Mammo Flashcards
Anatomy
nipple
The nipple is a circular smooth muscle that overlies the 4lh intercostal space. There
are typically 5-10 ductal openings. Inversion is when the nipple invaginates into the breast.
Retraction is when the nipple is pulled back slightly. They can both be normal if chronic. If
they are new, it should make you think about underlying cancers causing distortion. The
nipple is supposed to be in profile so you do n ’t call it a mass. The areola will darken
normally with puberty and parity. Nipple enhancement on contrast enhanced breast MRI is
n o rm a l, don ’t call it Pagets!
Anatomy
fibroglandular tissue
The breast mound is fibrous
tissue with fat, ducts, and glands laying on top o f the
anterior chest wall. The axillary extension is called the
“to// o f Spence.” The upper outer quadrant is more
densely populated with fibroglandular tissue, which is
why most breast cancers start there. There is usually no
dense tissue in the medial/ inferior breast and
retroglandular regions. These are considered “danger
zones” and are often where the cancer hides.
Anatomy
danger zones
where there is
usually no dense fibroglandular
tissue
Anatomy
coopers ligaments
These are thin sheets o f fascia
that hold the breasts up. They are the tiny white lines on mammography and the echogenic
lines on US. Straightening and tethering o f the ligaments manifests as “architectural
distortion” which occurs in the setting o f surgical scars, radial scars, and IDC.
Anatomy
breast asymmetry
This is common and normal (usually), as long as there are no other
findings (lumps, bumps, skin thickening, etc..). For multiple choice, an asymmetric breast
should make you think about the “shrinking breast ” o f invasive lobular breast cancer. I f the
size difference is new or the parenchyma looks asymmetrically dense, think cancer.
Anatomy
lobules
The lobules are the flower shaped milk makers o f the breast. The terminal duct
and lobule are referred to as a “terminal duct lobular unit” or TDLU. This is where most breast cancers start.
Anatomy
ducts
The ductal system branches like the roots or branches o f a tree. The branches overlap wide areas and are not cleanly segmented like slices o f pie. The calcifications that appear to follow ducts (“ linear or segmental”) are the ones where you should worry about cancer.
Anatomy
lactiferous sinus
Milk from the lobules drains into the major duct under the nipple. The
dilated portion o f the major duct is sometimes called the lactiferous sinus. This thing is normal (not a mass).
Anatomy
blood supply/lymphatic drainage
The majority (60%) o f blood flow to the breast is via the internal mammary. The rest is via the lateral thoracic and intercostal perforators. Nearly all (97%) o f lymph drains to the axilla. The remaining 3% goes to the internal mammary nodes.
Anatomy
axillary node levels
The axilla is sub-divided into three separate levels using the
pectoralis minor muscle as a landmark. Supposedly drainage progresses in a step wise
fashion - from level 1 -> level 2 -> level 3 and finally into the thorax.
Anatomy
rotter nodes
These are the nodes between the pec minor and major. They have a fancy
name which usually makes them high yield. However, Rotter was German and test writers
tend to prefer French sounding trivia. The only exception to this is Nazis. German sounding
medical vocab words named after Nazis are fair game. To save you the trouble o f looking it
up - Rotter died before Hitler took power so he wasn’t a Nazi (probably). Since they
probably aren’t gonna ask the vocab word, the only other conceivable piece o f trivia I can
imagine being asked would be that these are at the same level as level 2.
Anatomy
axillary nodes quick
Level 1: Lateral to Pec Minor
Level 2: Deep to the Pec Minor
Level 3: Medial and Above Pec Minor
Rotter Node: Between the Pec Minor and Major
Anatomy
Metastasis to the Internal Mammary Nodes
If you can see them on ultrasound they are abnormal. Isolated mets to these nodes is not a common situation (maybe 3%). When you do see it happen, it’s from a medial cancer. More commonly, mets in this location occur after
disease has already spread into the axilla (in other words - it’s spreading everywhere).
Anatomy
sternalis muscles
This is an Aunt Minnie. It’s a non-functional muscle next to the sternum
that can simulate a mass. About 5% o f people have one and it’s usually unilateral.
Anatomy
sternalis muscle testable trivia
- WTF is that ?- Recognize the Aunt Minnie, and d o n ’t get tricked into doing a biopsy on it, e tc …
- How You See It? It is ONLY SEEN ON THE CC VIEW.
Handling this in real life is all about the old gold. Find that thing on the priors (even better is a C T ) , CC only, never on the MLO.
Breast Development
overview
The “milk strea k ’’ is the embryologic buzzword to explain the location o f the normal breast
and location o f ectopic breast tissue. Just know that the most common location for ectopic
breast tissue is in the axilla (second most common is the inframammary fold). Extra
nipples are most commonly in the same locations (but can be anywhere along the “milk
streak”). At birth, both males and females can have breast enlargement and produce milk
(maternal hormones). As girls enter puberty, their ducts elongate and branch (estrogen
effects), then their lobules proliferate (progesterone effects). I f you biopsy a breast bud
(why would you do that?) you could damage it and potentially fuck up breast
development…. and then get sued.
Breast Development
Follicular Phase (day 7-14):
Estrogen Dominates. Best time to have both mammogram and MRI.
Breast Development
Luteal Phase (day 15-30):
Progesterone Dominates. This is when you get some breast tenderness (max at day 28-30). Breast density increases slightly.
Breast Development
Pregnancy:
Tubes and Duct Proliferate. The breast gets a lot denser (more
hypoechoic on US), and ultrasound may be your best bet if you have a mass.
Breast Development
Perimenopausal
Shortening o f the follicular phase means the breast gets more
progesterone exposure. More progesterone exposure means more breast pain, more
fibrocystic change, more breast cyst formation.
Breast Development
Menopause (“The Floppy S ta ge”):
Lobules go down. Ducts stay but may become
ectatic. Fibroadenomas will degenerate (they like estrogen), and get their “popcorn”
calcifications. Secretory calcifications will develop (*but not for 15-20 years post
menopause) .
Breast Development
Hormone Replacement Therapy
Breasts get more dense (especially estrogenprogesterone
combos). Breast pain can occur, typically peaking in the first year.
Fibroadenoma (who like to drink estrogen) can grow.
High Yield Trivia Regarding Breast Anatomy / Physiology
The nipple can enhance with contrast on MRI. This is normal (not Pagets).
Most cancers occur in the upper outer quadrant.
Most cancers start in the terminal duct lobular unit (TDLU).
Majority (60%) o f blood flow is via the internal mammary.
Mets to the Internal Mammary Nodes are uncommon (3%) - seen in medial cancers.
Axillary Node Levels (1, 2, 3 - lateral to medial)
Stemalis is usually unilateral, and only on the CC, NEVER on MLO.
Breast Tenderness is max around day 27-30.
Mammography and MRI are best performed in the follicular phase (days 7-14).
Don’t Biopsy a prepubescent breast - you can affect breast development
Perimenopause (5 0 ’s) is the peak time for breast pain, cyst formation
Fibroadenomas will degenerate (buzzword popcorn calcification) in menopause
Secretory Calcifications (buzzword “ rod-like) will develop 10-20 years post menopause
Lactation
density
As mentioned above, the breast gets a lot denser in the 3rd trimester.
Mammograms might be worthless, and ultrasound could be your only hope. In other
words, ultrasound has greater sensitivity than mammo in lactating patients.
Lactation
density track
Pituitary Prolactinoma, or meds (classically antipsychotics) can create a
similar bilateral increased density.
Lactation
biopsy
You can biopsy a breast that is getting ready to lactate / lactating - you ju st need
to know there is the risk o f creating a milk fistula. If you make one, they will have to
stop breast feeding to stop the fistula. The fistula can get infected, but th at’s not verycommon.
Lactation
galactocele
This is one o f those “benign fat containing lesions” that you can BR-2.
This is typically seen on cessation o f lactation. The location is typically sub-areolar. The
appearance is variable, but can have an Aunt Minnie look with a fat-fluid level. It’s
possible to breast abscess these things up.
Lactation
lactating adenoma
These things look like fibroadenomas, and may actually be a
charged up fibroadenoma (they like to drink estrogen). Usually these are multiple. If
you get pressed on follow up recommendation for these I would say 4-6 months
postpartum, post delivery or after cessation o f lactation -via ultrasound. They usually
rapidly regress after you stop lactation.
Technique basics
As I mentioned in the introduction, a screening mammogram starts with two standard
views; a cranial caudal view and a medial lateral oblique view.
Technically Adequate?
trivia
Ideally, the inframammary fold should be visualized
“Camel N o se” is the buzzword used to describe a breast on MLO that has not be pulled “up and out” by the tech
The nipple should be in profile in one o f two views (to avoid missing the subareolarcancer).
Relaxed pectoralis muscles are preferred (convex, instead o f concave) - showing more breast tissue.
When do you g et a LMO view ?
The MLO is the standard, but sometimes you need a LMO. The answer is women with kyphosis or pectus excavatum. Or to avoid a medial pacemaker / central line.
MLO View Trivia
The MLO view contains the most breast tissue o f all the possible views
When using Spot Compression Views
A big point is the recommendation to leave the
collimator open, giving you a larger field o f view, and helping to ensure that you got what
you wanted to get. Small paddles give you better focal compression. Large paddles allow
for good visualization o f land marks.
When using Magnification Views
A CC and ML (true lateral) are obtained. You get a ML
(as opposed to a MLO) to help catch milk o f calcium.
When using a True Lateral View ML vs LM
Using a true lateral is useful for localizing things
seen on a single view only (the CC). A trick I use is whatever 1 said on the screener, is the
last letter I’d use on the call backs. In other words, if it’s Lateral on the screener you want an
ML on the diagnostic. If it’s Medial on the screener then you want a LM on the diagnostic.
The reason is that you are moving it closer to the receptor. If you see the area o f interest on
the MLO only (not the CC), you should pick ML - because most (7 0%) breast cancers
occur laterally. — This would make a good multiple choice question.
Mediolateral Oblique View (MLO)
techniaue
Primary Image View
Maximized Visualization of the Axillary and Pos terior Tissue
Pectoral Muscle should be seen to the Level o f the Nipple
Pectoral Muscle should be Relaxed (convex a nterior border)
Motion A rtifa c ts Predominates at the Inferior Part o f the Breast (especially in w rin k ly flo p p y stink y saggy ones) se co n d a ry to a lack o f compression.
The “ sweep up and o u t” te ch n iq u e is used by techs to reduce a rtifa c t in this location.
Mediolateral Oblique View (MLO)
techniaue
Primary Image View
Maximized Visualization of the Axillary and Pos terior Tissue
Pectoral Muscle should be seen to the Level o f the Nipple
Pectoral Muscle should be Relaxed (convex a nterior border)
Motion A rtifa c ts Predominates at the Inferior Part o f the Breast (especially in w rin k ly flo p p y stink y saggy ones) se co n d a ry to a lack o f compression.
The “ sweep up and o u t” te ch n iq u e is used by techs to reduce a rtifa c t in this location.
Craniocaudal View (CC)
technique
Primary Image View
Ideally maximizes the p o s te rio r medial
tissue (the sp o t th a t can be missed on the MLO)
Should have a small am ount of skin at th e mos t medial a sp e c t to co n firm a d e quate coverage
Chest wall to nipple should be within 1 cm o f th e ch e s t wall to pectoral muscle on the MLO.
If you lack adequate coverage at the po s te rio r lateral edge or axillary tail th e next a p p ropriate s te p is an exaggerated lateral CC view (XCCL).
Mediolateral (ML)
technique
90 degree view
Can be used to triangulate (medial to the nipple lesions will rise on the true lateral - “muffins rise” )
Shows the lateral breast (the one c lo se s t to th e detec tor) in be tte r detail
Lateromedial
(LM)
technique
90 degree view
Can be used to tria n g u la te (medial to the nipple lesions will rise on the true lateral - “muffins rise” )
Shows th e medial breast in b e tte r detail.
Remember the p os terior medial breast is the to u g h e s t is image.
Conan! What is Best … View Given the Following Circumstances ?
“Nodule” seen only in CC View: Rolled CC
“Nodule” favored to be in the skin: Tangential (TAN)
“Nodule” favored to be milk of calcium: True Lateral
“Nodule” in the far posterior medial breast: Cleavage View (CV)
Breast Implants: “Eklund Views” or Implant Displaced (MLOID, CCID)
Calcifications: Magnification View
Blur artifact
Can be from breathing or inadequate compression (typically along the inferior breast
on the MLO). It can be tricky to pick up. The strategy 1 like to use is to look at Cooper’s
Ligaments - they should be thin white lines in the fat. If they are thick or fuzzy - it is
probably blur (or edema). If there is skin thickening, think edema.
You see blur in 3 scenarios
( 1 ) patient moved,
( 2 ) exposure was too long,
( 3 ) exposure was too short.
Grid line artifact
Basically mammograms always use a grid (unless it’s a mag view). That
would make a good multiple choice question actually. No grid on mag views. So, the grid
works by moving really fast, and only keeping x-rays that move straight in.
PPV
You are trying to find around 3-8 cancers per 1000 mammograms. Another way to ask this is to say that you are supposed to have a Positive Predictive Value (PPVi) of around 4% (in other words anything other than a BR1 or BR2 on a screener). This is demanded by the various regulating bodies.
Be aware that certain areas can sometimes
only be seen on a single view
the medial breast on a CC may not be seen on MLO, and the Inferior Posterior Breast on MLO may be excluded from the CC. That makes these areas “high risk” for missing a cancer.
Medial Breast
- Can be excluded on
the MLO View
Inferior Posterior
Breast
- Can be excluded on
the CC View
comparisons
It’s recommended to look at mammograms from 2 years prior (if available) for comparison.
Makes it a little easier to see early changes
Localizing a lesion (only seen in the MLO view):
This is a very basic skill, but if you had
absolutely no interest in mammography or just terrible training, a refresher might be useful as
this is applicable to multiple choice tests. A lesion that is seen in the MLO only will rise on the
true lateral (ML) if it is medial on the CC film. A lesion that is seen on the MLO only will fall
on the true lateral (ML) if it is lateral on the CC film. The popular mnemonic is “Lead Sinks,
and Muffins Rise ” - L for lateral, and M for medial.
Localizing a lesion (only seen in the CC view):
Sometimes you can only see the finding in
the CC view. If you want to further characterize it with ultrasound, figuring out if it’s in the
superior or inferior breast could be very helpful. One method for doing this is a “rolled CC
view.”
Rolled CC View:
This works by positioning the breast for a CC view, but prior to placing the
breast in compression you rotate the breast either medial or lateral along the axis o f the nipple. Your reference point is the top o f the breast.
• If you roll the breast medial; a superior tumor will move medial, an inferior tumor will move lateral.
• If you roll the breast lateral; a superior tumor will move lateral, an inferior tumor will move medial.
In other words, superior tumors move in the direction you roll and inferior tumors move in the opposite direction you roll. The “superior ” vs “inferior ” is inferred based on how it moves when you (the tech) roll the boob.
BI-RADS Assessment Categories’.
0: Incomplete
1: Negative
2: Benign finding!s)
3: Probably benign — < 2% Chance o f CA
4: Suspicious abnormality — 2 - 95% Chance of CA
* Some people use 4a (low suspicion), 4b (intermediate suspicion), and 4c (moderate suspicion).
5: Highly suggestive o f malignancy — > 95% Chance o f CA
6: Known biopsy - proven malignancy
BI-RADS 0:
This is your incomplete workup. They come in for a screener, you find
something suspicious. You give it a BI-RADS 0, and bring them back for spots, mags, or
ultrasound. You would also BI-RADS 0 anything that required a technical repeat (blur,
inadequate posterior nipple line, camel nose, etc ….).
BI-RADS 1:
its normal
BI-RADS 2:
Benign findings. Examples would be cysts, secretory calcifications, fat
containing lesions such as oil cysts, lipomas, galactoceles and mixed-density hamartomas.
* Multiple bilateral well circumscribed, similar appearing masses - This is BR-2
unless one is growing or different than the rest. The general rule is to not ultrasound
these things unless one is palpable.
* Multiple Foci - This MRI finding is also a classic BR2.
BI-RADS 3:
A key point is that BR-3 by definition means it has less than 2% chance of
being cancer. This is often a confusing topic. You can only use BR3 on a baseline. You
can’t call anything BR3 that is new. The typical BR3 scenario: 45 year old comes in for
screening and has a focal asymmetry. She gets called back for diagnostic work up with spots
and ultrasound. She is found to have mass with imaging features classic for fibroadenoma.
This can get a BR-3, and be followed (some places follow for 2 years, in 6 month intervals).
Any change over that time ups it to BR-4 and it gets a biopsy.
BI-RADS 3:
what if its palpable
This is a controversial topic. Classic teaching is that palpable lesions can
not be BR3. However, recent papers have shown that a palpable lesion consistent with a
fibroadenoma has less than 2% chance o f cancer. Some people think the new Bl-RADS will
change this rule. I really doubt they will paint you into a comer on this one - given the
controversy.
Things you can BR-3:
- Finding consistent with fibroadenoma
- Focal asymmetry> that looks like breast tissue (becomes less dense on compression).
- Grouped Round Calcifications
BI-RADS 4:
This is defined as having a 2-95% chance o f malignancy. Some people will
subdivide this into 4A, 4B. 4C depending on the level o f suspicion. Ultimately you are going to
biopsy it, and be prepared to accept a benign result.
BI-RADS 5:
prepared to accept a benign result.
BI-RADS 5: This is defined as > 95% chance o f malignancy. When you give a BR-5, you are
saying to the pathologist “ if you give me a benign result, I’ll have to recommend surgical
biopsy.” In other words, you can’t accept benign with a BR-5.
BI-RADS 6:
path proven cancer
Screening Mammogram
BR 0
You made a suspicious finding and they need a diagnostic workup
Technical Repeat for Blur,
inadequate positioning etc…
Screening Mammogram
BR 1
Tots normal
Screening Mammogram
BR 2
Multiple bilateral, well circumscribed similar appearing masses
Redemonstration o f an unchanged
previously worked up thing - a cyst e tc …
Diagnostic Mammogram
BR 2
You work it up and it’s a benign thing -
fat containing lesion, cyst, e tc … This returns to screening
Diagnostic Mammogram
BR 3
Very specific situation where you
are dealing with a baseline screener, now called back. Findings meet oneo f the three things described above;
(fibroadenoma, fat with breast tissue,
group o f round calcs). This gets 2 years
o f follow up.
Diagnostic Mammogram
BR 4
Suspicious finding, but you aren’t
convinced it’s cancer. In other words,
you would accept a benign result. - This
gets a biopsy.
Diagnostic Mammogram
BR 5
Suspicious finding, that you are
convinced is cancer. In other words, you
would NOT accept a benign result. - This
gets a biopsy.
Plain Mammography
MAss
This is a space occupying lesion seen in two different projections
Plain Mammography
describing the mass
You need to cover (1) Shape, (2) Margin, (3) Density
(1) Shape: Round, Oval, Irregular - “ROI”
(2) Margin: Circumscribed, Obscured, Microlobulated, Indistinct, Spiculated - “COMIS”
(3) Density (relative to breast parenchyma: Fat Density (radiolucent), Low Density, Equal
Density, High Density
Plain Mammography
MAss trivia
O f all the possible descriptors - margin is the most reliable feature for determining benign vs malignant.
Plain Mammography
asymmetry
Unilateral deposition o f tissue that doesn’t quite look like a mass.
* Asymmetry - This is a density (only seen in one view) that may or may not be a mass,
and is often a term used in screeners for BR-0 prior to call back.
* Global Asymmetry - “greater volume o f breast tissue than the contralateral side”,
around one quadrants worth (or more). It’s gonna get a call back, and then BR-2’d on
a baseline.
* Focal Asymmetry - This is seen in two projections, might be a mass - needs a spot
compression.
* Developing Asymmetry - Wasn’t there before, now i s … or bigger than prior.
Ultrasound
Describing the mass
You need to cover : (1) Shape, (2) Orientation, (3) Margin, (4) Echo
pattern, (5) Posterior acoustic features
(1) Shape: Round, Oval, Irregular (not round or oval)
(2) Orientation: Parallel (wider than tall), Not-Parallel (taller than wide)
(3) Margin: Circumscribed, Indistinct, Angular, Microlobulated, Spiculated
(4) Echo Pattern: Anechoic, Hyperechoic, Hypoechoic, Isoechoic, or Complex (cystic/
solid)
(5) Posterior Features: None, Enhancement, Shadowing
MRI
Background Parenchymal Enhancement
• This is a newly added B 1-RADS “feature.” In the literature, they specify that this
description is based o ff the first post contrast sequence (sounds testable to me). The
• Categories are : none, minimal, mild, moderate, and marked.
MRI
Lesion Analysis: There are 3 basic categories for this:
- Foci ( < 5 mm): You don’t need to describe shape and margin on these. They are too small.
- Mass ( > 5 mm): This will have shape, margin, internal enhancement characteristics, & T2.
- Non-Mass Enhancement: Distribution, Internal Enhancement, T2
MRI
Describing Masses
- Shape: Round, Oval, and Irregular. The word “lobulated” has been removed from the lexicon, so expect that to be a distractor.
- Margin: Circumscribed, Irregular, and Spiculated. The word “smooth” has been removed from the lexicon, so expect that to be a distractor.
- Internal Enhancement Patterns: Homogenous, Heterogenous, Rim, and Dark Internal Septations. “Enhancing Internal Septations” and “Central Enhancement” are NOT terms in the new vocab - and will likely be distractors.
MRI
T2 Signal - This is a new “feature” o f the lexicon
- Hyperintense:
- Greater than parenchyma (on T2)
- Greater than or equal to fat (on T2)
- Greater than or equal to water (on T2 Fat Sat)
MRI
NME - “Distribution ”
• Focal, Linear, Segmental (triangle shaped pointing towards nipple - suggestive o f a duct),
Regional (large area - not a duct), Multiple Regions (two or more regions) and Diffuse.
MRI
NME - Internal Enhancement
• Homogenous, Heterogenous, Clumped (looks like cobblestone), Clustered Ring (this is a buzzwordfor DCIS or IDC). “Reticular” and “Dendritic” have been removed and will likely be distractors.
MRI
Associated Findings
You are allowed to talk about nipple retraction, skin thickening, edema,
invasion o f the pec muscles, pre contrast signal, and artifacts.
MRI
implants
When you talk about implants you have to describe the type (silicone vs saline),
location (retroglandular vs retropectoral), and luminal features like radial folds, keyhole, linguine, e tc … I’ll cover this more in the Breast MRI section.
Calcifications overview
Calcifications can be an early sign o f breast cancer. “The earliest sign,” actually, according
to some. Calcifications basically come in three flavors: (1) artifact, (2) benign, and (3)
suspicious.
A rtifa c ts Simulating Calcifications:
Deodorant
High density material seen in the
axilla is the typical appearance. Another trick
is to show a speck o f high density material
that doesn’t change position on different
views (inferring that it’s on the image
receptor).
A rtifa c ts Simulating Calcifications:
Zinc Oxide
This is in an ointment old ladies like to put on their floppy sweaty breasts. It can collect on moles and mimic calcifications. If it disappears on the follow up it was probably this (or another dermal artifact).
A rtifa c ts Simulating Calcifications:
Metallic Artifact
It’s possible for the electrocautery device to leave small metallic
fragments in the breast. These will be very dense (metal is denser than calcium). It will also
be adjacent to a scar.
Benign vs Suspicious calcs overview
The distinction between benign and suspicious is made based on morphology and distribution
(those BI-RADS descriptors). Since most breast cancers start in the ducts (a single duct in most
cases), a linear or segmental distribution is the most concerning. The opposite o f this would be
bilateral scattered calcifications.
Calcs spectrum pattern
worse > benign
segmental linear grouped regional scattered/diffuse
Benign
Dermal Calcifica tions
These are found anywhere women sweat (folds, cleavage,
axilla). Just think folds. They are often grouped like the paw o f a bear, or the foot o f a baby.
The trick here is that these stay in the same place on CC, and MLO views. This is the so
called “tattoo sign. ” If you are asked to confirm these are dermal calcs, I ’d ask for a
“tangential view.”
Benign
Vascular Calcifications
are parallel linear calcifications. It’s usually obvious,
but not always.
Benign
Popcorn Calcifications
This is an immediate buzzword for degenerating fibroadenoma.
The typical look is they begin around the periphery and slowly coalesce over subsequent images.
Benign
Secretory (Rod-Like) Calcifications
These are
big, easily seen, and point toward the nipple. They are
typically bilateral. The buzzword is “cigar shaped with a
lucent center. ” Another buzzword is “dashes but no dots. ”
The buzz age is “10-20years after menopause. ” Don’t be
an idiot and call these in a premenopausal patient, they
happen because the duct has involuted.
Benign
Eggshell Calcifications:
“Fat necrosis” 1 call them. It can be from any kind o f trauma
(surgical, or accidental - play ground related). If they are really massive you may see the word
“liponecrosis macrocystica.” As I’ve mentioned many times in this book, anything that sound
Latin or French is high yield for multiple choice. “Lucent Centered’’ is a buzzword.
Benign
Dystrophic Calcifications
These are also seen after radiation, trauma, or surgery. These
are usually big. The buzzword is “irregular in shape. ” They can also have a lucent center.
Benign
Round calcs
The idea is that these things develop in lobules, are usually scattered, • e .
bilateral, and benign. When benign (which is most o f the time) they are going to . •
be due to fibrocystic change (most o f the time). The best way I’ve heard to think . •
about these is the same as a mass.
When masses are bilateral, multiple, and similar they are considered benign (BR-2). When a
mass is by itself or different it’s considered suspicious. Round calcifications are the same
way. They are usually bilateral and symmetric (and benign). If they are clustered together,
by themselves, or new, they may need worked up (just like a mass). Remember that if
grouped round calcs are on the first mammogram you can BR-3 them.
Benign
Milk of Calcium:
(1) On the CC view the calcifications look powdery
and spread out, on the MLO view they may
layer. I suspect they will show you a ML view
because they should layer into a more linear
appearance, with a curved bottom “tea-cupped.”
For the purpose o f gamesmanship if they show
you a ML view on a calcs question - look hard
fo r anything that resembles tea-cupping.
(2) It’s fluid-fluid in a lobule - due to fibrocystic
change.
No Calcifications on the Biopsy? milk of calcium
This is a common trick. Apparently Milk o f Calcium needs to be viewed with polarized
light to assess birefringence. Otherwise, you c an ’t see it. I imagine there are several ways to
get at that via multiple choice.
Suspicious calcs
Amorphous
These things look like powdered sugar, and you should
not be able to count each individual calcification.
Distribution is key with amorphous calcs (like many other types before). If
the calcs are scattered and bilateral they are probably benign, if they are
segmental they are probably concerning.
Suspicious calcs
Coarse Heterogeneous
These calcifications are countable, but
| their tips are dull. If you picked one up it would not be poke you.
They are usually bigger than 0.5 mm. Distribution and comparison to
priors is always important. They can be associated with a mass
(fibroadenoma, or papilloma).
Suspicious calcs
Fine Pleomorphic
These calcifications are countable, and their tips
appear sharp. If you picked one up it would poke you. They are usually
smaller than 0.5 mm. This pattern has the second highest likelihood o f
malignancy. .. probably
Suspicious calcs
Fine Linear / Fine Linear Branching
This is a distribution
that makes fine pleomorphic calcifications even more suspicious. The
DDx narrows to basically DCIS or an atypical look for secretory calcs or
vascular calcs. This pattern has the highest likelihood o f malignancy.
Suspicious calcs
C alcifica tions Associated with Focal Asymmetry/Mass
When you see increased tissue density around suspicious calcifications, the chance o f an
actual cancer goes up. This is sometimes called a “puff o f smoke” sign , or a “warning
shot.” This is a situation where ultrasound is useful, for extent o f disease.
Suspicious calcs
Gamesmanship - Next Step
Ultrasound is NOT typically used to evaluated pure calcification findings. Exceptions
would be (a) if the patient had a mass associated with the calcifications, or (b) if the patient
had a palpable finding - then they would get additional evaluation with ultrasound.
Suspicious calcs
Gamesmanship “Highest Suspicion for Malignancy”
Depending on what you read and who you ask, Fine Linear Branching and Fine Pleomorphic
Calcifications have the Highest Suspicion for Malignancy. So which one is it?
For sure fine linear branching is the worst. Morphologically it mimics the ductal
proliferation o f suspicious calcifications (DCIS). The confusion is that some people use
fine pleomorphic as an umbrella term under which linear and branching forms exist.
DDx Amorphous Ca+2
Fibrocystic Change (most likely) Sclerosing Adenosis Columnar Cell Change DCIS (low grade)
DDx Coarse Heterogeneous Ca+2
Fibroadenoma
Papilloma
Fibrocystic Change
DCIS (low - intermediate grade)
DDx Fine
Pleomorphic Ca+2
Fibroadenoma (less likely)
Papilloma (less likely)
Fibrocystic Change
DCIS (high grade)
Suspicious calcs
Gamesmanship “Highest Suspicion for Malignancy”
So how to handle this on multiple choice?
• If the answer choices include fine linear branching then that is the correct answer.
• If the answer choices do NOT include fine linear branching but instead have you pick fine
pleomorphic vs coarse heterogenous or some other obviously benign calcs (egg shell,
e tc …) then for sure pick fine pleomorphic.
Mondor Disease
This is a thrombosed vein that presents as a tender palpable cord. It looks exactly like y o u ’d expect it to with ultrasound. You don’t anticoagulate for it (it’s not
a DVT). Treatment is ju st NSA1DS and warm compresses.
Fat Containing Lesions
There are five classic fat containing lesions, all o f which
are benign: oil cyst / fat necrosis, hamartoma, galactocele, lymph nodes, and lipoma. Of
these 5, only oil cyst/fat necrosis and lipoma are considered “pure fat containing” masses.
Fat Containing Lesions
Hamartoma
The buzzword is “breast within a
breast.” They have an Aunt Minnie appearance on
mammography, although they are difficult to see on
ultrasound (they blend into the background).
Fat Containing Lesions
Galactocele
Seen in young lactating women.
This is typically seen on cessation o f lactation. The
location is typically sub-areolar. The appearance is
variable, but can have an Aunt Minnie look with a
fat-fluid level. It’s possible to breast abscess these things up.
Fat Containing Lesions
Oil Cyst / Fat Necrosis -
These are areas o f fat necrosis walled off by fibrous tissue.
You see this (1) randomly, (2) post trauma, (3) post surgery. The peripheral
calcification pattern is typically “egg shell.” I f you see a ton o f them you might think
about steatocystoma multiplex (some zebra with hamartomas).
Fat Containing Lesions
Lipoma
These are typically radiolucent with no calcifications. Enlargement o f a
lipoma is criteria for a biopsy.
Fat Containing Lesions
Intramammary Lymph node:
These are normal and typically located in the tissue along the pectoral muscle, often close to blood vessels. They are NOT seen in the fibroglandular tissue.
Does she need an ultrasound i f i t ’s palpable?
Usually a palpable finding is going to get an ultrasound. If you are under 30, most people will skip the mammo and
go straight to ultrasound. One o f the exceptions is a fat containing lesion definite benign BR-2er on diagnostic mammography.
Pseudoangiomatous Stromal Hyperplasia (PASH):
This is a benign myofibroblastic hyperplastic process (hopefully that clears things up). It’s usually big (4-6
cm), solid, oval shaped, with well defined borders. Age range is wide they can be seen
between 18-50 years old. Follow up in 12 months (annual) is the typical recommendation.
Pseudoangiomatous Stromal Hyperplasia (PASH): =
Benign thing with a scary sounding name
Fibroadenoma
This is the most common palpable mass in young women. The typical
appearance is an oval, circumscribed mass with homogeneous hypoechoic echotexture, and a
central hyperechoic band. If it’s shown in an older patient, it’s more likely to have coarse
“popcorn” calcifications - which is a buzzword. On MRI, it’s T2 bright with a type 1
enhancement (progressive enhancement).
Phyllodes
Although I clumped this in benign disease, this thing has a malignant
degeneration risk o f about 10%. They can metastasize - usually hematogenous to the lungs
and bone. This is a fast growing breast mass. They need wide margins on resection, as they
are associated with a higher recurrence rate if the margin is < 2 cm. It occurs in an older age
group than the fibroadenoma (40s-50s). Biopsy o f the sentinel node is not needed, because
mets via the lymphatics are so incredibly rare (if it does met - it’s hematogenous).
Distinguishing Features o f Phyllodes Tumor
- Rapid Growth
- Hematogenous Mets
- Middle-Age to Older Women
- Mimics a Fibroadenoma
IDC
Invasive Ductal Carcinoma is by far the most common invasive breast cancer, making
up about 80-85% o f the cases. This cancer is ductal in origin (duh), but unlike DCIS is not
confined to the duct. Instead it “ invades” through the duct and if not found by the heroic
actions o f Mammographers it will progress to distal mets and certain death. Clinically, the
most common story is a hard, non-mobile, painless mass. On imaging, the most common
look is an irregular, high density mass, with indistinct or spiculated margins, associated
pleomorphic calcifications, and an anti-parallel shadowing mass with an echogenic halo on
ultrasound.
Invasive Ductal NOS
By far the most common type o f breast cancer is the one that is
undifferentiated and has no distinguishing histological features. “Not Otherwise Specified”
or NOS they call it. These guys make up about 65% o f invasive breast cancer.
IDC Types - (Other than NOS)
tubular
Small spiculated slow
growing mass with a
favorable prognosis.
Often conspicuous on ultrasound. Associated
with a Radial Scar. Contralateral breast will
have cancer 10-15% o f the time.
IDC Types - (Other than NOS)
mucinous
Round (or lobulated) and
circumscribed mass
Uncommon. Better outcomes than IDC-NOS
IDC Types - (Other than NOS)
medullary
Round or Oval
circumscribed mass,
without calcifications.
Axillary nodes can be large even in the
absence o f mets. Typically younger patient
(40s-50s). Better outcome than IDC-NOS
-25% have BRCA 1 mutation
IDC Types - (Other than NOS)
papillary
Complex cystic and
solid
Axillary nodes are NOT common. Typically
seen in elderly people, favors people who are
not white, and is the 2nd most common (behind
IDC-NOS)..
Multifocal Breast C ancer
Multiple primaries in the same quadrant (classically same duct system)
Less than 4-5 cm apart from one another
Multicentric Breast Cancer
Multiple primaries in different quadrants
Think o f this like “multi-center” clinical
trial; multiple discrete tin-related sites.
Synchronous Bilateral Breast C a n c e r
h i s is seen in 2-3% o f women on mammography, with another 3-6% found with MRI. The risk o f bilateral disease is increased in infiltrating lobular types, and multi-centric disease.
DCIS
This is the “earliest form o f breast cancer.” In this situation the “cancer” is confined
to the duct. Histologists grade it as low, intermediate, or high. Histologists also use the terms
“comedo”, and “non-comedo” to subdivide the disease. If anyone would ask, the comedo
type is more aggressive than than the non-comedo types.
DCIS
Testable Trivia:
10% o f DCIS on imaging may have an invasive component at the time biopsy is done
25% o f DCIS on core biopsy may have an invasive component on surgical excision.
8% o f DCIS will present as a mass without calcifications
Most common ultrasound appearance = microlobulated mildly hypoechoic mass with ductal extension, and normal acoustic transmission
DCIS
If a test writer wants you to come down on this they will show it in 1 o f 3 classic ways:
(1) suspicious calcifications (fine linear branching or fine pleomorphic - as discussed above),
(2) non mass enhancement on MRI, or
(3) multiple intraductal masses on galactography.
Pagets
Paget’s disease o f the breast is a high yield topic. It is basically a carcinoma in
situ o f the nipple epidermis. About 50% o f the time the patient will have a palpable finding
associated with the skin changes.
Pagets
Things to know about Breast Pagets:
- Associated with high grade DCIS (96 %)
- Wedge biopsy should be done on any skin lesion that affect the nipple-areolar complex that doesn’t resolve with topical therapy.
- Pagets is NOT considered T4. The skin involvement does not up the stage in this setting.
Lobular ( IL C )
This is the second most common type o f breast cancer (IDC-NOS being the
most common). It makes up about 5-10% o f the breast CA cases.
This pathophysiology lends itself well to multiple choice questions:
Cell decides to be cancer -> Cells lose “e-cadherin” -> Cells no longer stick to one another and
begin to infiltrate the breast “like the web o f a spider” -> This infiltrative pattern does not cause
a desmoplastic reaction so it gets missed on multiple mammograms -> Finally someone (you)
notices some architectural distortion without a central mass, on the CC view only. You get
fancy and call it a “dark star.”
Lobular ( IL C )
on us
The typical look is an ill-defined area o f shadowing without a mass.
“Shrinking Breast” -
This is a buzzword for ILC. The breast isn’t actually smaller, it ju st doesn’t compress as much. So when you compare it to a normal breast, it appears to be getting smaller. On physical exam, this breast may actually look the same size as the other one.
THIS vs THAT: ILC VS IDC
ILC is more often multifocal. ILC less often mets to the axilla. Instead, it likes to go to strange places like peritoneal surfaces. ILC more often has positive margins, and is more often treated with mastectomy although the prognosis is similar to IDC.
Things to know about ILC
It presents later than IDC
Tends to occur in an older population
It often is only seen on one view (the CC - as it compresses better)
Calcifications are less common than with ductal cancers
Mammo Buzzword = Dark Star
Mammo Buzzword = Shrinking Breast
Ultrasound Buzzword = Shadowing without mass
On MRI - washout is less common than with IDC
Axillary mets are less common
Prognosis o f IDC and ILC is similar
(unless i t ’s a pleomorphic ILC - which is bad)
More often multifocal and bilateral (compared to IDC) - up to 1/3 are bilateral
“Dark Star”
Distortion without a central mass
Architectural distortion without a central mass.
The DDx includes: lobular carcinoma, radial scar, surgical scar, and IDC-NOS.
Inflammatory Breast Cancer (IBC)
IBC an asshole with a notoriously terrible prognosis (at presentation -30% will have metastases).
Inflammatory Breast Cancer (IBC)
Clinical Scenario
The classic clinical scenario is a hot swollen red breast that developed rapidly
over 1-3 months. They may even deploy the French sounding word “peau d’orange,” - which
basically means skin that looks like a delicious ripe grapefruit. Although there may be a mass on the
mammogram, in the most classic scenario there isn’t a focal palpable mass
Inflammatory Breast Cancer (IBC)
“Skin Thickening ”
is a mammography buzzword (non-specific). Skin thickening is not (by itself)
specific and lots of stuff including CHF can also cause skin thickening. In the case of inflammatory
breast cancer the skin thickening is the result of tumor emboli obstructing the lymphatics.
Inflammatory Breast Cancer (IBC)
Probably Fuckery
It is likely the question writer will try to make you think mastitis - even though the
scenario isn’t really classic for that. Remember - mastitis is seen in breast feeding women — that is
the most common scenario. If it is just “random woman with a hot swollen breast” - you 100% should
think cancer first. Even if they put them on antibiotics, and she has a history of recurrent infections
or whatever — that is all probably bullshit.
Inflammatory Breast Cancer (IBC)
Mind Map
confusing page 491
Inflammatory Breast Cancer (IBC)
MRI
Best method for detecting the primary lesion in IBC
Most common finding = extensive or segmental NML enhancement + diffuse skin thickening
Inflammatory Breast Cancer (IBC)
antibiotics
The inflammation associated with inflammatory breast cancer can actually improve with antibiotics, but does NOT resolve. So, don't be fooled (in the real world or on a multiple choice test).
Inflammatory Breast Cancer (IBC)
Trivia
• IDC is the most common subtype to result
in IBC (although any subtype of primary
breast CA can)
• IBC is stage 4
Inflammatory Breast Cancer (IBC)
treatment
They will try and do
chemotherapy prior to surgery because the
chance of a positive margin is so high. The
standard mastectomy is done for “local
control” , which just sounds awful.
This vs That = IBC vs LABC
IBC
Rapid onset
Younger (mid 50s)
30% mets at presentation
This vs That = IBC vs LABC
LABC
Prolonged onset
Older (mid 60s)
10% mets at presentation
Confirming the diagnosis of IBC requires:
Both
(1) Tissue Diagnosis and (2) Clinical Evidence of
inflammatory disease the diagnosis of IBC
High Risk lesions
There are 5 classic high risk lesions that must come out after a biopsy; Radial Scar, Atypical Ductal Hyperplasia, Atypical Lobular Hyperplasia, LCIS, and Papilloma.
Radial Scar
This is not actually a scar, but does look like one on histology. Instead you
have a bunch o f dense fibrosis around the ducts giving the appearance o f architectural
distortion (dark scar).
Radial Scar
things to know
- This is high risk and has to come out
- I t’s associated with DCIS and/or IDC 10%- 30%
- I t ’s associated with Tubular Carcinoma*
Atypical Ductal Hyperplasia (ADH):
This is basically DCIS but lacks the
quantitative definition by histology (< 2 ducts involved). It comes out (a) because it’s high risk
and (b) because DCIS burden is often underestimated when this is present. In other words,
about 30% o f the time the surgical path will get upgraded to DCIS.
Lobular Carcinoma in Situ (LCIS):
This is classically occult on mammogram. “An incidental finding” is sometimes a buzzword. The best way to think about LCIS is that it can
be a precursor to ILC, but isn’t obligated to be. The risk o f conversion to an invasive cancer is
less when comparing DCIS to IDC. Just like pleomorphic ILC is worse than regular ILC, a
pleomorphic LCIS is mo’ badder than regular LCIS.
Atypical Lobular Hyperplasia (ALH):
This is very similar to LCIS, but histologists
separate the two based on if the lobule is distended or not (no with ALH, yes with LCIS). It’s
considered milder than LCIS (risk o f subsequent breast CA is 4-6x higher with ALH, and 1 lx
higher with LCIS). For the CORE, the answer is excision. In the real world, some people do
not cut these out, and it’s controversial.
Papilloma
A few most commons come to mind with this one. Most common intraductal
mass lesion. Most common cause o f blood discharge. You typically see these in women in
their late reproductive years / early menopausal years (average around 50). The classic
location is the subareolar region (1cm from the nipple in 90% o f cases).
Papilloma mammo
Often normal - occasionally just showing calcifications.
Papilloma us
Well-defined smooth walled hypo-echoic mass. Maybe cystic with solid components.
Also, tends to have associated duct dilation.
Papilloma galactography
Solitary filling defect, with dilated duct.
Papilloma multiple papillomas
These tend to be more peripheral. On mammography it’s gonna be a
mass(es) or a cluster o f calcifications without a mass.
Phyllodes
Yes… I mentioned this already under benign disease. 1 ju st wanted to bring it
up again to make sure you remember that this thing has a malignant degeneration risk o f
about 10% (some texts say up to 25%). This is a fast growing breast mass. It occurs in an
older age group than the fibroadenoma (40s-50s).
Multiple Masses: Sounds Bad But Actually BR-2
To call multiple masses you need to have multiple (at least 3) bilateral well circumscribed masses without suspicious features. This gives you a BR-2. One common trick is to show multiple unilateral masses, that doesn’t fly - they have to be bilateral.
Primary Breast Lymphoma
Always , for the purpose of multiple choice, Non Hodgkin (Diffuse Large B-Cell)
Usually a hyperdense mass (,Architectural distortion is rare)
“ IHC” staining is need to co n firm lymphoma
Primary Lymphoma (in the breast)
Less Common
Typical Look:
• Usually Solitary
• Usually Larger (compared to secondary) and mos t often palpable
• C y s tic on US
Secondary Lymphoma (in the breast)
More Common
most common secondary malignancy or mets to involve the breast
Typical Look:
• Inflammatory th ic kening w ith o u t a mass (but can look like anything)
Breast Pain
This is super common and typically cyclic (worse during the luteal phase o f
the menstrual cycle). Pain in both breasts that is cyclical does not need evaluation. Instead it
needs a family medicine referral for some “therapeutic communication.” Focal non-cyclic
breast pain may warrant an evaluation.
Breast Pain
trivia
The negative predictive value o f combined mammogram and US for “focal pain” is right around 100%. When breast cancer is found it’s usually elsewhere in the breast (asymptomatic).
Breast Pain
Symptoms that are actually worrisome for cancer include
skin dimpling, focal skin thickening, and nipple retraction.
Non-Focal Skin Thickening I Breast Edema
This is usually the result o f
benign conditions (congestive heart failure, renal failure). For multiple choice tests it will
always be bilateral (in the real world you can sleep on one side and have asymmetric edema).
As long as the breast isn’t red, you can feel confident that it will be benign. On
mammography you will see trabecular thickening (diffuse, and favoring the dependent
portions o f the breast).
Breast Inflammation
The swollen red breast. This finding has a differential o f two
things: (1) mastitis / abscess, (2) inflammatory breast cancer
Mastitis / Abscess
This is a swollen red breast which is painful (Inflammatory breast CA
is often painless). Patients are usually sick as a dog. Obviously it’s associated with
breast feeding, and is more common in smokers and diabetics. Abscess can develop
(usually Staph A.).
Inflammatory Breast Cancer:
As previously discussed, this has a terrible prognosis.
The general rule is that a breast that doesn’t respond to antibiotics gets a skin biopsy to
exclude this. The typical age is 40s-50s. You are going to have an enlarged, red breast
with a “peau d ’orange” appearance. The breast is often NOT painful, despite its
appearance. Mammogram might show a mass (or masses), but the big finding is diffuse
skin and trabecular thickening. The treatment is fair game for multiple choice because it
is different than normal breast cancer. Instead o f going to surgery first, inflammatory
breast cancer gets “cooled down” with chemo and/or radiation - then surgery.
The leaky Tit
Women present with nipple discharge all the time, it’s usually benign
(90%). The highest yield information on the subject is that:
spontaneous, bloody, discharge from a single duct is your most
suspicious feature combo. Serous discharge is also suspicious.
The risk o f discharge being cancer is directly related to age (very
uncommon under 40, and more common over 60).
The leaky Tit
multiple ducts
benign
The leaky Tit
single ducts
(Maybe Malignant)
• Papilloma
. DCIS
Discharge is Bad when i t ’s
Spontaneous, Bloody, and from a Sintl3 duct.
Milky Discharge
Milky discharge is NOT suspicious for breast cancer but can be
secondary to thyroid issues or a pituitary adenoma (prolactinoma). Any medication that messes
with dopamine can stimulate prolactin production - (antidepressants, neuroleptics, reglan).
C a u s e s o f D is c h a rg e (N o t M ilk y )
benign
Pre-Menopausal Woman = Fibrocystic Change
Post Menopausal Women = Ductal Ectasia
C a u s e s o f D is c h a rg e (N o t M ilk y )
worrisome
Intraductal Papilloma (90%) - single intraductal mass near nipple
DCIS (10%) - multiple intraductal masses
Ductal E c ta s ia
The most common benign cause o f nipple discharge in a post menopausal
woman. On galactography you will see dilated ducts near the subareolar region, with progressive attenuation more posteriorly.
Discharge papilloma
this is the most common cause o f bloody discharge. As before they can be single or multiple, and carry a small malignant risk (5%).
Galactography
- Ugh… you take a 27 or 30 gauge blunt tipped needle and attempt to cannulate the duct which is leaking. To determine which duct you want - y o u ’ll need to have the patient squeeze the breast to demonstrate where it’s coming from.
- If you manage to cannulate the duct - gently inject 0.2 - 0.3 cc contrast (rare to need more than 1 cc). You then do mammograms (magnification CC and ML). Filling defect(s) get wire localization.
Galactography
contraindications
Active infection (mastitis), inability to express discharge at the time o f galactogram, contrast allergy, or prior surgery to the nipple areola complex.
architectural distortion
We ‘re talking about unchecked aggression here, Dude. We are talking about distortion
o f the normal architecture without a visible mass. This manifests in a few ways, including
focal retraction, distortion o f the edge o f the parenchyma, or radiation o f the normal thin
lines into a focal point.
Architectural Distortion vs Summation Artifact
This is the primary differential
consideration, with summation o f normal vessels, ducts, and ligaments being much more
common. The difference is summation should NOT radiate to a central point (AD will).
AD
All lines radiate to a point
Summation
Lines continue past each other
Surgical Scar vs Something Bad
Scars should progressively get lighter and harder to see.
Some people say that in 5-10 years a benign surgical scar is often difficult to see.
Lumpectomy scars tend to stick around longer than a benign biopsy. Basically, look at the
priors; if it is a surgical scar, it better be getting less dense. If it’s increasing, you gotta stick
a needle in it.
Work Up o f AD
If you see it on a screener you will want to BR-0 it, and bring it back for
spot compression views. If it persists ju st know you are either going to BR-4 or BR-5 it
(unless you know it’s a surgical scar). You should still ultrasound it for further
characterization (may help you decide between a 4 and a 5).
AD us trivia
The use o f harmonic tissue imaging can make it easier to see some
lesions. Be aware that compound imaging can make you lose your posterior features,
especially when they are soft to start with - like the shadowing o f an ILC. Remember, even
if you see nothing, this gets a biopsy. Harmonics can also make not so simple cysts look
simple by reducing superficial reverberation.
Things to Know fo r AD:
’Radiating lines to a single point = AD
w r y *AD + Calcifications = IDC + DC1S
A *AD without Calcifications = ILC
’Even with no ultrasound or MRI correlate, AD gets a biopsy.
A ’Never ever ever ever ever BR-3 an area o f AD.
’Even if it has been there a while, it still needs to be worked up.
^ ‘Remember ILC can grow slowly.
’ Surgical scars should get less dense with tim e … not more dense.
lymph nodes
You found a breast cancer - now what? Before you make the patient cry, it’s time to stage the
disease. Ultrasound her arm pit. About 1 in 3 times you are going to find abnormal nodes.
lymph nodes
Unilateral vs Bilateral
This can help you if you are thinking this could be systemic. Unilateral
adenopathy should make you worry about a cancer (especially if they have a cancer on that
side).
lymph nodes
Biopsy It?
Some people will recommend biopsy if you have the following abnormal features.
• Cortical Thickness greater than 2.3 mm (some people say 3 mm)
• Loss o f Central Fatty Hilum - “most specific sign”
• Irregular Outer Margins.
lymph nodes
Staging Trivia
Level 1 and Level 2 nodes are treated the same. Rotter nodes are treated as
Level 2. Level 3 and supraclavicular nodes are treated the same
lymph nodes
Gold Therapy
Long ago, when the pyramids were still young, rheumatoid arthritis was
treated with “chrysotherapy.” What they can do is show you an “Aunt Minnie” type picture
with very dense calcifications within the node.
lymph nodes
Snow Storm Nodes:
Snow Storm Nodes: Another Aunt Minnie look is the silicone infiltration o f a node from either
silicone leaking or ruptur
lymph nodes
gold appearance
high ensity specs int he node
lymph nodes
snowstorm appearance
silicone adenopathy
men do NOT get
lobule associated pathology (lobular
carcinoma, fibroadenoma, or cysts)
Gynecomastia
This is a non-neoplastic enlargement o f the epithelial and stromal elements
in a man’s breast. It occurs “physiologically” in adolescents, affecting about 50% o f adolescent
boys, and men over 65. If you aren’t 13 or 65 it’s considered embarrassing and you should hit the
gym. If you are between 13-65 it’s considered pathology and associated with a variety o f
conditions (spironolactone, psych meds, marijuana, alcoholic cirrhosis, testicular cancer). There
are three patterns (nodular is the most common). Just think flame shaped, behind nipple,
bilateral but asymmetric, and can be painful. Things that make you worry that it’s not
gynecomastia include not being behind the nipple, eccentric location, and calcification.
Patterns of Gynecomastia
Nodular
most common
“Flame Shaped” centered behind the nipple, radiating posterior as it blends into the fat. Breast is often tender. Usually lasts less than 1 year.
Patterns of Gynecomastia
Dendritic
Resembles a branching tree. This
is a chronic fibrotic pattern.
Usually not tender.
Patterns of Gynecomastia
Diffuse
Glandular
Mammographic pattern looks like a woman’s breast (diffuse increase in density). You see this in men receiving estrogen treatment.
Pseudogynecomastia
“Bitch Tits ” - This is an increase in the fat tissue o f the breast
(not glandular tissue). There will NOT be a discrete palpable finding, and the mound o f
tissue will not be concentric to the nipple.
Lipoma in a male
After gynecomastia, lipoma is the second most common palpable mass in a man.
Male Breast C ancer overview
It’s uncommon in men, and very uncommon in younger men
(average age is around 70). About 1 in 4 males with breast cancer have a BRCA mutation
(BRCA 2 is the more common). Other risk factors include Klinefelter Syndrome, Cirrhosis,
and chronic alcoholism. The classic description is eccentric but near the nipple. It’s almost
always an IDC-NOS type. DCIS can occur but is very rare in isolation. On mammography it
looks like a breast cancer, if it was a woman’s mammogram yo u ’d BR-5 it. On ultrasound
it’s the same thing, it looks like a BR-5. Having said that, nodular gynecomastia can look
suspicious on ultrasound.
Male Breast C ancer
things that make you think its breast cancer
- Eccentric to Nipple
- Unilateral
- Abnormal Lymph nodes
- Calcifications
- Looks like breast cancer
Male Breast C ancer
Some trivia on calcifications
Micro-calcifications alone are uncommon in men. When you
see them they are less numerous, coarser, and associated with a mass (25% o f male breast
cancers have calcifications).
Male Breast C ancer
Should men get screening mammograms?
Honestly, women shouldn’t even get them
(according to the New England Journal o f M edicine). This remains controversial, with the
bottom line being this: only Klinefelter patients approach the screening range with regards to
risk.
Male Breast C ancer
As a point o f trivia
males with gynecomastia from gender reassignment on hormone
therapy are not high enough risk for screening mammograms. Obviously, if they have a
palpable finding, they can get a diagnostic work up.
Implants
overview
There are two types , saline and silicone. They both can rupture, but no
one really gives a shit if saline ruptures. Saline does not form a capsule, so you can’t have
intracapsular rupture with saline. There is no additional imaging past mammo for saline
rupture, and you just follow up with primary care / plastic surgeon. You can tell it’s saline
because you can see through it. For silicone you can have both intra and extra capsular rupture.
You can only see extra on a mammogram (can’t see intra). Extra creates a dense “snow storm ”
appearance on US. Intra creates a “step ladder’’ appearance on US and a “linguine sign ” on
MRI. MRI is done with FS T2 to look at implants.
Implants
big points
• You CAN have isolated intracapsular rupture.
• You CAN NOT have isolated extra (it’s always with intra).
• If you see silicone in a lymph node you need to recommend MRI to evaluate for
intracapsular rupture
Implant Location
- Subglandular (retromammary): Implant behind breast tissue, anterior to pectoral muscle
- Subpectoral (retropectoral): Implant between pectoralis major and minor muscles
Silicone Implants
The body will form a shell around the foreign body (implant), which allows for both
intracapsular and extracapsular rupture (an important distinction from saline). About 25% of
the time you will see calcifications around the fibrous capsule.
Silicone Implants
things to know
- Implants are NOT a contraindication for a core needle biopsy
- Implants do NOT increase the risk for cancer.
Saline Implants
There are also subglandular and subpectoral subtypes. You can tell the implant is saline
because you can see through it. Implant folds and valves can also be seen. If it ruptures no one
really cares (other than the cosmetic look). The saline is absorbed by the body, and you have a
collapsed implant. A practical point o f caution, be careful when performing a biopsy in these
patients - even a 25g FNA needle can burst a saline implant.
Saline Implants
trivia
Some sources say that “physical exam” is the test o f choice for diagnosing saline
implant rupture - this is variable depending on what you read / who you ask.
Implant Complications
Generally speaking, MR1 is the most accurate modality for evaluating an implant
Capsular Contracture
This is the most common complication o f implants. It
occurs secondary to contraction o f the fibrous capsule, and can result in a terrible cosmetic
deformity. You see it in both silicone and saline implants, but is most common in
subglandular silicone implants. On mammo it looks like rounding or distortion o f the
implant (comparisons will show progression).
Gel Bleed:
Silicone molecules can (and do) pass through the semi-permeable implant
shell coating the exterior o f the surface. This does NOT mean the implant is ruptured. The
classic look is to show you silicone in the axillary lymph nodes (remember 1 showed a case
o f this under the lymph node section). Even with axillary lymph nodes, this does NOT mean
it has ruptured.
Rupture
As a point o f testable trivia, the number one risk factor for rupture is age o f the
implant. Rupture does not have to be post traumatic, it can occur spontaneously. Rupture
with compression mammography is actually rare.
Rupture
saline
Saline rupture is usually very obvious (deflated boob). It doesn’t matter all
that much (except cosmetically), as the saline is ju st absorbed. On mammo, you will
see the “wadded up” plastic wrapper. They could easily write a question asking you
what modality you need to see a saline rupture. The answer would be plain mammo
(you don’t need ultrasound or MRI).
Rupture
silicone
This is a more complicated matter. You have two subtypes; isolated
intracapsular and intracapsular with extracapsular
Rupture
silicone - Isolated Intracapsular
This will be occult on physical exam, mammography
and possibly ultrasound. You might see a stepladder on Ultrasound. MRI is
way more sensitive
Rupture
silicone - Intracapsular with Extracapsular Rupture
This is usually obvious on
mammogram with dense silicone seen outside the capsule. The contour o f a
normal intact implant is smooth. Silicone outside the implant can go to lymph
nodes. On ultrasound you want to know the buzzword “snow storm” pattern
- which is really echogenic with no posterior shadowing. A sneaky trick is
to show a lymph node with a snow storm appearance on ultrasound. On MRI
extracapsular silicon is T1 dark, and T2 bright. Lastly, a very important
concept is that you cannot have isolated extracapsular rupture. I f i t ’s
extracapsular, then it s also intracapsular.
Radial Folds - The Mimic of Rupture
Radial folds are the normal in-foldings o f the elastomer shell. They are the primary mimic
for the linguine sign o f intracapsular rupture. To tell them apart ask yourself “do the fo ld s
connect with the periphery o f the implant? ” Radial folds should always do this (linguine
does not).
Silicone Implant Rupture Summary
Intracapsular Rupture
- Remember the “ca psule” is not part of the implant. It’s the fibrous coat your body makes around the implant (the outer black line in my diagram). - Silicone can rupture through the shell of the implant, but stays confined inside the fibrous coat - this is intra-capsular rupture. - The classic sign is the floating “ linguine” - as in this case.
Silicone Implant Rupture Summary
Extra & Intracapsular
- This is when the rupture goes through the “capsule” (the thing your body made). - You can NOT have isolated extra capsular silicone. It has to make it through the implant shell first. - Silicone outside the capsule can create a “snow storm” look on ultrasound. It can also infiltrate lymph nodes and do the same (snow storm nodes). Remember gel bleed can also give you a node like this.
Silicone Implant Rupture Summary
Radial Folds
' Guys like squishy boobs. The bigger and the squishier the better. " Therefore, implants are not bound tightly - so they can be squishy. " Because they are loosely bound the shell in-folds creates radial folds " T he folds always attach to the shell* ' The folds are thicker than a rupture, because they represent both layers.
Reduction Mammoplasty
Yes, there is actually a subpopulation o f women who want SMALLER breasts. I know, it sounds impossible to believe , but Mammoplasty is actually done to reduce breast size. 1 can only pray that the sadistic bastard who developed this procedure has received appropriate punishment (in this life or the next).
Mastopexy
This is a “breast lift,”
Essentially, just a removal of skin.
Women get this done to address floppy,
saggy, pancake, or “ptotic” boobs.
Normal Findings Post Mastopexy
• Swirled Appearance A ffecting
Inferior Breast
• Fat Necrosis / OH Cysts
• Isolated Islands o f Breast Tissue
Keyhole Incision
This is done for
both mammoplasty and mastopexy,
creating a “ swirled” appearance in the
inferior aspect o f the MLO.
Lumpectomy
Surgical Removal o f Cancer (palpable or not)
Excisional Biopsy
Surgical Removal o f Entire Lesion
Incisional Biopsy
Surgical Biopsy o f a Portion o f the Lesion
Post Biopsy Changes
The first post operative mammogram is usually obtained around 6-12 months after biopsy. The
key is that distortion and scarring are worst on this film, and should progressively
improve. On ultrasound, scars are supposed to be thin and linear. If they show you a focal
mass like thickening in the scar - you’ve gotta call that suspicious for local recurrence.
Fat necrosis and benign dystrophic calcifications may evolve over the first year or two, and are
the major mimics o f recurrence. Fat necrosis can be shown on MR (T1 / T2 bright, and then fat
sat drops it out).
Recurrence I Residual Disease
Numerical Trivia
Numerical Trivia: Local recurrence occurs 6-8% o f the time when women have breast
conserving therapy. The peak time for recurrence is 4 years (most occur between 1-7).
Without radiation local recurrence is closer to 35%. Tumors that recur early (< 3 years)
typically occur in the original tumor bed. Those that occur later are more likely to be in a
different location than the original primary.
Recurrence I Residual Disease
What gets recurrent disease ?
Risk o f recurrence is highest in the premenopausal woman
(think about them having an underlying genetic issue). Other risks include: having an
extensive inarticulate component, a tumor with vascular invasion, multi centric tumors,
positive surgical margins, or a tumor that was not adequately treated the first go around.
Recurrence I Residual Disease
Residual Calcs
Residual Calcs: Residual calcifications are not good. Supposedly, residual calcifications near
or in the lumpectomy bed correlates with a local recurrence rate o f 60%
Recurrence I Residual Disease
New Calcs
When it does reoccur, something like 75% o f DCIS will come back as
calcifications (no surprise). The testable pearl is the benign calcifications tend to occur early
(around 2 years), vs the cancer ones which come back around 4 years.
Recurrence I Residual Disease
Sentinel Node Failure
Sentinel Node Failure: Sentinel node biopsy works about 95% o f the time (doesn’t work 5% o f
the time). So about 5 times in 100 you are going to have a negative node biopsy that presents
later with an abnormal armpit node
Recurrence I Residual Disease
Tissue Flap
Tissue Flap: The cancer is not going to start in the belly fat / muscle. The cancer is going to
come from either the residual breast tissue or along the skin scar line. Screening o f the flaps is
controversial - with some saying it’s not necessary. The need for screening o f tissue flaps is not
going to be asked. If you get asked anything it’s “where the recurrence is coming from / going
to be?”
Specimen Radiography
If the path report says “close margins” or “positive
margins,” there is a very high chance you are
going to have cancer still in the breast. If you are
shown a specimen radiograph, there are two things
you need to look at in real life and on multiple
choice: (1) is the mass / calcifications on the
sample, and (2) is the mass / calcifications near
the edge or touching the edge. I f the mass is at the
edge, the chance o f incomplete excision is going to
be near 80%. The “next step ” would be to call the
surgeon in the OR and tell him/her that.
Post Radiation Changes
Practical Point (the before picture):
The pre-radiation mammogram is very important. If
you can identify residual disease on it, the patient has many more treatment options. If you
discover the residual disease after the radiation therapy has been given, y o u ’ve forced the
patient to undergo mastectomy.
Radiation Changes
You are going to see skin thickening and trabecular thickening. This is
normal post radiation, and should peak on the first post-RT mammogram.
Radiation Changes
this would be a classic testable scenario
Film 1 Post RT: You see skin thickening / trabecular thickening
Film 2: Skin thickening / trabecular thickening is better
Film 3: Skin thickening / trabecular thickening is worse * - this is recurrent disease (maybe inflammatory breast CA).
Secondary Angiosarcoma
The primary type is so rare 1 won’t even mention it. The secondary type is seen after
breast conservation therapy / radiation therapy. It takes around 6 years post radiation
therapy to develop one o f these things. Clinically the classic presentation is “red plaques
or skin nodules.” The challenge with these is that the skin thickening due to the cancer is
often confused with post therapy skin thickening.
Breast Cancer Staging
The staging is based on size from T1-T3, then invasion for T4.
T l = < 2 cm. T2 = 2-5 cm T3 = > 5 cm T4 = “Any size” with chest wall fixation, skin involvement, or inflammatory breast CA. *Remember that Pagets is NOT T4.
Breast Cancer Staging
trivia 1
Axillary Status is the most important predictor o f overall survival in breast cancer
Breast Cancer Staging
trivia 2
Melanoma is the most common tumor to met to the breast.
Contraindications for Breast Conservation
Inflammatory Cancer,
Large Cancer Size Relative to Breast
Multi-centric (multiple quadrants)
Prior Radiation Therapy, to the same breast
Contraindication to Radiation Therapy (collagen-vascular disease).
Breast MRI can be used for several reasons
High risk screening, extent o f disease (known
cancer), axillary mets with unknown primary, diagnostic dilemmas, and possible silicone
implant rupture. The big reason is for high risk screening.
Breast MRI
How its done
You need a special breast coil and table set up to make it work. The patient lies belly down
with her breasts hanging through holes in the table. You have to position them correctly
otherwise they get artifact from their breasts rubbing on the coil. Basic sequences are going
to include a T2, and pre and post dynamic (post contrast) fat saturated T l . Remember the
breast is a bag o f fat - so fat sat is very important. Dynamic imaging is done to generate
wash out curves (similar to prostate MRI).
Breast MRI
basic algorithm to reading them
(1) Look at the background uptake. I use this to set my sensitivity when 1 compare it to prior
studies. Ideally you used the same kind o f contrast, and imaged at the same time o f the
month. As I ’ll mention below, hormone changes with female cycles cause changes in
how much contrast gets taken up (less early, and more later).
(2) I look for masses or little dots (foci). MIPS (maximum intensity projections) are helpful
ju st like looking for a lung nodule. If I see a mass or dot I try and characterize it - first by
seeing if I can make it T2 bright. Most T2 bright things are benign (lymph nodes, cysts,
fibroadenoma). If it’s not T2 bright, I look at the features - is it a mass? is it spiculated,
etc? These features are more important than anything else. Is it new? Nipple
enhancement is ok - don’t be a dumb ass and call it Pagets.
(3) Finally I’ll look at the wash out curve, but honestly I’ve made up my mind before I even
look at that. I will never let a benign curve back me o ff suspicious morphology.
(4) I deal with the findings similar to mammo. New masses get BR-4 or BR-5. NMLE (nonmass
enhancement) gets BR-4’d if new. T2 bright stuff for the most part (there is one
exception o f mucinous cancer) gets BR-2’d. Anything with a 4 or a 5 gets biopsy - via
MR guided stereo. I never pussy foot out and BR-0 something on MRI - unless it’s a
technical problem (example inadequate fat sat).
Who gets a screening MRI
- People with a lifetime risk greater than 20-25%
* Includes people who got 20 Gy o f radiation to the chest as a child
How do you estimate this risk, to decide who is 20-25%?
You use one o f the risk models that includes family history (NOT the Gail model). I f the
question is which o f the following is Not one to use ? The answer is Gail. I f the
question is which o f the following do you pick? I ‘d chose Tyrer-Cuzick, it s probably the
best one out now.
Breast MRI
Parenchyma Enhancement
is it normal
yes
Breast MRI
Parenchyma Enhancement
where is it most common
Posterior Breast in the upper outer quadrant, during the later
part o f the menstrual cycle (luteal phase - day 14-28)
Breast MRI
Parenchyma Enhancement
how do you reduce it
Do the MRI during the first part o f the menstrual cycle (day 7-14).
Breast MRI
Parenchyma Enhancement
what does tamoxifen do
Tamoxifen will decrease background parenchyma uptake. Then it causes a reb o u n d .
Parenchyma Enhancement
foci
how is it defined
Round or oval, circumscribed, and less th a n 5mm,
Parenchyma Enhancement
foci
are they high risk
Usually not. Usually they are benign (2-3% have a chance o f being a bad boy).
Parenchyma Enhancement
foci
what would make you biopsy one
Seemed different than the rest, ill-defined borders, or suspicious en h an cem en t.
Parenchyma Enhancement
foci
can you birads 3 one
If you have a solitary focus (< 5mm) with persistent kinetics on a baseline exam - you can BI-RADS 3 it.
Parenchyma Enhancement
NME (Non-Mass E n h an c em en t):
What is NME ?
It’s not a mass - but more like a cloud or clump o f tissue enhancement.
Parenchyma Enhancement
NME (Non-Mass E n h an c em en t):
What are the distributions ?
Segmental (triangular blob pointing at the nipple, indicates a single branch), Regional (a bigger triangle), and Diffuse (sorta all over the place).
Parenchyma Enhancement
NME (Non-Mass E n h an c em en t):
Which one is more suspicious
homogenous or heterogeneous enhancement o f NME ? Heterogeneous is much more suspicious.
Masses:
These are defined as being 5 mm or larger. They have definable vocabulary for their
features (round, oval, indistinct, e tc …)
Masses:
when are these bad
They are bad when you call them bad words. Irregular shape,
speculated margins, heterogeneous enhancement, or rim enhancement. Once you say
those words you are going to have to biopsy them, because morphology trumps
kinetics. It doesn’t matter what the kinetics shows, you must biopsy suspicious
morphology.
Masses:
when is kinetics helpful
When you are on the fence. If you have benign morphology
and you have suspicious kinetics - you probably are going to need to biopsy that also.
Kinetics
o (1) Initial upslope phase that occurs over the first 2 minutes. This is graded as
slow, medium, or rapid (fast),
o (2) The washout portion which is recorded sometime between 2 minutes and 6
minutes (around about). These are graded as either continued rise “type 1” ,
plateau “type 2”, or rapid washout “type 3” .
Kinetics
risk of cancer
Type 1: 6%
Type 2: 7-28%
Type 3: 29% or more
MRI
fibroadenoma
These things are classically T2 bright, round, with “non-enhancing septa”, and a type 1 curve.
MRI
DCIS
Clumped, ductal, linear, or segmental non-mass enhancement. Kinetics are typically not helpful for DCIS.
MRI
IDC
Spiculated, irregular shaped masses, with heterogeneous enhancement and a
type 3 curve.
MRI
ILC
Doesn’t always show enhancement.
T2 Bright Things
- Usually T2 Bright = Benign.
Things that are T2 Bright include: Cysts, Lymph nodes, fat necrosis, Fibroadenoma. - The exceptions (anytime I say the word “except ” you need to think high yield!):
Colloid Cancer, and Mucinous Cancer can be T2 bright.
f you have a patient with known breast CA, how often do you fin d a contralateral breast CA?
Answer is 0.1-2% by mammogram, and 3-5% by MRI.
Never BR-0 an
MRI case. This is as much workup as you are going to get, so ju st call it
benign or biopsy it. You can actually BR-0 something if you really want to prevent a
biopsy - possible lymph node - US and mammo to confirm benign sorta situation. This
is still kinda weak. For the purpose o f multiple choice, think twice before you BR-0 a
MRI case.
Spiculated margins
= 80% malignancy. This is the single most predictive feature of
malignancy.
Risk
estrogen
The more exposure to estrogen, the higher your risk
o f breast cancer. Anything that prolongs this exposure is said
to increase risk. For example, an early age to begin
menstruating or a late age to have menopause. Hormone
replacement therapy with estrogen alone obviously increases
exposure. Early maturation o f lobules, which can be achieved
by getting pregnant young, reduces your risk. Being fat
increases estrogen exposure (more aromatase = more
estrogen). Being a drunk increases estrogen exposure - via
messing with its normal breakdown in the liver.
Risk
High Risk Lesions:
Any o f the high risk lesions (ADH, ALH, LCIS, Radial Scar, Papilloma)
are associated with an increased risk. These are discussed more in detail later in the chapter.
Risk
density
Density is considered a “medium risk,” and is “dose dependent” with the denser you are the more risk you have.
Risk
Chest Wall Radiation
Chest wall radiation (usually seen in lymphoma patients) is a big risk
factor, especially at a young age. The risk is supposed to peak around 15 years post treatment. If the child had more than 20 Gy to the chest she is going to qualify for an annual screening MRI - at age 25 or 8 years post exposure (whichever is later).
Risk
Relatives with Cancer
A first degree relative with breast cancer increases your lifetime risk
from 8% to 13%. Two first degree relatives increases your risk to 21 %.
Estrogen Related Risks
Early Menstruation Late Menopause Late age of first pregnancy / or no kids. Being Fat Being a Drunk Hormone Replacement (with estrogen)
BRCA 1
Chromosome 17. More common than type 2. Increased risk for breast, ovary, and various GI cancers.
BRCA 2
Chromosome 13. Male carriers have a higher risk with 2.
Increased risk for breast, ovary, and various GI cancers.
Li Fraumeni
Their p53 does NOT work, and they are high risk for all kinds o f rare cancers.
Cowden Syndrome
Risk for breast cancer, follicular thyroid cancer, endometrial cancer, and Lhermitte-Duclos (a brain hamartoma).
Bannayan-Riley Ruvalcaba
Associated with developmental disorders at a young age.
NF-1
“Moderate Risk” o f breast cancer
Hereditary Breast and
Ovarian C ancer
Syndrome -B RC A 1
Breast Cancer (risk
72%)
Ovarian Cancer (risk
44%)
Triple Negative (estrogen, progesterone, HER2 negative) - IDC Medullary S u b typ e is the mos t com m o n breast CA
Fallopian Tube,
Pancreas, Colon
C ancers Also at
increased risk
Hereditary Breast and
Ovarian C ancer
Syndrome -B RC A 2
Breast Cancer (risk
69%)
Ovarian Cancer (risk
17%)
Fallopian Tube,
Pancreas, Colon
C ancers Also at
increased risk
Cowden Syndrome
Hamartomas in m u ltip le organs and gross facial and mouth bumps plague these u n fortunate souls
Breast CA is th e mos t com m o n malignanc y (risk 77%). Increased risk o f o ther breast c o n d itio n s (fibroadenomas, ADH, fib ro c y s tic changes
Thyroid Cancer (usually papillary). Also increased risk o f various benign th y ro id disease. Annual thyroid screening is ty p ica lly advised. Lherm itte- Duclos (dysplas tic g a n g lio c y tom a o f th e cerebellum)
H ereditary Diffuse
Gastric C ancer
Syndrome
Diffuse Gastric
Cancer Risk ~ 70%
Lo bular Breast Cancer
Risk -4 0%
P rophy lac tic
Ga s tre c tom y is
recommended.
Li-Fraumeni Syndrome
bad p53
Cancers literally
everywhere.
Breast C ancers are
usually seen in 3 0s -40s
w ith high grade.
Gail Model
Oldest and most
validated breast cancer
risk model
Focuses on personal
risk factors, biopsy of
ADH, and family
history
Doesn’t use genetics
(it’s too old school).
Only validated in
African Americans.
Claus, BODICEA, and
BRCApro
Focus on genetics
Do NOT include
personal risk or breast
related risk factors.
Tyrer-Cuzick
“Most Comprehensive ”
Focus on personal
risk, biopsy with
ADH or LC1S, family
history
Does NOT include
breast density.
High Yield Take Home Points Regarding Risk
- Anything that gets you more estrogen increases your risk
- BRCA 1 is more common than BRCA 2 (in women).
- Men with BRCA 2 get more cancer than men with BRCA 1.
- Breast Density is an independent risk factor (denser the breast, the more the risk)
- 20 Gy o f Radiation to your chest as a kid buys you a screening MRI - at 25 or 8
years after exposure (*whichever is later)
Cowden Syndrome - Bowel Hamartoma, Follicular Thyroid Cancer, Lhermitte-
Duclos, and Breast Cancer - All current risk models underestimate life time risk.
- Tyrer Cuzick is the most comprehensive risk model, but does not include breast
density. - Exercise (probably more like not being fat) reduces the risk o f breast cancer
Tamoxifen and Raloxifene (SERMs) reduce incidence o f ER/PR positive cancers.
Mortality may not actual be reduced {sound familiar?).
Variant 1: High Risk Women
BRCA (plus untested first degree relatives), History of Chest Radiation, Risk Model Showing 20% or greater lifetime risk
Variant 1: High Risk Women
Mammo (Highly Appropriate “9”):
- Beginning at age 25-30 or 10 years before age of first-degree relative with breast cancer
- 8 years after radiation therapy, but not before age of 25.
- Mammography + MRI ? They are complementary examinations, both should be performed.
Variant 1: High Risk Women
Tomosynthesis (Highly Appropriate “9 ”):
- Beginning at age 25-30 or 10 years before age of first-degree relative with breast cancer
- 8 years after radiation therapy, but not before age of 25.
- Mammography + MRI ? They are complementary examinations, both should be performed.
Variant 1: High Risk Women
MRI (Highly Appropriate “9”):
• Mammography + MRI ? They are complementary examinations, both should be performed.
Variant 2: Medium Risk Women.
Women with person history of Breast CA, lobular hyperplasia, Atypical Ductal Hyperplasia, or Risk Model Showing 15-20% life time risk
• Mammo and Tomo are “9s”
• MRI is a 7. Mammography + MRI ? They are complementary examinations, MRI should NOT replace mammography.
Variant 3: Average Risk Women
Women with < 15 % Lifetime Risk
• Mammo and Tomo are “9s”
• MRI is a “3” which means it is NOT appropriate.
Screening for Transgender Women
Screening Annual Mammogram IF:
• Past or Current Hormones (Estrogen & Progestin for > 5 years)
• > 50 years old
Trivia: BMI > 35 = increases Risk
Screening for Transgender Men
Screening Annual Mammogram IF:
• They still have breast tissue (even if they had a reduction mammoplasty)
Breast Pain
Variant 1:
Cyclical, Unilateral or Bilateral. Age < 40.
• No imaging is appropriate.
• Ultrasound is the least inappropriate and it’s rated at a “2”
Breast Pain
Variant 2:
Cyclical, Unilateral or Bilateral. Age > 40.
• No imaging is appropriate.
• Ultrasound, Mammo, and Tomo are the least inappropriate and all rated at a “2”
Breast Pain
Variant 3:
NON-Cyclical, Unilateral or Bilateral. Age < 40.
• Ultrasound Might Be Appropriate and is rated as a “5.”
Stage 1 Breast CA - Initial Workup and Surveillance (No Symptoms)
Newly Diagnosed - rule out mets to the bones, chest, liver, and/or brain
• No imaging is appropriate. (CT, MR1, PET etc… not indicated with initial stage 1)
Stage 1 Breast CA - Initial Workup and Surveillance (No Symptoms)
Surveillance / Rule Out Local Recurrence
- Diagnostic Mammo or Tomo is Appropriate and is rated as a “9.”
- Ultrasound might be appropriate and is rated as a “5.”
- MRI might be appropriate and is rated as a “5.”
Symptomatic Male Breast
Variant 1
Any Age with Physical Exam and History Consistent with Gynecomastia or Pseudogynecomastia (bitch tits).
• No imaging is appropriate.
Symptomatic Male Breast
Variant 2
Younger than 25 years old with indeterminate palpable.
- Ultrasound is Appropriate and is rated as an “8.”
- Mammo is in the “May Be Appropriate” category as a “5.” 1 would only do this if the ultrasound doesn’t answer your question. ** Page 441, Scenario 4A - has suggested multiple choice strategy.
Symptomatic Male Breast
Variant 3
Older than 25 years old with indeterminate palpable.
- Mammo is Appropriate and is rated as an “8”
- Ultrasound is in the “May Be Appropriate” category as a “5.”
Symptomatic Male Breast
Variant 4
Older than 25 years old with indeterminate palpable. The mammogram was indeterminate or suspicious.
• Ultrasound is Appropriate and is rated as a “9.”
Symptomatic Male Breast
Variant 5
Physical exam is highly concerning for cancer. Dude has an ulcerative mass, axillary nodes, nipple retraction, etc…
- Mammo is Appropriate and is rated as an “9”
- Ultrasound is Appropriate and is rated as an “8” - to stage the breast and axilla just like a female breast CA workup.
First/Next Step
Women > 40 with Palpable
Mammo is Appropriate and is rated as a “9.”
First/Next Step
Women > 40 with Mammo Suspicious for CA
Ultrasound is Appropriate and is rated as a “9.”
First/Next Step
Women > 40 with Mammo findings of a Lipoma at the Site o f a Palpable.
No additional imaging is appropriate.
First/Next Step
Women > 40 with Palpable Findings and a Negative Mammo
Ultrasound is Appropriate and is rated as a “9.”
First/Next Step
Women < 30 Initial Evaluation
Ultrasound is Appropriate and is rated as a “9.”
First/Next Step
Women 30-39 Initial Evaluation
Ultrasound is Appropriate and is rated as a “8.”
Mammo is Appropriate and is rated as a “8.”
First/Next Step
Women < 30 Ultrasound is Suspicious for CA
Core Biopsy is Appropriate and is rated as a “9.”
Mammo is Appropriate and is rated as a “8.”
First/Next Step
Women < 30 Ultrasound is Negative
No imaging is appropriate.
First/Next Step
Women < 30 Ultrasound has a B9 finding (like a cyst)
No imaging is appropriate.
First/Next Step
Women < 30 Ultrasound is BR3 able - example fibroadenoma
Short interval followup - usually Q6 months x 2 years.
Ultrasound
• Overall ultrasound is faster and easier than stereo. If you can see the mass under US - you should do the biopsy under US.
• Usually a 14 gauge automatic spring loaded device is used for masses
• You should put the mass on the far side o f the US screen - lets you see the length o f the needle better
• Ideally 4 things should line up during the biopsy: the lesion, the transducer, the skin nick, and the biopsy needle
• The needle angle should be parallel to the chest wall (pneumothorax is an embarrassing
complication o f a breast biopsy)
• Anesthetic should be placed right up to but not into the lesion (especially when the lesions is small).
• You should try and biopsy the deeper part o f a lesion first. If you obscure it from bleeding at least you can still get the superficial part.
• If you have two lesions to biopsy, try and hit the smaller one first. If the bigger one bleeds it may obscure the smaller one — it’s less likely the other way around.
• If you have a solid and cystic lesion - you should biopsy the solid part.
• About 90% o f the time you can make a diagnosis o ff 1 or 2 passes (though most texts still recommend doing 5).
Ultrasound
Next step scenario
Like an idiot you injected a bunch o f air around the mass, while you were trying to give lidocaine. Now you can’t see the mass. What do you do? You have to reschedule. Don’t try to biopsy it blind.
axillary procedures
- When you biopsy an axillary lymph node you should target the no d e’s cortex.
- Core biopsy is preferred over FNA if you have no clue what it is. If you have known breast cancer and you are nearly certain you are dealing with a met - FNA works fine.
Special Scenario - The C yst Aspiration
- Indications - Anxiety, pain, uncertain diagnosis.
- Size is NOT an indication for aspiration
- Cysts recur about 70% o f the time (this drops to around 15% if you inject air after you aspirate).
You suspect a hypoechoic mass is a debris filled cyst rather than
a solid m a s s … but you aren’t totally sure
aspirate it
Same hypoechoic mass vs cyst - you aspirate it and you get nonbloody
fluid. You also notice the lesion disappeared
You should pitch
it, no need for cytology. You are done.
Same hypoechoic mass vs cyst - you aspirate it and you get
bloody fluid. You also notice the lesion disappeared
Send it to
cytology and then place a clip.
Same hypoechoic mass vs cyst - you aspirate it and you get
purulent “poop like” fluid. The fluid smells like a zombie farted. You also notice the
lesion disappeared.
Send it to the microbiology lab for culture and
sensitivity.
Same hypoechoic mass vs cyst - you aspirate it and you get fluid.
You also notice the lesion does NOT disappear
Proceed to core biopsy
o f the residual solid mass.
Stereotactic Biopsy
overview
• This is the preferred move for calcifications. Typically the specimen
is x-rayed after the sample to confirm there are calcifications within
the biopsied tissue.
• Vacuum assisted devices are typically used for calcifications.
• The biopsy is performed in compression - with slightly less pressure
than a normal mammogram. Compressibility o f the breast tissue can
NOT be less than 2-3cm (some texts say 28 mm). Otherwise you risk
throwing the needle through the other side o f the breast into the
digital receptor. This is called a “negative stroke margin.”
Stereotactic Biopsy
quick
(using a mammogram to localize and target the lesion).
Stereotactic Biopsy
What i f the breast compresses too small (<20 mm)
You should do a
wire localization for excisional biopsy.
Stereotactic Biopsy
after each biopsy
A marker (tiny piece o f metal) should be placed after each biopsy. Clip migration can occur
(accordion effect). You will need a mammogram in the orthogonal view to evaluate for this
post placement.
Stereotactic Biopsy
performed Daily before patient exams.
QC “Localization and Accuracy Test” to verify system alignment and performance
Stereotactic Biopsy
Gauge Size vs
Samples:
- 10-11 Gauge Needle = 12 Samples - 7-9 Gauge Needle = 4 Samples
MQSA overview
The U.S. Food and Drug Administration Mammography Quality Standards Act (MQSA) - yes that
is a real thing - demands a medical audit and outcome analysis be performed once a year. You are
forced to follow up patients with positive mammos, and correlate with biopsy pathology results (so
you can see how much benign disease you biopsy and how much fear / anxiety you generate). You
have to grade the biopsy with the risk category (you can’t accept benign results with a BR-5).
MQSA and Other Crap they could ask
• 3 months o f mammography is required during residency training
• The recall rate should be less than 10%
Mammography facilities are required to provide patients with written results o f their
mammograms in language that is easy to understand. Also known as a “lay report,” and
must be given within 30 days o f the study.
A consumer complaint mechanism is required to be established in mammography
facilities to provide patients with a process for addressing their concerns.
Patients can obtain their original mammograms, not copies, when they are needed.
• For cases in which a facility’s mammograms are determined to be substandard and a
risk to public health, facilities will notify the patients and their doctors and suggest an
appropriate plan o f action.
The “Interpreting Physician” is ultimately responsible for the Quality Control program.
• The required resolution o f line pairs is 13 lp/mm in the anode to cathode direction and
11 line pair / mm in the left right direction
• To make it pass image quality; must show 4 fibers, 3 microcalcification clusters, and 3
masses, plus “acceptable artifacts”.
• The dose phantom is 50% glandularity, 4.2 cm thick, and is supposed to have a dose
less than 3 mGy per image (+ grid).
Don’t get it twisted; there are no patient dose limits in mammography, only a phantom
dose. A dense breast can result in a higher patient dose, which could easily exceed 3
mGy/view.
Typical patient and phantom doses are about 2 mGy per view, or 8 mGy for a bilateral two view (Left CC + MLO, Right CC + MLO) screening examination.
• The typical (average) compressed breast is 6 cm, glandularity o f 15 to 20%.
Digital systems generally uses higher beam qualities which results in lower doses;
Digital mammography does not use fixed dose (screen-film); can use as much (or little)
radiation as deemed appropriate.
Male Residents must urinate in the sitting position while on the mammography service
(standing urination is not allowed per MQSA).
Sp e c ific QA T a s k s
Processor QC
daily
Sp e c ific QA T a s k s
Darkroom Cleanliness
daily
Sp e c ific QA T a s k s
Viewbox Conditions
weekly
Sp e c ific QA T a s k s
Phantom Evaluation
weekly
Sp e c ific QA T a s k s
Repeat Analysis
quarterly
Sp e c ific QA T a s k s
Compression Test
semi-annually
Sp e c ific QA T a s k s
Darkroom Fog
semi-annually
Sp e c ific QA T a s k s
Screen-Film Contrast
semi-annually
Sp e c ific QA T a s k s
Evil Overlord behind MQSA ?
FDA
Appropriate Target Range for Medical Audit
Recall Rate 5-7%
Cancers/ 1000 Screened 3-8
The Privilege to Read a Mammogram
During the last two years o f training you have to read 240
Formal Training Requirement 3 months
Documented Hours o f Education 60
