Breast Imaging

Question 1

What types of imaging are part of the Triple Assessment in the Breast Clinic?

Answer 1

Mammography and US

Question 2

How is the appearance of a lesion classified on imaging in the Triple Assessment?

Answer 2

1-5

5 being malignant

Question 3

What is mammography?

Answer 3

• low density X-Rays
• breast is compressed to allow these to easily pass through
• provides contrast between tumour and fat

Question 4

HOw many projections are used in mammography?

Answer 4

2 projections

• oblique
• craniocaudal (CC) => looking from top to bottom of pt

Question 5

Describe what white and dark tissue represents on a mammogram

Answer 5

white - fibroglandular tissue

dark - adipose tissue

Question 6

Where is most fibroglandular tissue (white on mammogram) found in the breast?

Answer 6

Mostly in lateral part of breast

Question 7

Describe the sensitivity of mammography in a very fatty breast vs in a very dense breast

Answer 7

Fatty breast = HIGH

Dense breast = LOW (poor contrast)

Question 8

Breast density increases with age. TRUE/FALSE?

Answer 8

FALSE

• breast density decreases with age
• this is not related to the menopause

Question 9

What factors can change the rate at which breast density decreases?

Answer 9

• weight
• HRT use
• Tamoxifen use

Question 10

Patients with a higher density breast are at higher risk of breast cancer in their lifetime. TRUE/FALSE?

Answer 10

TRUE

Question 11

What are the advantages of mammography?

Answer 11

• images the whole breast at once
• high sensitivity for DCIS and invasive cancers
• has shown to decrease population mortality through its use in screening
• high reattendance rates to screening

Question 12

What are the disadvantages of mammography?

Answer 12

• false positives
• overdiagnosis (cancer may be slow growing and not life threatening)
• ionising radiation
• uncomfortable for some women

Question 13

Calcification may be identified on mammography at screening. What conditions can cause this?

Answer 13

• Duct ectasia

- DCIS

Question 14

Tomosynthesis is a feature of mammography. What does it do?

Answer 14

Allows slices of breast to be imaged (like CT)

=> increases sensitivity

Question 15

How can lesions be enhanced on mammography?

Answer 15

• Contrast
• Given IV
• Usually iodinated
• 2 images taken - 1 before and after contrast for comparison

Question 16

What is US used for in the breast clinic?

Answer 16

• Confirm lumps seen on mammography
• If patient is symptomatic (e.g. palpable lump)
• image guided biopsy
• inflammation
• breast problems in pregnancy (mammogram not helpful here as breast is too dense)

Question 17

What are the advantages and disadvantages of using US in the Breast Clinic?

Answer 17

Adv:

• not uncomfortable
• detects invasive cancer well
• can distinguish cyst from solid lump

Disadv:
- doesnt pick up DCIS as well as mammography

Question 18

Contrast enhanced US is often used in the Breast Clinic. TRUE/FALSE?

Answer 18

FALSE not used very often

Question 19

What is the purpose of elastography?

Answer 19

• measures stiffness of tissue
• cancers and their surrounding tissue are more likely to be stiff
• benign lesions (e.g. fibroadenoma) = very soft

Question 20

What are the different probes used for elastography?

Answer 20

Strain Elastography (probe should be moved to assess lesion)

Shear Wave (probe remains still when assessing lesion)

Question 21

Why are cancers usually stiff in comparison to benign pathology?

Answer 21

collagen in stroma becomes:

• disorganised
• poorly aligned
• lots of cross linking occurs

Question 22

The interaction between the tumour and surrounding stroma is important in predicting spread and patient outcome. TRUE/FALSE?

Answer 22

TRUE

Question 23

Tumours with what characteristics are usually stiffer than others?

Answer 23

• Node positive tumours
• Large tumours
• Tumours of high grade
• Lobular cancers

Question 24

What are the advantages and disadvantages of MRI in braest cancer?

Answer 24

ADV:
- Most sensitive and accurate for sizing of lesion

DISADV:
- Shows tiny foci of cancers away from main lesion that prompt patients to have a mastectomy instead of wide local excision

Question 25

Having a mastectomy as opposed to breast conservation and radiotherapy does NOT reduce the risk of recurrence. TRUE/FALSE?

Answer 25

TRUE | - Conservation and Radio is just as good if not better than mastectomy

Question 26

What can MRI be used to investigate?

Answer 26

- Lobular cancer - Cancer not picked up on mammography - Pagets disease of the nipple (investigate underlying DCIS) - Shrinking of cancer following neoadjuvant chemotherapy - Imaging of positive axillary lymph nodes following normal mammogram/US - Shows implant integrity (intra/extracapsular rupture)

Question 27

Describe how a contrast activity/time graph shows a lesion is malignant rather than benign?

Answer 27

- Graph shows tumour rapidly filling with contrast and then "washing out" after a couple of mins - benign or normal tissue has a slower increase in tking up contrast

Question 28

What types of biopsy may be used in the Breast clinic?

Answer 28

- Core biopsy - Vacuum biopsy - FNA (not widely used now)

Question 29

Why must a core biopsy be as large as a 14G needle?

Answer 29

breast tissue is friable | => this size of needle allows a large enough intact sample

Question 30

Core biopsy can be mammogram or US assisted. TRUE/FALSE?

Answer 30

TRUE

Question 31

Describe how a Mammogram Assisted Core Biopsy takes place?

Answer 31

2 views used on mammogram to plan injection site X marks the spot XRay the biopsy sample afterwards to check the right bit has been taken

Question 32

How large is a vacuum biopsy needle and what does this mean can be offered clinically?

Answer 32

11G needle => can offer to remove some lumps with this needle => e.g. papilloma as this can progress to cancer

Question 33

What is the commonest breast cancer lump by age?

Answer 33

<30 fibroadenoma 30-50 simple cyst >50 breast cancer

Question 34

Why are cysts uncommon after the age of 50

Answer 34

women are post-menopausal => not going through the horomonal changes that would create a cyst

Question 35

Describe the appearance of a cyst on US and how this would be treated

Answer 35

black - fluid | Tx = fluid drainage and reassurance

Question 36

Describe the appearance of cancer on mammography?

Answer 36

- spiculated - irregular margin - lesion is taller than it is wide (benign lesions are the opposite as they are compressable by the US probe)

Question 37

How is US used to assess axillary lymph nodes?

Answer 37

Used to measure cortical thickness and shape | - If over 3mm then biopsy

Question 38

How should staging be carried out for breast cancer and where do metastases normally appear?

Answer 38

- local staging if disease appears to be operable - CT chest, abdo, pelvis if worried about systemic spread - Normal spread pattern: bone, lung, pleura, liver, brain

Question 39

What breast conditions cause nipple discharge?

Answer 39

benign - duct ectasia | malignant - DCIS

Question 40

What are the main causes of abscesses and inflammation in the breast? Which group of women are most at risk?

Answer 40

``` breastfeeding duct ectasia (older women) ``` **women who smoke are most at risk due to poor healing**

Question 41

How is a breast abscess treated?

Answer 41

US guided drainage | antibiotics

Question 42

What takes place during breast screening?

Answer 42

- Mammography alone - for women aged 50-70 (extended trial elsewhere in UK) - screened every 3 years - Annual screening offered from age 40 if Moderate Family risk - Annual MRI offered if HIGH risk (e.g. BRCA)