Abnormal Development, Diagnosis and Imaging

Question 1

Poland syndrome

Answer 1

> > genetic disorder that presents as a unilateral variable loss of the breast tissue, pectoralis major and minor, and serratus anterior muscles as well as several ribs.

Question 2

Accessory breast tissue (polymastia) and accessory nipples (supernumerary nipples)

Answer 2

> > result of persistence of the mammary ridge

Question 3

Supernumerary nipples

Answer 3

> > usually rudimentary and occur along the milk line from the axilla to the pubis in males and females

Question 4

True polythelia

Answer 4

> > more than one nipple serving a single breast, which is rare

Question 5

Accessory breast tissue

Answer 5

> > is commonly located above the breast in the axilla.

> > The accessory mammary tissue may be removed surgically if it is large or cosmetically deforming or to prevent enlargement during future pregnancy.

Question 6

Gynecomastia

Answer 6

• Hypertrophy of breast tissue
• Pubertal hypertrophy is generally treated by observation - Surgical excision if the enlargement is unilateral, fails to regress, or is cosmetically unacceptable

Question 7

Drugs causing gynecomastia

Answer 7

• digoxin
• thiazides
• estrogens
• phenothiazines
• theophylline
• cannabis

> > hepatic cirrhosis, renal failure, or malnutrition.

Question 8

Cancer Vs Gynecomastia

Answer 8

> > Carcinoma is not usually tender
asymmetrically located beneath or beside the areola,
may be fixed to the overlying dermis or to the deep fascia.

Question 9

Nipple Discharge without a mass , any risk of cancer ?

Answer 9

In the absence of a palpable mass or suspicious findings on mammography, discharge is rarely associated with cancer.

Question 10

The most common cause of spontaneous nipple discharge

Answer 10

• Single duct is a solitary intraductal papilloma (60%–80%)
• Subareolar duct ectasia (20%) > multiple ducts

Question 11

Papilloma risk for cancer

Answer 11

• Papillomas that are located away from the nipple-areolar complex are at higher risk of malignancy (20%).
• A papilloma is the most common benign tumor to develop breast cancer, primarily DCIS.

Question 12

Nipple discharge that is bilateral and comes from multiple ducts

Answer 12

is not usually a cause for surgery

Question 13

Bloody discharge from a single duct, Tx ?

Answer 13

> > often requires surgical excision to establish a diagnosis and control the discharge

Question 14

Bilateral bloody spontaneous discharge , Cause ?

Answer 14

> > is likely endocrine in nature and is associated with pregnancy and hypothyroidism.

Question 15

Galactocele

Answer 15

• occurs after the cessation of lactation or when feeding frequency has declined
• may occur 6 to 10 months after breastfeeding has ceased
• Needle aspiration produces thick, creamy material that may be tinged dark green or brown.

Question 16

Galactocele Tx?

Answer 16

> > Treatment is large bore needle aspiration, and withdrawal of thick milky secretion confirms the diagnosis

> > surgery is reserved for cysts that cannot be aspirated or that become infected

Question 17

What is a clinic Sign specific for Malignancy

Answer 17

> > dimpling of the skin or nipple retraction is a sensitive and specific sign of underlying cancer

Question 18

Hallmark for Inflammatory Carcinoma by clinical exam

Answer 18

• Peau d’orange
• tenderness
• warmth
• swelling

> > may be mistaken for acute mastitis.

Question 19

What causes The inflammatory changes and edema

Answer 19

> > caused by obstruction of dermal lymphatic channels by emboli of carcinoma cells

Question 20

Inflammatory cancer onset

Answer 20

> > rapid onset (less than 3 months) as compared to a similar presentation for locally advanced cancer, which may have been present for years and neglected.

Question 21

Flattening or inversion of the nipple causes?

Answer 21

> > caused by fibrosis in certain benign conditions, especially subareolar duct ectasia.

Question 22

Paget disease

Answer 22

• Commonly associated with an underlying breast cancer
• Carcinoma cells invade across the junction of epidermal and ductal epithelial cells and enter the epidermal layer of the skin of the nipple
• Paget disease originates on the nipple and secondarily involves the areola

Question 23

FNA Role?

Answer 23

> > A limitation of FNA in evaluating solid masses is that cytologic evaluation does not differentiate noninvasive lesions from invasive lesions if malignant cells are identified.

> > If FNA demonstrates malignancy, a CNB is still required for definitive histologic diagnosis before surgical intervention.

Question 24

When FNA needed ?

Answer 24

> > One clinical scenario in which FNA still has utility is in the evaluation of a second suspicious lesion in the ipsilateral breast of a patient with a known malignancy.

> > evaluation of lymph nodes that are suspicious on either physical examination or imaging

> > sensitivity of approximately 90% and a specificity of up to 100%

Question 25

How to do FNA ?

Answer 25

- 22-gauge needle - syringe - alcohol preparation pad. - The needle is repeatedly inserted into the mass while constant negative pressure is applied to the syringe. - multiple areas of a mass could be sampled - The fluid and cellular material within the needle are submitted in buffered saline or fixed immediately on slides in 95% ethyl alcohol

Question 26

How to DO CNB ?

Answer 26

- trigger devices requiring multiple entries or with vacuum-assisted devices - Size of a CNB ranges from 8 to 14 gauge - under mammographic (stereotactic), ultrasound, or (MRI) guidance - During stereotactic CNB, the breast is compressed, most often with the patient lying prone on the stereotactic CNB table - After local anesthetic is injected - a small skin incision is made, - core biopsy needle is inserted into the lesion to obtain the tissue sample with vacuum assistance. - A clip should be placed to mark the site - specimens should be imaged - A mammogram obtained after biopsy confirms that a defect has been created within the target lesion and that the marking clip is in the correct position

Question 27

Image-guided localization and surgical excision are required if

Answer 27

>> the lesion cannot be adequately sampled by CNB or >> if there is discordance between the imaging abnormality and pathologic findings.

Question 28

Indications for Excisional Bx ?

Answer 28

- Less than 10% of patients who undergo CNB have inconclusive results and require surgical biopsy for definitive diagnosis. - Biopsy results that are not concordant with the targeted lesion (e.g., a spiculated mass on imaging and normal breast tissue on CNB) necessitate surgical excision. - When ADH is found on CNB, surgical excision reveals DCIS or invasive carcinoma in 20% to 30% of cases because of the difficulty of distinguishing ADH and DCIS in a limited tissue sample. - A finding of a cellular fibroadenoma on CNB requires excision to rule out a phyllodes tumor.

Question 29

Screening vs diagnostic mammo

Answer 29

- On screening mammography, two views of each breast are obtained, mediolateral oblique and craniocaudal and ready at a later time usually in batches - diagnostic mammography is indicated, which is read at the time of performance so additional views may be performed

Question 30

Digital mammography

Answer 30

>> superior to traditional film-screen mammography for detecting cancer in younger women and women with dense breasts

Question 31

mammo in younger than 30 and older women

Answer 31

>> women younger than 30 years, whose breast tissue is dense with stroma and epithelium, may produce an image without much definition. >> As women age, the breast tissue involutes and is replaced by fatty tissue. >> On mammography, fat absorbs relatively little radiation and provides a contrasting background that favors detection of small lesions.

Question 32

Recommendation for Screening

Answer 32

>> recommended biennial screening mammography for women 50 to 74 years old >> recommended against screening for women 40 to 49 years old or older than 75 years >> the American Cancer Society continues to recommend annual screening mammography for women older than 40 years

Question 33

Screening MRI ?

Answer 33

>> Younger women with a previous breast cancer >> significant family history of breast cancer >> histologic risk factors for breast cancer equal to a 20% lifetime risk

Question 34

Tomosynthesis ( 3D )

Answer 34

Tomosynthesis acquired thin sections of tissue with its main advantage being to separate overlapping breast tissues, decrease callbacks, and find smaller significant disease >> higher detection of breast cancer but a slightly higher false positive recall >> excels in delineating small and multiple masses, microcalcifications, and distortion due to ducts and vessels But has higher radiation

Question 35

US for Screening ?

Answer 35

No because operator Dependent

Question 36

MRI ? When MRI is used for screening, it should be used in addition to screening mammography.

Answer 36

- Unknown Primary - Axillary LN with no palpable mass in breast - patients with Paget disease of the nipple without radiographic evidence of a primary tumor - extent of the primary tumor, particularly in young women with dense breast - extent of residual disease after lumpectomy with positive margins; - presence of multifocal or multicentric cancer - screening of the contralateral breast - for evaluating invasive lobular cancers - assessment of treatment response after neoadjuvant chemotherapy. - used for assessing implant rupture or assessing the breast when silicone injections have been used. - Younger women with a previous breast cancer - significant family history of breast cancer - histologic risk factors for breast cancer equal to a 20% lifetime risk

Question 37

Women at High Lifetime Risk (Risk Criteria for Breast Magnetic Resonance Imaging Screening. ≈20%–25% or Greater) of Breast Cancer

Answer 37

* Known BRCA1 or BRCA2 gene mutation * First-degree relative with BRCA1 or BRCA2 gene mutation, but have not had genetic testing themselves * Lifetime risk of breast cancer of ≈20%–25% or greater * Radiation therapy to the chest between the ages of 10 and 30 * Li-Fraumeni syndrome or Cowden syndrome or a first-degree relative with one of these syndromes

Question 38

Women at Moderately Increased (15%–20%) Lifetime Risk

Answer 38

* Lifetime risk of breast cancer of 15%–20% according to risk assessment tools based mainly on family history * Personal history of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia * Extremely dense breasts or unevenly dense breasts when viewed by mammograms

Question 39

probably benign lesions are designated BI-RADS 3

Answer 39

>> monitored with 6-month interval mammograms over a 2-year period. >> Biopsy is performed only for lesions that progress during follow-up

Question 40

Non Visible lesions even in US , What to do ?

Answer 40

- wire is used to localize the lesion, it is placed through an introducer needle and has a hook that engages within the breast parenchyma at or near the abnormality - After excision, a specimen radiography confirms that the targeted lesion has been excised. >> Patients who have a diagnosis of benign findings on excision should undergo new baseline mammogram 4 to 6 months after the surgical procedure >> radioactive seed localization, which involves positioning a 4.5-mm 125I seed in the breast tissue >> a gamma probe, which detects technetium-99m (99mTc), commonly used for sentinel lymph node dissection (SLND), and 125I can be used to guide the breast resection - A newer technique, fluoroscopic intraoperative neoplasm or node detection