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Squamous cell carcinoma of breast

Rare.
Requirement for diagnosis
Single site
No skin thickening
No other breast malignancy present
Path shows squamous cells
No calcifications

US: Hypoechoic. Possible central cystic component -necrosis?

Usually large at presentation (5 cm)
2/3 or so are cystic.

Imaging
No specific appearance, but cystic component and vascularity can be seen on US.

Well defined mass on mammo

Cysts,
Fibroadenoma,
Hematoma,
Lymph nodes,
Primary malignancy,
Papillary
Medullary
Colloid
Metastatic disease and
Phylloides tumor
Scc is rare

Mass with cystic and solid component in breast

phyllodes tumor,
infected cyst,
organizing hematoma,
fat necrosis,
papillary carcinoma,
medullary carcinoma
colloid carcinoma.
SCC is rare.

Diabetic fibrous mastopathy

Benign breast disorder found in patients with Type I Diabetes Mellitus, which can mimic malignancy both clinically and radiographically

Typical patient is young female with a non-tender, firm, mobile, palpable mass. Involvement can also be multifocal or bilateral.

DM usually longstanding, 20 years or more.

Etiology is a secondary immune reaction to accumulation of abnormal matric and proteins resulting in fibrosis

Imaging:
On mammo
Very dense tissue possibly asymmetric
On US
Hypo-echoic lesion with irregular borders and increased posterior acoustic shadowing, and simulates a malignancy. Also can be circumscribed or hypo-echoic without shadowing.
On MRI
Variable depending on fibrous and water content
Biopsy required.
Recurrence common, but no associated risk of cancer.

Sternalis muscle

Rare chest wall musculature variant-unknown function.

Flame-shaped medial density seen on CC mammogram, no corresponding abnormality of MLO view.
1-2 cm in size
Usually smooth contour

Most important differential to rule out is a medially-located mass, which may also hide on MLO view if it's not taken well.

American CA Society recommendations for mamma

Women over 40 yearly
In 20s and 30s clinical exam every 2-3 years
OVer 40, yearly clinical exam

MQSA

Regulates all mammo faciilities.
All must be approved, most by FDA but some states are licenced to approve their own.
Regulates : Training for techs and physicians, reporting, enforcement by FDA, equipment, processing, QC and outcomes data.
There are yearly inspections
Falcification is punishable by prison time.

Lifetime CA risk from mammo

Lifetime risk in average pt is 1:100k, for >65 1:5mil
Chace of finding CA in ave pt is 1:3500, over 65 is 1:1000

Therefore benefit to risk ratio in average pt is 25:1, and in >65, it is 5K:1

Mammo technical considerations

kVp is 24-32 for Mo target and 26-35 for Rh or W. Low kVp needed for increased contrast in body and increased absorption in phosphor

For comressed 5 cm breast, need about 150 mAs for the exam. Machine should be able to provide 5-300 mAs to accomodate different size and density of breast

All have 1/2 v al layer equal to kVp/100 plus .03-.12 in mm of Al (for an Mo-Mo system).

Focal spot is 0.3 mm for nl views, 0.1 mm for mag providing resolution of 11 lp/mm and 13 lp/mm respectively.

Source to image distance is 55 cm for mag views.

Has to have both 18x24 and 42x30 plates.
Grid ratio 3.5-5:1
Colimation is to the plate, not breast contour.
The paddle must have at least 3 cm lip and provide 25-45 lb of pressure for at least a minute.

MQSA mandated QA

Must monitor repeat rate and reason for it
Muast have record keeping
A designated QA person

Daily: Darkroom cleanliness, processor QC.
Weekly: Screen cleanliness, viewbox cleanliness, phantom (must see at least 4 fibers, 3 speck groups and 3 masses)
Quarterly: repeat analysis, fixer retention
6 mths: Darkroom fog, screen-film contact, compression
Annual: physicist analysis

Breast CA risks

Fem and age by for the most imortant

Personal hist of Br CA
1st deg rel with Br or Ov CA, esp if young or bilateral
Early menarche or late menopause
Nulliparous or first after 30
Atypical ductal hyperplasia (4-5 x over gen population)
BRCA 1 (85% Br, 63% ov by age 70) or BRCA (lower, and mostly breast)
Early radiation exposure
Lobular carcinoma in situ (27-30% over 10 yers)
Le-Fraumeni, Cawden and ataxia-telangiectasia

Peau d'orange

Indicated Br edema causing the skin to rise around the tethered hair follicles.
It is nonspecific, occuring iwth inflammatory CA, matitis, lymph node obstruction

Basic gland anatomy

The lactiferous duct leads to excretory ducts, then interlobular ducts and teminral ducts which finally end in the acini.
THere are 15-20 lobes per duct.
Most glandular tussue is in the upper outer quadrant.

Breast density lexicon

Fatty- <25% gland
Scattered fibrogralndular - 25-50%
Heterogeneously dense - 50-75%
Dense - >75%

Nl course is for density to decrease with age.
Dnesity can increase with pregnancy and lactaion, or exogenous hormone therapy. Otherwise interval increase in density is always abnormal.

Common findings of Br. CA

Pleomorphic- CA or benign fat necrosis
Spiculated mass - CA, post op scar, fat necrosis
Round mass - Cyst, Fibroadenoma, CA, papilloma, mets
Architectural distortion - Post-op scar, CA
Developing density - CA, hormone effect, focal fibrosis
Asymmetry (focal or global) - normal in 3%, CA (esp if new, palpable, suspected CA)
Br Edema - Unilateral: mastitis, CA
Br Edema -bilateral: Systematic(liver dis, renal failure, CHF)
Lymphadenopathy - unilateral: Mastitis, CA
Lymphadenopathy - bilateral: systemic (collagen vasc., lymphoma, leukemia, infection,

BIRADS categoris

0 - incomplete. For screeners requiring recall or diagnostics that need mor images.
1,2 - negative and benign, neither requiring further action
3 - probably benign. Needs 6 month f/u
4 - suspicious, needs biopsy. categories a,b and C represent low, intermediate and moderate suspicion.
5 - highly suspicious >95% probability of CA
6 - known CA, pt is getting imaging prior to some procedure etc. after biopsy proven diagnosis.

Screen Mammo

Is done on a non-symptomatic patient. Includes CC and MLO views most commonly

Diagnositc mammo

Is done on a symptomatic pt or pt with abnormal results on a prior screening mammo. Includes additional views for imaging a suspicious finding
Lateral
Spot compression with and without mag
Rolled views.
Releating of same views as before
XCCL and cleopatra views.
Cleavage view.

Cacifications

Breast CA is almost invariably in glandular parenchyma, so calcifications in skin, muscle, nipple (except paget's) is almost invariably benign.
Clustered calcs are more suspicioud than scattered.
When reporting: report size of cluster, location, shape of cluster, characteristics of the worst looking calc, birads, associated findings (mass, distortion, adenopathy, skin retraction, nipple retraction, skin thickening, trabecular thickening)

Amorphous/indistinct calcifications

Indetermintae, tiny, flake shaped. Too small to characterize further. On screening, corelates to DCIS in about 25-48% of cases. If less than 5 calcifications, rarely malignant.

Fine linear or fine branching

Linear branching pleomorphic calcs that represent duct casts. Can be needlelike or dot dash in appearance. X, Y or Z shaped branching is concerning as it is often association with casts in necrotic tissue.

Pleomorphic or heterogeneous

Very tiny, irregular "bizzare broken glass shards formed into rounded pocket of necrotic tumor" appearance.

Calcification cluster shapes

Clustered
Linear
Branching
Segmental

Physiologic causes of gynecomastia

Liver disease
Renal failure
COPD
Diabetes
Hyperthyroid
Hypothyroid
Starvation/refeeding syndrome

Pharmacological causes of gynecomastia

Zoloft
Merijuana
Tricyclics
Spironolactone
Reserpine
Digitalis

Hormonal causes of gynecomastia

Neonatal and adolescent hormonal surges
Decreased hormones in older men
Hormone therapy (estrogen)
Testicle failure
Kleinfelter's syndrome
Hypogonadism

Tumors causing gunecomastia

Lung cancers
Pituitary cancers
Adrneal cancers
Hepatoma
Testicular cancers

Male breast CA

Occurs in less than 1 % of men
Usually at age over 60
The prognosis is the same normalized to same stage
Lymphadenopathy in 50% on presentation due to late presentation

Risks: Kleinfelter's, high estrogen such as prostate CA treatment, mumps orchitis at older age.

Presentation: Usually hard painless lump subareolar or eccentric to nipple or upper outer quadrant. Discharge is not uncommon.

86% is ductal > medullary > papillary > intracystic papillary > invasive lobular (rare as lobeles are rare in men)

Pregnnacy associated breast CA

Defined as CA found during pregnancy or within 1 year of delivery.
Incidence 0.2 - 3.8% of pregnancies
Most are ductal
Generally a hard lump, +/- bloody discharge, breast edema
US exam is first choice, but mammo can be done, backscatter to fetus is minimal. Pump mild first to decrease breast density.

MRI: Breast is highly glandular with diffuse enhancement, but the contrast enhancement of the mass is usually still higher.

Prognosis: same when normalized for stage.

Pregnancy is an absolute contraindication to radiation therapy. Chemo can be done in 2nd and 3rd trimesters.

Lactating adenoma

Occurs late in preganancy (2-3rd trimester) or in the lactation period.
Mammo: Solid, Well circumscribed, lobulated with distended tubules. On path has epithelial lining.
Usually firm, painless, rapidly enlarging during lactation, regresses after cessation of lactation.

US: oval/round/smooth with smooth margins. Can have cystic or necrotic spaces. Hypoechoic with echogenic bands (fibrotic)

Mild fistula

Due to ducts damaged by surgery or biopsy. Presents in 3rd trimester

Galactocele

Mild filled cyst. May have fat fluid level on uprights..

Mammo: usually low or equal density well-circumscribed mass.

US: Cystic or solid-like. Posterior shadowing is possible

Aspiration is therapeutic.

Breast CA doubling times

Usually a bout 100 days. Mass doubling much faster or much slower is usually not CA

Criteria for Bi-RADS 3 classification

Non-palpable mass.
Less than 2% malignant potential.
Occurs on about 3% of screeners

Examples:
Clustered small round or oval calcs on mag view
Noncalcified oval or lobulated well circumscribed solid mass
Asymmetric density resembling fibroglandular tissue

Recommendation is for 6 month follow-up to establish stability of the lesion

Postoperative changes in the breast

Scarring, distortion etc. Seen in about 50% of cases
Should decrease in size eventually stabilizing in the 305 year window.
50-55% have complete resolution
Fhould NEVER increase in size except immediate post-op period.
Fat necerosis is common post biopsy-results in oil cysts
There is strong enhancement up to 9 mths post biopsy or radiotherapy, which subsides in the 10-18 month window.

Contraindications to brast radiotherapy

Pregnancy
Prior radiotherapy (as in failure or recurrence)
Multicentric or diffuse disease
Collagen vascular disease
Poor expected cosmetic result is a relative contraindication

Breast CA recurrence

About 1% per year therefore
about 5% at 5 years and 10% at 10-15 years

Most recurrencese occur in 7 year window, but not earlier than 18 months (guess those are due to incomplete resection?)

High risk for breast CA recurrence

Invasive ductal CA with extensive ductal complnent
Residual tumor
Yonger age at presentation
Lymphatic or vascular invasion
Multicentric or diffuse disease

Breast lymphatics

Level 1: inferolateral to lateral edge of pectoralis minor

Level II: Behind the pectoralis minor

Leve III: Between pectoralis minor and subclavius (Hosted's ligaments)

Chome effects on imaging

Decreases both physiologic glandular enhancement and CA inhancement.
Can change the inhancement curve to a more benign one, but the CA is not gone.
Obtain baseling scan immediately on completion of the chemo

Implant rupture types

Intracapsular: The envelope is broken bu the gel is contained by the vascular capsule.

Extracapsular: Gel globs escape into the tissue

Gel bleed: controversial - gel outside apparently intact envelope. Probably means a tiny rupture thats not visualized.

Implant rupture risks

Increases with implant age
Retroglandular implant
Capsular contracture
Symptomatic
Single envelope type implant
Bad manufacturer

Sequences to get for implant MRI

T1, T2, GRE, STIR NO CONTRAST necessary

Signs of implant rupture

Linguine sign
Keyhole sign
Globs
Snowstorm (US)
Waterdroplets (sensitive bu not specific)

Reconstruction

Most popular is the TRAM: transverse rectus abdominis myocutaneous flap.

Also can do latissimus dorsi with prior tissue expander followed by implant.

DCIS

Can have almost any enhancement curve
Types:
Segmental
linear branching from nipple (which is more rare) Focal mass
Non-specific geographic.

When associated with anothe rtumor may form a surrounding halo with a less worrysome enhancement pattern than the tumor itself.

Common MRI false positives

Mimicks of DCIS
focal fibrocystic changes
hormone related enhancement
focal fibrosis
fibroadenomatous changes

Common false positive mimicking breast CA

Rapid enhancing intraductal papilloma
Avid enhancing fibroadenoma when it also has low T2
Lymph nodes without a fatty hilum
Rim enhancing fat necrosis
Enhancing spiculated surgical scar.

False negatives

Thankfully rare

Non-enhancing DCIS or invasive lobular carcinoma- often with recent or concurrent chemo

Indications for breast MRI

MRCA 1 or 2 positive
Family or personal risk equivalent to BRCA 1 or 2
Obscured breast tissue (implant)

Suspicious lesion seen on 1 mammo view and negative US
Bloody discharge and negative or unsuccessful ductogram
Palpable mass with negative mammo and US

Need to locate breast primary when axillary mets found
To look for chest wall invasion
To evaluate extent when mammo is poor (dense breast, implants)
To evaluate extent of mass that is not seen on mammo (infiltrating lobular CA, DCIS without microcalcs)

To get basline prior no neoadjuvant therapy
To asses response.
To localize potential residual disease when mammo shows complete response.

Daniel calssification

Referrs to the enhansement curves
I: no enhancement
II: Linear continuous
III: Rapid early with slower late inhancement
IV: Early enhancement with late plateau
V: Early enhancement and late washous

Types I and II are benign. III is indeterminate. IV and V are malignant

MRI imaging characteristics

Mass T2 signal = to breast is a milgnant sign.
Mass T2 >> gland is abenign feature
Central enhancement is benign feature
Peripheral enhancing first is a malignant feature

T2 >> gland and rapid enhancing = probably benign such as lymph node or fibroadenoma
T2 >> gland and no enhancing = benign such as a cyst or duct
T2 << gland and rapid enhancing is supicious
T2 << gland and nonenhancing is benign such as sclerotic fibroadenoma

Cyst or duct on MRI

High T2.
Ducts converge on the nipple.
No internal enhancement.
A cyst is allowed to have faint enhancing rim

Hormonal effect on MRI

Causes diffuse increased signal which changes with cycle or with hormone therapy. Best time to scan is 2 weeks post menses for the lowest diffuse signal

Fibrocystic changes MRI characteristics

Focal or regional enhancement especially in premenopausal women.
Usually gradual early with sustained gradual late curve (type II or III)
May have tiny associated microcysts

Lymph nodes on MRI

T2 >> gland
usually <5 mm with uniform high enhancement
Usually type IV or V curve-therefore looks suspicious
Look for the fatty hilum to prove it's a node

Fibroadenoma on MRI

Avid enhancing with dark septa
Yound adenomas are more enhancing.
Old ones are less enhancing and have dark regions corresponding to calcs
Enhancement is central first, usually type III or IV

Invasive ductal CA on MRI

Focal irregular or spiculated mass
Avid enhancing rim first. Enhancing septations. Often type IV curve.
T2 = to gland.

Look for skin/muscle/nipple invasion/distortion

Infiltrating lobular CA on MRI

Highly variale. Enhancement is similar to nl gland tissue.
No substantial mass effect.
Solitary or multiple
Just about any curve pattern

Mucinous CA on MRI

Round.
Central mucin does not enhance and has T2 >> gland.
Irregular/thick/nodular/enhancing rim (the actual mass)
Similar appearance to abscess.

Bi-RADS 2 criteria

Benign findings with no chance of malignancy

Examples:
Involuting calcified fibroadenoma
Multiple secretory calcifications
Fat-containing lesions (oil cysts, lipoma, galactocele, mixed dense hamartoma)
Intramammary lymph nodes
Vacular calcifications
Implants
Scar

Mammo positives and negatives

True positive: CA confirmed within 1 yr of positive mammogram
True negative: no CA within 1 yr of negative mammogram
False negative: Cancer confirmed within 1 yr of negative mammogram.
False positive: 3 types
1 - no CA confirmed within 1 yer of positive mammo
2- no CA identified within 1 year of recommendation for biopsy
3- Benign diagnosis within 1 year of a positive mammo

Mammo predictive values

Since there are 3 types of falswe positives, there are 3 types of predictive values
1 - TP/# of positive screening exams TP/(TP+FP1)
2 - TP/# of screens or diagnostics with recommendation for biopsy TP/(TP+FP2)
3 - Percent of biopsies resulting in positive findings as result of positive screenres or diagnostics. Also known as biopsy yield of malignancy or positive biopsy rate. TP/#niopsies or TP/(TP+FP3)

Terms for benign calcifications

Individual calcs - round, punctate
Clusters - cluster, regional, multiple clusters, diffuse

Terms for suspicious calcifications

Individual - pleuomorphic, fine linear branching, amorphous, coarse or fine heterogeneous, indistinct

Description of many calcs together

Cluster
Linear
Linear branching
Segmental

When reporting calcifications

Size of cluster
location
cluster shape
overall cahracteristics of the worst one
associated findings
any changes from prior
Bi-RADS classification
Management (US, more views etc.)

Skin calcifications

Located peripherally, close to skin surface
Size is similar to skin pores
Look for other pores nearby to confirm location

Common locations:
axilla
inframammary fold
medial part of brest (cleavage)

Plasma cell mastitis

Asymptomatic breast inflammation in older women

Imaging: usually see inspissated calcified secretions

Inflammataion is preductal or intraductal resulting in dense sausage like calcifications with lucent center or large solid rodlike or needle like calcifications respectively

The branching pattern is on order of centimeters since this is a disease of larger ducts. (DCIS branches multiple times within a centimeter since it involves smaller ducts)

Calcifying fibroadenoma

Exactly what it says.

Usual age about 30
Mass is oval, lobulated and = density to glandular tissue
Calcifications are coarse and arise at the periphery and can replace the whole mass giving rise to "fibroid in the breast" appearance.

10-20% are multiple

Dystrophic calcifications

An inflammatory process causes pleomorphic, bizarre shaped calcification.
Look for scars, oil cysts, fat necrosis on prior studies.

Calcifications that simulate DCIS

Skin calcifications
Scattere calcification that coalesce on one view
Sclerosing adenosis
Fibrocystic change

Malignant calcifications most often associated with DCIS

In decreasing order of frequency
Invasive ductal carinoma
Papillary
LCIS

calcifications increase in number over time, but a minority can stay stable in number over time

Bi-RADS mass shapes

Round
Oval
Lobular
Irregular

Bi-RADS mass margins

Circumscribed - least worrysome - <10% CA
Microlobulated - more worrysome
Obscured - by superimposed tissue etc.
Indistinct - the actual border is fuzzy
Spiculated

Last two may represent local infiltration.

Bi-RADS mass density

This is with respect to normal glandular tissue

High - worst
Equal
Low - can still be CA, such as mucinous
Fat containing - always benign except a rare liposarcoma

Bi-RADS associated findings

Skin retractions
Nipple retraction
Skin thickening
Trabecular thickening
Skin lesion
Axillary adenopathy
Architectural distortion
Calcifications

Bi-RADS ultrasound terms

Shape - Oval, Round Irregular
Margin - Circuscribed, Angular, Indistinct, Microlobulated, Spiculated
Boundary - Abrupt interfacr, Echogenic halo
Echo pattern - Anechoic, Hyperechoic, Complex, Isoechoic, Hypoechoic

Entities presenting as spiculated mass

Invasive ductal CA
Invasive lobular CA
Tubular CA
Post-biopsy scar
Radial scar
Fat necrosis (atypical presentation)
Sclerosing adenosis

Incasive ductal carcinoma

Most common CA - accounts for 90% overall
Usually a hard irregular mass

Imaging: Classicly dense, irrregular, spiculated with occasional p leomorphic calcifications and sometimes with DCIS.
US: shadowing is common but not 100%. Spicules are intermediate, appearing dark on dense breast background and light on a fatty background.
MR: Brightly enhancing, +/- spicules, type IV or V enhacement curve

Invasive lobular CA

Usually an equal density maa with spiculation and ill-defined borders.
More often bilateral or multifocal and ductal CA.
Not too frequent, <10% of overall CA

Imaging: often difficult to see on mammo due to single cell strands or sheets habit. Because of this also very infiltrative and non-palpable.
No microcalcifications. Often seen on only 1 view with sbtle architectural distortion.
US: hyperechoic, irregular shape with spiculations or ill-defined border. Can have +/- shadowing even when large.
MR: variably enhancing. Considered better than Mammo, but still not great.

Tubular CA

A slow growing CA, which is 12-40% bilateral on presentation. Has low metastatic rate. Radial scar may be precursor to this CA - controvercial.

Mammo: Dense, spiculated, occasional microcalcification.
US: Hypoechoic, irregular shape. +/- shadowing

Postoperative scar.

Can enlarge in the immediate potoperative period but SHOULD NEVER ENLARGE thereafter. It should contract over a period of years with resulting architectural distortion of surrounding gland tissue.

US: hypoechoic, spiculated, frequently shadowing with distortion of adjacent tissues.
Best thing to confirm is look for prior biopsy sites, history of surgery.

Sclerosing adenosis

Proliferative benign lesion from mammary hyperplasia - fibrous tissue distorts and envelops glandular tissue.
There is sclerosis of surrounding tissues, microcalcification in small ducts. No specific US characteristics.

Radial scar

Mostly benign prolefrative lesion - not an actual scar.
Common finding on biopsies and can not be distinguished form CA.

The central region atrophies pulling in and architecturaly distorting surrounding tissue - in other words, looks a lot like a scar.

Can contain or be associated with atypical ductal hyperplasia or DCIS-therefore excised when found.

Mammo: Spiculated mass appearing as a scar. Center can be dense or dar. May have microcalcs.
US: Hypoechoic, +/- shadowing

Lesions that are can be round

Cyst
Fibroadenoma
Invasive ductal CA
Medullary CA
Mucinous CA
Papillary CA
Intracystic carcinoma
Mets
Phyllodes tumore
Papilloma
Lactating adenoma
Adenoid cystic carcinoma
Sebacious cyst
Epidermal inclusion cyst

Invasice ductal carcinoma

Most common malignancy to present as a round mass (uncommon presentation of very common disease)
The round ones may be the most malignant o wing to very rapid expansion that does not allow for formation of spiculation.
Border may be irregular on alternate view.

US: may have classic taller than wide appearance

Medullary CA

Is a varian of invasive ductal CA, but with a better prognosis

Mammo: hyper or isoenhancing, well circumscribed margins.
US: Round, homogeneous echotecture, +.- shadowing.

Differential includes cyst or fibroadenoma

Mucinous carcinoma

Rare. The malignant cells float in the mucin of their own production within a solid capsule.

US: fluid filled hypoechoic spaces with post-void enhancement.
Not entirely anechoic since the contents are viscous and with cells.

Papillary CA

A rare CA accounting for only 1-2% of total
Is the malignant form of benign intraductal papilloma
Can be single or mutiple on presentation and can be associated with DCIS.
May have calcification, but more often not.

Intracystic carcinoma

Extremely rare
Solid mass in a cyst attached to the wall.
Mammo: may look like a cyst
US: Solid mass outlined by the darkness of the cystic fluid.
Fluid is often hemorrhagic on aspiration
Must be removed

Differential includes intracystic papilloma or a cyst with debris.

Mets

Common sources: are Breast and lymphoma

Usually round, well circumscribed and very dense.

Melanoma and RCC can cause multiple cannonballs appearance.

Multiple lound masses

Cysts
Fibroadenoma
Multifocal breast CA
Mets
Papillomas
Skin lesions (falce mass)

Fibroadenoma

Most common solid benign tumor.
Also most common benign tumor in patients < 30
Considered giant when over 8 cm diameter
Juvenile - self explannatory. These are often giant.

Imaging: Classically oval or lobular, uqual density, smooth margins, very cellular on path. Later on becomes sclerotic and less cellular developing popcorn calcifications peripherally.

US: usually has wider than tall appearance. Allowed up to 4 gentle lobulation. Hypoechoic and may have a cystic component, +/- posterior enhancement or even shadowing.

Contains ductal elements so can include DCIS. Biopsy any suspicious change.

MR: Classic oval or lobulater mass, well circumscribed borders, dark internal sptations, usually type III dynamic curve.

Phyllodes tumor

Mostly benign, 10% malignancy rate. Most common mets site is to lung.
Classically presents in the 40s and already large, up to 5 cm. Rapid growth.

Has stromal and epithelial components and can have fluid componenets

Mammo: dense round/oval/lobulated, no calcifications, smooth borders
US: Smoothly marginated, inhomogeneous echotexture with cystic spaces

Differential includes fibroadenoma, circumscribed CA.

Papilloma

Arises in ductal epithellium. Therefore it is in ducts and often subareolar.

It can be multiple. In that case more often periphreal (in smaller ducts) and more risk of CA.

When in young pt, is a juvenile papilloma

Can twist on its stalk causing ischemia and necrosis, leading to the classic bloody discharge.

Mammo: Round, well circumscribed, equal density mass with calcifications. Often they are not seen.
US: oval/round/microlobulated, often with small cystic spaces in the juvenile type. Can be outlined by the fluid in a dilated duct.

Usually excised since there is arisk for DCIS.

Adenoid cystic carcinoma

Is very rare tumor consisting of mixed glandular and stromal elements.

Presetns as palpable firm mass.
Infiltrates frequently (50% rate)
Since few have been reported, no specific imaging characteristics.

Solid masses with indistinct margins

Invasive ductal CA
Invasive lobular CA
Primary or secondary non-Hodgikin's lymphoma
Breast sarcoma
Squamous cell carcinoma
Focal fibrosis
PASH

Breast sarcoma

Is quite rare. Has malignant stromal elements.

Usually solid with ill-defined margins

Breast lymphoma

Can be primary or secondary
Lymphadenomathy is the most common manifestation. Look for loss of fatty hila.

Primary or secondary Hodgkin's usually infiltrates the breast and looks like invasive ductal CA.

US: Hypoechoic masses

Treatment is chemo/rads, not surgery.

If there is a known primary, this should be the first on differential of multiple masses.

PASH

Pseudoangiomatous Stromal Hyperplasia
Rare benign growing ill-defined non-calcifyign mass.
Round/oval.
Occurs in premanopausal women or potmenopausal on hormone therapy.

Can grow rapidly and can be synced to hormonal cycle

Fat containing masses

Lymph nodes
Hamartoma
Oil-cyst
Lipoma
Liposarcoma
Steatocystoma multiplex

Steatocystoma multiplex

Rare autosomal sominant disease that presents with maultiple intradermal oil-cysts bilaterally, which may be palpable.

Mammo: Bilateral radiolucent masses all resembling oil-cysts, but intradermal rather than in the breast tissue and no history of trauma.

Hamartoma

Mammo: Clasically oval with fat and fibroglandula tissue.
Can have a thin capsule or rim creating "breast within breast" sign.
Appearance is variable depending on ration of fat/stroma
Can develop it's own CA. Biopsy any suspicious changes.

Fluid icontaining masses

Cyst
Necrotic CA
Hematoma
Intracystic carcinoma
Intracystic papilloma
Abscess
Galactovele
Seroma

Do not touch breast lesions

Simple cyst
Scar
Lymph node
Hamartoma
Oil cyst
Lipoma
Hematoma
Seroma
Sebacious cyst
Spidermal inclusion cyst
Galactocele

Abscess

Usually occurs after mastitis, and usually associated with staph or strep
Immunosuppressed and diabetics are at increased risk
Usually subareolar, associated with erythematous skin with thickening and edema.

US: cyst with internal debris and septations.

Sebaceous cyst

Has epithelial lining
Subcutaneous with a little tail extending into the skin.

Epidermal cyst

Looks simial to sebacioius cyst, except has epidermal lining

Nl breast US characteristics

The nipple is hypoechoic
Subcutaneous fat is hypoechoic
Gland is medium
Cooper's ligaments are hyperechoic
Subareolar ducts are hypoechoic and point to the nipple
In juveniles the breast bud may be mistaken for a mass (then the breast does not develop if it gets removed.)

Edema results in graying of the fat and indistinct ligaments

Flatten the breast for US to aviod anisotropy artifact

Simple Cyst

Most common breast mass acccuring in 7-10% of overall population.

Mammo: Can be solitary, multifocal or in clusters. No malignant potential. Waxing and waning course with hormonal cycle.

US benign features of a mass

Elipsoid in horizontal direction (wider than tall)
4 or less gentle lobulations
Homogeneous echotexture
Thin echogenic capsule
and of course NO MALIGNANT FEATURES

US malignant features of a mass

Taller than wide, means it grew down through ligaments
Shadowing
Spiculation
Microlobulation
Microcalcs
Duct extension
Branching bpattern
Angular margins
Markedly hypoechoic to fat

Secondary signs of malignancy in the breast

Calcifications
Lymphadenopathy
SKin thickening
Distortion
Breast edema
Ligamentous retraction

Unilateral breast edema

Mastitis
Staph
Moluscum contagiosum
Rarities (TB, Syphilis, Hydatid disease)
Abscess
Inflammatory CA
Radiation
Lymphadenopathy secondary to obstruction
Coumadin necrosis
Trauma (esp post biopsy)

Bilateral breast edema

Anasarca
CHF
Bilateral lymphadenoapthy
Renal failure
SVC syndrome
Liver disease

Bioipsy results requiring surgical excision

Nonconcordant results
Insufficient sample
CA
DCIS
Atypical ductal hyperplasia
Papillary lesions with atypia
Phyllodes tumor

Lesions that could need biopsy

Radial scar
PASH
Nan-atypical papillary lesions
LCIS
Atypical lubular hyperplasia

Breast MRI

Hihgly sensitive but has low specificity

Try to image 7-10 days post perios for the lowest phase of normal tissue enhancement.

Include T1, T2, fut suppressed and 3d volumetric sequences.

Contrast: dynamic acquisition for about 7 minutes.

MRI benign features

Only mild enhancement
Smooth border or few lobulations
Homogeneous
Septations are nonenhancing
Growth parallel to cooper's ligaments
Microcysts
Type I, II and maybe III dynamic curves

MRI malignant features

Brightly enhancing early, type IV or V dynamic curve
Spiculated or very irregular border
Rim enhancement
Heterogeneous
Septations enhance
Frowth through Cooper's ligaments
Ductal linear branching form

Nipple discharge that is white or colors

Cystic ectasia
Physiologic
Endocrine (lactation or pregnancy)
Tumor (prolactinoma, other such)
Mechanical (trauma)
Drugs (dopamine recptor blockers or dopamine depletors

Nipple discharge that is bloody

Hyperplasia
Papilloma (twisting leads to ischemia, most common)
DCIS
Pregnancy

Nipple discharge principles

Usualy benign if discharge from multiple ducts
Do a ductogram
If unsuccessful or negative - do MRI

Benign intraductal papilloma

Fibrovascular stalk is attached to duct wall. Has ductal epithelium.
Can be single or multiple
Extends along the duct

MR: Small smooth nodule at terminus of a duct, which enhances.
Can be non-enhancing
Can be irregular, rapid enhancing with spicules. This type is not distinguishable from CA.

Look for a mass at the end of a fluid filled duct (not pathognomonic, but helps)

Recurrent abscess

Is secondary to plugging of a duct.
This entity recurrs after draining.
The only treatment is to excise the abscess and the fistulous duct.

Solid mass in a fluid filled cyst

Debris
Papilloma
Intracystic carcinoma etc.

Breast density changes

Occur with hormon cycling or hormone replacement in response to estrogen and progesterone, but not estrogen only.

Drugs:
Raloxifene increases density in rare case
Medroxyprogesterone depot can decrease density
Tamoxifen decreases density in some

Breast pain

Is usually not due to CA

Top differentialss
Monthly physiologic changes
Cysts

Axillary lymphadenopathy

50% of cases are benign
Unilateral:
Mastitis
CA
Silicone

Bilateral:
Infection (TB)
Rhematic disease
Collagen vascular disease
Lymphoma
Leukemia
Mets

Axillary lylmphadenopathy with calcifications

Metastatic disease
Granulomatous
Gold from RA therapy
Silicone to nodes

Mandor's disease

Acute thrombophlebitis of superficial breast veins

Is rare
Often secondary to trauma or surgery (biopsy)
Can be idiopathic

Presents with acute pain and point tenderness along the lateral breast or region of involved vein. THere is a tender palpable cord (the thrombosed vein)

Resolves over 2-12 weeks by recanalization or complete obliteration of offending vein.

Granulomatous mastitis

Rare, usually occurs after childbirth
Associated with:
Breast feeding,
oral contraceptives,
autoimmune diseases

Mammo: can present as asymmetric density, illdefined mass or negative. Does not have calcifications.

US: also variable. Findings aften suspicious leading to biopsy which shows granulomatous changed and giant cells

Treatment is surgical excision, hormonal treatment, methorexate, colchicine

But there is 50% recurrence rate

Desmoid tumor

Local fibromatosis

It is infiltrative and agressive
Can be multicentric
Recurrs after excision, often within 3 years
Associated with prior trauma/surgery or implants

Presentation: classic is a solitary hard painless mass that can be fixed to the skin or pectoral fascia

Treatment is surgical excision with wide margins. Radiation can be considered if surg expected to have ppor outcome

Mammo: spiculated mass - requirs biopsy

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