MAMMO – Flashcard
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BIRADS
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BIRADS 2
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BENIGN Entities: Involuting calcified fibroadenomas, secretory or diffuse beningn Ca+, multiple similar benign appearing masses (may be BIRAD3), fat containing lesions (GOLF H = Galactocele, Oil cyst, Lipoma, Fat necrosis, Hamartoma)
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BIRADS 3
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PROBABLY BENIGN Rec: 6 month unilateral f/u, bx if pt desires, changed to benign if 2 yr stability Info: probably just overlaping breast tissue 3. Cluster of round punctate Ca+ Not applicable: Palpable lesions, new or increased Ca+ or lesions
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BIRADS 4
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SUSPICIOUS Rec: biopsy Info: 2-95% Entities: palpable focal asymetry, suspicious Ca+ or mass
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BIRADS 5
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HIGHLY SUSPICIOUS Rec: Biopsy or direct one-stage surgical procedure Info: > 95% malignancy Entities: usually reserved for spiculated mass + calcs
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BIRADS 6
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KNOWN MALIGNANCY Entities: prior todefinative tx (excision, XRT, chemo, MRM), second opinion
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WORK UP
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DERMAL WORK UP
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Info: think of it like a needle loc > pick closest skin surface, compress w/ grid, place marker over Ca+, image, compress in orthogonal w/ marker in tangent
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CLEAVAGE VIEW
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Info: exaggerated medial, for medial lesions
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TANGENTIAL
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Info: confirm skin lesions, dermal calcs, place BB over skin thought to contain calcs (calcs that maintain same orientation on different views are in skin)
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LATERAL VIEW
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FOR: traingulation, biopsy, pre-op needle loc, additional view for lesion evaluation LM (beam lateral to medial): views lateral best ML: opposite
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COMPRESSION
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SPOT COMPRESSION: see if focal asymetry persists, used for things likely to spot out SCM: For Ca + > always CC and lateral (milk of Ca+ eval), characterize morphology and extent, For masses > eval margins and possible Ca+, CC and MLO if only for margins
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TERMS
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MASS
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Info: 3 dimensional structure, convex outward borders, 75% margin visible, denser in center, evident on orthogonal views SHAPE: round, oval, lobular, irregular MARGIN: circumscribed (75% well defined & not obscured), macrolobulated, obscured, intistinct, spiculated DENSITY: high, equal, low, fat containing SIZE, LOCATION, MULTIPLICITY
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GLOBAL ASYMETRY
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Info: asymetric disribution of normal breast tissue, different shape on two views, benign in abscense of palpable abnormality
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ASYMETRY
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GLOBAL ASYMETRY: abscense of palpable correlate, usually normal variant or hormonal FOCAL ASYMETRY: asymetric density on at least 2 views, focal in size, looks like breast tissue, lacks convex borders & conspicuity of true mass, persists on compression, comparison critical, more concern than global, not completely sure it is just breast tissue, requires ultrasound
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DEVELOPING DENSITY
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Info: new focal or one view asymetry, does not fit criteria of mas Rec: additional eval in abscense of surgery, trauma, infection
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ARCHITECTURAL DISTORTION
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Benign: ADH, fibrosis, radial scar, post surgical, post reduction Malignant: lobular Ca, IDC, nipple retraction
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HIGH RISK LESIONS
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LCIS
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Sx: pathologic diagnosis, no radiographic findings Info: risk marker lesion, 10x risk cancer, 25% dev cancer in 20 yrs, risk applies to both breasts (cancer may be ductal or lobular), usually incidental finding, if core bx is LCIS w/o other path this is disconcordant > excisional to excluded cancer > if excisional is LCIS this is concordant Tx: close surveillance
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ATYPICAL DUCTAL HYPERPLASIA
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Info: can present as a nodule, Ca+,10% risk of breast ca in either breast in a 10 year period, 5-10x risk cancer, surgical excision, possibly "upstaged" to DCIS
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RADIAL SCAR
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Sz: spiculated lesion w/ central lucencies, possible Ca+, distortion Info: benign lesion, proliferative breast lesion w/ central elastosis and entrapped fatty / ductal elements Tx: excisional biopsy as 25% ass w cancer
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INTRADUCTAL PAPILLOMA
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Sz: retroareolar mass, US: solid homogeneous intraductal mass, filing defect on ductogram, fibrovascular stalk, proximal and distal duct enlargeent (secondary to secretions not obstruction) Sx: MC cause serous/bloody drainage Info: ass w/ sl increased cancer risk, no risk of malignancy unless it is associated with atypical ductal hyperplasia Tx: excision
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CANCER
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MULTICENTRIC MULTIFOCAL
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MULTICENTRIC: different quadrants, contraindication to breast conserving surg MULTIFOCAL: same quadrant
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PAGET'S DISEASE
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Sz: nipple retraction, skin thickening, nipple Ca+, subareolar mass Sx: thick red and excoriated nipple, areaola Info: "DCIS of skin/nipple", 95% w/ underlying DCIS +/- invasive Px: good if caught early
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PHYLLOIDES TUMOR
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AKA CYSTOSARCOMA PHYLLODES Sz: large mass, no spiculation, US: circumscribed hypoechoic lesion with varying degrees of inhomogeneity and small cystic spaces, few calcify, fluid filld spacs, resembles FA, CT: no enhancement, MRI: progressively enhancing Sx: often palpable, rapid growth, can be locally aggressive, most benign (10% malig) Tx: resection
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TUBULAR CANCER
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Sz: small spiculated mass, possilble Ca+, possible multicentricity US: hypoechoic, possible shadowing Info: less than 2% breast Ca, excellent prognosis (slow growing), resembles radial scar histiologicallty
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INVASIVE DUCTAL CARCINOMA
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Ductal NOS 80% Lobular 10% Medullary 5 % Colloid Papillary Tubular 1% Inflammatory 1% Info: Increasded recurrence w/ extensive intraductal component, multicentric, comedocarcinoma
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INVASIVE LOBULAR CARCINOMA
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Sz: variable findings (mass, focal asymetry, distortion) Info: 10% breast CA, high bilaterality (MRI for contralateral breast)
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INFILTRATING DUCTAL CARCINOMA
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Sz: macrolobulated spiculated mass, arch distortion, US: hypoechoic, may have component of DCIS, usually taller than wide Info: MC breast cancer, originate in terminal ductal lobular unit Manage: SCM may preced US to eval for microCa+ btw lesion and nipple,biopsy even is US neg, US guided core bx vs one step surg management
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DCIS
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Sz: segment or clustered pleomorphic Ca+, amorphous Ca+, may have ass mass (invasive component), US: may see dilated duct w/ debres or Ca+ Info: 30% all breast CA dx by mammo Manage: do SCM to evaluate extent of disease (especially to nipple) and possible underlying mass Subtypes: comedo, cribiform, solid, micropapillary
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CYSTIC CANCER
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Info: intracystic papillary carcinoma, infitrating ductal carcinokma Sx: fluid usually bloody
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METASTATIC BREAST LESION
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Sz: solid mass, ovarian has Ca+ Info: contralateral breast CA most common
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INFLAMMTORY CARCINOMA
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Sz: diffusely enlaged and dense breast, trabecular and skin thickening, mass Sx: difficult differentiation w/ mastitis Tx: US to eval mass vs abscess
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MEDULLARY CANCER
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Sz: well circumscribed large mass w/o infiltration, "halo", may be dense due to hemorrhage, US: hypoechoic Sx: younger, fast growing, better prognosis, mobility due to lack of invasion Info: rare cancer of ductal origin
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BENIGN BREAST DISEASE
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OIL CYST
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Sz: ring Ca+ w/ lucent (fat) center Info: fat necrosis, non suppuratve inflammatory process related to trauma or surgery Tx: none STEATOCYTOMA MULTIPLEX: multiple Ca+ and nonCa+ oil cysts, asymptomatic (may develope secondary inflammation), autosomal dominant, lesions in other parts of body
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GYNECOMASTIA
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Sz: "flame shaped" subareaolar region Sx: proliferation of ductal elements Ass: testicular neoplasms, Kleinfelters Info: no inc risk male breast cancer Cz: excess estrogen (seminoma), , liver disease, marijuana Tx: none, BIRADS 2
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FAT NECROSIS
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Sz: fat containing mass, circumscribed, possible Ca+, ugly on US
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FIBROADENOMA
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Sz: well defined sharply circumscribed mass, coarse Ca+ (if involuting) US: variable solid mass, may have posterior enhancement or shaddowing, possible septations, thin echogenic capsule, parallel to chest wall (taller than wide) Sx: hard, mobile, hormonally cyclic changes Info: MC benign solid lesion of breast Complex: increased risk cancer, ass cysts, sclerosing adenitis, papillary apocrine changes GIANT JUVENILE FIBROADENOMA: large solid well defined lobulated mass, hypoechoic, (BIRAD 4), rapid growth, Tx w/ excision
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LYMPH NODES
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Malignant features: cortical thickening, increased peripheral flow, enlarged INTRAMAMMARY LYMPH NODE: circumscribed mass w/ fatty hilum
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HAMARTOMA
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AKA FIBROADENOLIPOMA Sz: "sausage shaped" mass, "breast w/i a breast", fat containing mass, may be encapsulated, well definaed margins Info: benign, composed of lipid & glandular & fibrous tissue
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IMPLANT RUPTURE
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EXTRACAPSULAR: saline extends beyond capsule, US w/ "snowstrom" INTRACAPSULAR: not present on mammo, MRI: "linguini" & "keyhole" signs, US w/ "stepladder" HERNIATION: not true rupture, intact envelope of the implant pushes through a defect in the fibrous tissue capsule Info: Implant patients w/ MLO and CC whole breast & implant-displaced views, intracapsular rupture is free silicone w/i fibrous capsule, saline not as dense as silicone Tx: implants removed and replaced
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DIRECT SILICONE INJECTIONS
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Sz: innumerable high density rim-calcified silicone masses/granulations, may travel to LN Info: Parafin injections have silimar appearance
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NEUROFIBROMATOSIS
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Sz: multiple superficial circumscribes lesions
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CALCIFICATION DESCRIPTION
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Punctate, round, fine pleomorphic (high prob malignancy), amorphous (20% prob malignancy), course heterogeneous Distibution: linear, clustered, grouped (prob benign), regional, fine or branching (casting = thin, irregular that are discontinuous and linear, suspicious) segmental (ductal, DCIS), diffuse (benign)
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CALCIFICATION TYPES
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SECRETORY: dense, smooth, rodlike Ca+ (can be in ductal distribution, ddx DCIS) VASCULAR: tubular, tram track appearance DERMAL: small w/ lucent centers, tangential view shows dermal or subdermal location MILK OF CALCIUM: layer on MLO, can appear amorphous "smudgy" on CC, confirm w/ lateral (linear, meniscal) DYSTROPHIC: diffuse, benign, round, some w/ lucent center, due to surgery or trauma BENIGN: smooth, cylindrical, coarse (popcorn), linear, punctate, spherical
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HORMONE REPLACEMENT TX
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Sz: can give dense breasts
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STERNALIS MUSCLE
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Sz: round density medially on CC views, anatomic variant
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SEBACEOUS CYST
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AKA EPIDERMAL INCLUSION CYST Sz: round, smooth bordered mass that abuts skin, projects connects into subQ tissues, tangential view demonstrates its location w/i skin Sx: may become inflammed Tx: incission and drainage
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LIPOMA
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Sz: fat containing circumscribed mass, thin capsule, US: solid hypoechoic mass Sx: MC in postmenopausal, asymptomatic, palpable Info: benign
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FILARIASIS
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Sz: serpiginous, tubular-wormlike calcifications w/o accompanying mass Cz: parasite Info: represent deenerated parasite tissue
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MYOFIBROBLASTOMA
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Sz: solid isoechoic mass, well circumscribed, well defined Info: rare bening tumor Sx: Men > Women Tx: do not require surgical excision.
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SIMPLE CYST
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Sz: posterior acoustic enhancement, well defined, echogenic posterior wall, edge shaddows, anechoic, mass on mammo w/ "halo" of lucency often Sx: may develop rapidly Cz: secretion not equal to resortion, apocrine metaplasia Tx: may SCM to better define, aspitration if symptomatic (or internal echoes / complicated) , reaspirate if recur COMPLICATED CYST: low level echoes or debres, no thick wall / thick septa / solid component, risk of malignancy is < 2%, f/u or aspiration COMPLEX CYST: thick walls, thick septa, solid components
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GALACTOCELE
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Sz: complex well defined cystic mass w/ fluid fluid level, posterior acoustic enhancement Sx: cysts w/ inspissated milk, palpable mass in pregnant or lactating Tx: BIRADS 4, US guided FNA (thick milky fluid)
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LACTATING ADENOMA
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Sz: well defined mass, macrolobulated, US: hypoechoic, fibrotic septae (echogenic bands), posterior acoustic enhancement Sx: rapidly enlarging modile mass during pregnancy, regress after cessation of lactation Info: benign Tx: usually removed surgically because of their large size and rapid growth
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DUCT ECTASIA
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Sz: tubular masslike density in subareolar bresst, possible secrestory calcs, US: dilated duct Sx: nipple retraction Info: accululation of debris in enlarged subareolar ducts, Tx: benign (in abscense of other findings)
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HEMATOMA
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Sz: mass, US: may have internal echoes / septations Sx: trauma, shoulod resolve spontaneously in weeks Tx: 6-8 wk f/u
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MONDOR'S DISEASE
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Sz: tubular mass w/ beaded appearance, "ropelike" US: superficial hypoechoic tubular structure Sx: skin inflammatoion, resolves Info: thromboplebitis of superficial vein or chest wall vein
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MASTITIS
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Sz: focal asymmetry, skin thickening, trabecular thickening, possible abscess Sx: abscess, lactation, chronic dz Tx: Abx, f/u mammo, punch biopsy if no resolution to exclude inflammatory cancer, US if abscess suspected (palp, drainage) LYMPHOCYTIC MASTITS: dense breast tissue, a w/ insulin dependant Diabetes
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SEBORRHEIC KERATOSIS
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Sz: skin lesion w/ reticular surface patternfrom air skin interface, may localize w/ tangential views
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CAPSULAR CONTRACTURE
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Sz: course Ca+ develop in fibrous capsule after capsular contraction Tx: capsulotomy
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ARTIFACTS
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GRID LINES: ultra-thin horizontal parallel lines, used to reduce scatter in large breasts THUMBNAIL: FINDERPRINT: may mimic microCa+ DEODORANT: lines or dots in axilla or axillary tail, may mimic microCa+
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HICKMAN CUFF
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Sz: Ca+ tubular structure in innter breast Info: catheter cuff induces fibrotic response w/ Ca+
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PROCEDURES
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NEEDLE LOCALIZATION
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Ix: excision required, not amenable to stereotactic core bx considerations for bx approach > distance, better seen one view, overlying vessl, pref for scar
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US GUIDED CORE BIOPSY
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Technique: sterility, localize lesion w/ US, 14 Guage coaxial needle, advance bx device just outside lesion, deploy (parallel to chest wall), 5 bx required, clip should be placed
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STEREOTACTIC CORE BIOPSY
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Ix: mammo suspicious Ca, mammo suspicious mass / asymetry /distortion not seen on US, US suspicious cyst w mammo correlate ContraIx: anticoagulants, lesion cannot be targeted, pt cannot tolerate Technique: prone table vs upright, 15 degree obliques to deermine location, sterile, local anethesia w/ epinephrine, skin incision w 11 blade, advance bx gun (11g vacuum assisted), sample in rotation fashion, rotate around clock, confirm lesion sampled, if compleely removed leave clip, controlled hemstasis
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US GUIDED CYST ASPITATION
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Ix: simple symptomatic cyst Technique: pre dring and post images, 20-22 guage coaxial needle w 25 Gu (spinal) sampling needle, post mammo view if finding on mammo,send to cytology if aspirate clear bloody or purulent Do not aspirate cyst w/ malignant features
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LYMPHOSCINTIGRAPHTY
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Tecfh: inject subQ tissue in region of tumor, if location not known inject periareolar tissue
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DUCTOGRAM
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Ix: unilateral spontaneous single duct nipple discharge ContraIx: mastitis, abscess Technique: supine position, identify duct w/ discharge (express), obtain specimen, allow cannula to drop 5-10mm into orifice,magnified CC view w/ nipple in profile, spot views BENIGN CAUSES: pregnancy, lactation, meds, injury, high prolactin, abnormal thyroid
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DIAGNOSTIC WORK UPS
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BREAST ULTRASOUND INDICATIONS
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Ix: palpable masses initial evaluation (women < 30, lactating, pregnant), further eval of mamographic abnormality, Interventional guidance SOLID MASS: malignant features: spiculation, taller than wide, angular margins, hypoechoic, shaddowing, calcifications, duct extension, branch pattern, micolobulation, disruption of tissue planes
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IMAGING MALE BREAST
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Ix: always do BL views, additional views if abnormality on initial views, only mammogram unless mass, always perform US if palpable mass Info: lobular lesions very rare, about 1 % of breast cancer,
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MRI BREAST
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T1, FSE T2, STIR T1 pre, early (2min) & late (5 min) post T2: eval cysts hematoma etc FIBROADENOMA: circumscribed, progessive enhancement DCIS: globular or nodular enhancement, possibly progressive CANCER: early arterial enhancement, delayed washout CYSTS: T2 bright, no enhancement Ix: 1. Work-up extent of disease of known cancer, when extent in question or if the patient is s/p lumpectomy with positive margins. 2. Axillary metastases with unknown primary and negative mammogram and ultrasound 3. Evaluate for implant rupture 4. Problem-solving when mammogram and/or ultrasound are indeterminate (possilbe Ix) 5. Screening for high-risk women (possible Ix) 6. Assessment of neoadjuvant chemotherapy
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MRI ENHANCEMENT PATTERNS
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Type 1. Persistent. Usually benign Type 2. Plateau. Indterminant Type 3. Washout. Usually malignant
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LUMPECTOMY
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Sz:post surg hematoma / seroma, scar w/ arch distortion ContraIx: multicentric dz, pregnancy, prior XRT to chest wall, CVD, Info: positive LN not a contraIx
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POST REDUCTION MAMMOPLASTY
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Sz: oil cysts, dystrophic Ca+, MLO: redistribution of tissue inferiorly w/ "swirling", skin thickening along sagital scar, CC: subareolar fibrotic bands, nonanatomic islands of breast tissue
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MANAGEMENT OF BIOPSIED CALCIFICATIONS:
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SCLEROSING ADENITIS: desmoplastic response, considered benign if calcs in core bs specimen ATYPICAL DUCTAL HYPERPLASIA: 5-10x risk cancer, surgical excision, possibly "upstaged" to DCIS ATYPTICAL LOBULAR HYPERPLASIA: surgical excision vs 6 mo f/u FOCAL FIBROSIS: not concordant, if no Ca+ on path, repear DCIS
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MANAGEMENT
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SOLID & PALPABLE MASS: suspicious BENIGN BIOPSY: 6 month f/u for benign biopsies POSITIVE BIOPSY RATE SCREENERS: 30% BENIGN BUT DISCORDANT: surgical excision ROUND MAMMO MASS WITH NO US CORRELATE: 2 stable, 3 baseline, 4 new / larger
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COLLOID CANCER
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Sz: mass, US: hyper or mixed echogenicity Sx: older pts, slower growing Info: 2 % of invasive ductal cancer Px: good
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PAPILLARY CANCER
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Info: don't arise from papilloma, slow growth, no fibrotic reaction like other cancers
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LESIONS OF MAJOR DUCTS
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Duct ectasia Papilloma Pagets
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LESIONS OF MINOR AND TERMINAL DUCTS
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DCIS Peripheral papillomas Hyperplasia
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LESIONS OF LOBULE
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Cysts Fibroadenoma Phyloides Invasive lobular cancer Adenosis
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INVASIVE LOBULAR CARCINOMA
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Sz: more difficult to detect early vs IDC, often focal asymetry, Ca+ uncommon, US: hypoechoic mass w/ shaddow Info: more often bilateral, propensity for adrenal mets Px: similar to invasive ductal (larger size at diagnosis)
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LESIONS OF EXTRALOBULAR STROMA
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Sarcomas: liposarcomas, fibrosarcomas, angiosarcomas
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TERMINAL DUCT LOBULAR UNIT
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Info: functional unit of breast, change with hormonal changes
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US ZONES
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SUBCUTANEOUS ZONE: fat, ligaments, vessels, ectopic ducts; pathology: sebaceous cyst, lipoma, edema, infection, hematoma, fat necrosis, retraction of Cooper's ligaments due to deeper cancer, cancer (in ectopic ducts = rare) MAMMARY ZONE: RETROMAMMARY ZONE:
