Breast - Flashcard | StudyHippo.com

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birads features of a mass

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space occupying lesion seen in two different projections convex outward contour denser center than periphery

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birads mass features that are important to note

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size location density shape margins interval change

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implications of mass size

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size does not predict malignancy size affects management large palpable masses can be biopsied with palpation

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implications of mass location

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quadrant location does not predict malignancy mass within the skin cannot be a primary breast carcinoma air halo is an artifact from a skin mass

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implications of mass density

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fat density and mixed density masses are benign

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breast masses containing fat

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oil cyst lipoma galactocele

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mixed density masses

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hamartoma fibroadenolipoma lymph node

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birads descriptors of mass shape

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round oval lobular irregular (suspcious)

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birads descriptors of mass margins

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circumscribed (well defined, only margin that is probably benign) microlobulated (50% chance of cancer) obscured indistinct spiculated (very suspicious)

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how much of a margin must be seen to be able to call it circumscribed

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>75%

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workup of breast mass

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spot-compresion magnification

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implications of interval change in a mass

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prior films are always helpful worrisome changes are newly apparent lesion, interval enlargement, more lobular or indistinct borders, apparent calcifications

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how to work up breast masses that contain multiple features

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always base management on most suspcious feature

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management strategy of masses

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identify benign masses ultrasound to identify cysts biopsy or follow-up for solid masses that are not clearly benign

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indications for following a mass (BIRADS 3)

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round, oval, or lobular shape circumscribed margin if a mass is stable for at least 2 years, call it benign (BIRADS 2) other solid masses should be biopsied

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types of asymmetries

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asymmetry global asymmetry focal asymmetry developing asymmetry

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definition of an asymmetry

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formerly called a density fibroglandular density visible only on one view 80% are superimposition of normal tissue

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global asymmetry

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substantially greater volume of fibroglandular tissue in one breast than in the corresponding location in the contralateral breast must occupy more than one quadrant should not have suspicous mass, calcifications, or architectural distortion almost always normal variant further workup indicated if associated mass, grouped microcalcifications, architectural distortion, or palpable

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focal asymmetry

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fibroglandular tissue asymmery occupying less than one quadrant visible on two views but does not have convex outward contours or conspicuity of a mass may be focal normal tissue, especially when there is interspersed fat <1% chance of malignancy if no associated mass, calcifications, architectural distortion, or palpable correlate easy way to work up is repeating to identify summation--repeat same view, change obliquity slightly, roll view, spot compression, targeted ultrasound if no mammographic, sonographic, or palpable abnormality, call it BIRADS 3; BIRADS 2 when stable at least 2 years

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developing asymmetry

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focal asymmetry that is new, larger, or denser than prior uncommon 13-27% chance of malignancy BIRADS 4 unless proven to be simple cyst

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general classification of asymmetries

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asymmetry BIRADS 1 global asymmetry BIRADS 2 focal asymmetry BIRADS 3 developing asymmetry BIRADS 4

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typically benign calcifications (BIRADS 2)

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calcifications with radiolucent center milk of calcium vascular coarse or popcorn-like large, rod-like (duct ectasia) round injection granulomas

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calcifications with radiolucent center

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lucent centered calcifications eggshell and rim calcifications skin and dystrophic calcifications may have lucent center but do not have to

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lucent centered calcifications

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variable size round or oval with smooth surfaces, lucent center wall is usually thicker than rim or eggshell type may be due to fat necrosis or calcified debris or oil cyst

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eggshell calcifications

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very thin, usually <1mm thick calcium on surface of sphere some fat necrosis and oil cyst

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skin calcifications

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usually along inframammary fold or parasternal axilla and areola can confirm with tangential view

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dystrophic calcifications

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usually in irradiated breast or following trauma irregular but coarse usually >0.5 mm often lucent center

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common clinical history with retroalveolar dystrophic calcifications

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prior breast surgery, usually reduction

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milk of calcium calcifications

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sedimented calcification in macro or microcysts on lateral, more clearly defined, semilunar and dependent on cc, less evident, fuzzy and round most important feature is change in shape on projections

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vascular calcifications

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parallel tracks linear calcifications associated with a tubular structure may want to report them in women <50 due to risk of CAD

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coarse or popcorn like calcifications

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usually large, >2-3mm involuting fibroadenoma

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rod-like calcifications (duct ectasia)

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can form solid or smooth linear rods may have lucent center if calcium is in duct wall that becomes solid when secretions calcify follow ductal distribution, radiate to nipple may branch often bilateral usually women >60

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round calcifications

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variable size (small or punctate) scattered cluster may warrant close surveillance or biopsy if new or ipsilateral to cancer

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foreign body injection calcifications

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characteristic appearance should have obvious clinical history illegal to inject in the US multiplicity and bilaterality helps

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amorphous or indistinct calcifications

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BIRADS 4 unless can be demonstrated as benign small or hazy morphology difficult to discern distribution is very important diffuse is usually benign--magnification views can help clustered, regional, linear, or segmental may warrant biopsy

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coarse heterogeneous calcifications

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irregular, conspicuous usually >0.5mm often coalesce but not right size for dystrophic calcifications can be due to malignancy, fibroadenoma, fibrosis, or prior trauma, so BIRADS 4

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fine pleomorphic calcifications

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BIRADS 4-5 variable size and shape usually <0.5mm

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fine linear or fine linear branching calcifications

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BIRADS 4-5 thin, linear or curvilinear irregular calcifications can be discontinuous can be smaller than 0.5mm wide appearance suggests ductal involvement

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BIRADS 4-5 calcifications

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amorphous 4 fine pleomorphic 4-5 fine linear 4-5

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diffuse/scattered calcification distribution

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random through breast punctate and amorphous calcifications with this distribution are usually benign usually bilateral

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regional distribution of calcifications

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scattered in a large volume >2cc of breast tissue not conforming to a ductal distribution

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grouped or clustered calcification distribution

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at least five calcifications occupying a small space <1cc of tissue BIRADS 4-5

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linear distribution of calcifications

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arrayed in a line may be suspicious for malignancy if represents a duct BIRADS 4-5

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segmental calcification distribution

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worrisome suggests deposits in ducts and branches in a lobe or segment of the breast BIRADS 4-5

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BIRADS 3 calcifications

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round or puncate and clustered linear or segmental distribution makes BIRADS 4

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zonal anatomy for breast ultrasound

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subcutaneous (premammary)--subcutaneous fat, suspensory ligaments, vessels mammary zone--ducts, fat, fibrous tissue retromammary zone--fat, few cooper's ligaments, superficial pectoralis

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reason cancers tend to be taller than wide

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TDLU points in that direction

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lymph node on ultrasound

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oval, reniform, notched circumscribed margins hyperechoic hilum, hypoechoic cortex may show increased through transmission may see hilar flow on color

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positioning for breast ultrasound

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ipsilateral arm abducted, hand under head supine to contralateral posterior oblique or decubitus degree of dependency depends on lesion location

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transducer selection for breast ultrasound

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highest frequency available usually linear high resolution (7MHz and higher) coupling agent is warm gel or stand-off pad for superficial or suspected skin lesion

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utility of doppler in breast ultrasound

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helpful to determine solid versus cystic hyperemia in an infected cyst wall hilar flow in node duplex doppler (spectral and color) can show true flow vs noise avoid excessive compression that can occlude flow

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uility of power doppler fremitus in breast ultrasound

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have patient hum normal tissues vibrate and light up with color signal true solid masses will not vibrate with the fat

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limitations of doppler in breast ultrasound

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PSV, RI, S/D, PI, pattern of flow are not helpful in predicting malignancy grayscale is better for predicting need for biopsy

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elastography

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measures differences in tissue stiffness (elasticity) superimposed strain images benign lesions get smaller on elastic overlay image malignant lesions get larger

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required annotations for breast ultrasound

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side clock face position distance from nipple scan plane orientation depth in tissue is optional

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mass characteristics to describe on ultrasoud

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size orientation margin lesion boundary echo pattern posterior acoustic appearance surrounding tissues

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indications for breast ultrasound

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first line imaging technique for evaluation of palpable masses in women under 30, lactating or pregnant further evaluation of mammographic findings identification and characterization of palpable and non-palpable clinical symptoms evaluations of problems associated with implants guidance of interventional procedure treatment planning for radiation

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palpable mass in young women <30

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start with ultrasound young breasts are very susceptible to radiation effects perform mammogram if no correlate to palpable finding mammogram when suspicious ultrasound needing further evaluation

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features of a benign simple cyst on ultrasound

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anechoic (internal echoes can be seen with high resolution probe) round or oval sharply marginated thin edge shadow artifact posterior acoustic enhancement no color flow

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cluster of benign cyst

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clustered microcysts correspond to dilated TDLUs cluster of 2-3mm cysts without discrete solid component BIRADS 2

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skin cysts

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sebaceous and epidermal inclusion cysts claw sign shows skin is origin turning on the lesion may demonstrate a hair follicle sebaceous cysts are hypoechoic and show a gland neck epidermal inclusion cysts are heterogeneous and show concentric echogenic layers neither have flow on doppler

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complicated breast cysts on ultrasound

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fibrocystic change, galactocele, lipid cyst internal echoes--mobile, ring-down, debris, protein, milk, cholesterol crystals, foam cells, apocrine cells uniformly thick walled is ok fluid-filled and fat-fluid levels circumferential wall calcifications are passable all these are BIRADS2

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complex mass

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cystic lesion wth solid components usually papillary neoplasms eccentric wall thickening, mural nodules, fibrovascular stalk, or thick septations may have microcystic appearance or microlobulated contour these are all BIRADS 4 and require biopsy

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BIRADS of breast cysts on ultrasound

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simple and skin cysts BIRADS 2 clustered microcysts or complicated cysts BIRADS 2-3 possibly solid mass (cannot confirm cystic) or complex mass BIRADS 4 when planning biopsy, ultrasound guidance should only be considered if a clip can be placed if a clip cannot be placed, excision should be performed

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benign features of solid breast masses on ultrasound

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hyperechoic compared to fat ellipsoid shape 3 or fewer gentle lobulations thin, echogenic pseudocapsule absence of any malignant features

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malignant features of breast masses on ultrasound

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spiculation taller than wide (nonparallel) angular margins shadowing branch pattern markedly hypoechoic calcification duct extension microlobulation disruption of tissue planes

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two features most predictive of malignancy in solid lesions on breast ultrasound

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spiculation taller than wide

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requirements for BIRADS 3 classification of a solid breast mass

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mammographically and sonographically benign appearance not new or growing personal audit <2% malignancy rate

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how to manage mammographically visible mass without ultrasound correlate

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BIRADS 3 if well circumscribed, not new or growing, no suspicious features, or it is possibly a lymph node

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mammographic findings necessitating ultrasound evaluation

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asymmetry focal asymmetry architectural distortion calcifications dilated ducts on targeted ultrasound look for correlate, determine benign vs malignant features, and assess if a lesion is amenable to ultrasound-guided biopsy

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clinical symptoms nescessitating ultrasound evaluation of the breast

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palpable lump, ridge, thickening, skin changes, focal non-cyclical pain suspicious nipple discharge--unilateral spontaneous clear or bloody cellulitis (rule out abscess)

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how to manage palpable finding with no mammographic or sonographic abnormality

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always defer to clinician/surgeon consider aspiration by palpation if indicated 4% of women with breast cancer have no imaging finding

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saline and silicone implants on ultrasound

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hypoechoic when intact two echogenic lines when single lumen; three when double palpable masses may represent radial fold, herniation, or valve capsular contraction can cause changes in breast size

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rupture of implants on ultrasound

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evident clinically with saline implants, ultrasound shows parallel echogenic lines representing collapsed implant silicone implants show snowstorm with extracapsular rupture, stepladder with intracapsular silicone can be seen migrating into echogeic granulomas or nodes

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second-look ultrasound following breast MRI

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appropriate for suspicious MR finding not seen on intial mammogram or ultrasound reassess for ultrasound findings determine if lesion is amenable to ultrasound guidance for biopsy

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malignant ultrasound features in lymph nodes

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diffuse, globular, or irregular cortical thickening abnormal node adjacent to a normal node increased peripheral flow, as opposed to hilar with a normal node

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indications for breast MRI

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evaluation of extent of disease axillary lymphadenopathy with unknown primary one time screen of contralateral breast in a patient with newly diagnosed breast cancer evaluation of treatment response in neoadjuvant population screening of high risk patients

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patients with risk high enough for MRI screening

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>25% risk of cancer risk calculators available, although true calculation should be left to experts

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indicators of high risk for breast cancer

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BRCA1/BRCA2 untested patient with primary relative who is mutation carrier very strong family history prior chest radiation therapy histologic diagnosis of LCIS/atypia personal history of breast cancer

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breast MRI technique

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closed systems are better than open higher field strength better need dedicated breast coil prone positioning dynamic contrast-enhanced T1 active fat-suppression or subtraction T2

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benefits of prone positioning

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minimizes motion degradation breast stabilized feet-first entry reduces claustrophobia

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components of breast MR report

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overall composition--almost entirely fatty...mostly fibroglandular tisue presence of implant background enhancement description of abnormal enhancement overall summary BIRADS category

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description of abnormal enhancment on breast MRI

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mass size, location, modifiers, kinetics non-mass-like enhancement--size, location, morphology, distribution small focus too small to characterize

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appearance of pectoral muscle invasion on MRI

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enhancement along the muscle in addition to mass abutting the muscle

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hormonal enhancement

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hormonal fluctuation causes variability in parenchymal enhancement most pronounced during second half of menstrual cycle optimal time to scan is between days 3 and 14 (UCSF policy 4-11)

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classic MR appearance of DCIS

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clumped ductal enhancement extending towards the nipple extent of DCIS should be proven by biopsy

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classic MR appearance of invasive ductal cancer

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spiculated mass rapid contrast uptake rapid contrast washout increased T2 signal morphology trumps kinetics

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classic MR appearance of fibroadenoma

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bright on T2 FSE enhances uniformly persistent or increasing kinetics biopsy may be needed for proof

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breast MRI for implants

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different protocol, no contrast in report, note that study does not evaluate for cancer silastic elastomer shell contains silicone, linguini sign when shell breaks and collapses when intracapsular rupture, silicone is contained by a fibrous capsule when extracapsular rupture, silicone leaks outside capsule and into parenhcyma

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when to biopsy a breast mass

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whenever >2% chance of malignancy BIRADS 4 or 5

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concordance

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pathology results make sense in light of imaging findings

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features of fine needle aspiration of breast lesions

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least traumatic can be performed in office for palpable lesions done best with cytologist to assess immediately often insufficient tissue to completely diagnose

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features of core biopsy of breast lesions

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tissue obtained rather than just cells architecture can be assessed histological underestimation common--DCIS may become invasive ductal, etc.

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borderline pathology lesions

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not clearly malignant or atypical papillary lesion, lobular neoplasia (LCIS, ALH), radial scar when in doubt, excise surgically

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borderline pathology lesions that should always be excised

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atypia/ADH radiologic-pathologic discordance any time pathologists recommends

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biopsy of calcifications

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sometimes will be visible on ultrasound--specimen x-ray still needed stereotactic biopsy now most common for biopsy of calcifications representative sample of calcifications need to be removed to consider the biopsy satisfactory--specimen x-ray!

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how many cores should be taken in a breast biopsy?

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six cores with 14G needle

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benefits of larger core sizes

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more calcification less underestimation the entire lesion may be removed, so a marker clip is important to leave

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biopsy of complicated breast cysts

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diffuse internal echoes otherwise fulfill criteria for simple cyst aspiration can establish that a complicated cyst is not a hypoechoic cancer

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needle localization

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when all biopsy modalities cannot be performed used when a known impalpable finding needs surgery can be placed by any modality

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complicated breast cyst

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meets all criteria for simple cyst except for internal echoes

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complex mass

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complex mass that contains cystic components

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steatocystoma multiplex

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numerous skin-based oil cysts bilaterally hypoechoic abutting or within dermis on ultrasound distinctive appearance on physical exam

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comments to make on surgical technique used for breast implants

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silicone verus saline prepectoral or retropectoral

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most common cause of spontaneous bloody discharge

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intraductal papilloma

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malignancy most likely to present as asymmetry or architectural distortion rather than a mass

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invasive lobular carcinoma

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swirled appearance with undulating fibroglandular components bilaterally

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reduction mammoplasty will often have dystrophic calcifications too

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likely true pathology when a lesion previously diagnosed pathologically as fibroadenoma grows

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phyllodes

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differential diagnosis of a complex mass

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phyllodes ductal carcinoma complex fibroadenoma PASH lactational adenoma abscess

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lactational adenoma

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complex mass, often cystic components usually young lactating woman often still requires biopsy because of appearance

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signficance of bilateral axillary lymphadenopathy without a known primary

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50/50 chance of malignancy collagen vascular disease, sarcoid, infection can cause this lymphoma, leukemia, and mets possible call BIRADS 2 if known benign cause of nodes call BIRADS 4 and biopsy if no known underlying process

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unilateral axillary lymphadenopathy without a visualized breast mass

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<1% of all breast cancers present as isolated unilateral lymphadenopathy breast cancer and mets are possible benign processes include mastitis, breast abscess, upper extremity infection, and granulomatous infection

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poland's syndrome

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unilateral absence of the pectoralis

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reasons for increasing fibroglandular prominence over time

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exogenous hormones endogenous hormones (pregnancy/lactation) weight loss

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radial scar

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complex sclerosing lesion not truly a scar indeterminate lesion although technically benign need to excise because associated with atypia and malignancy mammo shows long thin radiating spicules, central radiolucency, and architectural distortion, but findings are not specific enough for diagnosis

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three types of enhancing lesions on breast MRI

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focus (<5mm) mass non-mass-like enhancement

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enhancing foci on breast MRI

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<5 mm tend to have type 1 curves on enhancement considered part of normal parenhcymal background can be expected to be stable on follow-up

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expected appearance of fibroadenoma on MRI

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lobulated mass with non-enhancing septations unconcerning dynamics

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rate of malignancy with an irregular margin on MRI

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~1/3

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rate of malignancy with spiculated margins on MRI

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0.8

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lesions with containing fat on MRI

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lymph nodes fat necrosis hamartomas benign unless rapidly growing

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lesions with bright signal on T2 with fat sat

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cysts lymph nodes fat necrosis exception to rule of benignity is colloid carcinoma

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breast lesions with moderate T2 signal

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invasive lobular DCIS fibrocystic change

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breast lesions with low T2 signal

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invasive ductal sclerotic fibroadenoma scar

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six enhancement patterns of breast lesions

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homogeneous heterogeneous rim dark internal septations enhancing septations central enhancement

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lesions causing rim enhancement on MRI

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high-grade invasive ductal fat necrosis inflammatory cysts 40% chance of malignancy if not a typical cyst

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lesions with dark internal septations

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fibroadenoma septations do not enhanceme

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type 1 kinetic curve

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slow rise that continues with time 6% malignant rate

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type 3 kinetic curve

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rapid initial rise followed by drop (washout) 30-80% malignant rate

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type 2 kinetic curve

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slow or rapid initial rise followed by plateau plateau definition allows variance within 10% indeterminate finding, meaning malignancy is between 6 and 30%

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optimum timing for breast MR

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days 7-10 of the menstrual cycle limits background enhancement

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best indication that a lymph node is involved with metastases

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morphology all lymph nodes demonstrate rapid wash in and out, so this is not helpful helpful to compare with prior mammo/usg to assess for changes

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which phase of contrast is used for subtraction on MRI?

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phase 1 we want to identify lesions with rapid wash in

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features of male breast cancer

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increased risk with klinefelter, liver disease, XRT, occupational heat exposure, testicular atrophy, family history gynecomastia is not a risk factor usually firm painless retroareolar or upper outer mass may cause swelling, bloody nipple discharge, retraction usually unilateral, more common on left 1/2 have enlarged axillary nodes at presentation typically delayed diagnosis, so often advanced treated with surgery, hormonal manipulation

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sclerosing adenosis

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not a risk factor or precursor for cancer focally can show a cluster or microcalcifications or focal dense tissue mimicking a nodule or spiculated lesion diffusely will often show diffusely scattered calcifications

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atypical lobular hyperplasia

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proliferation of round cells of LCIS type grows along terminal ducts in permeative fashion no mammographic correlate

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atypical ductal hyperplasia

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low grade intraductal proliferation partial or incompletely developed features of noncomedo DCIS frequently calcifications present

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juvenile papillomatosis

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1-8 cm tumor with aggregated cysts calcfications common mean age 23 years localized firm tumor, no nipple discharge often familiy history of breast cancer ill-defined mass seen with multiple small peripheral cysts may have calcifications marked enhancement with benign dynamic curve on MR treated with complete excision

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juvenile fibroadenoma

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hyperplasia and distortion of normal lobules due to hormonal imbalances usually adolescents, often african american rapidly enlarging, well-circumscribed nontender mass dilated superficial veins, may stretch skin and eventually cause ulceration may see cleftlike depressions and tiny cysts like phyllodes tumor strong enhancement on MR with sharp demarcation

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paget disease of the breast

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uncommon manifestation of breast cancer infiltration of the nipple epidermis by adenocarcinoma can see nipple erythema, scaling, erosion, ulceration, retraction may cause bloody discharge and itching 1/3 have extensive invasive cancer; 2/3 DCIS in one duct

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pseudoangiomatous stromal hyperplasia

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PASH benign, hormonally stimulated myofibroblastic proliferation of mammary stroma tumoral form typically presents in 30-40s well defined mass with pseudocapsule single palpable movable painless firm rubbery mass, may grow rubbery dense, noncaclified, well circumscribed on ultrasound hypoechoic solid mass with long axis parallel to chest wall echotecture usually slightly heterogeneous, possibly with small cystic areas no posterior enhancement or shadowing excised when symptomatic or growing

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common pathological results that often underestimate disease and necessitate excision

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ADH DCIS fibroepithelial lesions

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columnar cell lesions

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controversial, involves alteration of ductal epithelium previously referred to as columnar alteration, blunt duct adenosis, peritubular hyperplasia, CAPSS, ELUCA 3/4 have intraluminal calcifications often clustered amorphous or pleomorphic calcifications on mammo typically non-circumscribed mass with irregular margins on US nonspecific finding with spectrum of atypia

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breast lumps in men

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most commonly gynecomastia no benign masses occur in men <1% will be cancer imaging features are similar to those in women, although calcifications rarely occur 85% are IDC same prognosis, although tend to diagnose later in disease than women 1/2 have axillary adenopathy at diagnosis

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BIRADS for clinically suspected abscess

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2 for young, lactating women 3 for premenopausal non-lactating women--3-6 month follow up to evaluate for resolution 4 for post-menopausal--biopsy, with excision indicated if does not resolve with antibiotics since tumor necrosis cannot be excluded

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suspicious types of nipple discharge

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unilateral bloody or clear from a single duct spontaneous not suspicious when bilateral, milky, green, yellow, or non-spontaneous

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