Imaging the Breast Flashcards

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1
Q

In what 4 scenarios might women be referred for breast imaging?

A
  • if they are symptomatic and notice an abnormality of the breast, such as:
  1. lumps / masses
  2. skin changes
  3. shape changes
  4. nipple discharge
  5. pain (rarely a sign of malignancy)
  • as part of a breast screening programme (asymptomatic women)
  • for surveillance after breast cancer
  • for surveillance due to family history
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2
Q

What is meant by the “triple assessment” for breast changes?

A
  • the “triple assessment” comprises clinical examination, imaging and histology
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3
Q

What are the risk factors for breast cancer?

What is the epidemiology like?

A
  1. smoking
  2. obesity
  3. nulliparity
  4. increasing age
  5. late menopause
  6. previous family history
  • around 50,000 women are diagnosed with invasive breast cancer each year and 8/10 are >50
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4
Q

Who is invited to the UK screening programme for breast cancer?

A
  • asymptomatic women between 50 - 71** are invited for screening **every 3 years
  • women < 50 may be screened if they are at a high risk of developing breast cancer
  • women > 71 are not invited to screening, but can have screening if they wish
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5
Q

What symptoms / signs would result in referral to a breast clinic for further investigation into possible breast cancer?

A
  1. a lump in the breast or chest wall
  2. an area of thickened breast tissue
  3. change in the size / shape of one or both breasts
  4. discharge from the nipple (may be streaked with blood)
  5. lumps / swellings in the armpit
  6. dimpling of the skin around the breasts
  7. rash on or around the nipple
  8. change in appearance of the nipple (becoming sunken into the breast)

pain is not usually a sign of cancer

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6
Q

What are the first line techniques for imaging the breast?

A
  • mammography
  • ultrasound
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7
Q

How does mammography work?

A
  • it uses X-rays that are equivalent to a couple of months’ background radiation
  • the X-rays are specialised and lower energy as normal and pathological breast tissue have similar properties
  • the breast is compressed prior to taking the image
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8
Q

Why is the breast compressed in mammography?

How many images are usually taken?

A
  • the breast is compressed to decrease tissue thickness** and **minimise image artefact / blurring
  • it is difficult to spot small lesions on mammograms due to the superimposition of strutures in a 2D image of a 3D structure
    • this is particularly the case in dense breasts
  • taking multiple projection images of the breast from different angles allows reconstruction of a 3D image that provides more detail of breast tissue
  • usually craniocaudal and mediolateral views are obtained
  • tomosynthesis involves 9 views and gives more information
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9
Q

What is the benefit of using digital mammography over analogue?

A
  • digital mammography allows for image manipulation
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10
Q

What views of the breast are shown here?

A

right mediolateral oblique and left craniocaudal views

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11
Q

What is Chassaignac bursa?

Why is it important to identify?

A
  • it is a lucency on the mammogram that represents connective tissue between the breast and chest wall
  • it should be seen on all CC and MLO mammograms
  • if it is not seen, the image is not technically adequate
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12
Q

As well as the presence of Chassaignac bursa, what other technical details must be present in both CC and MLO views in order for the image to be adequate?

A
  • all glandular breast tissue must be seen
  • image must be correctly annotated
  • no movement artefact
  • no skin folds
  • images should be symmetrical
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13
Q

What technical details specific to CC and MLO images need to be present in order for the image to be adequate?

A

Craniocaudal view (CC):

  • the nipple should be in profile and in the midline of the image

Mediolateral oblique view (MLO):

  • the pectoral shadow should be seen down to the level of the nipple or lower
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14
Q

When is mammography the first line investigation?

A
  • for routine screening (asymptomatic women) over 35 years of age
  • for symptomatic women over 35 years of age

women <35 have denser breast tissue, so USS is the first line imaging technique

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15
Q

What are the advantages and disadvantages of mammography?

A

Advantages:

  1. relatively cheap and quick
  2. non-invasive
  3. very good visualisation
  4. can be used to guide biopsy (but US is usually used)

Disadvantages:

  1. can be uncomfortable for some patients
  2. difficult if breasts are small
  3. not as effective if breast tissue is dense
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16
Q

How do invasive carcinomas typically appear on a mammogram?

A
  • they are spiculated
  • they have poorly defined / irregular margins
  • they distort the architecture of surrounding tissue
17
Q
A
18
Q

What is shown in these images?

A
19
Q

What is meant by 3D digital tomosynthesis and why is it performed?

A
  • it is difficult to spot small lesions on mammograms due to the superimposition of structures in a 2D image of a 3D structure
  • it is more difficult to spot lesions in dense breasts
  • taking multiple projection images of the breast from different angles allows for reconstruction into a 3D image that provides more detail of breast tissue
  • an X-ray tube rotates through 50o to obtain 9 projections
20
Q

What is the difference between these images?

A

the lesion is much easier to identify when 3D tomosynthesis is used compared to a 2D image

21
Q

When is USS used to image the breast?

A
  • USS is the first line imaging technique in women <35 due to denser breast tissue
  • USS is performed after mammography in women >35 to further evaluate a breast mass
22
Q

What are the advantages and disadvantages of US scanning?

A

Advantages:

  1. ​relatively cheap
  2. non-invasive
  3. portable
  4. can be used to guide biopsy
  5. excellent for showing features of a mass - size, shape, fluid-filled/solid, vascularity

Disadvantages:

  1. image quality is operator dependent
  2. more difficult in larger patients
  3. can take time
23
Q

What other structure can be evalutated with USS?

Why is this significant?

A
  • the axilla can also be evaluated with USS
  • lymph nodes may look suspicious for infiltration
  • if so, fine needle aspiration cytology is undertaken
  • if the nodes are negative on cytology then sentinel node biopsy is performed during surgery
24
Q

What are examples of benign breast lesions?

What features do they all share on US?

A
  • benign lesions include fibroadenomas, lipomas and simple cysts
  • they all appear as well-defined, hypoechoic lesions that are uniform in shape** with **normal vascularity
25
Q

How do cysts / complex cysts appear on US?

A

Cysts:

  • well-defined and oval in shape
  • they have posterior acoustic enhancement and are uniformally hypoechoic (black) as they are filled with fluid

Complex cysts:

  • these may have internal echoes, irregular walls and septations within them
26
Q

How do fibroadenomas, abscesses and galactocoeles appear on US?

A

Fibroadenomas:

  • appear well-defined and hypoechoic (black)

Galactocoeles:

  • can appear as either simple or complex

Abscesses:

  • can have a varied appearance as some appear more like simple cysts, whereas others appear more solid with internal echoes
27
Q

What are the US features of malignant lesions?

When do lymph nodes arouse suspicion?

A
  • carcinomas appear as irregular masses (less uniform in shape) that are poorly defined
  • they are hypoechoic
  • they may show posterior acoustic shadowing
  • they may have internal echoes / shadowing or calcifications
  • colour doppler can show abnormal vascularity
  • they tend to be taller rather than wide
  • lymph nodes are suspicious when they are enlarged** or have **thickened cortices
28
Q

How is a vacuum-assisted breast biopsy (mammotome / minimally invasive breast biopsy) performed?

When is this used?

A
  • a core biopsy needle is attached to a vacuum that sucks the tissue into the needle
  • a rotating cutting device takes the sample
  • it may place a clip in-situ for localisation once the procedure is finished
  • it uses local anaesthetic
  • it is suitable for small impalpable lesions under image guidance
29
Q

When does CT imaging play a role in imaging the breast?

A
  • it does not play a role in the initial assessment of breast lumps / masses
  • it has an important role when breast malignancy is confirmed, especially if lymph nodes are involved or metastatic disease is suspected
30
Q

What are the indications for using CT to image the breast?

Which regions of the body should be imaged?

A
  • CT is used to stage disease when there is confirmation on lymph node involvement or other features suggesting metastases
  • CT thorax, abdomen and pelvis performed to look for signs of visceral mets
  • CT can be used to assess for presence and extent of mets in the skeleton
  • clinical suspicion of metastatic spread to other regions based on symptoms/signs can prompt imaging of that region
31
Q

In what 2 situations does MRI imaging have a role in breast imaging?

A
  • contrast-enhanced MRI can be used in the assessment of breast tissue** and after **malignancy is confirmed
32
Q

When is contrast-enhanced MRI used in the assessment of breast tissue?

A
  • if the breasts are very dense
  • if the lesions are very small
  • if routine imaging (mammography and US) fails to allow adequate evaluation of masses
  • for screening in high-risk women
33
Q

When can contrast-enhanced MRI be used in confirmed malignancy?

A
  • lesions rapidly take up contrast, showing increased vascularity around malignancies
  • can be used in lobar carcinomas, which tend to be multifocal
  • in axillary lymph node assessment
  • to evaluate tumour response to chemotherapy prior to surgery and to detect recurrence
  • to assess scars at lumpectomy sites and differentiate scar tissue from recurrence
  • to assess invasion of malignancy (i.e. into underlying muscle) and the presence / extent of visceral and/or bony metastases
34
Q
A
35
Q

When is nuclear medicine used in imaging the breast?

A

sentinel node imaging

  • technetium-99m attached to sulphur colloid particles is injected into a tumour
  • the particles migrate through the lymphatic system to the nearest lymph node, where they are phagocytosed and retained
  • this allows identification of the sentinel lymph nodes
  • this aids staging of cancer and allows for planning of future surgery
36
Q

What is bone scintigraphy?

What symptoms might be present that lead to this being performed?

A
  • bone scintigraphy is performed in patients to assess the presence / extent of bone metastases
  • metastatic spread to bone is common in breast cancer
  • signs / symptoms suggestive of bone metastases are unremitting bony pain** or **pathological / low trauma fracture
37
Q
A