Breast Flashcards

Question

52 A 54 year old woman presents with a painful discharging nipple. Clinical examination suggests a small lump. Mammogram shows coarse, smooth bordered rod shaped calcifications in the subareolar area. However, no discrete mass could be identified on magnified views. On MRI dilated tubular structures containing high signal intensity material on T1W and T2WI are seen, with no enhancement following i.v. gadolinium. · What is the likely diagnosis? (a) Paget's disease (b) Lymphoma (c) Nipple adenoma (d) Duct ectasia (e) Subareolar carcinoma

Answer 1

(d) Duct ectasia Stasis of intraductal secretions leads to dilatation and inspissation of material within the subareolar ducts which can calcify. The diagnosis is much more likely if it is bilateral.

Answer 2

(b) The current detection rate is approximately 16 cancers per 1000 women screened The current detection rate is approximately 6 cancers per 1000 women screened. At the moment the age range for selection is 50-70 years although plans exist to expand the age range from 47-73 years.

Answer 3

10. c. Lymphoma Metastases to the breast are infrequent and can be difficult to distinguish from primary breast cancer. The most common primary source is lymphoma, followed by melanoma and then rhabdomyosarcoma. Most patients who are diagnosed with breast metastases already have a diagnosis of a primary tumour, however, in 25% of cases breast metastases are the first manifestation of malignancy.

Answer 4

23. d. Ductal carcinoma in situ The most commonly associated is ductal carcinoma in situ (60%). The next most common is invasive ductal carcinoma. Fifty per cent of cases of DCIS are over 5 cm at the time of diagnosis and this often involves the nipple and subareolar ducts.

Answer 5

46. e. Popcorn calcification is seen in fibroadenoma Popcorn calcification is pathognomonic for fibroadenoma. The majority of biopsied clusters of calcifications represent a benign process (75–80%). Malignant calcifications are usually small (<0.5 mm) and are usually irregular in size and density. They are, however, usually closely grouped. Benign calcifications tend to be numerous and scattered throughout the breast.

Answer 6

48. a. Acoustic shadowing Acoustic shadowing along with ill-defined margins, surrounding architectural distortion, heterogeneous internal echoes and a height measurement greater than width measurement (with the transducer parallel to the longitudinal axis) are all features more suggestive of a malignant rather than a benign pathology. A hypoechoic lesion containing echogenic debris along with lack of internal blood flow and hypervascularity of surrounding tissues are in keeping with a breast abscess.

Answer 7

58. d. One woman per 1000 screened will be diagnosed with ductal carcinoma in situ (DCIS) In the 2007–2008 review statistics, eight cancers were detected per 1000 women screened. Women between the ages of 50 and 70 years are invited to attend the Breast Cancer Screening Programme at three-yearly intervals. However, women over the age of 70 are encouraged to make their own appointments to attend. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35% reduction in mortality from breast cancer among screened women aged 50–69 years. This means that out of every 500 women screened, one life will be saved

Answer 8

59. b. T2N2M1 The correct TNM staging is T2N2M1. The presence of involved ipsilateral supraclavicular nodes makes the staging M1 even in the absence of other distant metastases. T2 tumours encompass those which are more than 2 cm but less than 5 cm in diameter. N2 disease signifies involved axillary nodes which are fixed either to one another or to underlying structures. N3 disease signifies internal mammary involvement.

Answer 9

60. c. Rim-like enhancement of the mass Rim-like enhancement is a relatively rare finding, but has a high correlation with malignancy (positive predictive value 84%). A focal area of hyperintense signal on T2 near a lesion is highly suggestive of malignancy. Whilst the other characteristics may be present in a malignant lesion, all are more suggestive of benign pathology. Irregular speculated margins of a mass have a high positive predictive value for malignancy. Other features suggestive of malignancy are heterogenous internal septations and enhancing internal septa.

Answer 10

C Postmenopausal changes

Answer 11

B Fibroadenoma Fibroadenomas may become calcified, particularly after menopause. Classically the calcifications have a coarse ‘popcorn’ appearance; however, they may also appear small and punctate. An oil cyst typically demonstrates eggshell calcification and is the result of fat necrosis.

Answer 12

B This is known as a Type 1 interval cancer.

Answer 13

B Ill-defined echogenic halo around the lesion On ultrasound, breast carcinomas are generally ill-defined, hypoechoic masses which can have a surrounding echogenic halo. They also tend to have larger anterior-to-posterior than transverse diameter.

Answer 14

C A smaller focal spot of 0.1 mm is used. To provide magnification views, a focal spot of 0.1 mm should be used (smaller than the 0.3 mm focal spot used for standard mammographic projections) with an air gap of 1 5—30 cm. Options D & E are correct regarding mammography in general and hold true for both standard and magnification views.

Answer 15

D The MLO view is taken with the radiograph beam directed from superomedial to inferolateral.

Answer 16

E Women over 70 years of age may stay in the Breast Screening Programme by choice. Women between the ages of 50 and 70 are invited for screening every 3 years. Women over 70 are encouraged to attend by self-referral but are not invited.

Answer 17

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months. Malignant breast lesions enhance postcontrast; however, normal hormonally active breast tissue can also enhance, particularly during the middle of the menstrual cycle (6th—17th days). In younger patients it may be helpful to repeat the scan earlier or later in the menstrual cycle to improve specificity

Answer 18

9. D. Dot-dash. Malignant calcifications vary in shape and size. Pleomorphic calcifications that are more linear or dot-dash in appearance are associated with intraductal carcinoma. DCIS is often detected as a result of such calcifications. Egg-shell calcification is seen in the walls of an oil cyst. Sedimented calcium appears as curvilinear on the lateral projection and as smudged on the cranio-caudal view. This is a feature of benign cysts. Arterial calcification presents as tubular, parallel calcification. Fibroadenomas typically exhibit large, coarse, and irregular calcification.

Answer 19

4. C. Gynaecomastia. Most male breast lumps are benign, with breast cancer accounting for <1% of all breast lesions. Gynaecomastia is the most common benign condition of the male breast. The radiological description is in keeping with early nodular gynaecomastia. Lipomas are encapsulated fatty masses on mammography, which are mildly hyperechoic on ultrasound. Approximately 85% of male breast cancer is invasive ductal carcinoma. This is typically retroareolar and hyperdense on mammography with irregular margins. Secondary features such as nipple retraction and skin thickening are usually present. Ultrasound will show a non-parallel, hypoechoic mass. Posterior acoustic features and internal blood flow are not useful for distinguishing benign versus malignant lesions. Lymphoma will exhibit multiple hyperdense lymph nodes on mammography. Dermatofibrosarcoma is hyperechoic on ultrasound.

Answer 20

13. B. Spiculated margin. A recent study examining incidental breast lesions detected by CT found that spiculated breast lesions and axillary lymphadenopathy should raise concern for malignancy and be referred to the breast clinic. These features were significantly more likely to be present in malignant breast lesions. Genuine mass lesions and spiculation are more easily appreciated in non-dense breasts. The mammographic features of ill-definition and calcification do not appear to be suggestive of malignancy on CT, probably due to poorer resolution, as normal breast glandular tissue appears ill-defined on CT and malignant microcalcification is poorly demonstrated. Lesion size and location also do not differentiate between benign and malignant disease.

Answer 21

18. C. Multiple curvilinear lines of low T2WI signal within the implant. Silicone gel implants are high signal on T2WI. Capsular contracture is caused by constriction of the fibrous capsule that invariably forms to some degree around the implant as a reaction to the foreign object. This is seen on MRI as increased thickening of the T2WI hypointense margin surrounding the implant. Rupture of the prosthesis is the most common complication with breast implants, occurring in up to 10–20%, although many are not noticed clinically. With intracapsular ruptures, the silicone gel is contained by the capsule. Curvilinear strands of low T2 signal within the capsule may be seen, representing the collapsed implant shell. This finding is known as the ‘linguine’ sign. T2WI hyperintense globules surrounding the implant are indicative of an extracapsular rupture. Inferior extension beyond the inframammary fold implies implant migration, which is a relatively uncommon occurrence. Marginal T2WI hypointense radial folds within the implant are a normal finding

Answer 22

22. A. Irregular margin. A woman over the age of 30 years who is a BRCA1 or BRCA2 carrier should be offered MRI annually for breast cancer surveillance. The description of the margin of the mass is the most predictive feature of the breast MR image interpretation. Irregular or spiculated margins have a positive predictive value of 84–91%. T2W signal hyperintensity is suggestive of benign pathology, but not in the setting of an irregular or spiculated mass. There is overlap in enhancement kinetics between benign and malignant disease, and thus reliance on kinetic assessment alone is not recommended. Progressive enhancement (type I) is associated with benign pathology, whereas plateau (type II) and washout (type III) curves are suggestive of malignant disease. Due to the importance of lesion morphology, the MRI technique should focus on optimizing high spatial and temporal resolution.

Answer 23

27. E. Two lives are saved for every over-diagnosed case. Over-diagnosis is defined as the diagnosis of cancer as a result of screening that would not have been diagnosed in the woman’s lifetime had screening not taken place. Approximately 5.7–8.8 breast cancer deaths are prevented per 1000 women screened for 20 years starting at age 50 compared with 2.3–4.3 over-diagnosed cases per 1000 women screened for 20 years. The WHO International Agency for Research on Cancer determined that there is a 35% reduction in mortality from breast cancer among screened women aged 50–69. The NHS Breast Screening Programme provides screening every 3 years for women between the ages of 50 and 70. After the age of 70, women are still screened, although they are not automatically called for. Expansion is planned to cover women from 47 to 73. A two-view (cranio-caudal and mediolateral oblique) mammogram is taken, performed with breast compression, which can be uncomfortable for the patient.

Answer 24

32. A. Reassurance and discharge with advice. The clinical and radiological findings in this case are typical for fibroadenoma. Standard practice for investigating breast lumps involves triple assessment with clinical examination, imaging with ultrasound, and tissue diagnosis (with either cytology or histology). However, in women under the age of 25 who present with a clinically and radiologically benign lump, biopsy is not needed unless there is overriding clinical concern. To be assessed as definitely benign on ultrasound, there should be no malignant features (spiculation, angular margins, acoustic shadowing, calcification, and marked hypoechogenicity) and the lesion should follow tissue planes (wider than it is tall). The ultrasound should also be performed by an experienced operator. The patient should be advised to seek further assessment if there is any increase in size or change to the mass.

Answer 25

37. D. Phyllodes tumour. This most commonly manifests as a rapidly growing mass, which is lobulated on mammography. Calcifications are rarely seen. A solid mass containing cystic spaces on ultrasound and demonstrating posterior acoustic enhancement is strongly suggestive of phyllodes tumour. Phyllodes tumour can be benign or malignant, but both have a tendency to recur if not widely excised. Adenoid cystic carcinoma is a slow-growing mass that is well defined on mammography. Fibromatosis presents as an indistinct mass on mammography, which is hypoechoic with posterior acoustic shadowing on ultrasound, simulating malignancy. Granular cell tumours are thought to arise from Schwann cells and have a very variable appearance. Metastatic disease to the breast is much more likely to be multiple or bilateral. Diffuse skin thickening is also a feature.

Answer 26

43. B. Architectural distortion. ILC is the second most common form of invasive breast cancer, after ductal carcinoma. It exhibits the same mammographic features as invasive ductal carcinoma, although architectural distortion is the most common mammographic finding. Due to the pattern of small cells growing around ducts (‘Indian files’), mammographic findings are subtle and thus ILC is the most frequently missed breast cancer. Prognosis is generally poor due to late diagnosis.

Answer 27

48. B. Ultrasound guided needle aspiration. Breast abscess is a potential complication of mastitis that may occur during breast-feeding, particularly in primiparous women. Staphylococcus aureus is the most common causative organism. Treatment of mastitis usually consists of breast-emptying procedures and antibiotics. Abscesses are difficult to detect clinically and so the patient should be investigated via ultrasound if mastitis does not promptly respond to appropriate therapy. Ultrasound-guided needle aspiration is a suitable method of treatment for abscesses less than 3 cm in maximum diameter. Continuing breast-feeding is not felt to be problematic.

Answer 28

9 Answer C: Perform ultrasound and ultrasound-guided core needle biopsy if a solid lesion is visible Although this lesion has the features of a fibroadenoma, ultrasound cannot reliably distinguish between a well-circumscribed carcinoma and a fibroadenoma. Usually, histological confirmation of the benign lesion is made via ultrasoundguided core biopsy. In individual cases, some patients may opt for excisional biopsy without prior biopsy.

Answer 29

10 Answer E: A hyperechoic posterior wall Strict ultrasound criteria for a simple cyst include well-circumscribed margins, round/oval shape, absence of internal echoes, through transmission and posterior acoustic enhancement with a bright posterior wall.

Answer 30

11 Answer D: Demonstration of eggshell calcification Both lesions may appear as rounded lucent lesions with a surrounding capsule on mammography. A history of recent lactation and multiple areas of fatty and fibroglandular density would make a galactocoele more likely

Answer 31

15 Answer C: An increase in size in the post-menopausal period, in the absence of HRT Cyst margins may be completely or partially defined (or even completely obscured) by adjacent fibroglandular breast tissue. Cysts frequently disappear or subside following menopause. Peripheral eggshell calcification is seen in fat necrosis. Tea cup calcification, seen on the floor of the cyst on an erect lateral film, may be seen in cysts containing milk of calcium (rare).

Answer 32

12 Answer C: Upper outer quadrant Fifty per cent of all breast cancers arise in the upper outer quadrant, which usually contains the most glandular tissue in the breast. The second most common site is the retroareolar region where 18% of cases arise.

Answer 33

13 Answer C: Bone Most common sites of initial distant metastasis from breast cancer are bone (58%), lung and pleura (26%), and lymph nodes other than ipsilateral axillary nodes (16%). Initial involvement of the liver or brain is less frequent.

Answer 34

14 Answer C: Every six months for the first two years and annually thereafter Exact follow-up regimes may vary from centre to centre, according to local policy. In patients treated with radiotherapy mammography skin thickening post-irradiation usually decreases within two years following treatment but may persist longer.

Answer 35

16 Answer A: Ductal carcinoma Ductal carcinoma accounts for the majority of invasive breast cancers and lobular carcinoma approximately 5-10%. Medullary and mucinous account for around 2 % each and <1 % of cases are of sarcomatous origin.

Answer 36

17 Answer D: Linear, branching Microcalcifications are defined as individual calcific opacities <0.5 mm in diameter. Characteristics suspicious of malignancy include a casting shape, linear, segmental and clustered distribution. Other non-specific characteristics that increase the degree of suspicion include pleomorphism, variation in size, increased density for size, irregular margins, irregular boundaries of the area of calcification, many calcifications per square centimetre (>5/cucm). Scattered small calcifications bilaterally with radiolucent centres are typical of calcified sebaceous glands of the skin, but may present as a localised cluster of calcification. Irregular coarse `popcorn' calcification may be seen within a fibroadenoma. Calcification within a fibroadenoma is typically peripheral but may be centrally or eccentrically situated, as may be seen in carcinoma.

Answer 37

18 Answer A: <0.5 mm Microcalcifications are defined as individual calcific opacities <0.5 mm in diameter. Characteristics suspicious of malignancy include a casting shape, linear, segmental and clustered distribution. Other non-specific characteristics that increase the degree of suspicion include pleomorphism, variation in size, increased density for size, irregular margins, irregular boundaries of the area of calcification, many calcifications per square centimetre (>5/cucm). Scattered small calcifications bilaterally with radiolucent centres are typical of calcified sebaceous glands of the skin, but may present as a localised cluster of calcification. Irregular coarse `popcorn' calcification may be seen within a fibroadenoma. Calcification within a fibroadenoma is typically peripheral but may be centrally or eccentrically situated, as may be seen in carcinoma.

Answer 38

19 Answer D: Lymphoma, melanoma, ovarian carcinoma, lung carcinoma In that order of frequency. Sarcoma can also metastasise to the breast.

Answer 39

20 Answer C (a) Type 2 curve. (b) Type la curve. (d) Type lb curve. Malignant lesions are associated with a type 3 (approximately 60%) or type 2 curve (approximately 30%). (e) consistent with a benign lesion.

Answer 40

21 Answer E: Phyllodes tumour Causes of large (>5 cm) well-defined opacities include the following: giant cyst, giant fibroadenoma, lipoma, sebaceous cyst, cystosarcoma phyllodes.

Answer 41

22 Answer C: 47XXY This is Klinefelter's syndrome in which there is a 20-fold increased risk of male breast cancer. 45 XO (Turners) and 47 XXX (triple X) are females. 46 XY is normal and 47 XY 13 is a male with Patau's syndrome (trisomy 13)

Answer 42

23 Answer D: Breast MRI Breast MRI is indicated when there is an axillary metastasis but no primary is visible on mammography or clinical examination. It is also indicated in a number of other situations: dense breasts plus high risk lesion of LCIS, positive BRCA screen, assessment of response to neoadjuvant chemotherapy and suspected multifocal breast carcinoma. The sensitivity to DCIS is relatively poor

Answer 43

1 Answer A: 20-40 mBq of nanocolloid injected subdermally into the quadrant of the breast where the cancer is located 20-40mBq is given into the skin in the same quadrant as the tumour depending on whether surgery is that day or the next. Surgeons often use methylene blue at the time of surgery, but it is not radio labelled. The surgeon may use both a detector probe and dye at the time of surgery

Answer 44

9 Answer E: T2-weighted fast spin echo MRI sequences Intracapsular ruptures are not detectable on mammography because the silicone is contained within the fibrous capsule that forms around the implant. Extracapsular rupture may sometimes be detected on mammography but may also be obscured by the overlying implant or may not be imaged if it occurs in an area of the breast or chest wall not included in the mammogram. Ultrasound has a lower sensitivity (70% vs. 94%) but similar specificity (92-97%) than MRI in detecting implant rupture. The fibrous capsule surrounding the implant is hypointense on T2 and silicone and saline both display high signal intensity on T2. The most effective sequences in evaluating implants are inversion recovery which suppresses fat, with an additional suppression of water for pure depiction of silicone, and with additional s ppression of silicone for pure depiction of the saline component.

Answer 45

10 Answer C: 5-10% Five to ten per cent degenerate into malignant fibrous histiocytoma/ fibrosarcoma/ liposarcoma/ chondrosarcoma osteosarcoma with local invasion and haematogenous metastases to lung, pleura and bone, with axillary metastases being quite rare. Incomplete excision results in recurrence in 15-20% despite their benign nature

Answer 46

11 Answer B: Gynaecomastia due to digoxin therapy The normal male breast appears on mammography as a mound of subcutaneous fat without glandular tissue. Gynaecomastia appears as described. It is NOT a risk factor for breast carcinoma. Thiazide diuretics and spironolactone are also recognised drug-induced causes of gynaecomastia. Invasive lobular carcinoma is distinctly uncommon as tubular structures are usually not found in the male breast. Gynaecomastia occurs in 60-75 % of healthy pubertal boys.

Answer 47

12 Answer B: Hamartoma of the breast (fibroadenolipoma) This description is classical.

Answer 48

13 Answer D: A lesion of mixed density on mammography with a fat-water level on a horizontal beam view This is a typical appearance in the second phase; a large radiopaque lesion of water density is seen in the first phase. They can also resemble a lipoma (small radiolucent lesion) and may contain a fluid calcium level. Ultrasound usually demonstrates a complex mass. Both conditions occur in the retroareolar portion of the breast. A cold abscess is associated with the features described in (b) and (e). Associated raised inflammatory markers, fever and pain are also seen.

Answer 49

14 Answer C: 50-70 years There are plans to increase the age range to 47-73 years in due course, but staffing considerations and the impact on current resources will have to be taken into account before this can be introduced.

Answer 50

15 Answer C: Craniocaudal and mediolateral oblique (MLO)

Answer 51

16 Answer C: Post-surgical seroma Silicone would appear hyperintense on water-suppressed STIR sequences. The appearances are consistent with a localised collection serum after surgery.

Answer 52

17 Answer D: Surgical excision is required for a definite diagnosis There is no association with trauma or previous trauma. It has a variable appearance in different projections. No skin thickening or retraction is seen. Frozen section, core needle biopsy or fine needle aspiration should be avoided. It is rarely palpable and is usually detected at screening mammography or occasionally in mastectomy specimens.

Answer 53

18 Answer C: The condition is associated with ductal carcinoma in situ in 60% of cases This patient has Paget's disease of the nipple. Associated with invasive ductal carcinoma in 30%, negative mammogram in 50%, and can display linearly distributed subareolar/diffuse malignant calcifications. The diagnosis is often delayed many months as the condition can resemble benign eczema.

Answer 54

19 Answer A: Inflammatory carcinoma One might expect these changes with recent surgery, but not seven years later, and the findings raises the suspicion of inflammatory carcinoma or lymphatic obstruction in a patient with previous breast malignancy

Answer 55

20 Answer D: Snowstorm sign posteriorly on ultrasound The snowstorm sign is a hyperechoic nodule, which is well-defined anteriorly with indistinct echogenic noise posteriorly (= free silicone droplets mixed with breast tissue). The other options are signs of intracapsular rupture

Answer 56

21 Answer E: Symptomatic treatment only Mondor disease is a usually self-limited thrombophlebitis of the subcutaneous veins of the breast and anterior chest wall, of unknown cause. It may be associated with carcinoma (in up to 12 %) and DVT. There are further possible associations with trauma, exertion, surgery, dehydration and inflammation.

Answer 57

22 Answer D: Plasma cell mastitis Mammary duct ectasia or plasma cell mastitis is often asymptomatic, but may present with breast pain, nipple discharge and retraction or a subareolar mass. The mean age at which it occurs is 54 years. Duct dilatation is seen up to the nipple, with ducts usually measuring >2 mm on ultrasound. It is often bilateral and symmetric but may be unilateral and focal. It is a rare aseptic inflammation of the subareolar region. Intraductal calcifications associated are fairly uniform, linear, often needleshaped, of wide calibre and occasionally branching. Periductal calcifications appear as oval/elongated rings around dilated ducts with very dense peripheries (due to surrounding deposits of fibrosis and fat necrosis).

Answer 58

23 Answer C: Choriocarcinoma Malignant melanoma, renal cell carcinoma and Kaposi sarcoma would be other possible primaries.

Answer 59

9 Answer C: Invasive ductal carcinoma This is most likely to appear as a spiculated mass, usually on both mammographic views. It is also the most common histological type of breast cancer. The other types most often appear as rounded lesions with a smooth border and may display a halo sign.

Answer 60

10 Answer D: A normal mammogram three years previously Neither cysts nor fibroadenomas grow after the menopause and any new mass lesion should be regarded with suspicion, despite an otherwise apparently benign appearance.

Answer 61

11 Answer E: Spiculated lesion with a plateau in the post-initial phase on contrast-enhanced T1- weighted images Malignant morphology always trumps kinetics. Features of malignancy on breast MR include reduced signal on T2 WI, irregular morphology, lymphangitic bridges, and the following on CE Ti WI: rapid wash-in -90/90 rule (SI increase of >90% in the first 90s), centripetal wash-in, plateau/rapid washout in postinitial phase, markedly higher amplitude than normal parenchymal tissue.

Answer 62

12 Answer D: Six months after open biopsy Optimal timing of MR of the breast includes 7-20 days after the beginning of the menstrual cycle, six months after open biopsy and 12 months after radiation therapy.

Answer 63

13 Answer B: Upper outer quadrant Fifty-four per cent occur in the UOQ, 14% in the UIQ, 15% are retroareolar, 7% in the LIQ and 10% in the LOQ

Answer 64

14 Answer C: Post-surgical haematoma Deoxyhaemoglobin of subacute haematoma. Seroma and abscess would display high signal intensity on T2 images due to fluid content. Fat necrosis usually occurs up to six months following insult, and would display increased signal intensity on T2 due to reactive oedema in a fresh lesion.

Answer 65

15 Answer D: High signal on T1- and T2 -weighted images with avid peripheral enhancement without central uptake on contrast-enhanced T1 images High Ti SI is due to the high protein content of fluid in a chronic/cold abscess of the breast in a lactating woman. The abscess wall enhances strongly post contrast.

Answer 66

16 Answer C: 6 per 1000 women screened

Answer 67

17 Answer E: Calcification may be present The patient has fibrocystic changes of the breast. Tea cup calcification on horizontal beam lateral view, low-density round calcification on CC projection (milk of calcium)/`oyster pearllike'/psammoma like/`involutional type' fine punctate calcifications in one or more lobes against fatty background are all described. Symptoms usually occur with ovulation; regress with pregnancy and at menopause. It is the most common diffuse breast disorder, found in 72% of the screening population >55 years of age.

Answer 68

18 Answer A: 0% It is not pre-malignant Fat necrosis is not pre-malignant but is an important differential for carcinoma, particularly if it causes distortion of the skin or breast tissue or has mammographic features which are indistinguishable from malignancy as in this case.

Answer 69

19 Answer B: Central solitary papilloma Papillary carcinoma is a rare form of ductal carcinoma. MRI features usually differ slightly in that the lesion is hypointense on T1-weighted images, shows strong initial enhancement with contrast sometimes with ring enhancement and a postinitial plateau or washout. T2 -weighted images demonstrate a well-circumscribed intermediate intensity lesion in a signal-intense cyst.

Answer 70

26. (c) Fibroadenoma Fibroadenomas are benign lesions often seen in young women. With advancing age, they shrink and may degenerate. This can then calcify resulting in a typical ‘popcorn’ type calcifcation.

Answer 71

37. (b) Simple cyst These sonographic features are diagnostic of a simple cyst.

Answer 72

38. (c) Cyst Other lesions are known to show contrast enhancement.

Answer 73

39. (c) Core biopsy or FNAC For lesions as described, the appropriate management for lesions 15–20 mm in size is core biopsy or FNAC to exclude the possibility of malignancy.

Answer 74

40. (b) Fat necrosis ‘Egg shell’ calcifcations are seen in patients with fat necrosis. This can be secondary to blunt trauma or it can be post-surgical.

Answer 75

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: Two views of each breast are taken as baseline, but single view is taken as follow up. However two views are recommended as follow up as it increases lesion detection. Ultrasound currently has no role as a screening tool in any age group. In UK, screening is available for patients from 50-65 yrs.

Answer 76

Answers: (a) Not correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: Medullary carcinoma presents as well defined mass which may show lobulated margins or halo sign. Calcification is not a feature. The most common invasive cancer in male breast is invasive ductal carcinoma. Colloid carcinoma is seen in older age group (over 60 yrs) and has a good prognosis as tumour is slow growing.

Answer 77

Answers: (a) Correct (b) Not correct (c) Correct (d) Correct (e) Correct Explanation: Milk of calcium appears amorphous and ill-defined on cranial caudal view. On medial-lateral oblique view it is typically sharply defined, semilunar or crescent shaped and upwardly concave

Answer 78

Answers: (a) Not correct (b) Correct (c) Not correct (d) Correct (e) Correct Explanation: Fibroadenomas are multiple in 10%- 20% of cases but are found bilaterally in only 4 % of cases. They are well circumscribed masses with homogenous internal echoes but variable posterior acoustic pattern.

Answer 79

Answers: (a) Correct (b) Not correct (c) Correct (d) Not correct (e) Correct Explanation: Sclerosing adenosis is only mildly associated (2.5 folds) with increase in risk of infiltrating breast cancer. The condition in itself is non-malignant. It is frequently detected only on mammography, though may present as a palpable mass.

Answer 80

Answers: (a) Correct (b) Correct (c) Not correct (d) Not correct (e) Correct Explanation: 50% of metastases are superficial with no associated skin changes. Diffuse skin involvement is seen in melanoma. The metastases are more commonly located in outer upper quadrant, without speculation, calcifications or desmoplastic reaction as in primary carcinoma.

Answer 81

Answers: (a) Correct (b) Not correct (c) Not correct (d) Not correct (e) Not correct Explanation: Phyllodes tumour presents as a large well circumscribed oval or lobulated mass which may have radiolucent halo on mammography. Coarse plaque like calcification is rare. On ultrasound it appears as inhomogeneous solid appearing mass. Cystic spaces within the mass with posterior acoustic enhancement are typical of phyllodes tumour. On histology is appears like a giant fibroadenoma, with upto 25% containing areas of malignant degeneration with infiltrative borders. 10% of phyllodes tumours are true sarcomas presenting with hematogeneous spread. Nodal spread is rare. Both benign and malignant have a tendency to reoccur if not widely excised.

Answer 82

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Correct Explanation: A band of linear striated reverberation in the anterior aspect of implant approximately equal in thickness to the breast tissue overlying the implant is a normal finding indicating an intact silicone gel implantUltrasound signs of intracapsular rupture include the ‘stepladder sign’ (a series of parallel horizontal echogenic lines indicating a collapsed implant shell). A ‘snowstorm’ pattern has been described in extracapsular rupture indicating free silicone droplets within the breast tissue. 22% of ruptures are extracapsular.

Breast Flashcards

(106 cards)