Breast EXAM WITH PICS

Invasive Ductal Carcinoma (80-85%)

DCIS is confined to the duct and IDC invades through the duct - most commonly presents as a hard, non-mobile, painless mass - Mammo: irregular, high density mass with indistinct or spiculated margins

Invasive Ductal NOS (65%) = papillary subtype is second most common

"PM Two" - tubular - mucinous - medullary - papillary

Tubular IDC: - spiculated slow growing mass - favorable prognosis - associated with a RADIAL SCAR Contralateral breast: 10-15% cancer

mucinous IDC - well circumscribed mass on mammo - T2 bright on MRI

BRCA1

common - axillary nodes can be Large even in the absence of mets

uncommon

Papillary IDC

Multifocal: Multiple primaries in a FOCAL area (same quadrant) - less than 4-5 cm apart Multicentric: Multiple primaries scattered through the breast (different quadrants) - multiple discrete unrelated centers of cancer

DCIS - cancer confined to the duct

multiple intraductal filling defects in affected duct

Comedo type is more aggressive

10%

25%

8%

1% per year

- suspcious calcs (fine linear branching or fine pleomorphic) - NMLE on MRI - multiple intraductal masses on galactography

invasive LOBULAR carcinoma - 5-10% of all breast cancers

e-cadherin, so they no longer stick to each other and infiltrate the breast - infiltrate the breast like "the web of a spider"

Mammo: - architectural distortion without a central mass on a single view (typically the CC) - "dark star"

ill defined area of shadowing without a mass

ILC - breast is not actually smaller, it just doesn't compress as much

Dark Star: - lobular ca - radial scar - surgical scar - IDC-NOS

ILC: - more often multifocal and bilateral - mets to strange places - positive margins - treated with mastectomy IDC: - more often mets to axilla - more often has calcs

- presents as a swollen red breast - "skin thickening" on mammo - chemotherapy done prior to surgery; mastectomy is still done - prognosis is terrible

carcinoma in situ of the nipple epidermis - only 50% will have palpable finding associated with the skin changes - pagets is NOT considered T4: skin involvement does not up the stage

high grade DCIS

True

"the PPARLAr is dangerous" 1. Atypical Ductal Hyperplasia (ADH) 2. Atypical Lobular Hyperplasia (ALH) 3. Lobular Carcinoma In Situ (LCIS) 4. radial scar 5. papilloma 6. phyllodes

dense fibrosis around the ducts, giving appearance of architectural distortion Associated CA - Tubular IDC - DCIS and/or IDC 10-30%

basically DCIS but lacks quantitiatve definiton by histology (< 2 ducts involved)

30%

"incidental finding" - classically occult on mammogram - 11x higher risk for cancer

4-5x higher

LCIS has a distended lobule - ALH does not

papilloma

papilloma

- usually around 50s - classically in subareolar region - Mammo: normal (may show calcs) - US: Well defined smooth walled hypo-echoic mass; may have cystic and solid components and associated duct dilation - Galactography: solitary filling defect with a dilated duct

10 - phylloides is fast growing

BR2 - multiple means at least 3

luteal phase (increased progesterone and density)

100%

NO - breast cancer is usually found elsewhere

- skin dimpling - focal skin thickening - nipple retraction

benign conditions - CHF - renal failure *trabecular thickening on mammo (favoring dependent portion of breast)

- mastitis - inflammatory breast cancer

- smokers and diabetics are at risk - painful swollen red breast associated with breast feeding

- PAINLESS swollen red breast that does not improve with antibiotics - breast has a "peau d'orange" appearance - diagnosis via biopsy - Tx: chemo/radiation, then surgery

SPONTANEOUS, BLOODY discharge from a SINGLE duct - serous (clear) discharge is also suspicious

Milky discharge is NOT suspicious Causes: - thyroid issues - pituitary adenoma/prolactinoma - meds (antidepressants, reglan)

Benign: - Premenopausal: Fibrocystic change - Postmenopausal: Ductal ectasia Worrisome: - Intraductal papilloma (90%): single intraductal mass near nipple - DCIS (10%): multiple intraductal masses

ductal ectasia

take a 27-30 gauge blunt tipped needle and attempt to cannulate the single duct that is leaking (pt will express fluid from nipple) - gently inject 0.2 - 0.3 mL contrast and then do mammos

wire localization

1. active infxn 2. inability to express discharge 3. contrast allergy 4. prior surgery to nipple complex

distortion of the normal architecture without a visible mass - radiation of normal thin lines into a focal point

AD: all lines radiate to a focal point Summation: lines continue past each other

Scars should progressively get lighter and harder to see - if asymmetry is increasing, you have to biopsy

BR 0 on screener - if it persists on additional views, BR4 or 5 (unless a scar) - should ultrasound it for further characterization

Biopsy it still (stereo biopsy) or seed localization for surgical excision

AD (architectural distortion)

IDC + DCIS

ILC

NO - even if it has been there for a while, it needs to get worked up

Unilateral axillary adenopathy is worrisome

- Loss of a fatty hilum (most specific) - Cortical thickness (> 2-3mm) - Irregular outer margins

- Gold therapy "chrysotherapy" (previously treated RA with gold)

Silicone infiltration of a node - silicone implant LEAKING or RUPTURE

thyroid, ovarian, breast

NO - they don't get lobular carcinoma, fibroadenoma, or cysts

- it is a non-neoplastic enlargement of epithelial and stromal elements Causes: - physiologic in adolescents - drugs (spironolactone, psych meds, marijuana) - cirrhosis - testicular cancer Mammo: flame shaped, behind nipple; can be bilateral but asymmetric - can be painful

nodular - most common - painful

dendritic - non-tender - chronic fibrotic pattern

diffuse glandular - seen in men receiving estrogen treatment

increase in the fat tissue of the breast (not glandular tissue) - NO discrete palpable finding

most common: gynecomastia second: lipoma

BRCA 2 is more common RFs: - Klinefelter syndrome - cirrhosis - alcoholism

- eccentric to nipple - unilateral - abnormal lymph nodes - calcifications (uncommon in men) - looks like breast cancer

IDC-NOS (by far most common)

True

You can see through the saline implant on a mammo, silicone you can't

Silicone implants form a shell around the foreign body (implant) which allows for both INTRA and EXTRA capsular rupture - saline does not form a capsule

No, saline implant rupture is NOT dangerous - saline does not form a capsule, so cannot have an intracapsular rupture with saline - there is only one kind of rupture

the saline is absorbed by the body, and you have a collapsed implant

can only see EXTRAcapsular rupture on mammogram - can also see implant folds and valves - cannot see intracapsular rupture

INTRAcapsular silicone implant rupture - multiple parallel hyperechoic lines within collapsed implant shell - corresponds to linguine sign on MRI

EXTRAcapsular rupture

- CAN have INTRAcapsular rupture by itself - CANNOT have EXTRAcapsular by itself (always occurs with intracapsular rupture)

MRI to look for intracapsular rupture

subglandular silicone implants

Subglandular (retromammary) - behind breast tissue - anterior to pectoral muscle Subpectoral (retropectoral) - between pec major and minor muscles

subpectoral --> better sensitivity for screening for ca

NO

NO

MRI

Capsular Contracture - secondary to contraction of the fibrous capsule - terrible cosmetic deformity - most common in subglandular silicone implants (occurs with saline as well)

gel bleed - does not mean rupture

Silicone molecules can (and do) pass through the semi-pereable implant shell coating the exterior of the surface - NOT a rupture - will show silicone in axillary LNs

- AGE of the IMPLANT is the number one risk factor - post traumatic - spontaneously - rupture with compression mammography is rare

Saline rupture is very obvious (deflated breast) - will see "wadded up" plastic wrapper - best modality is mammography (don't need ultrasound or MRI)

MRI is the most sensitive modality ("linguine" sign) - can see "stepladder" on US - will be occult on physical exam and mammography

Mammogram: dense silicone seen outside the capsule - "snow storm" US appearance: really echogenic with no posterior shadowing - MRI: extracapsular silicone will be T1 dark and T2 bright

NO

Radial folds are the normal in-foldings of the elastomer shell - can mimic linguine sign of intracapsular rupture

Folds ALWAYS attach to the shell of implant - folds are thicker than rupture

Capsule is the fibrous coat body makes around implant - CAN rupture through shell of implant, confined within fibrous coat - "linguine sign" on MRI

when rupture goes THROUGH the fibrous capsule your body makes - CANNOT have isolated extra (if it went through the outer, it also went through the inner) - "snow storm" on ultrasound (can also be gel bleed)

reduction mammoplasty

a "breast lift" - just removal of skin to address floppy "ptotic" breasts - swirled appearance affecting inferior breast - fat necrosis/oil cysts - isolated islands of breast tissue

- mammoplasty - mastopexy "swirled" appearance in the inferior aspect of the MLO view

Lumpectomy: surgical removal of cancer Excisional biopsy: surgical removal of the ENTIRE lesion Incisional biopsy: surgical removal of a PORTION of the lesion

Distortion and scarring are worst on the first post-operative mammogram and should progressively improve - First mammo normally done 6-12 months postop

Scars should be thin and linear - if you see focal mass-like thickening, that is suspicious - fat necrosis and dystrophic calcs may evolve over the first year or two

6-8%

4yrs

35%

1. PREMENOPAUSAL WOMEN (genetic issues) 2. extensive inarticulate component 3. tumor with vascular invasion 4. multicentric tumors 5. positive surgical margins 6. inadequate treatment of first tumor

60%

benign calcs: 2 years (early) bad calcs: 4 yrs (late)

95% of the time it works

Recurrence is from residual breast tissue or along the skin scar line - NOT going to start in belly fat/muscle

- mass/calcs included in the sample - mass/calcs near the edge or touching the edge

call the surgeon because chance of incomplete excision is 80%

identification of residual disease prior to radiation give the patient more treatment options - discovery of residual disease after radiation therapy has started --> pt has to undergo mastectomy

Skin thickening and trabecular thickening - peak on first post-RT mammogram

Recurrent disease! - may be inflammatory breast CA

T1: < 2cm T2: 2-5 cm T3: > 5 cm T4: any size with chest wall fixation, skin involvement, or inflammatory breast cancer

no

axillary status

melanoma

1. inflammatory cancer 2. large cancer size relative to breast 3. multicentric 4. prior radiation therapy to same breast 5. contraindications to radiation therapy (collagen-vascular disease)

HIGH RISK SCREENING (biggest) - extent of disease (known cancer) - axillary met with unknown primary - possible silicone implant rupture - diagnostic dillemas

special breast coil and table are set up, and the patient lies belly down with breasts hanging through holes Sequences: - T2 - pre and post dynamic post contrast fat sat T1 - may also get a non fat sat T1

1) look at background uptake (adjusts sensitivity level) 2) look for masses or foci (little dots) - associated features such as spiculated 3) look at washout curve - morphology of lesion trumps washout curve 4) New masses --> BR4 or 5 NMLE --> BR4 if new T2 stuff --> BR2 mostly

T2 things are bright - LNs, fibroadenoma, cyst

> 20% lifetime chance of cancer - includes people who got 20 Gy radiation to chest as a child

- use a risk model that includes family history (NOT the Gail model) - Tyrer-Cuzick scale is probably the best

Parenchymal enhancement is NORMAL - most common in POSTERIOR breast in UPPER OUTER quadrant - worst in the luteal phase (14-28 day) - Improve: image in follicular phase of menstrual cycle (7-14)

decreases background - then causes a rebound

Focus: < 5 mm - not typically high risk Biopsy if: - SUSPICIOUS ENHANCEMENT - different than the rest - ill-defined borders

solitary focus (< 5 mm) with persistent kinetics on baseline exam

NMLE: not a mass, but more like a clump of tissue enhancement Distributions: - Segmental (triangular blob point to the nipple) - Regional (a bigger triangle) - Diffuse (all over the place) Suspicious: - HETEROGENEOUS enhancement

> 5 mm

- Irregular shape - Spiculated margin - Heterogeneous or rim enhancement

MORPHOLOGY - use kinetics only if you are on the fence

- intial upslope phase (occurs over the first 2 minutes); slow, medium, or fast - the washout portion (2-6 minutes); continued rise, plateau, or rapid washout

Type 3 has washout on delayed (most worrisome) - 29% or higher risk of cancer

has progressive enhancement on delayed - 6% risk of cancer

has plateau of enhancement on delayed - 7-28% risk of cancer

Fibroadenoma

DCIS - kinetics not typically helpful

IDC

ILC (vague findings like on mammo)

- fibroadenoma - LNs - cyst - fat necrosis

- colloid - mucinous

Mammo: 0.1 - 2% MRI: 3 - 5%

TRUE

80% - single most predictive feature of malignancy

True - more estrogen --> increased risk

- Early menstruation - Late Menopause - late age of first pregnancy/no kids - being fat (increased aromatose) - alcoholism - hormone replacement therapy

"the PPARLAr is dangerous" - Papilloma - Phyllodes - ALH - Radial scar - LCIS - ADH

Increased density --> increased risk

15 yrs post treatment

at age 25 or 8 yrs s/p exposure (whichever is LATER) - for a kid with > 20 Gy to the chest (usually lymphoma patients)

8% to 13%

21%

chromosome 17 - increased breast, ovary, and GI cancers

13 - increased breast, ovary, and GI - male breast cancer

p53 does NOT work - increased risk for a bunch of cancers

breast follicular thyroid cancer endometrial Lhermitte-Duclos (brain hamartoma)

"moderate risk" of breast cancer - because neurofibromas obscure real breast cancer

Gail model - oldest and most validated (in African americans) Tyrer-Cuzick - most comprehensive - but does not include breast density

Women: BRCA 1 more common Men with BRCA 2 get more cancer than with BRCA 1.

TRUE - denser breast, more risk

Exercise decreases risk of breast cancer - probably because of being less fat

reduce breast cancer incidence of ER/PR positive

Ultrasound guided biopsy is easier

20mm

14g

mass should be on the far side of the US screen - lets you see the lenth of the needle better

lesion, transducer, skin nick, and biopsy needle

needle angle should be parallel to chest wall - PTX as a complication is embarrassing

False - should be placed up to the lesion, but not in it

biopsy the DEEP portion first - if bleeding obscures it, you can at least get the top part

the small one - so bleeding from the big one doesn't obscure it

the solid part

5

reschedule; don't try to biopsy it

the cortex - core biopsy is preferred over FNA

Aspirate

discard the fluid; no need for cytology - you are done

- send fluid to cytology - place a clip

- sent it to micro lab for culture and sensitivity

proceed to core biopsy

to biopsy calcifications - sample is xrayed after to confirm that calcs are in there

vacuum assisted

Compressibility of the breast tissue can NOT be less than 2-3 cm (28 cm) - you will get a "negative stroke margin"

negative stroke margin

wire localization for excisional biopsy - or seed localization

accordion effect

- anxiety - pain - uncertain diagnosis

NO - symptoms are an indication for aspiration

70%

3 months

< 10%

30 days - written results in language that is easy to understand

True

True

the Interpreting physician

13 lp/mm in the anode to cathode direction - 11 lp/mm in the left to right direction

- 4 fibers - 3 microcalcification clusters - 3 masses - "acceptable artifacts"

50% glandularity, 4.2 cm thick and supposed to have less than 3 mGy per image (with a grid)

NO

- 6 cm - 15 - 20% glandularity

Higher beam qualities --> lower doses

NO

PROgram DireCtor and Vice President REPEATedly C DARK Souls PRO/DC: daily V/P: weekly REPEAT: quarterly C/DARK/S: semi-annually

daily

daily

weekly

weekly

quartery

semi-annually

semi-annually

semi-annually

Recall rate: 5-7% 3-8 cancers/1000 screened