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Year 3 Radiology > Imaging the Breast > Flashcards

Imaging the Breast Flashcards

1
Q

Region of the breast?

A

Over the 2nd-6th ribs, midclavicular line

Extends towards the axilla (axillary tail of Spence)

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2
Q

Does everyone with a breast problem require a breast imaging test?

A

No

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3
Q

When is breast imaging required?

A 
Symptomatic patients:
• Lumps
• Unilateral or blood-stained nipple discharge
• Skin tethering or dimpling
• Signs of inflammation
• Axillary lumps

Not indicated for pain, tenderness or for symmetrical nodularity

Imaging is also performed as part of screening

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4
Q

What is triple assessment?

A
  1. Clinical - history & examination
  2. Imaging
  3. Pathology - histology, cytology
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5
Q

Grading of breast tissue biopsy?

A

Grade 1 - normal

Grade 2 - benign

3 - atypical, probably benign

4 - suspicious

5 - malignant

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6
Q

When is imaging performed for breast pain and what does this involve?

A

Only is assoc. with focal or asymmetrical nodularity, in order to exclude an underlying mass

Perform mammography (XRM), USS or both

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7
Q

How does age affect the choice of imaging?

A

If woman <40 years of age, USS

If woman >40 years, XRM +/- USS

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8
Q

Modalities available for breast imaging?

A

Mammography:
• Film / screen (conventional)
• Full field digital mammography (FFDM)

USS

MRI

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9
Q

What is mammography?

A

Low-dose X-ray designed specifically to maximise contact between the breast tissues, whilst minimising radiation dose

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10
Q

Advantages of mammography?

A

Cost-effective

Non-invasive

Reproducible and easy to document

ONLY technique that reliably visualises micro-calcifications (<0.5mm)

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11
Q

Significance of micro-calcifications?

A

Assoc. with ~30% of invasive cancers

Very sensitive for DCIS

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12
Q

Advantages and disadvantages of digital mammography?

A

Advantages:
• Excellent contrast resolution, between dense and non-dense tissues
• Better in dense breasts, e.g: younger women
• Shorter exam time, fewer technical repeats and fewer films
• Easy image storage and transfer

Disadvantages:
• Compression of breasts causes discomfort

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13
Q

Problems with imaging a woman who has breast implants?

A

Obstructs view of potentially significant breast findings

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14
Q

Difference between mammography as part of screening and mammography in symptomatic patients?

A

For screening - mammography is performed on
asymptomatic women at regular intervals, with
the aim of detecting clinically occult breast
cancer at an early stage

In symptomatic patients - mammography used to
demonstrate if there is any abnormality and nature of the
abnormality

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15
Q

Indications for mammography?

A
  1. Screening - it is the only proven population-based method of reducing mortality
  2. Problem-solving:
    • For all women >40 years old with a palpable mass
    • To exclude/confirm malignancy and assess the contralateral breast
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16
Q

In which women is mammography not routinely indicated?

A

Women <40 years of age (either for screening or symptomatic patients)

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17
Q

Options for breast imaging in women <40 years of age?

A

USS

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18
Q

If breasts appear dense on mammography, what imaging options are available?

A

Follow the mammogram with an USS

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19
Q

Structures visible on a normal mammogram?

A

Skin and pores

Fat (low-density)

Glandular tissue (higher density)

Trabeculae (thin & sharply defined)

Blood vessels +/- vascular calcifications

Lymph nodes (oval/horseshoe shape, visible fatty hilum)

Bright white calcifications - normal ones due to:
• Arterial
• Sebaceous (polo mint
• Oil cysts (eggshell curvilinear)

20
Q

Views on a mammogram?

A

Main views:
• Mediolateral oblique (MLO)
• Craniocaudal (CC)

Extended CC

Other additional assessment views:
• Paddle (localised compression) views
• Magnification views
• Etc

21
Q

Explain the mediolateral oblique (MLO) view on mammogram

A

Best single view, as it is the least foreshortening

Table at 45 degrees, off vertical, and the X-ray beam is perpendicular to the long axis of the breast

22
Q

Explain the craniocaudal (CC) view on mammogram

A

Table is horizontal and nipple is in profile; it shows the medial and most of the lateral tissue and allows visualisation of the retromammary fat

Does not show the axillary tail

23
Q

Explain the paddle view on mammogram

A

Apply very firm localised compression; this produces less scatter and more contrast and demonstrates the borders of a mass

24
Q

Explain magnification views on mammogram

A

CC and lateral views with a magnification table (air gap); it is not just electronic zooming

25
Q

How does breast density vary with age?

A

Breast involution after menopause

Young women have dense breasts generally but a proportion have fatty breasts

Similarly, a proportion of older women have dense breasts

26
Q

Method of classifying breast density?

A 
BIRADS parenchymal patterns:
• a - nearly all fat
• b - scattered fibroglandular tissues
• c - heterogeneously dense
• d - extremely dense
27
Q

Types of calcification on breast mammogram?

A

Benign OR malignant

28
Q

Features of malignant calcification?

A

Distribution:
• Benign - scattered or diffuse
• Suspicious - cluster or segmental

Cluster shape / size - rhomboid forms suggestive of malignancy

Individual particle shape - linear, branching, Y-shaped forms are suggestive of malignancy

Pleomorphic nature - in both size and density

29
Q

Newer methods of imaging breasts?

A

Digital breast tomosynthesis (DBT) - delineates lesion borders, showing any spiculation, and has increased cancer detection rates

Contrast-enhanced spectral mammography (CESM) - shows neoangiogenesis; very good for dense breasts

30
Q

Indications for USS?

A

Characterisation of mammographic findings - differentiation of cystic and solid lesions

Palpable lesions in women <40 years of age

Nipple discharge

Women with breasts implants or augmentation

For inflammatory conditions, e.g: abscess

Evaluation of the response to chemo

31
Q

If lesions are multiple, bilateral and well-defined, is this an indication or benign disease or malignancy?

A

Benign

32
Q

Appearance of cystic lesion on breast USS?

A

Fluid collections (black)

Can have clustered and complex cysts

33
Q

Features of benign solid nodules?

A

Well-circumscribed and homogenous

Can be hypoechoic / hyperechoic

“Wider than they are tall”

Peripheral/no vascularity

Often multiple

34
Q

Features of malignant solid nodules?

A

Poorly circumscribed and heterogeneous

Hypoechoic

“Taller than they are wide”

Spiculate

Have oedema / peri-tumoral fat

35
Q

Types of USS-guided procedures?

A

Aspiration/drainage

Cutting needle biopsy or vacuum-assisted biopsy (VAB)

Radiofrequency interventions

Sentinel lymph node analyses

Vacuum-assisted removal of lesions

36
Q

Why is another imaging modality required for imaging of breast disease?

A

XRM - low sensitivity in dense breasts, limited contrast, observer limitations, compression, irradiation

USS - operator-dependent, time consuming, misses calcifications

37
Q

Advantages of MRI?

A

Excellent intrinsic tissue contrast

No compression and no ionising radiation

Accuracy is independent of breast density

38
Q

Types of MRI used to asses various features of the disease?

A

Morphology - high resolution T1 & T2 weighted scans

Vascularity - dynamic contrast enhancement kinetics

Cellularity - diffusion-weighted imaging (DWI)

Metabolism - spectroscopy (MRS)

Oxygenation - intrinsic susceptibility-weighted MRI

39
Q

Method of assessing an MRI?

A
  1. Any enhancement? Either mass (space-occupying effect) or non-mass
  2. Morphology
  3. Rate of enhancement (ROIs)
40
Q

Types of enhancement curves?

A

Type 1 - benign

Type 2 - suspicious

Type 3 - malignancy (AKA washout curve)

ADD IMAGE

41
Q

Contraindications to an MRI?

A 
Absolute:
• Cardiac pacemakers
• Ferromagnetic aneurysm clips
• Cochlear implants
• Renal impairment

Relative - due to effect of gadolinium-based contrast and also more difficult due to increased breast enhancement:
• Pregnancy
• Lactation

42
Q

Indications for an MRI of the breasts?

A

Benign:
• Implants
• Characterisation of a lesion

Malignant:
• Diagnosis
• Staging and management plan
• Residual disease post wide local excision
• Assess response, e.g: chemo
• Check for recurrent disease
• Screening in high-risk groups
43
Q

Examples of high-risk groups requiring breast MRI?

A

Previous irradiation (HL, mantle XRT), esp. if treated as children (lifetime risk of 30-50%)

BRCA 1, 2 or TP53 mutations

Personal Hx of breast cancer

44
Q

Disadvantages of breast MRI?

A

Patient acceptability and tolerance

Overdiagnosis

Localisation/biopsy of lesions only seen on MRI

Cost and access

45
Q

What is the standard technique for evaluation of symptomatic breast disease in women >40 years of age?

A

Mammography

46
Q

Technique for younger women and for evaluation of mammographic abnormalities?

A

USS

Year 3 Radiology (3 decks)

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