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.
