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AA Sal Mammo > Mamms general > Flashcards

Mamms general Flashcards

1
Q

What is the name of the measurement to quality check if the CC and MLO views are adequate?

A

The posterior nipple line (PNL) refers to a line drawn posteriorly and perpendicularly from the nipple towards the pectoral muscle on the mammogram. In an adequately exposed breast, the measurement difference of this line between a CC view and MLO view should be ideally within 1 cm. It is the first key to triangulate mammographic lesions.

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2
Q

Which quadrant are most breast cancers?

A

upper outter quadrant

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3
Q

What do you do if you only see something on MLO

A

If you see something on MLO, but not CC, then you can get an ML view

Lead sinks (Lateral will sink lower)

Muffins rise (medial rises)

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4
Q

If you see a lesionon only on CC view, what do you do to localize?

A

Get a roll view

Superior lesions will move medially on medial roll and laterally on lateral roll.

Vice versa for inferior lesion.

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5
Q

Vocab:

Radian

Mulifocal lesion (multiple but focal)

Multi-centric lesion (multiple centers)

A

Radian: a triangluar area extending from center of breast

Multifocal lesions: 2 lesions that are within the same quadrant, or within 5cm of each other (multiple lesions but in a focal spot)

Multicenric lesion: 2 or more lesions in different quadrants (Multiple centers

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6
Q

vocab:

assymetry

Global assymetry

Focal asymmetry

developing asymmetry

A

Assymetry: density only seen on one view

Global assymetry: Greater volume of breast tissue than contralateral side (Birads 2 - need to get a callback for a baseline image)

Focal asymmetry: seen in 2 views, might be a mass, needs a spot compression

Developing asymmetry: new thing that wasn’t there before.

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7
Q

Mammogram Lexicon (3,5,4)

Margin is like ultrasound except for 1 difference

A

Shape, margin, density

Shapes: oval, round, irregular

Margin: circumscribed, microlobulated, indistinct, spiculated. , OBSCURED (can be obscured on mammogram but not U/S)

Density: Luscent, Low, equal, or high

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8
Q

Classic differential for fat containing lesion (5 - all benign)

A

hamartoma, lymph node, galactocele, oil cyst/fat necrosis, lipoma

All are BR2

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9
Q

Breast u/s lexicon

  1. Shape - 3
  2. Orientation - 2
  3. Margins - 5 (1 is different from mamms)
  4. echo pattern - 5
  5. posterior features
A
  1. Round, oval, irregular
  2. parallel, antiparallel
  3. Circumscribed, indistinct, spiculated, microlobulated. ANGULAR (can have angles in u/s but not mammo)
  4. Anechoic, hypoechioc, isoechoic, hyperechoic, complex cystic and solid
  5. None, Enhancement, shadowing, combined.
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10
Q

If you find a breast cancer on u/s, what imaging should you try to get before the patient leaves?

A

Scan the remaining radian w/ u/s. Scan for lymph nodes

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11
Q

What is the multi-step progression of breast cancer?

A

Normal -> Flat epithelial atypial (FEA) -> ADH -> DCIS -> IDC

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12
Q

2 most important risk factors for breast cancer are female gender and advancing age. Name other risks

A

BRCA

first degree relative w/ breast cancer

prior chest radiation for hodgkin or non-hodgkin lymphoma

long term extrogen exposure

prior bioposy result of lobular neoplasia spectrum (ALH and LCIS are considered a marker of disease risk, and not a precuror)

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13
Q

ALH and LCIS arise from terminal duct lobule and are considered a marker of increased risk rather than a precursor oto cancer. What is the chance of developing invasive cancer in patients w/ LCIS?

A

30% (and most cancers will be invasive ductal)

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14
Q
  1. Types of invasive ductal cancer (5)

A. IDC NOS,

B. Other less common breast cancer with a better prognosis than IDC (4 - MMTP)

  1. Bonus: rare nonductal cancer (1)
A
  1. A. IDC

B. Tubular carcinoma - small, spiculated, slow growing. A/w radial scar. contralateral breast can have cancer 10-15% of time.

Mucinous carcinoma - round, uncommon.

Medullary carcinoma - Round/oval. Circumscribed. A/W BRCA1. Axillary nodes can be large

Papillary carinoma - complex cystic and solid. No axillary nodes. Common in old people.

  1. Adenoid cystic carcinoma
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15
Q

Low grade breast cancer presents as a small spiculated mass. Looks like Radial scar or complex sclerosing lesion on path. Radial scar may be a precursor.

A

Tubular carcinoma - good prognosis.

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16
Q

Breast cancer - low density circumscribed mass - can mimic fibroadenoma on u/s. Hyperintense on MR

A

Mucinous carcinoma (AKA colloid carcinoma, mucoid carcinoma, gelatinous carcinoma)

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17
Q
  1. locally aggressive breast cancer that occurs in young women. - a/w BRCA1
  2. What is another distinguishing feature?
A
  1. Medullary carcinoma
    - medullary carcinoma is rare, like BRCA1 is rare (analagous to medullary carcinoma in kidney’s being rare, like sickle cell is rare)
  2. Large axillary lymph nodes (can think of these as large medulla regions of lymph nodes in medullary cancer)
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18
Q

Malignant form of intraductal papilloma

A

Papillary carcinoma

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19
Q

very rare breast cancer that presents as a palpable firm mass. Good prognosis

A

Adenoid cystic carcinoma.

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20
Q

Describe inflammatory carcinoma

A

tumor invasion of dermal lymphatics.

Breast erythema, edema, firmness

affected breast is larger, denser, trabecular thickening/skin thickening.

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21
Q

Describe Paget disease of nipple etiology and clinical presentation

How do you make diagnosis?

A

DCIS that infiltrates the epidermis of the nipple.

Clinically Presents w/ erythema, ulceration, and eczematoid changes of the nipple

Punch biopsy

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22
Q

what is most important prognostic factor in non-metastatic breast cancer

A

axillary lymph node status.

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23
Q

When do you perform axillary lymph node dissection?

A

If sentinel lymph node is positive, or not identified.

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24
Q

Key factors in prognosis of DCIS

A

Necrosis is a key prognostic factor

Triple negative scans have a worse prognosis. They are most often seen in BRCA1 pts. They may have benign imaging features despite aggressive behavior

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25
Q

cyclical and proliferative breast disease (2)

A

Fibrocystic change

sclerosing adenosis

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26
Q

benign proliferative lesion caused by lobular hyperplasia and formation of fibrous tissue.

A

Sclerosing adenosis

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27
Q

List - infectious and inflammatory breast disease (6)

A

Mastitis

breast abscess

Granulomatous mastitis

periductal mastitis

diabetic mastopathy

mondor diseease

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28
Q
  1. rare, idiopatthic, noninfectious cause of breast inflammation that occurs in young women after child birth?
  2. associated w/ what?
  3. Management?
A
  1. Granulomatous mastitis
  2. may be a/w breast feeding or oral contraceptives.
  3. biopsy may be warranted because features mimic breast cancer.
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29
Q

large, rod-like secretory calcifications in post-menopousal women

A

Periductal mastitis - aka plama cell mastitis. caused by irritating contents of intraductal lipids.

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30
Q

ill-defined asymmetric density w/o microcalcifications in a patient w/ diabetes.

Clinical exam?

Ultrasound appearance?

Management?

A

Diabetic mastopathy - sequela of long-term insulin dependent diabetes. autoimmune reactio nto matrix proteins from chronic hyperglycemia.

firm/painful mass.

hyperechoic mass w/ regional acoustic shadowing

-biopsy is required to r/o cancer

(I guess you can think of this as a granuloma in your breast)

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31
Q

Mammography: superficially located tubular beaded density corresponding to a palpable rope-like mass

u/s: “bead-like” tublar structure w/ no flow on color doppler

Treatment?

A

Mondor disease: thrombophlebitis of superficial vein of the breast

pain and tenderness at region of thombosed vein.

Treatment: NSAIDS and warm compress ( no need to anticoagulate - its a superficial vein)

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32
Q

What views can be done at tech’s discression in addition to the standard CC and MLO views?

A

Cleavage view (CC)

Exaggerrated CC view (XCC)

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33
Q

relationship of breast density and cancer risk?

Unilateral increase in fibroglandular density is worrisome for what?

A
  1. dense breasts are 5x more likely for cancer than fatty breasts
  2. lymphatic obstruction, which may be malignant.
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34
Q
  1. DDx - Amorphous calcs (4)
  2. DDx - Coarse heterogenous calcs (4) (same as fine pleo)
  3. DDx fine pleomorphic calcs (4) (same as coarse hetero)
  4. Fine linear branching calcs (basically 1)
A
  1. Fibrocystic change (most likely). Sclerosing adenosis, columnar cell change, DCIS (low grade)
  2. Fibroadenoma, papilloma, fibrocystic change, DCIS (low/intermediate)
  3. Fibroadenoma and papilloma are less likely. Fibrocystic change, DCIS (high grade)
  4. fine linear branching is basically DCIS or maybe it can be atypical look for secretory calcs or vascular calcs.
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35
Q

DCIS Trivia:

  1. which is more malignant, comedo or noncomedo (pathology classification?
  2. % of DCIS that is invasive at time of biopsy
  3. % of DCIS that has invasive component on surgical excision
  4. Most common u/s appearance is what?
A
  1. Comedo is more aggressive
  2. 10%
  3. 25%
  4. Microlobulated mildly hypoecoic mass

(8% of time DCIS will present as a mass w/o calcs)

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36
Q

3 classic patterns of DCIS that can be shown on multiple choice?

A
  1. Fine linear branching or fine pleomorphic
  2. NMLE (non-mass like enhancement) on MR
  3. Multiple filling defects on galactogram
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37
Q

Paget’s Disease of breast trivia

  • basically carcinoma in situ of nipple/epidermis. A/w high grade DCIS

50% will have palpable mass

Is paget’s considered T4?

  1. Management of Paget’s?
A
  1. Wedge biopsy of skin

Pagets is NOT considered T4

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38
Q

Flowchart of what to do w/ lesion found on diagnostic study

  1. If palpable mass
  2. If calcs
  3. If nipple discharge
A
  1. Spot compressoin/u/s
  2. Mag views
  3. Galactography
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39
Q

criteria for abnormal lymph node

  1. Cortical thickness (Not the normal short axis measurement. You just measure cortical thickness)
  2. Other features
A
  1. cortex of lymph node is 3mm or more
  2. Loss of central fatty hilum (most specific sign)
  3. irregular outer margins.
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40
Q

Type of cancer - Complex cystic and solid mass

A

Papillary carcinoma (rare to have axillary nodes)

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41
Q

If you have DCIS which is not excised, what is your yearly chance of developing IDH? (from Dr. Terada)

A

Between 30 to 50% after 10 years

(However Dr. Tirada said 1% chance per year..)

42
Q

If a calcification changes shape on a different view or breast orientation, what is it? What is this associated with?

A

Milk of calcium

Associated with multiple cysts

43
Q

How often is breast cancer found to be bilateral on mammogram? on MRI?

A

2-3% on mammography, 3-6% on MRI

44
Q

Name 3 risk factors for bilateral breast cancer

A

Multicentric cancer

BRCA

Lobular carcinoma

45
Q

“shrunken breast” Aunt Minnie

A

Lobular cancer - Breast may appear normal on physical exam, but on mammography, it won’t compress, therefore it will look smaller

46
Q

3 ways to show ILC

A
  1. Shrinking breast
  2. Dark star - architectural distoration but without the central mass (dark in the middle)
  3. Shadowing w/o a mass on u/s
47
Q

Dark star - Describe it

give DDx (3)

A
  1. Architectural distortion w/o central mass (dark in the middle).

2.

  • Cancer
    • Lobular carcinoma
    • IDC - NOS
  • Radial scar (can be white or black in middle
  • Surgical scar.
48
Q

Invasive lobuar cancer overview

  1. Demographics and frequency
  2. Mammo image
  3. MRI image
  4. Presence of axillary mets?
  5. Prognosis compared to IDC
  6. How often bilateral
A
  1. Older patients (5-10% of breast cancers)
  2. Calcifications less common. Often seen only on one view (CC)
  3. On MRI, washout is less common than with IDC
  4. Axillary mets less common (tends to metastasize other places, like peritoneal..)
  5. Similar prognosis, unless pleomorphic ILC, which is very bad
  6. 1/3 are bilateral
49
Q

Architectural distortion Ddx (3)

AD never gets a Birads 3. It will always get a biopsy.

A
  • Cancer
    • IDC (calcs)
    • ILC (no calcs)
  • Radial scar
  • Post-surgical
50
Q

Ddx - Swollen red breast (2)

A

Mastitis

Inflammatory breast cancer

51
Q

Inflammatory breast cancer

Presents as swollen red breast w/ or w/o mass.

(Will initially improve with antibiotic treatment, but will not resolve)

Skin thickening on Mammo

  1. Treatment?
A
  1. Chemo and then surgery
52
Q

Birads 4 A-C breakdown

A

4A - 2-10% low risk

4B - 10-50%

4C - 50-95%

53
Q

What are the “high risk” lesions on pathology (5)

Which is most concerning?

A

ADH

ALD

LCIS *Most concerning finding* - (occult on mammogram, may be incidental)

Radial Scar - dense fibrosis around ducts. A/w DCIS,IDC, and tubular carcinoma

Papilloma

54
Q

When is nipple discharge bad? (3)

A

Spontaneous

Bloody

from a single duct

55
Q

galactogram contraindictations (4)

A

Infection

mastitis

no discharge at time of exam

prior surgery to nipple which makes cannulation difficult

56
Q

Benchmarks for positive predictive value

PPV1

PPV2

PPV3

A

PPV1 - call back from screeining - 4%

PPV2 - recommend biopsy - 25%

PPV3 - Biopsy recommendation was correct - 30%

57
Q

Tattoo sign.

What view should you get to confirm it?

A

Dermal calcifications. They look the same on CC and MLO view

found anywere, mostly in sweat folds

often grouped, like the foot of a baby.

If you want to prove it, get a tangiential view.

58
Q

Bulky rod-like calcs with dash dash (no dots) appearance in a post-menopausal person

A

Secretory (rod-like, cigar shaped) calcs

Typically bilateral and always after menopause (usually 10-20 years after menopause)

59
Q

If a patient requests a biopsy of a breast lesion that you think is benign, what do you do?

A

You biopsy the lesion if they ask

60
Q

Fibroadenoma

  1. Demographic
  2. typical appearance on u/s
  3. Typical mammogram appearance in an older person
  4. MRI appearance
  5. Typical MRI enhancement pattern
A
  1. Pre-menopausal (peak age 30)
  2. Oval, circumscribed mass w/ homogenous hypochoic exchotexture and a central hyperechoic band.
  3. Popcorn calcs on mammogram
  4. MRI can vary, but classic appearance is T2 bright lesion w/ thin nonenhancing septations.
  5. Usually have a type 1 enhancement pattern.
61
Q

Enhancement patterns in MRI

Type 1, 2, and 3

A

Type 1: Rises normally and keeps rising (good stock market graph) - benign

Type 2: rises normally then plateaus (intermediate)

type 3: Rises fast, then crashes (bad stock market crash)

62
Q

Lesion that looks like fibroadenoma on u/s but occurs in older people (not benign)

  • treatment
  • how does it metastasize
A

Phyllodes tumor

Rapid growth, high rate of recurrence, needs wide margins

hematogenous mets

middle age to older women

63
Q

1 .5 different types of calcification distributions

  1. What is birads classificaiton if ROUND calcs are in various distributions on baseline exam?
A
  1. Scattere, regional, grouped/clustered, segmental, linear
  2. Regional/scattered - BR2

Grouped/clustered: BR3

Segmental/linear - BR4

64
Q

What is management of BR3?

A

Follow every at 6, 12, 24 months. If it ever changes, it should become BR 4 and be biopsied.

65
Q

3 situations where you can use Birads 3

(You can only use BiRads 3 on a baseline mammogram)

You follow up every 6 months for 2 years.

A
  1. Circumbscribed benign appearing solid mass - circumscribed margings, benign on u/s (presumed fibroadenoma)
  2. Punctate (<5mm) or round (>5mm) calcs in grouped distribution
  3. focal asymmetry w/ no ultrasound correlate
66
Q

What is the criteria for bilateral well circumscribed masses to be BIrads 2?

A

multiple (at least 3) well circumscribed masses without suspicious features. Have to be BILATERAL

67
Q

Describe hamartoma

A

Fat containing lesion (breast w/in a breast)

BR2 (fat lesions are BR2 by definition)

Difficult to see on u/s

68
Q

What is a complication of biopsying a galactocele?

A

Milk fistula

69
Q

Pseudoangiomatous stromal hyperplasia (PASH)

Management?

A

Benign myofibroblastic hyperplastic process

usually big (4-6cm), solid, oval shaped, well defined borders

f/u in 12 months

70
Q

Aunt Minnie: calcification in a lymph node

A

Sequalae of gold therapy from treatment of RA.

71
Q

Mammogram - Calcification lexicon

9 benign

4 suspicious

5 distribution

A
  1. Skin calcs, round calcs, vascular calcs, rim calcs, coarse/popcorn like, milk of calcium, large rod-like, dystrophic calcs, suture calcs
  2. Amorphous calcs, coarse/heterogenous, fine pleomorphic calcs, fine linear or fine linear branching.
  3. Grouped, segmental, linear, regional, diffuse.
72
Q

Skin thickening

  1. Benign causes (3)
  2. Malignant causes (3)
A
  1. Radiation therapy (usually unilateral)

Acute mastitis (usually unilateral)

Fluid overload

  1. Inflammatory carcinoma

locally advanced carcninoma

Lymphatic obstruciton from axillary adenopathy.

73
Q

Definition of a mass in mammogram

A

Space-occupying lesion w/ convex borders seen in 2 different projections.

74
Q
  1. When do you see skin retraction?
  2. Nipple retraction vs. Inversion.
A
  1. most commonly post-surgical, but may be a desmoplastic reaction
  2. Tethering or angulation of the nipple. Retraction is not the same as inversion (whole nipple points inwards). Nipple inversion may be developmental.
75
Q

Importance of spot compression

A

Cancers are a/w parenchymal fibrosis due to desmoplastic reaction. If an apparent asymmetry ‘presses out’ with focal compression, then the apparent abnormality can be presumed to represent superimposed normal pliable fibroglandular tissue

76
Q

Explain XCC (XCCL and XCCM)

A

XCCL puts lateral breast tissue in detector

XCCM pulls medial breast tissue in detector

77
Q

what is a ‘reduced compression”

A

obtained for posterior lesions that may ‘slip out’ of detector when fuly compressed.

78
Q

3 times when you should get a true lateral view

A

Dx milk of calcium

triangulate a lesion seen only on MLO view

planning a sterotactic procedure

79
Q

All palbable masses are cases of breast pain are evaluated by:

A

ultrasound

80
Q

Name of axillary extension of breast tissue?\

What are cooper’s ligaments?

A
  1. Tail of spence
  2. Thin sheets of fascia that hold up breast. Tiny white lines on Mammo, and echogenic lines on u/s. The lines holding up the
81
Q
  1. What is lactiferous sinus?
  2. Blood supply/lymphatic drainage of breast
A
  1. Dilated portion of major ducts
  2. Majority of blood (60%) is from internal mammary. The rest goes to lateral and thoraic and intercostal perforators

97% of lymphatic drainage is to axillary nodes.

3% (think medial cancers) drians to internal mammary nodes.

82
Q

Most common locations for ectopic breast tissue

A

Most commonly axilla. 2nd most common is inframammary fold. However they can be anywhere along the “milk streak”

Extra nipples are most commonly in same loc

83
Q

Describe phases of menstrual cycle and how they related to breast imaging

A

Follicular phase (days 7–14), estrogen dominates - best time to have both mammogram and MRI

Luteal phase (15-30). Progesterone dominates. You will get some breast tenderness (Mostly days 27-30)

84
Q

Effect of hormone replacement therapy on breasts

A

Breasts get more dense. Breast pain may occur, peaking in first year. Fibroadenoma may enlarge.

85
Q

Rare diagnosis - if you see lots of “egg shell calcifications”/Oil cysts

A

Steatocytoma multiplex.

86
Q

DCIS trivia

  1. Percent of DCIS on imaging that may have invasive componenet at time of biopsy
  2. % of DCIS on core biopsy that may ahve invasive component on surgical excision
  3. % of DCIS which will present as mass w/o calcs
  4. Most common u/s appearance of DCIS
A
  1. 10
  2. 25
  3. 8
  4. Microlobulated hypoechoid mass w/ ductal extension, normal accoustic transmission.
87
Q

Milky discharge is usually benign. It is suggestive of what?

A

thyroid issues, pituitary adenoma (prolactinoma), psychotic meds (mess w/ dopamine and prolactin production).

88
Q

causes non-milky discharge?

  1. Benign (one in pre-menopausal, one in post-menopausal)
  2. worrisome causes - 2
A
  1. fibrocystic change in pre-menopausal.

Ductal ectasial in post-menopausal

  1. Intraductal papilloma, DCIS.
89
Q

Architectural distortion vs. Summation artifact

A

AD: all lines radiate to one point

Summatio artifact: lines continue past each other.

90
Q

Using harmonics on u/s can result in loss of what?

A

Posterior acoustic features. (this is important because you don’t want to miss posterior shadowing ILC).

91
Q

Snow-storm lymph node

A

Silicome infiltration of node from silicone leak or rupture

92
Q

Approximate number of ducts per nipple?

A

8-12 (like a clock)

93
Q

BR3 option for MRI

A

Solitary focus <4mm) of enhancement. Persistent kinetics.

94
Q

Management for a papilloma?

A

Excision. Because it may progress

95
Q

Describe fibromatosis from pectoralis. What is management?

A

Locally aggressive proliferation of fibroblasts and myofibroblasts. Usually arises from pectoralis fascia. Wide local excision is standard.

96
Q

Which organization created BIRADS?

A

ACR

97
Q

3 zones of the breast and what is in them.

For some reason, parenchymal fat is hypoechoic, unlike fat elsewhere

A
  1. Pre-mammary (Subcutaneous) zone contains skin, dermis, subcu fat, and coopers ligaments.

Site of skin and epidermal lesions (epidermal inclusion cyst, sebacious cyst). Subcutaneous can include normal breast pathology.

  1. Mammary zone: site of most breast pathology. Includes TDLUs, fat, fibrous tissue, Cooper’s ligaments.
  2. Retromammary zone;just superficial to pectoralis. Contrains fat and few cooper’s ligaments.
98
Q

Ultrasound of benign mass vs. malignant mass

A

Hyperechogeniticy, circumbscribed, parallel, ellipsoid, few/gentle macrolobulation. Thin/echogenic paseudocapsule

Malignant: spiculated (most specific sign of malignancy), antiparallel (2nd most specific sign), angular/microlobualted, psterior shadowing. Hypoechoid, associated calcificaitons. Wide zone of transition

99
Q

Birads 3 on ultrasound

A

Complicated cyst or clustered microcysts

Oral, hypoechoic, circumscribed, parallel mass (fibroadenoma)

100
Q

2 most common locations of skin calcs on mammography?

A

Parasternal, inframammary fold

101
Q

when is it appropriate to do an FNA of an axillary lymph node

A

Suspicious lymph node in a patient w/ recent dx of breast cancer. You only need FNA because you just need a small amount of tissue to confirm. Normally you need core biopsy.

AA Sal Mammo (4 decks)

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