Grouped distribution of calcifications
> 5 small calcifications within <2 cm; suspicious
Bilateral flame shaped subareolar masses (male)
gynecomastia
Shrinking breast
ILC
Fat-fluid level
galactocele
Rapidly-growing fibroadenoma
phyllodes tumor
Mastitis refractory to antibiotics
inflammatory breast cancer
Architectural distortion with calcifications
IDC + DCIS
Architectural distortion without calcifications
ILC
Type of DCIS associated with highest rate of recurrence
micropapillary
Snowstorm appearance on US
extracapsular silicone
Stepladder sign on US
intracapsular rupture
Linguine sign on MRI
intracapsular rupture
Calcifications in lumpectomy bed
must exclude residual or recurrent disease
Biopsied calcifications absent from mammo but not in core specimen
likely milk of calcium calcifications; use polarized light
Nipple enhancement on MRI
normal
Darkening of areola
normal with puberty and parity
Breast tenderness peak during cycle
day 27-30
Most comprehensive breast cancer risk model
Tyrer Cuzick (does not include breast density); Gail model is the worst (does not include genetics)
BRCA type most assoc. with male breast cancer
BRCA2
BRCA type more likely to have triple negative cancer
BRCA1
Surgical scars should get lighter over time
If getting darker or focal nodular, consider local recurrence
Silicone in a lymph node on US - NEXT STEP
MRI to evaluate for implant rupture
Biggest risk factor for implant rupture
age of implant
Invasive lobular carcinoma represents ____ of breast cancer
5-10%
Tumor invasion of dermal lymphatics
inflammatory breast cancer
Prognosis for ER/PR positive cancers
good prognosis (better than negative types)
Most common pathogen causing of mastitis
S. aureus; seen in nursing mothers and diabetics
Mondor disease + treatment
thrombophlebitis of a superficial vein; tender; Tx NSAIDs + warm compresses
BI-RADS 3
<2% chance of malignancy; gets 2 year diagnostic follow-up (6-6-12)
BI-RADS 4
2-95% chance of malignancy; benign path result is ok
BI-RADS 5
> 95% chance of malignancy; CANNOT accept a benign path result
BI-RADS 6
biopsy-proven malignancy
Women with extremely dense breasts have a ____ increased risk of cancer compared with almost entirely fatty breasts
5x
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.
New mass on screening mammogram (any characteristics) - NEXT STEP
ultrasound; cannot call any mass benign on screening mammo alone
Pathologic nipple discharge
unilateral; clear or bloody; often spontaneous
Non-pathologic nipple discharge
bilateral; green, brown, or milky
Most common cause of pathologic nipple discharge
papilloma
Clustered microcysts
due to apocrine metaplasia or fibrocystic changes; BR-3 (if no solid component)
ILC (compared to IDC)
more often multifocal and bilateral
Most common type of lymphoma involving the breast
B-cell lymphoma
Non-mammo finding in Poland syndrome
ipsilateral syndactyly; more common in males; often absence of breast tissue as well
Definition of focus on MRI
focal enhancement <5 mm, round/oval, well-circumscribed; no mass effect, no pre-contrast correlate
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
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
Eklund view (mammo)
implant-displaced view
Implant type with a valve
saline
Implant type that is semi-lucent
saline
US-guided core biopsy needle characteristics
14G, spring-loaded
Standard breast biopsy needle advances approximately ___ when fired
2 cm
US-guided cyst aspiration needle characteristics
18G or 20G needle (FNA)
Cyst aspirate should be sent for cytology if…
bloody; may discard clear, green, grey, yellow, or cloudy fluid (benign)
Complex cystic mass biopsy - FNA or core
core needle biopsy
Stereotactic biopsy needle characteristics
11G, vacuum-assisted
Components of the mammographic report
history/indication/risk factors, comparison studies, breast composition, findings, impression/BI-RADS/recommendation
Required annotation for US image
side (left/right), clock face position, distance from nipple, orientation of probe
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
Triple negative cancers
ER, PR, and her2/neu negative; aggressive, bad prognosis; may show paradoxically benign features
Bilateral axillary lymphadenopathy DDx
collagen vascular disease, lymphoma, leukemia, rheumatoid arthritis, HIV
Multiple intraductal papillomas
tend to occur in younger patients than solitary papillomas; not typically assoc. with nipple discharge; increased risk of breast cancer
Multiple skin masses DDx
neurofibromas (NF1), steatocystoma multiplex
Angiosarcoma MRI characteristics
T2 hyperintense, intense enhancement
Mets to the breast
most frequently from melanoma > RCC; also consider contralateral breast cancer if that is an option on multiple choice
Contraindications to stereotactic needle biopsy
<3 cm breast tissue when compressed, far posterior or subareolar location, inability to be positioned on table, uncontrolled coagulopathy
Complicated cyst
contains low-level echoes or layering debris; can perform aspiration or follow with US (BR-3)
Complex cyst
cystic and solid components; solid component needs to be biopsied (BR-4)
Sclerosing adenosis
benign; diffusely scattered microcalcifications
Tail of Spence
axillary extension of breast tissue
Quadrant most breast cancers arise from
upper-outer (most densely populated with fibroglandular tissue)
Regions of breast with least fibroglandular tissues
lower-inner and retroglandular regions (“danger zones” = areas where cancer hides)
Breast asymmetry
normal, but consider a “shrinking breast” (ILC)
Where do most breast cancers start?
TDLU
Lactiferous sinus
dilated portion of major duct just deep to nipple
Major blood supply to the breast
internal mammary artery (medial)
Major lymphatic drainage of the breast
axillary (97% of drainage)
Level 1 axillary nodes
inferior-lateral to pectoralis minor
Level 2 axillary nodes
deep to pectoralis minor
Level 3 axillary nodes
superior-medial to pectoralis minor
Rotter nodes
between pectoralis major and minor
Sternalis muscle
5% of population, usually unilateral; seen on CC view only
Most common location for ectopic breast tissue
axilla > inframammary fold
Most common location for polythelia
axilla > inframammary fold
Best time in cycle for mammogram and MRI
day 7-14 (follicular phase); lowest BPE for MRI
Increased breast density - when?
luteal phase, 3rd trimester, HRT, prolactinoma, antipsychotics, weight loss, hypothyroidism, young age, diabetic mastopathy
Lipoma appearance on US
appears isoechoic relative to fatty breast tissue
Mets to internal mammary node
consider a medial breast cancer
Peak time for breast pain and cyst formation (during life)
perimenopause
Risk of breast biopsy while lactating
milk fistula; must stop breast feeding if fistula forms
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
Indications for LMO view
pacemaker/central line, pectus excavatum, kyphosis
Which view includes the most breast tissue?
MLO
Collimation on spot compression views?
leave the collimator open (for wide FOV)
Choosing between an ML vs. LM view
last letter (detector side) should match lesion location on screening study; lateral => ML, medial => LM
Skin thickening + trabecular thickening DDx
edema (CHF, renal failure, liver failure), radiation, mastitis, lymphatic obstruction, inflammatory breast cancer
Recall rate benchmark
10%
PPV1 benchmark
cancers in patients called back (BR-0, BR-3, BR-4, or BR-5); 4%
PPV2 benchmark
cancers in patients recommended for biopsy (BR-4 or BR-5); 25%
PPV3 benchmark
cancers in patients who underwent biopsy; 31%
BI-RADS 4a
low suspicion for malignancy, >2 to ≤10%
BI-RADS 4b
moderate suspicion for malignancy, >10 to ≤50%
BI-RADS 4c
high suspicion for malignancy, >50 to <95%
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
Findings that can be BR-3 (mammo)
classic appearance for fibroadenoma, focal asymmetry, grouped punctate round calcifications; must be on baseline exam (NOT new)
Breast composition (mammo)
entirely fat, scattered fibroglandular, heterogeneously dense, extremely dense
Shape (mammo)
ROI - round, oval, irregular
Margins (mammo)
COMIS - circumscribed, obscured, microlobulated, indistinct, spiculated
Density (mammo)
fat density, hypodense, isodense, hyperdense; relative to breast parenchyma
Global asymmetry
asymmetric amount of breast tissue density in only one breast; must involve >1 quadrant
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
Shape (US)
ROI - round, oval, irregular
Margins (US)
CAMIS - circumscribed, angular, microlobulated, indistinct, spiculated
Orientation (US)
parallel or anti-parallel
Echo pattern (US)
anechoic, hypoechoic, isoechoic, hyperechoic, complex (cystic & solid), heterogeneous; relative to subcutaneous fat
Posterior features (US)
none, shadowing, enhancement, combined pattern
Background parenchymal enhancement (MRI)
minimal, mild, moderate, marked; based on first post-gad sequence
NME - distribution (MRI)
focal, linear, segmental, regional, multi-regional, diffuse
NME - enhancement pattern (MRI)
homogeneous, heterogeneous, clumped, clustered ring
Mass - shape (MRI)
ROI - round, oval, irregular
Mass - margins (MRI)
CIS - circumscribed, irregular, spiculated
Mass - enhancement (MRI)
homogeneous, heterogeneous, rim enhancement, dark internal septations
High density foci in axilla
deodorant
Parallel linear calcifications
vascular calcifications
DDx for amorphous calcifications
fibrocystic change, sclerosing adenosis, DCIS (low grade), columnar cell change
DDx for coarse heterogeneous calcifications
fibroadenoma, papilloma, fibrocystic change, DCIS (low to intermediate grade)
DDx for fine pleomorphic calcifications
DCIS (high grade), fibrocystic change, fibroadenoma, papilloma
Enlarging lipoma - NEXT STEP
biopsy
Steatocystoma multiplex
multiple oil cysts (intradermal)
Do fat-containing lesions (on mammo) get an US?
no
Benign myofibroblastic hyperplasia
a.k.a. PASH; well-circumscribed, solid mass
Fibroadenoma MRI characteristics
T2 bright, dark internal septations, type I enhancement
Breast mass that mets hematogenously
phyllodes tumor; 10% chance of malignant degeneration
IDC subtype associated with radial scar
tubular (presents as a small spiculated mass)
IDC subtype that is T2 bright
mucinous (a.k.a. colloid)
IDC subtype that is complex cystic and solid
papillary; 2nd most common subtype (IDC NOS is 1st)
IDC subtype associated with BRCA1
medullary; 25% have BRCA1
Multifocal breast cancer
within same quadrant or within 5 cm
Multicentric breast cancer
different quadrants AND >5 cm apart
3 ways to show DCIS
fine linear branching or fine pleomorphic calcifications, NME on MRI, or multiple intraductal masses on galactography
Architectural distortion without a central mass DDx
ILC, radial scar, surgical scar, IDC-NOS
Inflammatory breast cancer
bad prognosis; dermal biopsy if not identifiable mass; Tx chemo/radiation before surgery
Paget’s disease of the breast association
high-grade DCIS; NOT T4 (despite nipple involvement)
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
Reduction mammoplasty
nipple moves superiorly, glandular tissue moves inferior (with swirling)
Age to start screening for BRCA patients
25-30 years old (varies based on guidelines)
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
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
Clinical symptoms worrisome for breast cancer
skin dimpling, focal skin thickening, nipple retraction
Bilateral skin thickening
CHF, renal failure, liver failure
Unilateral skin thickening
inflammatory breast cancer, prior radiation, lymphatic obstruction, mastitis/abscess
Risk factors for mastitis
breastfeeding, smoking, diabetics
Causes of milky discharge
thyroid issues, prolactinoma, antidepressants/neuroleptics/reglan
Most common cause of benign nipple discharge in postmenopausal women
ductal ectasia; dilated ducts in subareolar region
Contraindications to galactography
active infection, unable to express discharge at time of exam, contrast allergy, prior surgery to nipple-areola complex
BI-RADS for architectural distortion
BR-4 (or BR-5 if other suspicious findings, e.g. mass); always biopsied
Suspicious mass identified on US - NEXT STEP
scan the remainder of the radian and the axilla
Indications for lymph node biopsy
cortical thickness of 3 mm or greater, loss of fatty hilum, irregular cortex or focal bulge, round shape
High density material in lymph nodes
gold (prior TB Tx), tattoo, sarcoidosis, nodal met
Most common pattern of gynecomastia
nodular (flame-shaped); others are dendritic and diffuse glandular
Most common palpable findings in men
gynecomastia > lipoma
Risk factors for male breast cancer
BRCA, Klinefelter’s, cirrhosis, chronic alcoholism
Most common complication of implants
capsular contracture; contraction of fibrous capsule => cosmetic deformity; most common in pre-pectoral implants
Gel bleed
“leakage” of silicone through implant (not ruptured); seen as snowstorm in a lymph node
Keyhole sign
intracapsular implant rupture
Mastopexy
breast lift (removal of skin)
Peak time for recurrence after resection
4 years; occurs in 6-8% of patients following breast conservation therapy (higher without radiation)
Specimen radiograph evaluation
- Are the mass/calcifications present? 2. Are the mass/calcifications at the edge?
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
Most important predictor of overall survival in breast cancer
axillary node status at diagnosis
Most common met to breast
melanoma
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
Breast cancer types that present as a well-circumscribed mass
papillary, mucinous, medullary (“Peanut M&M’s”)
Causes of gynecomastia
hormone-producing tumor (especially testicular), cirrhosis, marijuana, spironolactone, pituitary hormone dysfunction, anti-depressants
New mass on MRI
BR-4 or BR-5 depending on characteristics => MR-guided biopsy
New NME on MRI
BR-4 => MR-guided biopsy
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
Amount of chest radiation between 10-30 y/o to justify MRI screening
20 Gy
Effect of tamoxifen on breast MRI
decreased BPE, with rebound increased BPE after cessation
Timing of early phase of enhancement (MRI)
within the first 2 minutes; slow, medium, rapid
Timing of delayed phase of enhancement (MRI)
2-6 minutes; persistent (type I), plateau (type II), washout (type III)
Enhancement kinetics warranting biopsy
type II or III
Most predictive feature of malignancy (MRI)
spiculated margins
Bilateral disease is more common with…
BRCA, ILC, multicentric disease
Patient on HRT needing breast MRI
discontinue HRT for 1-3 months prior
Multiple foci (MRI)
report as BPE (not a separate finding)
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
USPSTF screening guidelines
every 2 years starting at 50 y/o; continue until 74 y/o
ACR screening guidelines
annually starting at 40 y/o; continue until life expectancy is less than 5-7 years
BI-RADS meaning
Breast Imaging Reporting And Data System
BRCA1 chromosome
17; most common type of BRCA
BRCA2 chromosome
13
Men should be evaluated with US before age…
25 y/o; mammo for older males
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
Paget disease represents what histologically?
DCIS
HER2/neu-specific treatment agents
trastuzumab, lapatinib
Granulomatous mastitis
occurs after childbirth, non-infectious inflammation
Periductal mastitis
a.k.a. plasma cell mastitis; produces secretory calcifications in post-menopausal women
Diabetic mastopathy
sequelae of insulin-dependent diabetes; ill-defined, asymmetric increased density
Definition of a mass (mammo)
space-occupying lesion with convex borders seen on two different projections
BI-RADS for diffusely distributed punctate calcifications
BR-2
Reduced compression view
for far posterior lesions that “slip out” of view with full compression
Superficial cysts
epidermal inclusion cyst, sebaceous cyst; located completely within the echogenic dermis, may communicate with skin surface
Findings that can be BR-3 (US)
complicated cyst, clustered microcysts, mass with fibroadenoma characteristics, hyperechoic mass with central hypoechogenicity (fat necrosis)
Fibroadenolipoma
a.k.a. hamartoma
Known lymphoma diagnosis + new breast mass
primary consideration is still breast cancer
Male with clinical gynecomastia - NEXT STEP
nothing; no imaging required
Benign lesions with type 3 kinetics
lymph nodes, adenosis, papillomas
Rim enhancement
descriptor for masses in MRI; highly suspicious; benign mimics include peripheral enhancement of inflammatory cyst or fat necrosis
Most common NME distribution of DCIS
segmental (triangular-shaped pointing towards nipple)
Most common NME internal enhancement of DCIS
clumped (cobblestone pattern or “bunch of grapes”), especially in a linear or segmental distribution
Susceptibility artifact on T1
calcifications, biopsy clips
BI-RADS for mass or NME with benign morphology and enhancement kinetics (MRI)
BR-3
Mass adjacent to vessel with type II or III enhancement kinetics
likely an intra-mammary lymph node (reniform shape)
Syndromes assoc. with a high risk of breast cancer
BRCA 1/2, Li Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba, ataxia telangiectasia
Lay report due within…
30 days
MQSA requirements - CME
15 credit hours with last 3 years, 960 studies during the last 2 years
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
Needle angle for US-guided biopsy
parallel to chest well
Negative stroke margin + NEXT STEP
insufficient tissue thickness for stereotactic biopsy (<3 cm); next step is needle localization for excisional biopsy
Breast phantom characteristics
50% glandular, 4.2 cm thick, 6 fibers/5 masses/5 specks
Biopsy samples obtained - NEXT STEP
place marker clip then obtain orthogonal views to verify clip position
Gad or no gad for MRI-guided biopsy?
almost always requires gadolinium
Best approach for needle localization
shortest approach should be used
Amount of contrast used in galactography
0.2-0.3 cc
IDC subtype with best prognosis
tubular
Digital mammo is superior to film screen for which patient groups?
women <50 y/o, women with dense breasts, peri-menopausal women
Abscess treatment
aspiration + antibiotics
Stuff males do NOT get
ILC/LCIS/ALH, fibroadenoma, phyllodes
Complex sclerosing lesion definition
radial scar >1 cm
Palpable diagnostic mammography views
CC + MLO + spot tangential, then US
Minimum ultrasound probe frequency
10 MHz
Benefits of tomosynthesis
decreases recall rate, increases sensitivity for small masses
Stroke margin (definition)
distance from image receptor to tip of needle (post-fire); negative stroke margin => needle loc for excision
Breast cancers detected from screening
2-8 cancers per 1000 women screened
