BREAST IMAGING Flashcards

Question

Answer 1

Sclerosing adenosis of the breast Dr Francis Deng◉ and Radswiki◉ et al. * Sclerosing adenosis (SA) is a benign proliferative condition of the terminal duct lobular units characterized by an increased number of acini and their glands. * It manifests as multiple small, firm, tender nodules, fibrous tissue, and variable microcysts within the breast. * It is sometimes placed under the category of borderline breast disease. **Clinical presentation** * Many women with sclerosing adenosis experience recurring pain that tends to be linked to the menstrual cycle. * In most cases, sclerosing adenosis is detected during routine mammograms or following breast surgery. * A biopsy is required to confirm the diagnosis, because the condition may be difficult to distinguish from breast cancer by imaging. * Sclerosing adenosis can appear as a focal or diffuse lesion. * It is not physically palpable in 80% of the cases, although in some cases may cause skin retraction. **Pathology** * **Sclerosing adenosis is a type of adenosis in which enlarged acini become slightly distorted by surrounded stromal fibrosis ("sclerosis"). The normal lobular architecture of the breast is maintained but becomes exaggerated and distorted.** **Associations** * Sclerosing adenosis can be seen as a component of other proliferative lesions: * intraductal and/or sclerosing papilloma * complex sclerosing lesion * fibroadenoma * breast cancer, both invasive and in situ **Radiographic features** **Mammography** * Sclerosing adenosis has a wide range of mammographic presentations, and can be difficult to distinguish from an infiltrating carcinoma: * mass, with irregular to well-defined contours * architectural distortion * microcalcifications * present in 40-55% of cases 5,6 * may be amorphous, pleomorphic, or punctate 3,5 * more commonly clustered, although may present in diffuse scattered distribution 3,5 **Treatment and prognosis** * Although not considered a pre-malignant lesion, sclerosing adenosis is considered an independent risk factor for the development of subsequent breast cancer 3,5. * Studies suggest that women with sclerosing adenosis may have approximately **1.5-2 times as high a risk of developing breast cancer.** MMG:Large area of parenchymal distortion with a small number of concerning microcalcifications. Note that the centre of the lesion has a relatively low density. USS: This is the ultrasound images of the lesion above. The microcalcifications are visible on ultrasound. The lesion is relatively speaking noted to have a low echogenicity centre, i.e. there is no central mass lesion.

Answer 2

Radial scar Dr Alexandra Stanislavsky◉ and Dr Jeremy Jones◉ et al. **Radial scar, or complex sclerosing lesion**, is a rosette-like proliferative breast lesion. It is not related to surgical scarring. Some authors, however, reserve the latter term to lesions over 1 cm 5. It is an idiopathic process with **sclerosing ductal hyperplasia.** Its significance is that it is a mimicker of scirrhous breast carcinoma. Although some classical differential descriptions exist (see below), these cannot be relied on, and the diagnosis must not be made on radiological features alone. **Furthermore, there is an association with atypical ductal hyperplasia and carcinoma.** **Epidemiology** **The reported prevalence of radial scars is 0.1-2.0 per 1,000 screening mammograms. Radial scar is very rare in women younger than 40 years and older than 60 years. Most often in women between 41-60 years 12-13 .** Clinical presentation They are usually not palpable. Clinical examination of the breast containing regions of radial scar is often normal, although in about 25% of cases radial scars can be palpable. They do not cause skin thickening or retraction. Lesions are usually small and detected by mammography when they are at least 5 mm in size. Lesions \<1 cm are called radial scars, while larger ones are often referred to as complex or radial sclerosing lesions. Pathology A radial scar is a benign hyperplastic proliferative disease of the breast. Proposed possible causes include localized inflammatory reaction and chronic ischemia with subsequent slow infarction. Histopathologically radial scars contain hyperplastic tissue cells and a central fibrous core, with radial extension of tubular structures (the spiculated peripheral borders), mimicking infiltrating carcinoma. This tubular formation has two rows of cells, epithelial and myoepithelial 9-10. The malignant potential is two times greater than in the normal population without radial scar 11-12. **Associations** **In approximately 30% of cases, a radial scar is associated with ductal carcinoma in situ and tubular carcinoma of the breast. The occurrence of these is higher when there is associated atypia on histology.** Other associations include 4: atypical ductal hyperplasia atypical lobular hyperplasia Radiographic features Mammography A radial scar has a spiculated appearance similar to carcinoma, but the center tends to be a translucent, low-density area rather than a mass. The breast tissue behind the lesion is almost visible through the lesion. The relatively low density of the center is a relevant and visible difference between carcinoma and a radial scar. **A carcinoma tends to have a dense center.** **With radial scars there is no dense center; in fact, the lesion is usually as dense centrally as peripherally.** There is no "attempt" at forming a mass in a radial scar. The spicules running from the center are in general longer and gracile than those of a carcinoma (look at the image in Case 1 and 2 thoughtfully. These are representative images). The spicules are described as long and thin with radiating radiolucent linear structures, which against a radiolucent fat background gives a black star or dark star appearance 6. Microcalcifications are possible but rare in a radial scar. However, unlike a carcinoma, features such as skin thickening and retraction are characteristically absent 2. There is no visible scirrhous reaction in the radial scar. Its mammographic appearance is also similar to a post-surgical breast scar and can vary markedly with differing projections (i.e. CC vs MLO). Ultrasound On ultrasound, a radial scar is often ill-defined and disturbs the architecture of surrounding breast parenchyma. The lesion is usually round, oval or lobulated. Variable internal echoes can be found. Some radial scars show retro-acoustic attenuation. MRI Features are replicated as described in the aforementioned modalities. There will be spiculation and archiectural distortion. Non-enhancement of the lesion favors a benign process. Enhancement suggests an underlying malignancy. Treatment and prognosis A radial scar is considered a high-risk breast lesion and histological differentiation from associated carcinoma is required. FNA and core biopsies can underestimate the underlying associated malignancy and are controversial. The lesions are biopsied and removed. Differential diagnosis Differential considerations for mammographic appearances include: breast cancer: a central mass tends to form. The spicules are shorter and thicker and there is retraction of the parenchyma; however sometimes the invasive lobular carcinoma, due to lack of the E-cadherin and diffuse infiltration of the tumor cells, it can be impossible to distinguish it from radial scar post-surgical breast scar: in practice this is rarely if ever a source of confusion; it is really rare to find post-surgical scarring with such long spicules as a radial scar and you also have the history on the technologist notes and if all else fails, the scar on the patient's skin MMGThe image shows a well defined density upper left which was a cyst. The spiculated parenchymal distortion centrally was the abnormality being worked up. Note the relatively low density centre and the long spiculated bands running concentrically from the centre. MMG 2 Stromal distortion in the right central breast with a central lucency. No mass.

Answer 3

Atypical ductal hyperplasia Dr Yuranga Weerakkody◉ and Radswiki◉ et al. **Atypical ductal hyperplasia (ADH)** is a histologically borderline lesion that has some, but not all the features of ductal carcinoma in situ (DCIS). Sometimes the distinction between ADH and DCIS is simply on the basis of the number of ducts involved. Pathology **Atypical ductal hyperplasia is a lesion with a lot of malignant potential. It lacks the strict criteria for ductal carcinoma in situ. A lesion which is qualitatively similar to DCIS yet quantitatively is inadequate (\< 2 ducts involved) is termed as atypical ductal hyperplasia 3.** Treatment and prognosis **ADH is considered a high risk breast lesion.** Therefore surgical excision is advised as under-estimation of ductal carcinoma in situ is encountered when atypical ductal hyperplasia is retrieved on a large core needle biopsy (up to one-third of cases may be upstaged to DCIS). Tamoxifen may be used as a chemopreventative agent.

Answer 4

**Atypical lobular hyperplasia** Dr Daniel J Bell◉ and Radswiki◉ et al. Atypical lobular hyperplasia (ALH) is a pre-malignant lesion of the breast which falls at the milder end of the spectrum of lobular neoplasia. It is therefore considered a part of borderline breast disease. Clinical presentation It is usually asymptomatic and mammographically occult and is invariably found incidentally, in a biopsy specimen obtained for another lesion. Pathology ALH represents a proliferation of monomorphic cells which are morphologically identical to **lobular carcinoma in situ (LCIS).** The distinction is that ALH occurs in **a non-distended lobule** or small lobular duct, **whereas LCIS is characterized by distention.** Not surprisingly, there is a s**pectrum of change from ALH to LCI**S. To reflect this spectrum and to avoid the connotation of malignancy per se, use of the term "**lobular neoplasi**a" has been advocated by some authors. Treatment and prognosis Treatment is controversial. Some centers surgical excise while others do not. **Compared with the general population, the risk of subsequent breast cancer is _4-6x higher_ after a diagnosis of ALH** (compared to approximately 11x after a diagnosis of LCIS).

Answer 5

Ductal carcinoma in situ Ductal carcinoma in situ (DCIS) refers to a breast carcinoma limited to the ducts with no extension beyond the basement membrane, as a result of which the disease has not infiltrated the parenchyma of the breast and the lymphatics and cannot therefore metastasize. Epidemiology The detection of ductal carcinoma in situ has increased markedly in recent years secondary to the widespread use of screening mammography, and it now accounts for 25-40% of mammographically detected breast cancers 1,3. It also accounts for approximately 15-20% of all detected breast cancers. Associations up to 11% of predetermined ductal carcinoma in situ on imaging may have an invasive component at the time a biopsy is done 2 20-25% of DCIS revealed on core biopsy may have invasive ductal carcinoma following surgical excision Risk factors Risk factors for ductal carcinoma in situ are similar to those for invasive carcinoma and include: increasing age family history of breast cancer nulliparity age of 30 years or older at the birth of the first child Clinical presentation Although most patients are asymptomatic, some present with nipple-related disease (nipple discharge or Paget disease of the breast) or have palpable abnormalities. Pathology Ductal carcinoma in situ (DCIS) is the non-obligate precursor of invasive breast carcinoma. In the context of "overdiagnosis" the low grade DCIS cases found on screening mammography are likely to cause the number of cases where the diagnosis of breast malignancy has been made but could conceivably not have been fatal to the patient. Remember that to try and guess the grade of DCIS on the mammogram images is not plausible or reproducible. Low grade DCIS is not a dangerous disease and there is actually some thought on following the disease with MRI after a histological diagnosis has been made. Ductal carcinoma in situ is not a single entity, but rather a spectrum of disease 3. In essence, it refers to breast epithelial cells that have become "cancerous" but still reside in their normal place in the ducts and lobules 10. Markers In some situations, immunohistochemical staining for E-cadherin may help to differentiate from lobular carcinoma in situ. Subtypes The traditional classification broadly divided ductal carcinoma in situ lesions into two types mainly based on central necrosis, grade, and cell type: comedo - large cell: more aggressive form; also referred to as comedocarcinoma non-comedo - small cell: less aggressive; can be further divided into cribriform micropapillary papillary solid A new pathological classification of DCIS is based on nuclear atypia and degree of necrosis. Radiographic features Mammography There are varied mammographic manifestations of ductal carcinoma in situ, with casting-type calcifications being the most common (present in 50-75% of cases 3). Other manifestations include a soft-tissue opacity either with or without associated calcifications. Although DCIS calcifications may assume varied appearances, linear calcifications are more likely to be associated with comedo-type DCIS, while granular calcifications are more often correlated with non-comedo DCIS. Occasionally DCIS appears as a simple mass or asymmetry without calcification (~8% of cases) 12. There may be a significant discrepancy between the distribution of the disease as seen on the mammogram and the distribution of the disease on the pathology specimen of the breast as examined by the pathologist. In general, the calcification underestimates the distribution of DCIS in the breast, i.e. not all the DCIS calcifies. Breast ultrasound One of the benefits of identifying a corresponding sonographic abnormality in women with mammographically detected DCIS is to use ultrasound to guide interventional (e.g. biopsy/hook wire) procedures. A microlobulated mild hypoechoic mass with ductal extension and normal acoustic transmission is considered the most common feature in sonographically detected DCIS. With good quality ultrasound and enough effort, it is possible in everyday practice to identify the DCIS process as it grows in the ductal system of the breast. It is quite possible to identify those minute wild and crazy calcifications of DCIS in the ducts itself and ultrasound-guided biopsy of DCIS is now an everyday procedure. Breast MRI DCIS most commonly appears as non-mass enhancement, most commonly with a segmental or linear distribution and clumped or heterogeneous internal enhancement pattern 14. Within non-mass enhancement, the clustered ring internal enhancement pattern is most specific for malignancy, usually DCIS 15. Treatment and prognosis Treatment options for ductal carcinoma in situ include mastectomy, lumpectomy with breast irradiation, or, for patients with small lesions (\<1-2 cm) of low-grade DCIS, lumpectomy alone. This disease is likely the precursor of invasive ductal carcinoma at a stage when the therapy is potentially curable. The advantage of diagnosis of DCIS is that the chances of encountering metastatic disease are in theory zero when compared to invasive ductal carcinoma. With the introduction of screening mammography, the decreased mortality of breast carcinoma is in some part due to the identification of DCIS and effective therapy. In large screening programmes, DCIS makes up to 30% of malignancies diagnosed.

Answer 6

thi sis common and normal as long as there are n o other findings Mor MCQ, an asymmetric breasrt should make you think about the 'SHRINKING BREAST" of INVASIVE lobular br. ca..

Answer 7

Yes. dont call it pagets.

Answer 8

TDLU Terminal duct lobular unit * lactiferous sinus * major duct * lobules

Answer 9

yes. should worry about linear or segmental.

Answer 10

* 60% via the internal mammary. * the rest is via the lateral thoracic and intercostal perforators * 97% of lymph drains to the axilla. * 3% to the internal mammary nodes

Answer 11

* the axilla is subdivided into 3 separate levels using the pec minor * supposedly drainage is in a step wise fashion from Lv 1 to 2 to 3 and finally to the thorax

Answer 12

* nodes between the pec minor and major. * fancy name = high yeild * same as level 2

Answer 13

AUNT MINNIE * non funcitonal muscle next to the sternum that can simulate a mass. * about 5% of ppl have one and its usually unilateral. * Should only be seen on CC. Never on MLO Sternalis muscle Assoc Prof Craig Hacking◉◈ and Radswiki◉ et al. The sternalis muscle is an uncommon anatomic variant of the chest wall musculature and is of uncertain aetiology and function. Its importance lies in that it should not be mistaken for a pathological lesion. Epidemiology Cadaveric studies have shown that the muscle is present in ~5% (range 1-8%) of both males and females and is twice as often unilateral as bilateral. Gross anatomy The sternalis muscle runs from the jugular notch of the manubrium superiorly, to approximately the caudal (inferior) aspect of the sternum. It is found adjacent to the medial edge of pectoralis major. Radiographic features Mammography The mammographic appearance of the sternalis muscle is variable. Typically it is visible in the medial aspect of the breast on the craniocaudal mammogram and appears as a small soft tissue density/mass abutting the chest wall. Its margins and shape are variable (can range from flame shaped to an irregularly rounded density) 3. The muscle is usually not seen on the standard MLO or ML views. It typically measures 1-2 cm in maximum dimension. As long as the radiologist is aware of the entity, there is usually little confusion. Ultrasound or CT or even MRI may be obtained for confirmation when the diagnosis is uncertain. The sternalis muscle should be considered in the differential diagnosis if a posteromedial mass is noted on the CC view 2. CT appears as a flat parasternal muscle, longitudinal in orientation 6 Additional work up In occasional situations, a "cleavage/valley view" may help to confirm bilaterality.

Answer 14

* the MILK STREAK is the embryologic buzz word to explain the location of the normal breast and location of ectopic breast tissue * The most common location for ectopic bresat tissue is in the axilla * The second most comon 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 from maternal hormones. * As girls enter puberty, their ducts elongate and branch (estrogen) * then their lobules proliferate (progesterone effects). * If you bx a breast bud you could damge it and potentially damage breast development.

Answer 15

* Menstural * follicular phase * d 7 - 14 * Estrogen dominates * best time to have both MMG and MRI * Luteal Phase * d 15 - 30 * Progesterone dominates * breast tenderness * breast density increases slightly *

Answer 16

HRT * breasts get more dense * especiialy estrogen-progesterone combos * breast pain can occur * typically peaking n the first year * Fibroadenomas - who like to draink estrogen can grow

Answer 17

* benign fat containing lesions * Br2 * typically seen on cessation of lactation. * usually subareolar * variable appearance but can have an AUNT MINNIE look with a fat fluid level * Can become an abscess. Galactocele Dr Adam Eid Ramsey and Radswiki◉ et al. Galactoceles, also referred as lactoceles, are the most common benign breast lesion typically occurring in young lactating women; however, they mostly happen on cessation of lactation 1. Clinical presentation Patients usually present with a painless breast lump occurring over weeks to months. The lesion can present as single or multiple nodules and can be unilateral or bilateral. Complications Secondary infection with development of a breast abscess. Pathology It is essentially a retention cyst resulting from lactiferous duct occlusion. Diagnosis can be achieved with percutaneous aspiration 8. Biochemical analysis of material aspirated from galactoceles shows a variety of proportions of proteins, fat, and lactose. Macroscopically, the milk within the galactocele may appear white and of usual viscosity if fresh, or thickened if the liquid is older. Location There may be predilection towards the sub-areolar region. Radiographic features Mammography Mammographic appearance of galactocele can be varied depending on the fat and protein content and the consistency of the fluid. Based on these, the galactoceles could appear like a: pseudolipoma: due to significant fat content, the mass seems radiolucent fat-fluid level within cyst: when fat and water are present, and the milk is in a fresh liquid state, a characteristic fat-fluid level is seen due to viscosity difference. This can be demonstrated on mediolateral view with the beam horizontal to the upright patient pseudohamartoma: seen when contents are old milk and water. Due to highly viscous old milk, significant separation of fat and water is not possible and hence gives a hamartoma-like appearance on the mammogram Ultrasound Ultrasound appearances can be widely variable. Sonographic characteristics according to one study is as follows 3: cystic/multicystic: ~50% mixed (cystic + solid): ~37% solid: ~13% Colour Doppler interrogation will show a lack of blood flow. In uncertain cases, an aspiration is recommended in the first instance which will classically yield milky fluid 10. Treatment and prognosis They are benign lesions and spontaneous resolution occurs in a vast majority of cases. A small percentage have a residual collection that may mimic a fibroadenoma or complex cyst. History and etymology The term galactocele derives from the Greek words galatea meaning milky white and -cele (-coele) meaning pouch 9. Differential diagnosis General considerations on imaging include: lactating adenoma: seen as a solid lesion and may show colour flow within it breast abscess: has a different clinical presentation, but can develop as a complication fibroadenoma: classically ovoid or almond shaped with smooth border, internal homogeneous echogenicity and acoustic enhancement 7 carcinoma of the breast: especially for certain lesions on ultrasound

Answer 18

pregnancy * tubes and ducts proliferate * the breast gets a lot denser and more hypoechoic on USS. * USS may be your best bet iff you have a mass Lactation * you can bx a breast that is getting ready to lactate/lactating. You just need to know there is the risk of creating a milk fistula * if you make one, they will have to stop breast feeing to stop the fistula. * it can get infected - uncommon.

Answer 19

Perimenopausal * shortening of the follicular phase means the breast gets more mprogesterone exposure. * most progesteron exposure means more breast pain, more FCC and more breast cyst formation Menopause * the floppy stage * lobules go down * ducts stay but may become ectatic * fibroadenomas will degen. they like estrogen * they will get their pop corn calc * secretory salcs will develop 15-20 years after menopause

Answer 20

or medications (antipsychotics) can create bilateral increased density of the breasts.

Answer 21

Breast within a breast Hamartoma

Answer 22

* Looks like a fibroadenoma * may actually be a chraged up fibroadenoma they like to drinj estrogen * usually they are multiple * if you get [presson follow up reommendation for these i would say 4-6months post partum, post delivery or after cessation of laction via uss. * they usually radpidly regress after you stop lactation.

Answer 23

The MLO is the standar, but somttimes you need a LMO. The answer is women with kyphosis or pectus excavatum. or to avoid a medial pace maker/central line

Answer 24

* Start with MLO and CC. * if you can see a medial lesion in the CC, and cant see/localise it on the MLO, then get a lateral and it should rise ie Muffins rise \*medial rises on the Lateral. * If you see a lateral lesion on the CC, and cant localise it on the MLO, it will 'sink' on the lateral. Lead/lateral sinks. *

Answer 25

1. Huigh risk screening 2. Personal Hx 3. Family hx 4. High risk lesions * ADH * ALH * LCIS 5. mantle radiotherapy 6. Li-Fraumeni syndrome * Brain cancers * Breast * Leukaemias * Sarcomas * Adrenocorticocarinomas 7. Cowden 1. Multiple hamatoma syndrome * breast cancer * thyroid cancver * dysplastic cerebellar gangliocytoma, occurs when in association with Lhermitte-Duclos disease (LDD) * mucocutaneous lesions: present in \>90% of cases * trichilemmomasmucocutaneous papillomatous papules 8. Bannayan-Riley-Ruvalcaba 1. hamatomatous syndrome 9. Extent of disease eval in contralat and ipislat breast 10. positive marges 11. To asses residual disease post treatment 12. Axillary adenopathy unknow primary 13. Posterior lesion to assess chest wall invasion

Answer 26

1. referes to distorted breast paranchyma and appears as thin, straight lines radiating from a sing e focal point withoutan an associated discrete mass. 2. Architectural distortion may be due to 1. scar 2. trauma 3. surgery 3. in the absence of trauma or surgery, architectura distrosion should always be biopsied.

BREAST IMAGING Flashcards

(52 cards)