Breast Imaging

Question 1

what is the triple breast assessment

Answer 1

clinical
radiological (mgm, USS)
pathology (image guided core biopsy)

Question 2

where do most breast cancer occur

Answer 2

in upper outer quadrant (more fibroglandular tissue in outer breast)

Question 3

why is breast density important

Answer 3

high breast density increases cancer risk and also makes them harder to see on mgm
density decreases with age

Question 4

what are the pros and cons of mammograms

Answer 4

pros- images whole breast, 2-3 views, high sensitivity for DCIS and invasive cancer, screening reduces population mortality

cons -screening overdiagnosis and false positives (1 in 5 +ves will have cancer), small radiation dose, can be uncomfortable (breast compressed),

Question 5

what can cause calcification

Answer 5

duct ectasia

DCIS (cell necrosis)

Question 6

what is tomosynthesis

Answer 6

3D mgm (increases sensitivity)

Question 7

what is contrast enhanced spectral mgm

Answer 7

identifies contrast enhancement in the breast with Iv injection of iodinated material, low energy image and high energy image, subtract these from each other to show what contrast is enhancing- good for removing density of breast from image

Question 8

when is USS better than mgm

Answer 8

if patient symptomatic

better for seeing lumo

Question 9

what are the indications for USS

Answer 9

palpable mass, mmg detected lesion, image guided biopsy, breast inflammation, breast problems during pregnancy (have very dense mammograms when pregnant)

Question 10

what are the pros of USS

Answer 10

Doesn’t use radiation, not uncomfortable. good sensitivity for invasive cancer, can differentiate cystic from solid, cheap, image guided biopsy, quick and tailored to one area.

Question 11

what are the advanced forms of breast USS

Answer 11

shear wave elastography (assessment of anatomical structures, measures the stiffness of the tissue, strain produced by waves in USS probes probe measures how fast is goes through tissue- soft faster, red stiff yellow soft), 
contrast enhanced (allows assessment of perfusion, IV agents, 2d or 3d), 
strain elastography (same as shear wave except strain created by pressure of probe)

Question 12

why is shear wave elastography good

Answer 12

measures the stiffness of the tissue- benign lumps are soft, cancer and the surrounding stroma are stiff
good at differentiating masses seen on greyscale USS

Question 13

what makes breast cancers stiff

Answer 13

due to the collagen in the stroma- poorly aligned, varies in size, cross links

Question 14

why is tumour stiffness important

Answer 14

Turmour stroma important in predicting prognosis, why stiffness is important to know. Higher the grade more stiff

Question 15

what USS is good at detecting lobular breast cancer

Answer 15

elastography

loses cell adhesion molecule E-cadherin= harder to detect on other methods

Question 16

what is the most sensitive test for breast cancer

Answer 16

MRI

Question 17

what are the pros and cons of MRI

Answer 17

pros- very sensitive, most accurate in sizing

cons- increases mastectomy rate without decreasing mortality rate and recurrence or increasing +ve margins

Question 18

when is MRI used

Answer 18

screening for very high risk 
lobular cancers 
those that dont show on mgm 
uncertainty of size of tumour 
when aim is breast conserving Tx and nees size and focality assessment- pagets disease, lobular cancer, mgm occult cancer, downsizing with neo ad chemo

+ve axillary node but normal mgm and US
implant integrity

Question 19

what are the breast biopsy method

Answer 19

core
vacuum (MRI, mhm or USS guided)
FNA (not done these days)

Question 20

what is a stereotactic biopsy

Answer 20

mgm guided

Question 21

what are the commonest causes of breast lump by age

Answer 21

<30 fibroadenoma
30-50 cysts (need oestrogen to get cysts)
>50 cancer

breast cancer under 25 is very rare

Question 22

what lumps can a vacuum biopsy remove

Answer 22

fibroadenoma
papillomas
radial scars

Question 23

what Ix to see if mass solid or cystic

Answer 23

USS

Question 24

when do you do mgm under 40

Answer 24

when red flags for cancer

Question 25

do you need to biopsy a cyst

Answer 25

no

Question 26

what does a spiculate mass on imaging suggest

Answer 26

malignancy

Question 27

what can axillary USS detect

Answer 27

40% of lymph mets by cortical thickness and shape of nodes

Question 28

how is breast cancer staged

Answer 28

operable- only local staging needed

locally advanced/ recurrent- CT chest abdo and pelvis

Question 29

what are common breast met sites

Answer 29

bone, lung, pleura, liver and brain

Question 30

when is nipple discharge worrying

Answer 30

unilateral single duct only
if bloody
persistent
new in development over 50

Question 31

what can cause nipple discharge

Answer 31

invasive cancer
breast abscess
duct ectasia
papillomas

Question 32

what causes breast abscesses

Answer 32

breast feeding

duct ectasia

Question 33

what is the management of breast asbcess

Answer 33

US guided drainage and Abx

Question 34

summarise breast screening

Answer 34

done by mammography alone
Every 3 years aged 50-70.
If moderate FHx get it yearly from age 40.
If very high risk for cancer then get offered MRI screening (BRCA carriers/ similar risk)