Core Radiology Breast Flashcards
Indications for breast ultrasound
- Critical adjunct to diagnostic mammography
- Further evaluation of symptomatic patent when mammography is negative
- Supplemental to mammo in screening
- Characterization of palpable mammographic lesions
- First line evaluation of breast abnormality in young patient under 30
- Pregnant or lactating women
- Guidance for interventional procedures
- Evaluation of breast implants
Indications of breast MRI
- Screening high risk patients
- Evaluation of extent of disease in patient newly diagnosed with breast cancer
- Evaluation of neoadjuvant chemo response
- Assessment for residual disease after positive surgical margins
- Tumor recurrence after breast conserving treatment
- Evaluation for occult breast cancer in patient with axillary metastases
- Breast implants; most sensitive, and most definitive in implant integrity
Risk Factors for developing breast cancer
- Most imp risk factors; Female sex, advanced age
- BRCA1 or BRCA2 mutation
- First degree relative with breast cancer in young age
- Prior chest radiation for lymphoma
- Prior biopsy result for high risk lesion; ALH, LCIS, FEA, Radical scar, intraductal papilloma, atypical papilloma
- Long term estrogen; early menarche, late menopause, late first pregnancy, nulliparity, obesity.
DCIS typical presentation and mammography findings
Typically asymptomatic
Mammo; calcifications
Note: This is variable, this is the MOST common.
Most common subtype of breast cancer and how does it present?
Findings on mammo
Invasive ductal carcinoma
Presentation; palpable breast mass
Mammo; irregular mass with spiculated margins and associated calcifications
Which cancer is difficult to diagnose on imaging and clinically and why
irregular mass with spiculated margins and associated calcifications
Reason: Spreads without discrete mass
Inflammatory breast cancer
Presentation
Prognosis
DDx
Breast cancer with tumor invasion to the dermal lymphatics (aggressive)
Clinically; breast erythema, edema, firmess, peu d’orange
DDx Mastitis
Mammography findings in inflammatory breast cancer
Affected breast is larger and denser, trabecular thickening, skin thickening, mass may or may not be present.
What is Paget’s disease of the nipple?
Clinical presentation
How is it diagnosed?
DCIS that infiltrates the epidermis of the nipple
Clinically; nipple erythema, ulceration, eczematoid changes of the nipple.
This is diagnosed by skin punch biopsy not by radiologists
What’s the most important prognostic factor in breast cancer?
Axillary lymph node status is most important prognostic factor
Increase number of lymph nodes involved equals to worse prognosis
Majority of breast cancer in BRCA1 mutation is
Triple negative.
Triple negative may show features of benign lesions although malignant
BIRADs 0
Only appropriate for screening.
Patient is brought back for additional views or adjunct/complementary ultraosund
BIRAD 1
Normal breasts with no findings
BIRAD 2
Benign and no additional follow up is required.
Examples
1. Vascular or other typically benign calcifications
2. Simple breast cysts
3. Intra-mammary lymph nodes
4. Accessory breasts
BIRAD 3
Defintion
Malignancy Potential
Never appropriate for ________
Follow up recommendation
Probably benign
<2% chance of malignancy.
Never appropriate for screening mammogram.
FU recommendation: 6m,12m,24m if stable then BIRAD 2.
Any change => biopsy.
BIRAD 4
Suspicious, 2-95% change of malignancy
Next step: Biopsy
BIRAD 5
> 95% of malignancy
Action; biopsy any other pathological result other than cancer would be discordant
BIRAD 6
Biopsy proven malignancy
Role of screening mammogram?
To detect preclinical breast cancer in asymmptomatic patients.
Why is mammogram recommended at the age of 40?
Greatest reduction in breast cancer specific mortality
If lesion only seen on
MLO
CC
next step
MLO > true lateral
CC > preform roll view
Indications for diagnostic mammogram
- Breast problem
- Annual mammography in asymptomatic woman with past history of breast cancer
- Short term follow up (BIRAD 3)
- Abnormality on screening US
If on CC view, the inferior nipple fold or the pectorals cannot be visualized
Draw the posterior nipple line and it should be within 1cm to be considered adequate.
State the 4 breast density types
- Almost entirely fatty
- Scattered areas of fibro-glandular tissue
- Heterogeneously dense; which may obscure small masses
- Extremely dense; lowers sensitivity for mammography
Benign causes of breast skin thickening
- Acute mastitis (or inflammation)
- Radiation therapy.
- Fluid Overload
What is a poor indicator of malignancy?
What does it contribute in TNM staging?
Size
Gives us the T!
Benign calcifications
- Skin calcifications
- Vascular calcifications
- Large rod-like calcifications
- Coarse/Pop-corn like calcification
- Milk of calcium
- Suture calcifications
- Dystropic
- Round and punctate calcifications
- Rim calcifications
Skin calcifications
Usually punctate or lucent-centered, medially where the concentration of sweat glands is higher.
Vascular calcifications
When is it mentioned?
Extensive or patient very young.
Large rod-like secretory calcifications
Caused by
Demographic
Differentiated from DCIS
Plasma cell mastitis/ periductal mastitis.
Demo; postmenopausal women
DCIS; dot-dash appearance.
Coarse or “popcorn-like” calcifications
Caused by
Zoning
Hyalinizing/Involuting fibroadenoma
Zoning; peripheral then central
Milk of calcium
CC and MLO view
CC view:
indistinct, fuzzy, amorphous deposits.
90-degree lateral semilunar or crescent- shaped in morphology due to dependent layering (tea cup)
Suture calcifications are especially deposited after
Radiation therapy
Dystrophic calcifications causes
Surgery, biopsy, trauma, or irradiation.
Round and punctate calcification
Punctate defintion
When are they considered benign
Smaller than 0.5 mm, the term “punctate” is preferred.
When diffusely or randomly distributed, round and punctate calcifications are considered benign.
Isolated group of punctate calcifications on a baseline mammogram BIRAD
BIRAD 3
Rim calcifications
Fat necrosis or a cyst with calcified walls.
Suspicious morphology calcifications (BIRAD 4)
- Amorphous calcifications
- Coarse heterogeneous calcifications
- Fine pleomorphic calcifications
- Fine linear or fine-linear branching calcifications
