Mammography, Benign vs. Malignant Features – Flashcards
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Risk Factors for Breast Cancer
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#1 female gender #2 increasing age early menarche late menopause nulliparity late first pregnancy
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Primary Signs of Breast Cancer on Mammography
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irregular (spiculated), high density mass clustered pleomorphic micro calcifications focal distortion
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Secondary Signs of Breast Cancer on Mammography
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nipple or skin retraction skin thickening lymphedema pattern increased vascularity
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Highest PPV for breast cancer on ultrasound and mammography is
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a spiculated mass
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Screening Mammogram
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early detection of breast cancer in asymptomatic patient best imaging modality to detect micro calcifications
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When should an asymptomatic woman start having yearly screenings for breast cancer?
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over the age of 40
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Disadvantages of Mammography
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radiation uncomfortable/ painful limited detection of pathology in dense breasts
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Diagnostic Mammogram
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patient has symptoms - lump - nipple discharge - skin changes more images of abnormality discovered on screening
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Where is the radiographic marker always placed?
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lateral aspect of the breast (axilla)
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Two most commonly used views for a screening exam
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CC- craniocaudal MLO- mediolateral oblique
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CC- Craniocaudal
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- will tell you is the lesion medial or lateral to nipple - superimposes superior over inferior - marker placed lateral margin of breast - comparable to transverse scan plane in ultrasound
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MLO- Mediolateral oblique
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- will tell you if the lesion is superior or inferior - superimposes the tissue from supermodel to inferiolateral - parallel to pectoralis muscle - marker placed at axilla ** used to see UOQ axillary tail and pectoralis major** - comparable to sagittal scan plan in ultrasound
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You cannot accurately determine the location of a lesion with only one mammographic view
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You cannot accurately determine the location of a lesion with only one mammographic view
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In a CC view
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MULD: medial, up; lateral, down a medial mass will lie slightly higher than projected in the MLO view because it is an oblique view a lateral mass will lie slightly lower than projected in the MLO view peripheral mass will show greater shift
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Radiolucent
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allows the X-rays to pass/ appear dark
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Radiopaque
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does not allow the X-rays to pass/ appears white
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Water density
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appears white (ducts, cysts, implants)
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Fat density
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appears gray
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Fat
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medium gray radiolucent
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Fibroglandular tissue
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greater than fat (more white) water density radiopaque
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Fluid Filled duct/ blood vessel
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water density (appears white)
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Cyst
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radiopaque water density (appears white)
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Lymph Node
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cortex- radiodense hilum- radiolucent (dark)
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Solid Mass (benign or malignant)
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water density (white) radiopaque (white)
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Calcification
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radiopaque (white)
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Pectoralis Muscle
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higher density than fat radiopaque (white)
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Pitfall to mammography
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mammography is limited with dense breast tissue
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Cystic and Solid masses appear similar on mammogram
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cystic and solid masses appear similar on mammogram need ultrasound to tell the difference
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Radiolucent (dark/ black)
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fat lymph node
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Radiopaque (white)
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fibroglandular tissue cyst solid mass (benign or malignant) calcification pectoralis muscle
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When used properly mammogram and ultrasound will catch approximately 97% of breast cancers
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When used properly mammogram and ultrasound will catch approximately 97% of breast cancers
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Primary Signs and Symptoms on Ultrasound
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- size - shape - orientation - marin clarity and regularity - echogenicity - homogenicity - attentuation effects
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Secondary signs and symptoms on Ultrasound
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- interruption of tissue planes - duct dilatation; tumor extension - echogenicity of the subcutaneous fat - thickening on cooper's ligaments - edema - skin changes - lymph node enlargement
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BI- RADS
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breast imaging- reporting and data system
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BI- RADS: category 1
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normal
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BI- RADS: category 2
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benign finding
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BI- RADS: category 4a
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mildly suspicious
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BI- RADS: category 4b
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moderately suspicious
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BI- RADS: category 5
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highly suspicious (spiculated shape)
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Biopsy is recommended for 4a, 4b and 5
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Biopsy is recommended for 4a, 4b, and 5
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ACR
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american college of radiology
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Shape
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round, oval, irregular
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Orientation
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parallel, not parallel to skin
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Margin
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circumscribed, not circumscribed, angular (thick echogenic halo in points), spiculated (tentacles growing up into layers)
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Echo pattern
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anechoic, complex, heterogenous, homogenous, isoechoic
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Posterior acoustic features
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enhancement, shadowing
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ACR: category 1
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negative
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ACR: category 2
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benign (proved benign) cyst
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ACR: category 3
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probably benign
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ACR: category 4
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suspicious
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ACR: category 5
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highly suspicious
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ACR: category 6
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known cancer
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Cyst- Simple Sono features
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round, oval smooth THIN walls anechoic posterior enhancement edge shadowing
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Cyst- Complex Sono features
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low level echoes fluid/ debris level septations- thin septations- thick** wall thickening** intramural nodule** ** more suspicious for malignancy**
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Benign Sono Features
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round, oval well defined wider than tall homogenous enhancement
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Malignancy Sono Features
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irregular ill- defined taller than wide heterogenous shadowing
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Compressibility
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benign- compressible and mobile malignant- non compressible and fixed
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Vascularity
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benign- less or absent blood flow malignant- increase blood flow within
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Calcifications
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benign- macrocalcifications >0.5mm can shadow malignant- microcalcifications <0.5 mm usually do not shadow
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Surrounding Tissue
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benign- compress the tissue with no distortion of tissue planes malignant- mass grows into tissue planes, thickening and straightening of cooper's ligaments
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Nipple Discharge: benign
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- expressible - bilateral - multiple ducts - milky or green
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Nipple Discharge: malignant
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- spontaneous - unilateral - single duct - bloody, clear serosaguinous discharge
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Lymph Nodes: benign
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- oval - smooth - hypoechoic cortex - hyperechoic hilum - blood flow seen at hilum
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Lymph Nodes: malignant
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- round - irregular - lobulated - loss of fatty hilum - hypoechoic - increased blood flow in cortex
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Normal Skin measurement
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less than or equal to 2 mm at areola area less than or equal to 3 mm
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Benign reasons for skin thickening
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- trauma - inflammation - radiation
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Cancer that can look benign
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- colloid cancer - lymphoma - medullary cancer - phyllodes tumor - metastasis
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Benign mass that looks malignant
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- fat necrosis - radiation changes - diabetic fibrosis - scar - abscess - hematoma
