Radiology and Cytology of the Breast

Question 1

Using which modalities can breast imaging be done?

Answer 1

• Mammography (gold standard)
• Ultrasound (not normally used in isolation- in conjunction with mammography can be helpful)
• MRI
• Nuclear medicine
• CT

Question 2

Which are the two standard views for mammography?

Answer 2

Mediolateral oblique

Craniocaudal

Question 3

What additional views can be used in mammography?

Answer 3

• Coned view
• Magnification view
• True lateral
• Extended cc
• Eclund views

Question 4

How are the breasts compressed for mediolateral oblique and craniocaudal mammography?

Answer 4

Mediolateral oblique- left/right compression

Craniocaudal- top/bottom compression

Question 5

What are the characteristics of cancer on mammography?

Answer 5

• Mass
• Asymmetry
• Architectural distortion
• Calcifications
• Skin changes

Question 6

What are the characteristics of malignant soft tissue masses on mammography?

Answer 6

• Irregular, ill-defined
• Spiculated
• Dense
• Distortion of architecture

Question 7

What are the characteristics of benign soft tissue masses on mammography?

Answer 7

• Smooth or lobulated
• Normal density
• Halo
• No distortion of architecture

Question 8

When is ultrasound used for breast imaging?

Answer 8

Can differentiate between solid and cystic masses as well as benign and malignant
First line investigation <40 as breast tissue will be too dense for mammography

Question 9

What are the characteristics of benign solid lesions on ultrasound?

Answer 9

• Smooth outline
• Oval shape
• Acoustic enhancement
• Orientation

Question 10

What are the characteristics of malignant masses on ultrasound?

Answer 10

• Irregular outline
• Interrupting breast architecture
• Acoustic shadowing
• Anterior halo

Question 11

What are the uses of image guided needle biopsy in breast clinic?

Answer 11

Obtain FNA or core biopsy from mass

Therapeutic excision of lesion

Question 12

What are the indications for an MRI of the breast?

Answer 12

• Recurrent disease
• Implants
• Indeterminate lesion following triple assessment
• Screening high risk women

Question 13

What are the downsides of a breast MRI

Answer 13

Sensitive but not specific
Claustrophobic
Noisy
Uncomfortable
Involves IV contrast
Expensive

Question 14

How is sentinel node sampling done?

Answer 14

Sentinel node sampling involves a peritumoral injection of dye followed by a lymphoscintigraphy and removal of one (sometimes two) nodes

Question 15

Between what ages are women invited for mammography and how often are they invited?

Answer 15

50-70 every 3 years

Question 16

What are the possible outcomes of breast screening?

Answer 16

Detects 5 cancers for every 1000 women screened

5-10% recalled for further investigation

Question 17

What are the characteristics of benign and malignant breast masses on cytology?

Answer 17

Benign:
-Flat layers of cells
-Cells of uniform size 
-Cohesive groups of cells 
Malignant:
-High cellularity 
-Loss of cohesion
-Crowding/overlapping of cells
-Nuclear pleomorphism
-Hyperchromasia
-Absence of bipolar nuclei

Question 18

How is breast cytology scored?

Answer 18

C1- unsatisfactory
C2- benign
C3- Atypia (probably benign)
C4- suspicious (probably malignant)
C5- malignant

Question 19

What steps are taken based on cytology score?

Answer 19

Anything C3 or worse will get an ultrasound guided core biopsy. Aspiration of cysts is curative and if only straw-coloured fluid is withdrawn then it is almost definitely not malignant.

Question 20

What are the downsides of FNA?

Answer 20

Can give false positives
Can give false negatives
Cannot give a grading
Has complications:
-Pain
-Haematoma
-Fainting
-Infection (Rare)
-Pneumothorax (Rare)

Question 21

When is a core biopsy done?

Answer 21

In everyone with clinical, radiological or cytological suspicion

Question 22

What are the pros of a core biopsy?

Answer 22

Gives full picture of disease pre-operatively

Useful in confirming invasion and giving grade/stage