Breast – Malignant Pathology – Flashcards
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What are typical sonographic features of malignant diseases of the breast?
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Taller than wide Invades other tissue planes Irregular shape Spiculated Ill-defined borders microlobulations Radial extension
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How is duct extension different than branch pattern?
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Duct extension starts at a tumor and courses towards the nipple Branch pattern extends from a tumor away from the nipple
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What does a thick echogenic halo indicate?
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A tumor invasion with fibrotic host response (desmoplasia)
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What is desmoplasia?
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Tissue fighting cancer turns fibrotic and forms an echogenic ring around the tumor; can make it appear larger on mammography.
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What are the sonographic characteristics of malignancy?
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Echogenicity - hypo- to anechoic; heterogeneous Artifacts - shadowing Doppler - peripheral and internal blood flow Calcifications - microcalcifications typically seen in mammography
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What is the most common sign of breast cancer?
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A new lump or mass
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Where do 90% of breast cancers originate?
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The duct, specifically the TDLU
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Where are the majority of breast cancers found?
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The upper outer quadrant
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What is DCIS?
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Ductal carcinoma in situ - cellular changes in the TDLU that give rise to atypical hyperplasia which lead to cancer within the duct
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What is the frequency of occurrence of breast cancer?
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One in nine women will develop breast cancer The most common cancer among women Second leading cause of cancer related death after lung cancer in women
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What are the risk factors of breast cancer?
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Gender - female 100x greater than men Age - increasing risk with age Family Hx of breast CA Personal Hx of breast CA and other CA (OV, endometrial) Late menstruation/menopause Women who have not had children or have children after 30 Hormonal - prolonged use of oral contraceptives; HRT Radiation therapy Atypical hyperplasia Obesity - more fatty tissue increases estrogen levels
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What are the characteristics of multifocal lesions?
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2 or more lesions within the same ductal system or quadrant of the breast 2 or more lesions within a 5cm distance
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What are the characteristics of multicentric lesions?
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2 or more cancer lesions found in separate quadrants of the same breast or in different breasts 2 or more lesions greater than 5cm apart
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What is the most common non-invasive CA?
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DCIS
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What are the characteristics of DCIS?
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Malignant changes in the ductal epithelium without extension past the basement membrane Arises from the TDLU 3rd most common breast CA Usually confined Excellent cure rate
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What can DCIS progress to?
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Invasive carcinoma
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What are the two forms of DCIS?
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Comedo - high grade, aggressive with necrosis within the tumor Non-comedo - low grade and slow growing
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How is DCIS best diagnosed?
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Mammography
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What can be seen with DCIS?
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Ductal dilation Microcalcifications Patient is asymptomatic May be no distinct tumor Possible nipple discharge Possible palpable mass
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What is LCIS?
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Lobular carcinoma in situ - malignant changes in the lobular epithelium without invasion outside of the lobule
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What population does LCIS generally affect?
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Pre-menopausal women
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What are the characteristics of LCIS?
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Small Not palpable Bilateral and multicentric
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What is the risk of invasive carcinoma with LCIS?
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10x and is associaed with invasive carcinoma in the opposite breast
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When is CA classified as invasive?
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When it extends beyond the duct or lobule and invades the surrounding stroma and fatty tissues (metastasis)
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What is the usual type of invasive carcinoma?
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Invasive ductal carcinoma
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What are the specified types of invasive carcinoma?
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Invasive lobular carcinoma Medullary carcinoma Colloid (mucinous) carcinoma Tubular carcinoma Papillary carcinoma Paget's disease
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What is the most common form of breast CA?
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IDC - invasive ductal carcinoma; it accounts for 75% of all breast cancers
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What are the characteristics of IDC?
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Malignant changes of the ductal epithelium with invasion through the basement membrane Desmoplasia is common Palpable mass with hard gritty texture Fixed tumor Skin dimpling Retraction or nipple retraction
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How does IDC appear on mammography?
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Spiculated or irregular Microcalcifications Thickened or retracted Cooper's ligaments
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How does IDC appear sonographically?
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Solid Irregular, angular, spiculated Hypoechoic Heterogeneous Shadowing Duct extension or branch pattern Fascia interrupted
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What is ILC?
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Invasive lobular carcinoma. The 2nd most common type of breast cancer 8-15%
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What are the characteristics of ILC?
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Most frequently missed Usually not palpable Usually no microcalcifications Highly aggressive May produce architectural distortion with no mass effect More likely to be multifocal, multicentric and bilateral than IDC Difficult to detect on mammography and US
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What are the characteristics of Medullary carcinoma?
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5% of all invasive cancers Tends to occur in younger women Well circumscribed, soft Non-tender Compressible and slightly movable Commonly mistaken for fibroadenoma More common among African-american and Asian american women Good prognosis
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How does medullary carcinoma appear?
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Large solid mass Round, oval or macrolobulated May have irregular margins on close inspection May be taller than wide Hypoechoic Homogenous or mildly heterogenous Possible enhancement Shadowing is uncommon Possible central necrosis
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What is colloid carcinoma?
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2-3% of all breast cancers Contains mucous producing cancer cells that create a gelatinous or syrup-like interior Large firm smooth mass Slow-growing - non-aggressive Typically affect older women Good prognosis
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How does colloid/mucinous carcinoma appear?
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Hypo- to isoechoic Well-circumscribed May be microlobulated Homogenous Shadowing is uncommon May appear as a complex cystic mass
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What is tubular carcinoma?
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2-3% of all breast cancer Usually small Good prognosis Associated with radial scar Spiculated on mammography Small, hypoechoic mass with ill-defined margins Posterior shadowing
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What is the malignant version of intraductal papilloma?
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Papillary carcinoma
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Is papillary carcinoma invasive and where does it typically appear?
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Can be invasive and non-invasive and is subareolar
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What population does papillary carcinoma typically affect?
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Primarily post-menopausal women
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What is the primary symptom with papillary carcinoma?
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Bloody nipple discharge - seen more commonly with intraductal papilloma
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What is the sonographic appearance of papillary carcinoma?
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Well-marginated solid mass May appear complex Ductal dilation Microcalcifications With duct obstruction intracystic papillary carcinoma may develop
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How does Paget's disease develop?
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Begins in the lactiferous ducts and spreads to the skin of the nipple and areola
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How common is Paget's disease?
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Rare, 1%.
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What does Paget's typically accompany?
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Invasive carcinoma, but can also be seen with CA in situ
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What are the clinical symptoms of Paget's disease?
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The skin of the nipple and areola may appear crusted, scaly and red May cause bleeding, oozing, burning and itching
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How does Paget's disease appear sonographically?
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Skin thickening of the areola Possible duct dilation Possible subareolar mass
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How common/rare is inflammatory CA?
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Rare but aggressive 1-3%
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How does inflammatory CA develop?
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Primary breast CA invading the lymphatic vessels of the breast (usually IDC)
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How does inflammatory CA spread?
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Lymph involvement with poor prognosis due to mets
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What is the predominant feature with inflammatory CA?
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"Red hot breast"
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What are the clinical symptoms of inflammatory CA?
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Warm, red, swollen, hard and painful breasts Orange peel appearance due to edema and skin thickening Flattening or retraction of the nipple Palpable mass from primary CA Axillary lymph node enlargement
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What is the main differential for inflammatory CA?
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Severe mastitis
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What is the occurrence of male breast CA?
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1%
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What are the risk factors for male breast CA?
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Advanced age Family of breast CA Radiation exposure Cryptorchidism Testicular injury or surgical removal Klinefelter's syndrome
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Where is male breast CA typically located?
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Subareolar
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What types of CA are typical in male breast CA?
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DCIS or IDC
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Where does Cystosarcoma phyllodes arise?
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From the stroma (connective tissue)
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Are phyllodes tumors benign or malignant?
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Usually benign, but occasionally malignant
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What does phyllodes mean?
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Leaf
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What are the characteristics of a phyllodes tumor?
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Occur in women 30-50 Solitary Rapid growth Large Large lobulations leading to leaf shape large, palpable, firm, mobile mass that may bulge the skin Tendency to reoccur
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When phyllodes tumors become malignant, what form of CA are they?
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Sarcoma
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What are characteristics of malignant phyllodes?
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Faster growth than benign form Can have central degeneration May spread to the lungs Does not respond well to hormonal chemo or radiation therapy
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Where can malignant phyllodes spread?
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The lungs
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Where does primary lymphoma originate?
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Within the lymph nodes of the breast
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Where does secondary lymphoma originate?
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In the lymphatic system outside the breast, then metastasize to the breast
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Is primary or secondary lymphoma more common?
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Secondary via metastasis
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How common is lymphoma of the breast?
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Less than 1%
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What population does lymphoma typically affect?
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Women 50-60
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What are the clinical symptoms of lymphoma?
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Palpable mass with palpable axillary nodes Loss of definition of the fattly hilum of the lymph node Can be singular or multiple
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What is the most common source of metastasis to the breast?
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Melanoma
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What does BIRADS stand for?
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Breast Imaging Reporting and Data System
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What is BIRADS used for?
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ACR classification system for breast lesions with 6 categories
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BIRADS Category 0
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Needs additional imaging. Inconclusive findings.
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BIRADS Category 1
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Normal with routine follow-up
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BIRADS Category 2
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Benign. Breasts with dense tissue, implants or many benign lesions. Routine follow-up
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BIRADS Category 3
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Possibly benign. Findings unlikely to ne CA. Round or oval solid masses. Short term follow-up or biopsy recommended.
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BIRADS Category 4
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Suspicious. Findings are often cancer - irregular solid masses, microcalcifications, growth of a solid mass. Biopsy is recommended.
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BIRADS Category 5
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Malignant. Spiculated mass, solid mass with nipple retraction or skin thickening. Appropriate action should be taken.
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What is a useful imaging modality in evaluating ruptured augmented breasts?
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MRI
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What are MRIs useful for in terms of breast imaging?
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Evaluating augmented breasts for rupture Staging breast CA
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Can MRIs be used to visualize microcalcifications?
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No
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What is imaging of the lactiferous ducts called?
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Ductogram or galactography
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What is a ductogram typically used for?
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Nipple discharge. Dye is injected into the orifice where the discharge was noted
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How is mammography used in relation to a ductogram?
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To look for a filling defect in the duct for intraductal papilloma or papillary carcinoma
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What is a sentinel node?
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It is the first node that drains lymphatic fluid from a specific area of the breast.
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How is a sentinel node used?
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Radioactive isotope is injected around the site of a confirmed breast CA. The flow of the dye identifies the sentinel node to be biopsied. This occurs 2 hrs before surgery and a gamma probe is used to trace the injected isotope
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If a sentinel node is found to be cancerous, what additional steps are taken?
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Axillary node dissection is warranted Mastectomy is considered
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With a double lumen breast implant, what is in the outer layer? The inner layer?
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Outer - saline Inner - silicone
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What are the placement options for breast implants?
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Subglandular - posterior to the parenchymal layer and anterior to the muscle Subpectoral
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What are possible artifacts when imaging the augmented breast?
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Reverb - common along the anterior surface of the implant Speed error - only with silicone; speed through silicone is slower, so the implant appears deeper in the chest wall than the surrounding tissue
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What is a complication that can occur with breast implants?
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Fibrous encapsulation of the implant
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What are signs and symptoms of fibrous encapsulation of a breast implant?
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Change in appearance Hardening of the breast Tenderness or burning Lump Autoimmune problems
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What are common complications associated with breast implants?
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Hematoma Abscess Migration of the implant Partial or total collapse Capsular contraction
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What is the cause of capsular contraction of breast implants?
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Implant becomes fixed due to fibrosis The breast becomes hard and painful May cause a radial fold
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What are the characteristics of an intracapsular rupture?
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80% Stepladder sign Linguine sign
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What are the characteristics of extracapsular rupture?
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Snowstorm appearance caused by silicone granuloma - soft tissues walled off by an inflammatory response
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What is breast reduction aka?
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Reduction mammoplasty
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What can scars from breast reduction surgery mimic?
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Palpable mass
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What pathology may be present with breast reduction surgery?
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Oil cysts and fat necrosis
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What does a mammogram show with breast reduction surgery? Ultrasound?
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Mammogram - Architectural distortion Ultrasound - swirling pattern and shadowing from the scar
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What is a TRAM flap?
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Transverse Rectus Abdominus Myocutaneous flap - used for breast reconstruction following mastectomy. A rectus abdominus muscle is used for blood supply and a flap of skin from the suprapubic region is used to form the new breast
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FNA vs Core biopsy
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FNA is less invasive but false positive is possible - cytologic evaluation, fast results - 1-2 hrs Core biopsy takes a larger tissue sample and is a true histologic evaluation; results take 2-3 days
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What are the cancer stages?
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Stage 0 - in situ. No lymph node involvement or metastasis Stage 1 - less than or equal to 2cm. No LN involvement or mets Stage 2 - >2cm. Possible LN involvement, no mets Stage 3 - >5cm. Possible LN involvement. No mets Stage 4 - any size with LN involvement and positive metastasis
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What does a lumpectomy consist of?
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Removal of the breast lump and some surrounding tissue. 10-20 lymph nodes are also removed and evaluated Usually followed by radiation therapy Considered as "breast conservation therapy"
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What is removed with modified radical mastectomy?
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Breast Lymph nodes Pectoralis fascia
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What is removed with a radical mastectomy?
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Breast Lymph nodes Pectoralis major and minor
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What is considered the "gold standard" of mastectomies?
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The modified radical mastectomy
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What does axillary lymph node dissection consist of?
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Removal of lymph nodes performed during lumpectomy or mastectomy
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What does Tamoxifen block?
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Estrogen
