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MAMMOGRAPHY

BEFORE DOING ANYTHING FURTHER, CHECK THIS OUT:

BREAST ABSORBED DOSE ANNUALLY:

not > than 300 mrem/breast/view

MAMMO RULES (dont ask me how many times I looked at this and still cant remember it):

1 d: processor qc and darkroom cleanliness

1w: phantom, viewboxes, screen cleanliness

1mo: visual checklist

quarterly: fixer retention, repeat analysis, meetings with the radiologist

6mo: darkroom fog, film-screen contact, compression

INCIDENCE OF BREAST CANCER SUBTYPES:

which is more common comedo, papillary, cribiform, medullary? Need to look these up!

BREAST CANCER STAGING:

tx cannot assess primary tumor

t0 no evidence of primaryt tumor

tis cis (ductal, lobular, pagets)

t1 (<2 cm) a (<0.5 cm), b (>0.5 cm and <1 cm), c (>1 cm and < 2 cm)

t2 >2 cm and < 5 cm

t3 > 5 cm

t4 any size with extension to the chest wall or skin: a: chest wall, b: skin, c: both, d: inflammatory

nx cannot assess

n0 no regional nodal mets

n1 met to moveable ipsilateral LN's

n2 axillary LN's fixed to each other

n3 mets to ipsilateral internal mammary chain

staging:

0 is tis n0 m0

1 is t1 n0 m0

2a is t0 n1 m0 or t1 n1 m0 or t2 n0 m0

2b is t2 n1 m0, or t3 n0 m0

3a is t0 n2 m0 or t1 n2 m0 or t2 n2 m0 or t3 n1 m0 or t3 n2 m0

3b is t4 any n and m0 or any t n3 m0

stage 4 is any t and any m with m1

THE POST SURGICAL BREAST:

When malignant calcifications are present initially, it is advisable to obtain a mammogram of the breast shortly after surgery. Any residual calcifications indicate residual tumor and re-excision is indicated. Any increasing malignant calcifications on follow-up mammography indicate recurrent tumor. At times, it may be difficult to differentiate malignant from dystrophic calcifications. Recurrent tumor in a prior irradiated breast is treated with mastectomy. Increase in density and architectural distortion at the lumpectomy site stabilizes 6 to 8 months following completion of therapy. Any later change is most likely due to recurrent tumor. Note that usually, post surgical changes to the breast stop changing by 2-5 years

RECALL RATE IN MAMMO:

Svane cites a 4-5% recall rate at her institution and states that is a reasonable goal.

LOBULAR CA IN SITU:

Lobular carcinoma in situ (LCIS) has no radiographic findings. The diagnosis is based on histologic findings following biopsy. LCIS is associated with an increased risk for the subsequent development of invasive carcinoma (>20% to 30% during the next 15 to 20 years). Interestingly, the invasive carcinoma may be either lobular or ductal. Both breasts are at equal risk. No treatment is indicated for LCIS, except close surveillance

While LCIS is typically not bilateral, its presence implies an increased risk of later developing invasive carcinoma (usually ductal) with equal risk (15%) in each breast. It is not a true carcinoma in a sense but a significant risk marker for subsequent CA

MONDORS:

superficial thrombophlebitis

IF MAMMO WAS DONE WITHOUT A PHYSICAL EXAM:

5-10 % of breast ca would not be discovered

FOCAL CLUSTER OF MICROCALCEFICATIONS:

then chance of malignancy is 20%

PAPILLOMATOSIS:

the difference between this and the others is this lacks a fibrovascular core

MULTIFOCAL VS MULTICENTRIC:

multifocal is all confined to one quadrant and multicentric is confined to multiple quadrants. Multicentric has the higher risk of recurrence with conservative management

BREAST CA PREVALENCE AND INCIDENCE:

6-10 per 1000 women for prevalence (ie initial screen) and 2-4 per 1000 in incidence (rescreen)

PERCENT REDUCTION IN MORTALITY FROM SCREENING:

30%

PERCENT CA IN ALL LESIONS WITH CA++:

20% incidence of cancer

S/P XRT AND CHEMO BREAST:

<7y tumor occurs at or close to the lumpectomy site and > 7 y can occur in any quadrant. The mean time for recurrence is 3 years. Post lumpectomy changes resolve by 12 months and post lumpectomy plus XRT changes resolve by 12 m  to 2 years

SPATIAL RESOLUTIONS:

breast: 11 lp/mm

cxr: 8 lp/mm

ct: 4 lp/mm

mr: 2 lp/mm

us: 0.5 lp/mm

LCIS:

this is bilateral in 30% and IDC or invasive lobular ca is bilateral in 30%. Ie a 15% risk of ca per breast. This is because LCIS is a marker of ILC in addition to IDC

BREAST ECHOGENICITY:

breast fat is hypoechoic and tumor is mostly hypoechoic so it would be difficult to pick out the tumor by US if it is located in the breast fat

NIPPLE PAPILLOMA OR JUST PAPILLOMA:

is not the same as nipple adenoma. There is no risk of malignancy unless it is associated with atypical ductal hyperplasia. It has a fibrovascular core and is located within 2 to 3 cm of the nipple.  It is also called a solitary papilloma. This is the most common source of nipple discharge

PAPILLOMATOSIS:

Duct papillomatosis has no fibrovasuclar core. They have a 25% to 30% risk of malignancy (-recalls) and according to Dahnert a 5% risk of malignancy

MULTIPLE PAPILLOMAS:

located in the periphery of the breast. Multiple circumscribed nodules sometimes with Ca++ and slight increase risk of CA even without the presence of atypical ductal hyperplasia

ADH:

can present as a nodule or architectural distortion. It is a marker for 10% risk of breast ca in either breast within a 10 year period

FIBROID:

involuting fibroid has Ca++ beginning peripherally (becomes popcorn like). Can also have Ca++ in the center

BREAST CA:

75% of breast Ca are taller than wide

BREAST CYST:

Simple cysts do not have rim CA++. However, oil cysts from fat necrosis gave rim Ca++

BREAST LESION SAMPLING:

4 samples for breast vs 7 for the thyroid

THINGS WHICH INCREASE THE CHANCE OF A BREAST RECURRENCE:

extensive intraductal component

multicentric

comedocarcinoma subtype

FOCAL ASSYMMETRIC DENSITY IS NOT THE SAME AS ASSYMMETRIC BREAST TISSUE:

1.4% of people with a palpable focal assym density have breast ca. However, for assym breast tissue, the risk of ca is <1%

DEFINITION OF A CIRCUMSCRIBED MASS:

need to have >75% of the margin visible

MEDULLARY AND COLLOID CA:

medullary is younger pts and is faster growing. Colloid is in older pts (>65), and they are slower growing and hyper or mixed echogenicity

NATURAL HISTORY OF TRAUMA TO THE BREAST:

the post traumatic changes that occur disappear completely in 50%, and remain stable in the remainder

XRT ON BREAST:

the edema is most pronounced at 6 mo. It stabilizes at 12 mo

DEFINITION OF A MASS:

it is a density seen on 2 projections

BREAST HAMARTOMAS:

they rarely calcify

NIPPLE DISCHARGE:

breast ca 83% bloody and 27% clear. Only 13% cases of breast ca have discharge.

UNILATERAL DISCHARGE:

papilloma, fibrocystic changes, papillomatosis; the most common presentation of a solitary papilloma is nipple discharge

BREAST CA++:

punctate < 0.5 mm and round >0.5 mm

in malignant lesions: 70% of the Ca++ are confined to the tumor and 30% are adjacent to the tumor

malig dz: calcium hydroxyapatite

benign dz: calcium oxalate

distribution of malig Ca++: clustered, linear, segmental

ORIGIN OF INVASIVE CA:

90% from TD and 10% from the lobular unit

GIANT FIBROADENOMA VS ADENOMA:

in teenagers, no difference histologically, no true capsule on either of them. Cancer in a fibroadenoma is rare. The giant one is huge and can take up the whole breast as it is so fast growing

PHYLLOIDES

the mean age is 45. They can be benign, low grade malignant, or malignant. Ca++ are uncommon. They contain cystic areas. There is a 5-10% potential for malignancy. Also, if non malignant, they can be locally aggressive

EFFECT OF ESTROGEN AND PROGESTERONE:

estrogen causes cystic disease

estrogen plus progesterone causes fibrocystic disease

so the effect on breast density is increased with the combination

SMALL LESION:

if <5mm, then excision or vacuum

if >5mm, then can do a core bx

LEAD TIME VS SOJOURN TIME:

lead time bias is interval that cancers are undetected at sreening ie it is false negative screening

sojourn time is the duration of preclinical disease, ie it is a fixed time period

the lead time can never be > than the sojourn time. The soujourn time is shorter in younger women due to denser breasts

Another way to explain it is point at which preclinically detected to time at which it would have presented. Based on this, slower growin tumors have a longer lead time bias

RELATION OF DCIS TO IDC:

DCIS is not an obligate precursor to IDC because IDC can occur in the absence of DCIS. 10% of pts with DCIS have a palpable abnormality. For gado enhanced MRI, rapid wash in and wash out is more correlated with cancer

FDG VS SESTAMIBI:

they both have similar sensitivity for detection for malignant and benign breast lesions

RISK FROM 1 RAD TO THE BREAST:

6 cancers per million per year after a 10 to 15 year latency period (according to pretest Hovespin)

PINCH TECHNIQUE:

this is also called the Eckland view. 25% of breast tissue is still obscured 

STEATOCYTOMA MULTIPLEX:

it is a familial disorder with multiple sebaceous cysts on the upper torso that affects both men and women

CANCER IN CALCIFIED LESIONS:

20 to 30% are malignant

MINIMAL CANCER LESIONS:

lcis, dcis, invasive ca not > than 0.5 cm

PLASMA CELL MASTITIS:

it is a type of secretory dz. It is a chronic inflammatory process. It occurs due to duct ectasia with accumulation of gummous material. The process is bilateral. There are smooth intraductal calcifications, and indurative mastopathy. Nipple discharge is not uncommon. It involves several ducts with white, yellow and green discharge

MANAGEMNT OF LCIS:

bilateral mastectomy has been suggested. However, close clinical follow up of both breasts is the accepted clinical practice

OVERALL PREVALENCE OF BREAST CANCERS:

medullary: 4%

IDC nos: 80%

colloid: 3%

comedo: 5%

papillary: 1%

lobular 8%

tubular: 4%

PROSTHESIS RUPTURE:

intracapsular>extracapsular

BREAST SCREENING STATS:

FN: 6%, FP: 5%, PPV: 10%, NPV: 90%

likelyhood of ca in a <10 mm well circumscribed mass: <2%

recall rate on initial screening: not >10%

technical repeat: not >5%

recall rate on subsequent (incidence screening): 5%

biopsy PPV: 30%

cancer detection rate: <1%

cancers <2 cm in diameter and confined to the breast: >50%

mortality reduction: 30%

prevalence screen: 6-10/1000

incidence screen:  2-4/1000

EFFECT OF HRT:

has increased the recall rate and decreased the sensitivity and specificity of mammo screening

TO ESTABLISH A LESION AS BEING A REAL OR NOT:

90 degree view, compression view, compression plus magnification view, angled view, rolled view. Note that pec muscle can be seen in only 30% of CC. This means that can achieve better compression with CC than with MLO to help rule out summation lesions. Also note that sclerosis distorts the uniform round Ca++ of adenosis and makes them look more malignant

ALTERNATIVE NAME FOR PHYLLODES TUMOR:

same as cystosarcoma named as such because it contains cyst like component

GRANULAR CELL MYOBLASTOMA:

it is a spiculated mass that occurs in the tongue and breast, but is non malignant. It is a rare lesion

BREAST LYMPHOMA:

primary lymphoma is 0.1% of all breast malignancies. The most common tumor met to the breast is melanoma

PHANTOM IN BREAST IMAGING:

q weekly, contains 6,5,5 and have to detect 4,3,3  fibers/speck groups/masses in  4.2 cm thick compressed breast. It it fails the test, than the processor chemistry is the first thing that is investigated

CHARACTERISTICS OF MALIGNANT LESION:

PHYSICAL: hard, gritty, decreased mobility, skin thickening, retraction

MAMMO: spiculated, mass, ill defined, microlobulation, clusters of Ca++ with a branching pattern, skin thickening, taller than wide, angular margins

MAMMO CALCS: linear, branching, casting, pleiomorhic, multiple clusters

US: marked hypoechogenicity, taller than wide, branch pattern, duct extension

OTHER TUMORS:

extraabdominal desmoid: spiculated, related to prior trauma, local wide excision requred, with this there is a 20% recurrence rate. It occurs close to the pectoralis. It is also associated with Gardners syndrome

BREAST LYMPHOMA:

primary is rare. Secondary is more common. The more common cell type is B cell. Burkitts is rapidly fatal

BREAST ANGIOSARCOMA:

macrolobulated, cloud like, hematogenous mets, younger women, contralateral breast involvement is common

METS:

most common is ca from the contralateral breast that spreads via the lymphatics