Breast Imaging PBRE 2 Flashcards
(116 cards)
1
Q
Breast cancer survival is influence by what factors of the tumor?
A
Size of tumor
and
lymph node status
At the time of diagnosis
2
Q
What is the goal of screening asymptomatic women?
A
Find breast cancer in its earliest stages
3
Q
Defined as those that are noninvasive or invasive but less than 1 cm in size with negative nodes
A
Minimal cancers
4
Q
Starting age of annual screening?
A
40 - American College of Radiology and Society of Breast Imaging
45 - American Cancer Society
5
Q
Factors known to increase a woman’s risk for breast cancer
A
- History of breast or ovarian cancer
- Laboratory evidence (carrier of BRCA1 or BRCA2 genetic mutation)
- Having a mother, sister, or daughter with breast cancer
- Atypical ductal hyperplasia or lobular neoplasia diagnosed on a previous breast biopsy
- History of chest irradiation received between the ages of 10 and 30 years
6
Q
In addition to mammographic screening - women who are at high risk should undergo what screening modality?
A
Screening MR
7
Q
If patient cannot undergo MR screening, what modality can be used?
A
Screening with US can be considered in high-risk women who cannot undergo MR screening
8
Q
Is screening mammography required for:
Women with reconstructed breast without native breast tissue after mastectomy
A
No
9
Q
Is screening mammography required for:
Women with implants for breast augmentation
A
Yes
10
Q
How many mammographic views are performed per breast in patients with implants?
A
Four
Standard CC and MLO plus two implant-displaced views
11
Q
What are the two most widely used materials in breast implants?
A
Silicone and Saline
12
Q
These implants appear uniformly hyperdense on mammography
A
Silicone implants
13
Q
These implants appear less dense than silicone, where the x-ray beam is able to penetrate the filling material
A
Saline implants
14
Q
What is the body’s reaction after implants are placed?
A
Generates a fibrous capsule
15
Q
Locations of implants
A
Subglandular
and
Subpectoral
16
Q
Location of implant that is less associated with capsular contracture
A
Subpectoral implants
17
Q
This is a clinical diagnosis where there is abnormal constriction of the fibrous capsule on the implant
Patient states the implant feels abnormally spherical and firm
A
Capsular contracture
18
Q
What implant, when ruptured, will be decompressed and retracted against the chest wall?
A
Saline implants
19
Q
Why is silicone implants rupture more difficult to evaluate on MR?
A
Because of the density of the silicone filling
20
Q
What imaging study is most sensitive for evaluation of silicone implant rupture?
A
MR imaging
21
Q
Bonus question:
Linguine sign:
A. Intracapsular rupture
B. Extracapsular rupture
A
A. Intracapsular rupture
22
Q
Also referred to as three-dimensional mammography?
A
Digital breast tomosynthesis
23
Q
In DBT patient is positioned exactly as standard digital mammography during DBT
What is the difference?
A
Image acquisition:
The x-ray tube pivots in an arc while the patient and the breast remain stationary
*Images consist of multiple thin (1 mm) “slices” of breast after reconstruction
24
Q
Advantages of of DBT?
A
Differentiating true masses from superimposing breast tissues
25
Classic mammographic signs of malignancy?
Spiculated masses or pleomorphic clusters of microcalcifications
*Only 40% of all breast carcinoma presents in these ways
26
Composition of breast (regarding breast density)
Radiopaque breast parenchyma
and
Radiolucent fatty elements
27
Four mammographic density categories (BI-RADS)
a. Almost entirely fatty (<25%)
b. Scattered areas of fibroglandular densities (25% to 50%)
c. Heterogeneously dense, which may obscure small masses (50% to 75%)
d. Extremely dense, which lowers sensitivity of mammography (>75%)
28
Imaging modality that has proven to reduce breast cancer mortality
Mammography
29
Examples of functional imaging of the breast
Contrast-enhanced spectral mammography
Breast-specific gamma imaging
30
Imaging modality that aids in the detection of increased blood flow associated with breast cancer
Contrast-enhanced spectral mammography
31
Imaging modality that employs the use of technetium-99m sestamibi to detect malignancy
Breast-specific gamma imaging
32
Indications for diagnostic mammography
1. Recent abnormal screening mammogram
2. Current sign or symptom of malignancy
3. Being followed for a probably benign finding
4. Have a personal history of breast cancer
33
In diagnostic mammography:
This is used to evaluate equivocal findings seen on full-field mammographic views
Spot compression views
34
Some benefits of compression (mammography)
1. Decreases breast thickness to improve contrast
2. Reduces blurriness of the image
3. Displaces glandular tissue
35
Characteristic of breast cancers in contrast to glandular tissue (during compression)
Breast cancers tend to be firm and not easily compressible - Less displacement
Glandular tissue is easily displace
36
Why is breast cancers firm and not easily compressible?
Due to desmoplastic response initiated by some tumors
37
Any indeterminate mammographic finding the persists after spot compression views should further be evaluated with what modality?
Ultrasound
38
Most microcalcifications recommended for biopsy result in:
Benign or malignant?
Benign (70 to 80% of cases)
Can be a sign of underlying malignancy- Most commonly = ductal carcinoma in situ
39
View to evaluate milk of calcium
Lateral projection (instead of MLO)
40
Diagnostic mammographic view:
Use to determine whether lesion is real or is a summation shadow
Spot compression
41
Diagnostic mammographic view:
Use for better definition of margins of masses and morphology calcifications
Spot compression with magnification
42
Diagnostic mammographic view:
Use to show lesions in outera aspect of breast and axillary trail not seen in CC view
Exaggerated craniocaudal
43
Diagnostic mammographic view:
Use to show lesions in in postermedial breast not seen in CC
Cleavage view
44
Diagnostic mammographic view:
Use verify true lesions and show palpable lesions obscured by dense tissues
Tangential view
45
Diagnostic mammographic view:
Use verify true lesions and determine location of lesion seen in one view by seeing how location changes
Rolled views
46
Diagnostic mammographic view:
Use to improve visualization of superomedial tissue
It also improve tissue visualization and comfort for women with pectus excavatum, recent sternotomy, and prominent pacemaker
Lateromedial oblique
47
Ultrasound appearance of a cyst
Circumscribed, anehoic masses, usually with posterior acoustic enhancement
48
Ultrasound apperance of fibroadenomas
Circumscribed, oval, and homogeneously hypoechoic
49
BI-RADS category of fibroadenoma
BI-RADS 3: Probably benign
50
Initial imaging modality is based on age
What are the initial imaging recommendation for a palpable breast mass?
<30 years - US
30-39 - Mammography or US
> 40 - Mammography
51
Mastalgia can be divided into two types of pain
Cyclic breast pain
| Noncyclic breast pain
52
This is defined by intermittent breast pain the spikes during the luteal phase, right before the menses, and is thought to be primarily hormonal in etiology due to its relatioship to the menstrual cycle
Cyclic breast pain
Pain or tenderness is also associated with swelling in the breasts
Usually, no imaging evaluation of cyclic breastis necessary (likelihood of malignancy is low)
53
Breast pain that tends to be unilateral and more focal than cyclical breast pain
Noncyclical breast pain
54
Imaging used for evaluation of noncyclical breast pain
Mammography is usually performed for women older than 40
Ultrasound - younger than 30
Mammo/US - between 30-39
Similar to palpable breast mass recommendation
55
Preferred imaging modality in young and pregnant women
Ultrasound
56
Categories of nipple discharge
1. Pathologic nipple discharge
| 2. Physiologic nipple discharge
57
Nipple discharge that present as serous or bloody in color, spontaneous, unilateral, and arising from a single duct
Pathologic
58
Nipple discharge that can be green, yellow, or milky in color, spontaneous, bilateral, and usually from multiple ducts
Physiologic
59
Most common cause of pathologic nipple
Intraductal papilloma
60
Region in the breast - where most lesions cause nipple discharge
Retroareolar region
61
Next step if mammography and ultrasound are negative
Galactography (AKA ductography) and breast MR imaging - have been demonstrated to be useful in the evaluation of pathologic nipple discharge
62
Modality of choice of initial evaluation of breast inflammation
Ultrasound
Patients cannot tolerate the compression of mammography
63
Ultrasound characteristic of mastitis
1. An area of heterogeneous altered echotexture from the edema within the parenchyma
2. Skin thickening
3. Increased vascularity
64
Ultrasound characteristic of abscess
An irregular, indistict, heterogeneously hypoechoic collection
Sometimes with multiple loculations
65
Important mimicker of infection mastitis
Inflammatory breast cancer
66
When is inflammatory breast cancer considered?
If the patient is older and antibiotics do not provide complete resolution within 1 to 2 weeks
67
Imaging findings of inflammatory breast carcinoma
1. Diffuse breast enlargement
2. Diffuse increased density
3. Skin thickening
4. Enlarged axillary lymph nodes
68
Paget disease should be considered in what clinical presentation?
Itching, eczema, or ulceration of the nipple
69
Disease that is characterized pathologically as invasion of the epidermis of the nipple by malignant cells
Paget's disease
70
Diagnostic standard for the diagnosis of Paget's disease
Biopsy
71
Axillary lymph nodes are visualized on what mammographic view?
MLO
72
Mammographic appearance of pathologic axillary nodes
Homogeneously dense and enlarged
73
Coarse calcifications in axillary nodes may reflect what disease?
Granulomatous disease
74
On ultrasound
Benign or normal lymph nodes have a hyperechoic hilum with a thin hypoechoic cortical rim
What is the upper limit of normal cortical thickness?
It ranges from 2.3 to 3 mm
75
Deposits in the lymph nodes that create focal hypoechoic cortical thickening or complete replacement of the lymph node
Metastatic deposits
Results in absence of fatty hilum
76
Appearance of a normal male breast on mammography
It appears as a mound of subcutaneous fat without glandular tissue
77
Most common indication for imaging the male breast
Gynecomastia
78
Benign proliferation of ductal and stromal tissue in men
Gynecomastia
79
Etiologies of gynecomastia
```
Idiopathic
Drugs
Cirrhosis
Hypogonadism
Hormone-secreting neoplasms
Hyperthyroidism
Chronic renal disease
```
80
Drugs that can cause gynecomastia
```
Anabolic steroids
Leuprolide acetate
Thiazide
Spinorolactone
Digitalis
Marijuana
```
81
Initial imaging recommendation for palpable male breast mass
<25 is ultrasound
| > or = to 25 is Mammography
82
Mammographic finding of gynecomastia
Appears as a triangular or flame-shaped area of subareolar glandular tissue that points toward the nipple with fat interspersed within the parenchymal elements
83
What are the three patterns of gynecomastia?
Nodular
Dendritic
Diffuse glandular
84
Accounts for about 80% of the breast cancer types in men
Invasive ductal carcinoma
85
Any palpable abnormality on the mastectomy side should be assessed with what modality?
Ultrasound
To evaluate for possible recurrence
86
What modality should still be performed for women who underwent breast conservation therapy?
Annual mammography with either 2D or DBT
To detect any evidence of recurrence
87
These are common findings within the first year of surgery
Mass-like postoperative fluid collections
88
Lumpectomy site is commonly associated with what findings?
Scar formation and dystrophic or fat necrosis calcification
Instead of mass
89
Appearance of scar formation on mammography?
Architectural distortion
Which either stabilizes or diminishes in conspicuity over the years
90
These are common findings if the patient receives radiation treatment
Breast edema and skin thickening
91
What are the mammographic evidence of recurrence?
1. Enlarging masses
2. Developing asymmetries
3. New or increasing suspicious calcifications within or adjacent to the lumpectomy bed
92
Indications for breast MRI
1. Breast cancer screening of high-risk patient
2. Preoperative staging of breast cancer
3. Postoperative evaluation in women with positive margins after lumpectomy
4. Monitoring response to neoadjuvant chemotherapy
5. Detection of mammographically occult malignancy in patients with axillary nodal metastasis
6. Work-up of nipple discharge (selective)
7. Evaluation of silicone implants
93
Imaging modality that can distinguish scar and fibrosis from recurrence in women status post breast conservation therapy
MRI
94
MR imaging can visualize structures outside the breast parenchyma
What are these structures?
1. Axilla
2. Dome of the liver
3. Mediastinum
4. Bones of the ribcage and sternum
95
Most common sites for breast cancer metastases
```
Bone - MC
Lung
Brain
Liver
Lymph nodes
```
*In descending order
96
Diagnosis of saline implant rupture does not require MR
True or False?
True
It can be diagnosed clinically by rapid breast shrinking and can be seen as collapsed or absent implant on mammography or US
97
It comes from the collapsed implant membrane (dark signal) layering dependently in the silicone (bright T2)
Linguine appearance
98
Silicone signal is seen outside the dark fibrous capsule
Extracapsular rupture
99
Screening breast MR shoud be performed when?
During the first half of the menstrual cycle
| days 3 to 14
100
Features of a focus that re more typical of malignancy
1. Dominant or single focus, one that does not have features suggestive of a lymph node (no fatty hilum)
2. Change from prior examination
3. Associated suspicios kinents (washout delayed pattern)
101
If a focus is hyperintense on T2, it is more likely malignant
False
It is more likely benign
Especially if it is stable and have a fatty hilum or persistent delayed kinetics
102
Differential diagnosis of a focus on breast MRI
1. Intramammary lymph node
2. Papilloma
3. Small fibroadenoma
4. Fibrocystic changes
5. Usual ductal hyperplasia
6. Atypical ductal hyperplasia
7. Invasive ductal hyperplasia
8. Ductal carcinoma
103
Defined as a unique punctate enhancing dot, usually < 5 mm that lacks features of a mass
Focus
104
It describes shape, margin, and internal enhancement characteristic
Needs to be 3- dimensional with convex outward margins
Mass
105
Most concerning internal enhancement pattern
Rim-enhancement
106
Most concerning shape
Irregular
107
Defined as enhancement that is not a mass nor a focus and stand out compared to BPE
Nonmass enhancement
108
Most common cause of of nonmass enhancement
Fibrocystic changes
109
Most common malignancy to present as nonmass enhancement
Ductal carcinoma in situ
110
Differential Diagnosis of nonmass enhancement
1. Fibrocystic change
2. Inflammatory benign lesion
3. Usual ductal hyperplasia
4. Atypical ductal hyperplasia
5. Invasive lobular carcinoma
6. Ductal carcinoma in situ
111
Complications of image-guided biopsies
1. Hemorrhage
2. Infection
3. Pneumothorax (rare)
112
Indications for surgical excision
1. Needle biopsy results
(Malignant, Benign discordant, Atypia)
2. Unsuccessful image-guided biopsy
(Tissue too thin to perform need biopsy, location inaccessible, patient factors)
3. Patient preference
113
This is indicated for women with spontaneous, unilateral, single duct clear, or bloody nipple discharge
Galactography
Often conventional imagings are normal
114
Differential diagnosis for suspicious nipple discharge
1. Ductal carcinoma in situ
2. Papilloma
3. Duct ectasia
4. Mastitis
5. Fibrocystic changes
115
Reasons why galactography can be unsuccessful
1. Failure to elicit discharge
2. Failure to cannulate the duct
3. Extravasation of contrast material through the duct wall
4. Imaging of the incorrect ductal system
116
A contraindication to galactography
Allergy to iodinated contrast material
