Invasive and Other Procedures Flashcards
Breast implants have been used for over a
century
Today, an estimated _____________ women have breast implants
6 million
What are the 2 types of breast implants? Which one is more popular?
Silicone and saline
Silicone, more natural look/feel
Are single or double lumen implants more popular?
Single
Since the speed of sound is much slower in silicone, what will we seen when imaging?
A step off phenomenon. The tissue deep to the implant will appear further away
Do we see the step off phenomenon with saline implants?
No, the speed of sound in saline and soft tissue is similar
Breast implants typically consist of what type of shell?
elastomer shell or envelope (composed of hard silicone)
The body then forms a fibrous capsule around the implant in attempt to wall it off
Breast implants can be placed in which 2 locations?
Subglandular
Subpectoral
Subglandular implants are placed where:
Between the glandular and pectoral muscle (anterior to the pectoralis major muscle
Acute angle to the inferior margin of the pect major muscle
Subpectoral implants are placed where:
Between the pectoralis major and minor muscles
Obtuse angle to the inferior margin of the pect major muscle
A normal fibrous capsule-elastomer shell complex appears as? What do the lines represent?
a smooth, trilaminar line
Outer- outer aspect of fibrous capsule
Middle- inner aspect of fibrous capsule and the outer wall of the elastomer shell
Inner- inner wall of the elastomer shell
What’s the speed of sound in silicone? Soft tissue?
990m/s
1540m/s
What eliminates the reverberation artifact in an implant?
Single focal zone at the anterior implant surface
What normal appearance may be seen in an implant?
Radial folds, may be confused w rupture
Should a normal implant be compressible?
Yes. A firm, non compressible, rounded or balloon shaped implant is a sign of capsular contracture
What are gel bleeds?
A normal variant. Can’t be seen on sonography, as they are microscopic diffusion of the silicone across an intact membrane. However, if the silicone travels and accumulates within nearby LN’s, it caused them to enlarge and demonstrate the appearance of free silicone.
Do capsular calcifications indicate capsular contracture or rupture?
No
When do we see capsular calcifications? What is thought to cause it?
We see it in older implants. Thought to be caused by chronic inflammation at the site of the implant
Is it normal to see fluid around the implant?
Yes – periprosthetic fluid. Esp w/ polyurethane implants.
Why is it important to know if the patient has a single or double lumen?
As echogenic lines within an implant compartment may be suspicious of implant rupture.
Double lumens will have 5 lines
What are Becker expanders?
An inner chamber that is filled through a valve by a series of small serial injections in order to help expand the tissue in preparation for a permanent implant. The outer silicone compartment may appear echogenic.
What can a Becker expander be mistaken as?
Rupture
What’s the most common complication of breast implants?
Capsular contracture
What is capsular contracture?
Scar tissue forms on the implant and squeezes varying degrees of firmness, discomfort, and implant deformation. May occur right after surgery or years later. May be symmetric, asymmetric, unilateral or bilateral.
Grade 1 (none) capsular contracture:
Augmentated breast feels as soft as the unoperated breast
Grade 2 (minimal) capsular contracture:
The augmented breast is less soft, the implant can be palpated by is not visible
Grade 3 (moderate) capsular contracture:
The augmented breast is firmer; the implant is felt easier and its presence is visible.
Grade 4 (severe) capsular contracture:
The implant is firm and often tender, painful, cool and distorted. Its presence is obvious.
What’s the typical lifespan of an implant before it can rupture?
13yrs
Saline implant rupture:
can be diagnosed clinically, as the implant deflates rapidly. Saline is reabsorbed by the body and the implant may appear as folded in on itself
Silicone implant rupture:
Silent. However, some pt’s may experience changes in size and shape of the breast, pain or tenderness, numbness and a burning or tingling sensation.
Intracapsular rupture:
occurs when there’s a break in the elastomer shell and silicone leaks out, but the silicone is still confined within the fibrous tissue capsule that the body has formed around the implant
What’s the most common type of silicone rupture?
Intracapsular
What signs do we see w intracapsular rupture?
Key hole/noose sign, subscapular sign, and stepladder sign
Keyhole / Noose Sign
Early sign of intracapsular rupture. It is when the apex of a radial fold becomes an area of weakening of the implant shell, silicone may collect within the fold, causing it to expand and produce a ‘keyhole’ or ‘noose’ sign
Subscapular sign:
Silicone may escape through weak areas within the shell and expand the space between the fibrous capsule and the elastomer shell, disrupting the normal trilaminar appearance of the capsule/shell complex.
Stepladder sign aka parallel line sign:
As silicone escapes the implant shell, the shell progressively folds inwards on itself and produces a series of thin, parallel, echogenic lines.
Which sign is the most reliable finding to suggest intracapsular rupture?
Stepladder/parallel line sign
The stepladder sign is analogous to the _______________ on MRI
Linguine
Implants can also contain ______, which may mimic rupture
Impurities
What is it called when there’s a rupture in both the elastomer shell of the implant and the fibrous capsule, and silicone moves freely into the surrounding breast tissue?
Extracapsular rupture
Snowstorm sign:
aka echogenic noise
Hyperechoic, homogenous echoes w a loss of the posterior wall
Can also be identified in axillary LN’s
Silicone masses (granulomas) may be similar to
snowstorm sign
What’s the difference between silicone masses and the snowstorm sign?
Granulomas can appear as the echogenic noise, but also can appear hypo or hyperechoic, and similar to other breast lesions like carcinomas, or anechoic like cysts
A telltale sign of extracapsular rupture?
Snowstorm appearance
The speed of sound in silicone is much ________ than that in soft tissue. Consequently, structures on screen appear _________ than they actually are:
slower; deeper
Why is the anterior margin of a snowstorm sign well defined but the posterior detail is lost in echogenic noise?
Thought to be caused by phase aberration related to the speed of sound being slower in silicone than the surrounding soft tissues
What’s the most common type of silicone breast implant?
Single lumen, gel filled (at approx 80%)
What’s the second most common silicone implant?
Double lumen implant w an inner silicone chamber surrounded by saline
Is mammo or ultrasound better at detecting implant ruptures?
Ultrasound
What makes MRI better than US?
avoids the steep learning curve and operator dependence
What (non contrast) DI modality is the most accurate method of detecting breast implant failure?
MRI
Radial folds can be seen in which imaging modalities?
US and MRI (not mammo)
The linguine sign shows what?
Intracapsular rupture on MRI
MRI scans for breast implants are performed _______ contrast. MRI scans for mass lesions are performed _________ contrast
without; with
Constrast - gadolinium
Patients who undergo breast augmentation have their implants placed
subglandular - prepectoral
Patients who undergo breast reconstruction have their implants placed
subpectoral or submuscular location
Myocutaneous flap (autogenous myocutaneous flap):
surgical technique which uses the patient’s own (autogenous) muscular and subcutaneous tissues to reconstruct a breast following a skin-sparing mastectomy
Which is the most common method of autogenous myocutaneous flap surgery?
Transverse rectus abdominus myocutaneous (TRAM) flap
The tissue is enough to create a breast shape, precluding the addition of an implant
Why would an autogenous myocutaneous flap be preferred over a prosthetic implant?
more natural and durable. Lower incidence of capsular contracture
The tissue expander has a port (metal or plastic plug/valve) which allows the surgeon to add increasing amounts of liquid over a period of up to _________, without having to perform additional surgery.
six months
When do they do ductography?
When patients present w single duct discharge, some pt’s indicate a trigger point
Can air bubbles be present in the syringe for a ductogram?
No, it is critical there is no bubbles as they will confuse the images later
Where do we insert the cannula?
The nipple, into the duct as far as possible. 0.2-0.4mL of fluid is then injected and then the needle is fixed to the nipple with tape
When there is abrupt termination of a duct on a ductography, what must we suspect?
ductal carcinoma
What presents with a greenish discharge?
fibrocystic disease
If a patient has ductal ectasia, what symptoms might they have?
thick, whitish discharge
Are ductograms and galactograms the same thing?
Yes, the terms can be used interchangeably
What type of discharge is most suspicious for malignancy?
bloody
What is the strongest prognostic indicator of breast carcinoma?
Axillary LN’s
The most important predictor of breast cancer survival is the status of?
the lymph nodes
The survival rate decreases by ______ when a patient is node positive.
15%
What is a side effect with sentinel node resections?
lymphedema, swelling, numbness or chronic pain
Is a sentinel node procedure indicative of metastatic disease?
No
What is a sentinel lymph node?
The first node to receive drainage from a tumor
What is a sentinel lymph node biopsy?
provides the clinician with information on if the cancer has spread. Instead of removing 10-15 LN’s, they can just do 2-3
How do they figure out the sentinel lymph node?
2 ways: lymphoscintigraphy (radioactive material -sulfur colloid) or a blue dye injection that is seen during surgery
What is the process for identifying the sentinel node?
Radioactive material (black areas on nuclear med procedure) then injecting blue dye to confirm. This procedure allows us to only remove 1-3 nodes vs the more invasive 10-15
What is the benefit to the gummy bear implant? The disadvantage?
They have a firmer silicone gel and are teardrop (natural) shaped. Disadvantage of it are the possibility of rotation and distortion.
The IDEAL implant:
double lumen that are both filled with saline. This allows for the rupture to be easily detectable, but not have the health effects of silicone rupture.
Which mammo view is the best to see an implant?
MLO
Histology:
a branch of anatomy that deals with the minute structure of animal and plant tissues as discernible with the microscope
Cytology
a branch of biology dealing w structure, function, multiplication, pathology and life history of cells
What biopsy techniques are used for palpable masses?
Cyst aspiration or FNA
Core biopsy
Open surgical biopsy (incisional or excisional)
What biopsy techniques are used for non palpable masses?
Needle directed biopsy
Stereotactic core biopsy
US directed core biopsy
Why would we do a cyst aspiration?
reserved for atypical or complex cysts, as well as symptomatic cysts
Vertical or upright needle approach for cyst aspirations are used for
superficial and large, palpable cysts
Horizontal approach is used for
smaller and deeper cysts
Which approach provides superior real time ultrasound needle visualization?
horizontal approach
Which fluid has the greatest risk for malignancy?
bloody
Milky fluid is typically aspirated from?
galactoceles
What is a pneumocystography?
When air (50%) is injected into the evacuated cyst to provide a a therapeutic benefit of reduced cyst recurrence Then a mammogram is taken
Breast localizations are used to locate non-palpable lesions.
True
Which is the least precise methods of lesion localizations?
Skin localizations
When would we use the skin localization method?
when lesions are superficial
If not superficial, we end up removing more tissue than necessary
Dye Method:
involves injecting methylene blue dye or inert carbon into a questionable lesion. After the dye is injected, the needle is then removed and a track is left behind, leading the surgeon to the lesion
Needle/Needlewire Combo (mammo technique)
A breast is compressed with a compression paddle, and a needle is put in using a anteroposterior approach or parallel to chest wall approach. A image is then taken to confirm the place. The needle is then withdrawn leaving a wire in place
For needle / needlewire combinations (US techniques) how should the lesions be approached?
Superficial - acute angle
Deep lesions - angle as close to parallel with the rib cage as possible to avoid penetrating the pleural space
When is the needle shaft best visualized?
When the needle is advanced parallel to the long axis of the transducer
Why do we have to make sure we scan the needle in two planes?
To make sure the needle has fully hit the lesion
What’s the gold standard for biopsies?
Open surgical biopsy
What’s the biggest advantage of an open excisional biopsy?
Complete removal of the lesion
What’s the biggest disadvantage of an open excisional biopsy?
size of the incision (1.5-2inches) and discomfort to the patient
When would we do an incisional biopsy?
When the lesion is large and ill defined. Only removes a portion of the lesion
Core biopsy needle:
large needle with a hollow or recessed core is inserted into the mass and then small cores of suspicious tissue are extracted for lab study
What is the most common needle gauge with a core biopsy? How many samples are extracted?
11
3-6 (usually 4)
Core samples are usually how long?
1-2cm long
1.5mm wide
Can we xray core biopsy tissue samples?
no, they are too small
What do we do if lesions are too close to the chest wall?
they may be elevated slightly by injecting a bolus of saline or local anaesthetic deep to the lesion, raising it up from the wall.
Vacuum assisted core biopsy aka
mammatome
What two procedures are referred to as mammotomy procedures? Do they provide larger or smaller samples?
Vacuum assisted core biopsy or ABBI. Larger
What type of biopsy is utilized especially if there are calcifications identified on mammo?
Vacuum assisted biopsy (mammotome)
What type of needle is used for a vacuum assisted biopsy?
large bore, 11 gauge needle probe.
US or stereotactic mammography is used to guide the instrument
A tissue sample is collected, and then?
The thumbwheel is rotated 30 degrees, about 8-10 times until a full 360 degree sample has been acquired
What does ABBI stand for
Advanced breast biopsy instrumentation
Once the breast is positioned, mammograms are obtained in ____________, using the ______________ _____________ _______.
Several planes
stereotactic mammography unit
Acute breast abscesses are typically where in location?
retroareolar
What do we do with ultrasound before we drain an abscess?
Estimate the volume (2 planes)
The needle should be _________ to the transducer so we can visualize it
parallel
or paralle to the chest wall
What size of needle do we typically used for abscess drainage?
18-25
What should be seen after draining an abscess procedure?
resolution
Larger abscesses may require?
serial drainage and possibly a drainage catheter
All aspirated samples should be sent for pathological examination
Local injection of a broad spectrum antibiotic
Abscesses smaller than _______, seem to be more sucessfully treated by US guided percutaneous drainage than those greater than 3cm
2.5cm
What are some complications of biopsies?
Excessive bleeding, hematoma, pneumothorax, infection, vasovagal reaction, no diagnosis due to insufficient samples
Neoadjuvant therapy:
the delivery of treatment prior to surgery in order to shrink the cancer an facilitate more complete surgical removal of it
Neoadjuvant therapy provides the same survival rate as adjuvant therapy, but leads to higher
rates of breast conserving surgery
Surgery (lumpectomy or mastectomy w non concomit radiation) takes place how long after neoadjuvant therapy has concluded?
4-6weeks
Neoadjuvant therapy may be in the forms of?
chemo or radiation therapy
What happens to those whose cancer has improved/not progressed following neoadjuvant therapy?
They will go on tamoxifan for 5yrs
What’s the most important mammo view as it images the tissue by the chest wall and axilla?
MLO
Which mammo view images the most carcinomas?
MLO
What tissues are least seen with this view?
inferomedial tissues
MLO projections may vary from ___to____ depending on the body habitus and breast size
30-90
What view best visualizes the glandular tissue on the medial aspect of the breast?
CC
What view is used for imaging implants and when the breast implant is pushed back and tissue is pulled forward?
Eklund
XCC
exaggerated craniocaudal
CV
cleavage view
On the MLO view, markers are placed
at the upper breast, near the axilla
On the CC view, markers are placed
on the lateral or outer aspect of the breast
