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08) Modalities & Interventional Procedures (pgs 153-171)

Terms in this set (45)

Other Breasts Imaging Studies

1) Digital Tomosynthesis - DBT
2) Ultrasound
3) MRI

Interventional Procedures
1) Ductography/Galactography
2) Cyst Aspiration
3) Fine needle aspiration
4) Core Biopsy
5) Clip Placement
6) Needle Localization
7) Specimen radiography
8) Sentinel Node Procedure
""
Extra info not from MTMI

The sentinel nodes are the first few lymph nodes into which a tumor drains.

Sentinel node biopsy involves injecting a tracer material that helps the surgeon locate the sentinel nodes during surgery. The sentinel nodes are removed and analyzed in a laboratory.
""
1) Compression creating an overlapping in breast tissue, causing a fake mass (psuedomass) is called _____________

2) Even with FFDM (which is what?) imaging is limited to ____D image of any position taken.
1) summation artifact

2) FFDM = Full Field Digital Mammography
images limited to 2D
DBT
1) Stands for?

2) Predicted to replace Digital mammography T/F?

3) What percentage of breast cancers are detected with 2D mammography? ____% to ____%
1) Digital Breast Tomosynthesis (DBT)

2) True

3) 70% - 85%
DIGITAL BREAST TOMOSYNTHESIS

1) Takes multiple images of each breast from many ______

2) "Positioned the same as a mammogram"

3) X-ray tube moves in arc around breast.
Exam duration is (#) seconds and takes (#) images

4) Can have issues with _______

5) Images are processed by computer to produce ___D images

6) Research says makes malignancies easier to see in ____ tissue (type of breast tissue)
1) angles
2) ""
3) 7 seconds and takes 11 images (study tip: 7-11)

4) motion

5) 3D

6) dense
DBT possible board points:

1) Explain to patient: it takes slices through anatomy like a cat scan.
2) Dose is a little higher
3) Longer Exposure, so must not breathe
""
Breast Ultrasound

What are the indicators for Ultrasound? (info only)

1) Abnormal mammogram
2) Clinical symptoms
3) Screening
4) Guidance for Intervention
""
Breast Ultrasound
1) In U/S fat is good or bad?
Note: unlike Mammography, where fat is good.

MRI
2) MRI does/doesn't show spiculation very well?
1) Fat is not our friend in U/S!

2) Does not
Implants - Sonography

1) Fibrous capsule
2) Anterior surface of an elastomer shell
3) Posterior surface of the shell
""
BENIGN LESION Features
BOARD STUFF!!
1) Are the margins defined well or poorly?
2) Borders are smooth or rough?
3) Microlobulations or Macrolobulations?
4) Round, oval, _____ than tall
5) Anterior or Posterior Enhancement?

6) Echogenicity:
(a) Anechoic: ___ internal echoes. appears _____
(b) Mildly hypochoic: echoes are ________ than fat
(c) Hyperechoic: echoes ________ than fat
1) well defined
2) smooth
3) Macrolobulatoins
4) wider
5) Posterior

6) Echogenicity
(a) No internal echoes. Appears black
(b) darker gray than fat
(c) brighter gray than fat
Echogenicity - Benign (U/S)

Compared to FAT!

1) Cyst is _________ with ________ enhancement.

3) Echoes darker gray than fat is _____

4) Echoes lighter gray than fat is ______
1) anechoic with posterior enhancement


3) hypo-echoic

4) hyper-echoic

Study tip: brighter means more echo.
So darker means either
no echo (anechoic/black)
or
less echo (hypoechoic/darker grey)
Mammography sees early stages of cancer (like calcifications)

but

Ultrasound sees other cancers better like lobular cancers
info only
Cyst contents
Simple Cyst

1) "Thin, watery fluid"
2) Rough or smooth borders?
3) What type of echoic?
4) "Can be round or oval""
5) _______ enhancement
6) If there is ___ % or more suspicion of malignancy, a biopsy is recommended.

Note: cystic and solid lesions that have thick walls and other suspicious features are not simple cysts and may need aspiration and/or biopsy
1) ""

2) smooth borders

3) anechoic

4) ""

5) posterior enhancement

6) 2% or more suspicion - so basically almost ANY suspicion at all, it should be biopsied.
Posterior Enhancement refers to a ________
bright echo
SUSPICIOUS Lesion Features

1) Borders are regular or irregular?

2) Microlobulations or Macrolobulations?

3) More tall than wide? Or more wide than tall?

4) Type of echoic?

5) "Have angular or ill-defined margins"

6) Anterior or posterior shadowing?

7) Color shows _________ within lesion
1) Irregular

2) Microlobulations (BUMPY)

3) More TALL than wide.

4) hypo echoic (solid)

5) ""

6) Posterior shadowing (not posterior enhancement)
study tip: "shadow of doubt = suspicious"

7) blood flow

Note: Mostly all the same as Mammography
MRI

1) If there are inconclusive masses on Mammogram AND Ultrasound??? MRI can have improved tissue ___________

2) Because malignancies are ____________, the malignancies are enhanced using the most common contrast agent __________

3) MRI is BEST for evaluating patients who have _______
1) improves tissue contrast

2) hypervascular
Gadolinium

3) Implants
*Indications for Breast MRI* (info only)

1) New cancer staging
2) Implants
3) Evaluation of scarring (reconstruction or therapy)
4) Problem solving post surgery.
5) residual or recurrent CA
6) Monitoring of neoadjuvant chemotherapy
7) Searching for primary tumor
8) Screen for high risk patients
Re: number 6)

Neoadjuvant therapies are delivered before the main treatment, to help reduce the size of a tumor or kill cancer cells that have spread.
Breast MRI

1) Cancerous lesions take up/release contrast fast or slow?

2) Benign lesions take up/release contrast fast or slow?
1) fast
2) slow
Breast MRI pitfalls and precautions

1) MRI is more _____ than mammo and U/S
2) Can have ________ when actually benign masses
3) Only effective in _____% of patients with DCIS but...
4) very effective with patients who have ______ or ______
5) Frequently a _______ *re-evaluation* is necessary

If a patient asks why doing Mammo when they are having an MRI:
DCIS is the earliest detectable stage of CA.
DCIS doesn't show well on MRI.
DCIS shows well on Mammogram.
1) expensive
2) false positive
3) 50%
4) dense breasts or implants
5) ultrasound
*Invasive Procedures* (list only for overview, detailed slides later)

1) Tech is responsible for informed consent
2) Aseptic Technique is used
3) Galactography
4) Cyst Apsiration
5) Abcess drainange
6) Fine Needle Aspiration
7) Core Biopsy
8) Vacuum assisted biopsy
9) Needle localization/Surgical biopsy
10) Sentinel node biopsy
""
Stereotactic Breast Biopsy
(Aseptic Technique)

Combines _______ and _________ - assisted biopsy to obtain tissue from a breast lesion.
Combines mammography and computer-assisted biopsy to obtain tissue from a breast lesion

For context only: stereotactic = relating to or denoting techniques for surgical treatment or scientific investigation that permit the accurate positioning of probes inside the brain or other parts of the body, based on three-dimensional diagrams.
Galactography aka Ductography

1) Done to evaluate the _________ when there is spontaneous ___________

2) _______ are injected into the discharging duct to look for _______ (or "filling defect")
1) lactiferous ducts
nipple discharge

2) contrast agents
blockage or filling defect
Galactography Indicatons

1) Before or after negative mammo AND ultrasound?
2) Patients with spontaneous non-milky discharge are usually uni or bilateral? Note, can be bloody.
3) Discharge has cytology that is ___________
4) Not one image, but a ________. After contrast. Duh
5) Does galactography require magnification?
1) After negative Mammo and US. Invasive, so don't want to do it straight away!

2) usually uni-lateral

3) atypical

4) series of photos after contrast is injected. dynamic?

5) Magnification is necessary
Galactography

Causes of nipple discharge and/or filling defects

1) Benign (2)

2) Malignant (2)
1) BENIGN:
a) Intraductal papilloma
b) Duct ectasia (dilation or distention)

2) MALIGNANT:
a) Intraductal Papillary CA
b) DCIS

Study tip: they are essentially the same, except with our without cancer.
Aspiration and Drainage/ Cyst Aspiration

Indications for cyst aspiration

1) Cystic lesions that have thick _______ and other suspicious features are not simple cysts and may need aspiration

2) _________ relief

3) Eliminate mammographic ______
1) walls

2) pain/symptom relief

3) masses
*Cyst Aspiration*

1) After a local ________ is given, *fluid* is drawn from a cyst that is large or causes the patient _______

2) What modality is usually used to assist the physician during the aspiration?

3) The *cytology fluid will only be evaluated* if the ______ is suspicious to the Radiologist.
1) anesthetic
pain

2) sonography

3) color
Abscess DRAINAGE
1) Most are ________ mothers.
2) Breastfeeding causes ________ with medications

INDICATIONS
3) Patient with an infection fluid collection that is not responding to __________.
4) May have to be _______
1) breastfeeding mothers
2) contraindications
3) antibiotics
4) repeated
Fine needle aspiration (FNA)
Like cyst aspiration, but different needle used

1) Local ______ is applied, then a fine needle ( ___ to ___ gauge) is used to aspirate ___________

2) "Adequate tissue sampling is usually assured by bedside evaluation of the cells!"

3) A __________ will be present and prep the sample by placing the cells on a glass slide and applying a ________

4) It is cytology vs histology
1) anesthetic
aspirates cells
18 - 25 gauge (memory trick: 18 x 24 cm IR in film for mammo)
aspirates cells

2) ""

3) cytotechnologist
stain

4) ""

study tip: "FINE" it is small, detailed = cells, not tissue.
Fine needle aspiration (FNA)

Indications

1) _________ guided FNA is used when small lesion is not ______ malignant

2) Yields cytologic evaluation of _______ rather than a histologic evaluation of a _____.
1) Ultrasound guided
not clearly malignant

2) cells
tissue (which is a core biopsy)
*Fine needle aspiration (FNA)*

Advantages

1) LESS invasive than core biopsy
2) Local anesthesia may be used
3) Safer, minimal complications
4) Cost effective
5) Results in <1-2 hours

Disadvantages on back
Disadvantages

1) Possible false negative due to small sample size
2) Cytologic evaluation doesn't differentiate in situ from invasive cancer
3) Not used for sampling microcalcifications
Core Biopsy - (No Vacuum)
Note: has replaced FNA

Indications
1) _____ guidance ONLY
2) Solid lesions with other ________ features should be biopsied
3) Lesions near _____ _______
4) Patients w/ bleeding or clotting disorders where vacuum assistance may be _______
1) ultrasound guidance

2) suspicious features

3) near chest wall

4) contraindicated
Core Biopsy (No Vacuum)
Technique

1) Uses a ____ to ____ gauge needle.
2) Special needle called a ___________________ needle. Spring loaded design, short or long throw
3) ________ (modality) is used to guide and direct the biopsy in real time
4) ___ to ___ passes are required for specimen retrieval
(needle has to go in and out of breast at each pass!)

Percutaneous disposable needles
1) 14-16 gauge needle, so kinda big because it needs to rip out chunks (eew!)
Memory trick: not a wide range of gauges.

2) *core tru-cut biopsy needle* (very similar to procedure name)

3) sonography

4) 3 to 5 passes
Core Biopsy (no vacuum) (info only)

Advantages
1) Less Invasive than the open surgical biopsy
2) Requires small incision, and only a local anesthetic
3) Sample volume is enough for histologic evaluation
Disadvantages on back
Core Biopsy

Disadvantages
1) Risk of bleeding, infection or hematoma
2) Dense lesions are difficult to sample
3) Histologic analysis usually requires a minimum of 24 hours
Vacuum assisted core biopsy
Indications

1) Solid lesions with other suspicious features should be ___

2) Most ______ type of imaged guided biopsy, used for stereotactic, ultrasound, MRI and Tomo guided biopsies

3) ____ to _______ gauge automated sampling system
(study tip: half the gauge of non-vacuum core which is 14-16)

4) After _______ anesthesia, _____ inch skin incision is made

5) Needle enters lesion how many times?
Then sampling notch is ________.
(remember needle enters 3-5 times with non-vac core biopsy)
1) biopsied

2) most common

3) 7 - 14 gauge (big-ass thing)

4) local
1/4 inch skin incision

5) once
rotated
Vacuum Assisted Biopsy*
Advantages
1) Less invasive than surgical Bx - local anesthetic
2) Greater accuracy sampling dense masses
3) Vacuum assisted one needle pass
4) Small lesions may be completely excised
5) Less cost

Disadvantages on back
Disadvantages

1) Greater risk of bleeding, infection, hematoma or other complications
2) Healthy tissue may be compromised
Clip Placement
1) Metallic clip placed in breast after a _______
2) Made of?
3) Placed so we can keep track of the area in the following years. If the area needs to be surgically removed, the clip will be removed at that time.
1) biopsy
2) Titanium
3)""
Localization
Indications

1) Placement of a ______________ needle wire for pre-operative guidance in locating:
a) ___________ - proven breast cancer OR
b) ________ risk lesion
c) palpable or non-palpable breast lesions?
1) percutaneous
a) biopsy proven breast cancer
b) high
c) non-palpable breast lesions
think: if it was palpable, surgeon wouldn't need needle loc, they could just "feel" it.
Localization

1) ______ goes in first to position the ________
2) The needle comes out and the _____ stays in
3) The wire guides the surgeon to the _______
4) This can be done using what modalities? (4 - and not all are the 'usual')
1) Needle goes in first to position the wire
2) wire
3) mass
4) Mammo, Ultrasound, Digital Breast Tomosyntheses and CT
Needle Localization

1) It is desirable that the needle goes ______ the lesion.
2) How far past the lesion?
3) Marker placed on abnormality as per physician preference
4) What view will show the "true" location?
1) THROUGH the lesion
2) 15 mm past the lesion
3) ""
4) lateral
Sonographic Needle Localization (info only)

1) Locate the mass
2) Position the transducer along the shortest path to mass
3) Determine needle approach
4) Remember location technique must be see in 2 planes
5) Needle positioned 15 mm deep to lesion
""
Localization

1) Following localization using a ____ wire, the pt is taken to surgery

2) Surgeon removes the ______ along with the surrounding breast tissue. Hope it to remove as little tissue as possible, but get all malignancy out.

3) "Post procedure mammography is performed"
1) hook wire
2) wire
3) ""
Localization - Specimen

An x-ray of the specimen is taken to assure that the area of __________ and/or the ______ is in the excised tissue.

2) "Specimen is sent to pathology lab for examination and interpretation"
a) area of interest
b) clip
Sentinel Node Procedure

1) The first __________ that drains lymph from a specific area of the body.

2) Determines if newly diagnosed breast CA has ________ to the sentinel node.
1) lymph node

2) metastasized

Notes from Quizlet: Uses dye and radioisotope that are injected around a previously confirmed breast cancer
Take place 2-4 hours prior to surgery
Uses a combination of dye, saline, and radioactive isotope
If the Sentinel node is cancer free there is a 95-100% likelihood of clear axillary nodes
Sentinel Node Procedure
1) _______________ (tough one) and radioactive ________ are injected at the site of the lesion
.
2) ____ hours prior to surgery.

3) A ______ detector is used to locate the path of ______ from the ______ to the lymph nodes.
1) Isosulfan Blue (a type of contrast for lymph)
radioactive isotopes

2) 2 hours prior to surgery.

3) gamma detector
path of drainage
tumor to the lymph nodes
Sentinel Node Procedure

1) Intra-operatively, the surgeon uses a hand held __________ and the sentinal nodes are ___________

2) Most useful in patients with ________ (big or small?) primary cancers that are most likely node negative or those the have microscopic involvement.
1) gamma detector
removed

2) small

think: if they're very small, they're harder to find. this procedure seems very involved so it would likely only be done in these circumstances.
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