Brant

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Brant Helms Chapter 21Breast Imaging

• Omid J. Bendavid, M.D.
• UC Irvine Medical Center, Department of Radiology
• September 10th 2008

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Breast Imaging

• Two purposes
• Screen asymptomatic women to increase early
  detection of breast cancer
• Evaluate potential abnormalities in symptomatic
  patients and patients with indeterminate
  screening mammograms

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Breast Cancer

• One woman in every eight will develop breast
  cancer in lifetime
• 1 in cancer incidence in women (NCI SEER 2005)
• 2 in cancer mortality in women (NCI SEER 2005)
• Screening (imaging and clinical)
• Reduce breast cancer mortality
• Survival
• Tumor Size
• Lymph Node Status

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Breast Cancer Screening Trials

• Health Insurance Plan (HIP) of New York, 1963
• 31,000 asymptomatic women, 40-64 years old
• Annual screenings by mammography and physical
  examination
• Control group not offered screening
• 29 reduction in breast cancer mortality in the
  screening group at 9 nine years into the study
• Additional studies in the 1970s and 1980s
• Overall data reveals 24 reduction in breast
  cancer mortality among women aged 40-74 years who
  were invited to screening
• Subsequent meta analyses confirm benefit of
  screening in women aged 40-49 years as well as
  those 50 years and older

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Screening Guidelines and Recommendations

• Mammography and clinical examination both
  essential for adequate screening
• 9 to 16 of breast cancers are detected by
  physical examination only and are not visualized
  mammographically (false-negatives)
• ACS, ACR, AMA, NCI recommendations
• Annual screening mammography beginning at age 40
  years
• No recommended age to discontinue screening while
  woman is in good health

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Radiation Risk

• Decreasing radiation risk with increasing age of
  exposure
• Studies based on extrapolation of data from
  varying sources
• Age at exposure
• Women in teens and young age at greater increase
  in risk
• No significant increased risk demonstrable at age
  40 years or older
• Estimated lifetime risk of breast cancer death
  from single mammogram
• Age 40 to 49 2 in 1 million
• Age 50 to 59 less than 1 in 1 million
• Comparable to risk of dying in accident when
  traveling 300-400 miles by car and 5,000 miles by
  airplane

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Other Imaging Modalities

• Ultrasound
• No role for ultrasound in breast cancer screening
• Ultrasound useful in diagnosis or further
  characterization of specific lesion
• Most useful in distinguishing simple cyst from
  solid mass
• MRI
• Also has a non-screening role in breast cancer
  imaging
• Indications include (but not limited to, and
  growing)
• High risk patients with dense breasts
• Patients with implants
• Response to therapy
• Post-operative evaluation, recurrence versus
  scarring
• Find unknown primary tumor if axillary lymph
  nodes are malignant
• PET
• Scintimammography

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Evaluation of the Symptomatic Patient

• Age less than 20 years with suspicious palpable
  abnormality
• Mammography not recommended
• Age 20 to 29 years with suspicious palpable
  abnormality
• Ultrasound for first evaluation
• Single oblique view mammogram
• Mammography used sparingly in women aged less
  than 30 years due to greater increased radiation
  risk and limited evaluation of denser breasts

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Technical Considerations

• Need greater contrast and spatial resolution than
  standard radiography
• Molybdenum anode allows for lower energy x-rays
• Small focal spot sizes (0.3 mm, 0.1 mm)
• Single screen-emulsion film combinations

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Technical Considerations

• Compression required for optimal mammography
• All mammography units equipped with compression
  paddles
• Spreads overlapping breast structures to minimize
  overlap and reduce summation artifact
• Improves breast immobilization to help reduce
  patient motion and reduce blurring and motion
  unsharpness
• Reduced radiation dose due to overall thinner
  caliber of the compressed breast
• Main drawback of compression is patient
  discomfort
• Automated compression devices allow technologist
  to release compression tension once the film is
  exposed

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Mammographic Positioning for Screening

• In the United States, two views obtained
• Craniocaudal (CC)
• Mediolateral Oblique (MLO)
• By convention, markers indicating the type of
  view and the side imaged are placed along the
  lateral side (axillary side) on both the CC and
  MLO views

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MLO View

• Oblique angle between 40 to 60 degrees parallels
  the orientation of the pectoralis major muscle
• Compression is applied from the superomedial
  direction to the inferolateral direction, same
  course x-rays will take
• MLO view is the most useful view in mammography,
  depicts the greatest amount of breast tissue
• Limited evaluation of superomedial tissues
• Nipple should be in profile
• Pectoralis major should traverse the posterior
  nipple line (PNL)
• Pectoralis major border should be convex towards
  nipple and not blurred
• Inframammary fold should be visible ensure
  inferior extent of breast has been imaged

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CC View

• X-ray tube is positioned vertically,
  perpendicular to the floor
• Nipple should be in profile
• Need to confirm adequate visualization of
  posterior (deep) breast tissue
• Pectoralis major muscle may be seen in about
  30-40 of cases
• If not seen, compare PNL (measurement of depth)
  in MLO and CC views
• PNL on CC view should be no more than 1 cm
  shorter than PNL on MLO view

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Interpretation

• CC and MLO views displayed together in mirror
  image configuration (right/left)
• By convention, labels placed on side nearer to
  axilla
• Adequate viewing conditions, many specifics
• 3,000 cd/m2 luminance
• darkened rooms to lt50 lux
• Magnifying glass
• Comparison to prior mammograms
• Correlation with patient history and
  questionnaire responses
• Correlation with physical examination findings

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Indeterminate Mammogram

• Additional mammographic imaging
• Additional projections
• Spot compression
• Magnification
• Ultrasound
• High frequency transducer (7-10 MHz linear)

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Diagnostic Mammographic Views

• True 90 degree lateral views (ML and LM)
• Localize lesion seen on only one view (CC or MLO)
• Demonstrate milk of calcium
• Spot compression (with or without magnification)
• Evaluation of calcifications
• Better definition of lesions and margins
• Determine if densities are real or related to
  summation
• Cleavage view
• Evaluate lesions in far medial breast not seen on
  CC view
• Axillary tail view (Cleopatra)
• Evaluate lesions in far lateral breast near
  axillary tail

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Diagnostic Mammographic Views

• Tangential view
• Evaluate/confirm dermal lesions or superficial
  lesions
• Rolled views (rolled medial RM, rolled lateral
  RL)
• Determine location of lesion seen in one view by
  assessing how its position changes with rolling
• Superior lesions move laterally on RL, medially
  on RM
• Implant Displacement view (Ecklund technique)
• Lateromedial Oblique (LMO)
• Better evaluation of superomedial tissues
  (evaluated least well on MLO view)
• Better visualization and comfort for patients
  with pectus excavatum, pacemakers, recent
  sternotomy

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Localization/Triangulation

• Side (right/left)
• Four quadrant, clock face technique
• Upper inner, upper outer
• Lower inner, lower outer
• Depth
• Anterior, middle, posterior thirds
• Subareolar, central, axillary tail

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Localization/Triangulation
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Normal Breast Gross Anatomy

• Anatomy (deep to superficial)
• Pectoralis Major
• muscle
• Pectoral Fascia
• Retroglandular fat
• Mammary gland
• Skin
• Coopers
• suspensory
• ligaments
• Bands of connective tissue attaching glandular
  tissue to the overlying skin

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Lymphatics

• Axillary nodes (many subdivisions)
• Pectoral nodes most common
• Internal mammary/ parasternal nodes
• Intercostal nodes
• Contralateral nodes
• Abdominal nodes

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Breast Architecture

• 15 to 20 lobes arranged in radial pattern around
  nipple
• Each lobe drains into a main lactiferous duct to
  the nipple
• Basic building block is the TDLU (terminal
  ductal-lobular unit)
• Multiple TDLUs make up lobe

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Breast Architecture

• Basic building block is the TDLU (terminal
  ductal-lobular unit)
• Acinus
• Ductule
• Intralobular Terminal Duct
• Extralobular Terminal Duct
• Most breast diseases arise in the TDLU
• Others arise in supporting breast stroma or major
  ducts

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Lexicon

• Mass
• Lesion seen in two views
• Density
• Potential mass seen on only one view
• Shape
• Round
• Oval
• Lobulated
• Irregular

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Lexicon

• Margins
• Circumscribed (well-defined)
• Obscured
• Microlobulated
• Indistinct (ill-defined)
• Spiculated
• Density (relative to normal fibroglandular breast
  tissue)
• High density
• Equal density (isodense)
• Low density (lower attenuation but not fat
  containing)
• Fat containing (radiolucent)

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Calcifications

• Typically Benign
• Skin Ca
• Lucent-centered, confirm with tangential view
• Vascular Ca
• Tubular parallel linear tracks
• Coarse Ca
• Popcorn-like involuting fibroadenoma
• Large rod-like Ca
• Associated with ectatic ducts, filling or
  surrounding them (often referred to as secretory
  Ca)
• May be branching, wider than 1 mm diameter
• Found in secretory disease, duct ectasia

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Calcifications

• Typically Benign
• Round Ca
• Usually considered benign
• Less than 1 mm formed in acini
• Less than 0.5 mm termed punctate
• Lucent-centered Ca
• Smooth surfaces, round or oval
• Found with fat necrosis, fibroadenomas, calcified
  ductal debris
• Eggshell, Rim Ca
• Most commonly along wall of cyst
• Less often fat necrosis (oil cyst)

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Calcifications

• Typically Benign
• Milk of calcium Ca sedimented Ca in cysts
• CC view fuzzy, round, amorphous deposits
• True lateral sharply defined, semilunar,
  crescent-shaped, curvilinear (concave up)
• Suture Ca
• Ca deposited along suture material, common
  post-XRT
• Dystrophic Ca
• Post-radiation, post-traumatic
• Lucent centers, usually greater than 0.5 mm size
• Punctate Ca
• Round or oval, less than 0.5 mm, well-defined
  margins

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Calcifications

• Intermediate Concern Usually biopsy
• Amorphous or indistinct
• Flaky calcifications, not very conspicuous
• Often associated with fibrocystic change
• Higher Probability of Malignancy Always biopsy
• Pleomorphic, heterogeneous
• Irregular but more conspicuous than amorphous
• Varying sizes and shapes, usually less than 0.5
  mm
• Dot-dash branching pattern
• Fine, linear, branching
• Thin, irregular Ca
• Discontinuous, less than 0.5 mm wide
• Filling of duct lumen by breast cancer

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Calcifications

• Distribution
• Grouped, Clustered
• Multiple Ca occupy small volume lt2 cc tissue
• Linear
• Arranged in a line
• Segmental
• Worrisome ductal distribution
• Regional
• Scattered in a large volume of breast not
  conforming to ductal distribution
• Diffuse, Scattered
• Distributed randomly throughout breast
• Indicative of benign process (sclerosing adenosis)

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Calcifications

• Malignant calcifications almost always within
  ducts, even if primary tumor is not intraductal
• Approximately 1/3 of all nonpalpable cancers
  manifest by calcifications alone without
  associated mass
• Only 25-35 of Ca that are biopsied will prove
  to be malignant
• Slight over-penetration of films is optimal for
  detection of calcifications
• Magnification views helpful in characterizing Ca

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Architectural Distortion

• Tissue architecture is distorted without definite
  mass identified
• Appearances
• Spiculations radiating from a central point
• Focal retraction or distortion of edge of
  parenchyma
• Abnormal arrangement of suspensory ligaments
• Differential considerations include
• Malignancy
• Fat necrosis related to prior surgery
• Radial scar
• Biopsy required for differentiation

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Increased Density of Breast Tissue

• Hormonal Variations bilateral
• Estrogen replacement therapy in postmenopausal
  women
• Hormonal fluctuations in premenopausal, pregnant,
  lactating women
• Inflammatory Carcinoma unilateral
• Diffuse involvement of dermal lymphatics
• Warm, erythematous, firm, tender breast
• Diffusely increased breast density, often no mass
  seen
• Associated with skin thickening

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Increased Density of Breast Tissue

• Radiation Therapy
• Changes most pronounced during first 6 months
• Generally resolve by 2 years
• Associated with skin thickening
• Diffuse Mastitis
• Associated with diffuse skin thickening
• Obstruction of Lymphatic or Venous Drainage
• Thrombosis, post-surgical, metastatic disease
• Associated with skin thickening due to edema
• CHF, Renal Failure, Cirrhosis, Hypoalbuminemia
• Involvement usually bilateral, may be asymmetric
• Associated with skin thickening

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Diffuse Skin Thickening

• Tumor
• Inflammatory Carcinoma
• Lymphoma
• Leukemia
• Inflammation
• Mastitis
• Post-radiation, post-surgical
• Lymphatic or Venous Obstruction
• Generalized Edema

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Benign Processes

• Fibrocystic changes
• Cellular proliferation of the TDLU and
  surrounding connective tissue with development of
  fibrosis
• Found in over 70 of women age 55 and over
• Broad spectrum of entities generally categorized
  based on risk of subsequent cancer development
• Risk of cancer development applies across
  population, not necessarily to individual female

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Fibrocystic Changes

• No increased risk
• Cysts
• Adenosis
• Fibrosis
• Duct ectasia
• Mastitis
• Squamous or apocrine metaplasia without atypia
• Mild hyperplasia
• Fibroadenoma

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Fibrocystic Changes

• Increased Risk 2x
• Sclerosing adenosis (differing opinions as to
  true risk 1.5-2X vs no significant increase)
• Hyperplasia moderate/florid, solid/papillary
• Increased Risk 5x
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia
• Atypical hyperplasia on the same spectrum as
  ductal and lobular carcinoma in situ

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Fibrocystic Changes

• Cysts
• Most common well-circumscribed mass ages 35-50
• Micro (lt3 mm), Macro (gt3 mm)
• Arise from terminal acini and enlarge due to
  obstruction or secretion imbalance
• Round or oval, may be lobulated
• Can be deformed with gentle pressure
• Anechoic with increased through transmission
• Thin septation not worrisome
• Milk of calcium, egg-shell calcifications
• Tumor within cyst very rare, suspect papilloma or
  papillary carcinoma

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Cysts
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Fibrocystic Changes

• Adenosis
• Proliferation of glandular structures leading to
  formation of new ductules and lobules
• May be accompanied by sclerosis sclerosis
  adenosis
• May contain diffuse calcifications
• Fibrosis
• Etiology unknown
• Focal or diffuse
• Focal form may mimic cancer, biopsy required

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Fibrocystic Changes

• Duct Ectasia
• Accumulation of cellular debris in enlarged
  subareolar ducts
• Serous or serosanguinous discharge (second most
  common cause)
• May have nipple retraction
• Pain if inflammatory response present (plasma
  cell mastitis)
• Benign-pattern secretory calcifications (large,
  rod-like calcifications)
• US may show an area with dilated ducts

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Duct Ectasia
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Fibrocystic Changes

• Fibroadenoma
• Most common well-defined solid breast lesion
• Commonly found from teens to age 40 years
• Glandular and fibrous components
• Proliferation of connective tissues
• Sensitive to hormonal influences
• Enlarge during pregnancy (lactating adenoma)
• Involute following menopause (except if HRT)
• Well-defined, oval, often lobulated, homogeneous
• Large, coarse, popcorn calcifications
• Solid hypoechoic on ultrasound
• AP diameter shorter than transverse diameter
• Multiple in 20
• Giant Fibroadenoma (juvenile fibroadenoma)
• Large size, usually gt6 cm, more cellular variant

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Fibroadenoma
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Benign Processes

• Phyllodes Tumor (Cystosarcoma phyllodes)
• Large rapidly growing breast mass similar to
  fibroadenoma (esp. giant fibroadenoma)
• Average age 45 years (older than fibroadenomas)
• Large round, oval, or lobulated mass
• US shows hypoechoic solid mass with low level
  internal echoes and fluid-filled cystic spaces
• Definitive diagnosis requires biopsy
• Most are benign, 10 malignant degeneration with
  hematogenous metastases
• Local recurrence if incompletely resected (25)

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Phyllodes Tumor
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Benign Processes

• Intraductal Papilloma
• Benign tumor of the lactiferous ducts, no
  increased cancer risk
• Duct containing the papilloma is dilated (usually
  subareolar major duct)
• Most common cause of bloody or serous nipple
  discharge (2 is duct ectasia)
• Often not seen on mammography except in presence
  of dilated duct
• Galactography confirms diagnosis
• Intracystic Papilloma
• Arises within an isolated cystically dilated duct
• Best diagnosed with pneumocystogram or ultrasound
• Papillomatosis
• Multiple peripheral papillomas, increased risk of
  malignancy

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Intraductal Papilloma
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Benign Processes

• Radial Scar
• Idiopathic proliferative scarring process
• Not related to surgical scar
• Central sclerosis with epithelial proliferation
• Appears as area of architectural distortion or as
  stellate lesion, spiculated
• Usually not palpable
• Must be differentiated from cancer histologically
• Adenoma
• Tubular, ductal, lactating (fibroadenoma
  pregnancy)

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Radial Scar
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Benign Processes

• Hamartoma (lipofibroadenoma)
• Well-circumscribed tumor, pseudocapsule
• Homogeneously dense except for scattered areas of
  fat density
• Lipoma
• Common tumor, slow growing, older patients
• Thin capsule may be calcified, lucent
• Galactocele
• Usually occur in lactating or recently lactating
  women
• Inspissated milk causes duct obstruction
• May be entirely lucent (fat) or mixed fat/water
  density
• True lateral view may show fat-fluid level

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Hamartoma
Galactocele
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Benign Processes

• Fat Necrosis
• Injury to fat cells following blunt trauma,
  surgery, radiation therapy
• Results in inflammatory process with eventual
  fibrosis and calcification
• May be palpable with skin or nipple retraction
• Variety of mammographic appearances
• Oil Cysts
• Well-defined lucent lesions with rim
  calcifications
• Some appearances may resemble breast cancer
  (spiculated, pleomorphic calcifications)

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Oil Cyst
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Benign Processes

• Mastitis
• Acute mastitis
• Most common during lactation
• Retrograde infection from nipple (staphylococcus,
  streptococcus)
• Granulomatous mastitis
• Tuberculosis, sarcoidosis
• Other causes include fungal (histo, crypto,
  actino) and parasitic (trichinosis) infections

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Benign Processes

• Mastitis
• Increased breast tissue density
• May mimic inflammatory carcinoma
• Abscess
• Focal mass may be seen, commonly subareolar
  location
• May appear spiculated mimicking cancer
• Pain, erythema, skin thickening, nipple
  retraction, axillary adenopathy
• Many advocate treatment with antibiotics first
  if no improvement, consider aspiration

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Abscess
Mastitis
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Breast Implants

• Silicone and/or saline implants, single/double
  lumen
• Silicone more radiopaque than saline
• Positioning
• Anterior (prepectoral, retroglandular)
• Posterior (postpectoral, subpectoral)
• Fibrous capsule surrounds implant
• Same approach in screening and diagnostic imaging
  as with women without implants
• Additional views include implant displacement
  views and possibly 90 degree true lateral views

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Implant Displacement Views
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Breast Implants

• Implant Rupture
• Intracapsular
• Implant shell only
• Linguine sign on MRI (collapsed implant shell)
• Extracapsular
• Implant shell and fibrous capsule
• Irregular border on mammogram (bulge, peak)
• Dense lymph nodes
• Intracapsular and extracapsular implant rupture
  generally better evaluated with MRI

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Implant Ruptures
Extracapsular
Extracapsular
Intracapsular
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Post-Radiation Breast

• Usually baseline study at 6 months then annual
  follow-up
• Diffuse increased density of breast peaks at 6
  months and generally resolves by 2 years
• Skin thickening also seen, resolves within months
• Benign dystrophic calcifications may arise 2-4
  years after radiation therapy

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Breast Cancer

• Risk Factors (female)
• Age
• Family history (first degree mother, sister)
• BRCA-1, BRCA-2, other genetic predispositions
• Early menarche, late menopause, nulliparity, late
  first pregnancy (all contribute to prolonged
  unopposed exposure to estrogens)
• Prior history of breast cancer
• LCIS (lobular carcinoma in situ)
• Atypical proliferative changes
• Staging by TNM classification

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Breast Cancer

• 99 of malignant breast tumors are
  adenocarcinomas with origins in the TDLU
• 90 ductal origin
• 10 lobular origin
• Histological Classification
• (breast adenocarcinoma)
• Non-invasive
• Invasive

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Non-Invasive Breast Cancer

• In situ carcinoma no penetration of basement
  membrane or invasion of stroma
• Ductal carcinoma in situ (DCIS)
• Noncomedo
• Lower nuclear grade
• Solid, cribriform, papillary growth patterns
• Comedo
• Central area of necrosis with high nuclear grade
  of surrounding tissue
• Comedonecrosis
• Dystrophic (heterogeneous, irregular)
  calcification may be produced in the necrotic
  debris

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Non-Invasive Breast Cancer

• Lobular carcinoma in situ (LCIS)
• No gross morphological changes on clinical or
  mammographic examinations
• Histological diagnosis usually related to its
  presence adjacent to a separate lesion
  (clinically or mammographically identified) that
  is being evaluated
• Characteristically multicentric and bilateral
• Indicator of increased relative risk for
  development of invasive carcinoma in either
  breast (may be ductal or lobular)
• 30 risk of eventual invasive carcinoma (15 each
  breast)

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Invasive Breast Cancer

• Invasive ductal carcinoma
• Most common form (75-80)
• Calcifications common
• Invasion of dermal lymphatics leads to
  inflammation and skin thickening
• Desmoplastic response of breast tissue causes
  radiographically visible spiculations
• May invade perivascular, perineural spaces

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Breast Carcinoma
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Invasive Breast Cancer

• Invasive ductal carcinoma
• Ultrasound characteristics
• Taller than wide (depthwidth ratio gt 1)
• Irregular shape
• Ill-defined margins, spiculations
• Vascularity
• Posterior acoustic shadowing

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Breast Carcinoma
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Invasive Breast Cancer

• Medullary carcinoma
• Well-differentiated tumor with circumscribed
  growth pattern, relatively favorable prognosis
• Lymphocytic cellular infiltrate
• Highly cellular with little stroma, lacks
  desmoplastic reaction
• Presents as mass, calcifications typically absent
• May grow very large before discovery (5 to 10 cm)
• US may show posterior enhancement as opposed to
  shadowing

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Medullary Carcinoma
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Invasive Breast Cancer

• Mucinous (colloid) carcinoma
• Extensive extracellular mucin production
• Well-circumscribed
• Generally favorable prognosis
• Papillary carcinoma
• May be invasive or non-invasive
• Slower growth rate, tumors generally large at
  presentation (gt5 cm)
• May arise as intra-cystic tumor
• Bloody discharge from nipple

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Invasive Breast Cancer

• Tubular carcinoma
• Well-differentiated, tubule formation
• Most benign and slow growing of breast cancers
• Excellent prognosis
• Usually less than 2 cm
• Mammographically indistinguishable from more
  aggressive forms (spiculated margins, etc.)
• Inflammatory carcinoma
• Aggressive with early dermal lymphatic invasion
• Usually no mass seen mammographically
• Warmth, skin thickening, nipple retraction, peau
  dorange, adenopathy

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Invasive Breast Cancer

• Pagets disease of Nipple
• Eczematous lesion of the nipple involvement by
  high grade DCIS
• Associated with underlying carcinoma which can be
  located anywhere in the breast
• Invasive Lobular Carcinoma
• Usually mammographically occult early on,
  difficult to diagnose often better evaluated on
  CC view (better compression)
• May be occult on physical examination
• Most commonly an asymmetric density without
  definable margins
• Ill-defined margins with architectural distortion
• May involve a large portion of the breast due to
  diffuse tumor seeding
• Other types
• Stromal origins (fibrosarcoma, liposarcoma)
• Lymphoma
• Carcinosarcoma

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Metastases

• Breast cancer metastasizes to
• Bones
• Lungs
• Liver
• Metastases to breast from
• Melanoma (most common)
• Sarcoma
• Lung
• Lymphoma

• Contralateral Breast
• Skin
• Breast
• Gastric
• Renal

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Axillary Lymph Nodes

• Normal lymph nodes
• Less than 2 cm in size
• Lucent center or notch due to fat (key finding of
  benignity)
• Pathologic lymph nodes
• Enlarged and/or homogeneously dense
• Primary breast cancer
• Metastases
• Lymphoma
• Inflammation
• Rheumatoid arthritis, Psoriasis
• SLE, Scleroderma
• Nodal calcifications
• Metastasis (breast, other)
• Lymphoma
• Granulomatous disease
• Gold deposits (rheumatoid arthritis treatment)

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Male Breast

• Normal male breast contains subcutaneous fat w/o
  significant glandular tissue
• Gynecomastia
• Triangular shaped area of subareolar glandular
  tissue
• Unilateral or bilateral, frequently asymmetric
• Drugs
• Estrogens
• Digoxin
• Cimetidine
• Spironolactone, Thiazides
• Reserpine
• Marijuana
• Hormone-producing tumors
• Testicular (seminoma, embryonal cell,
  choriocarcinoma)
• Adrenal
• Pituitary
• Chronic hepatic disease, cirrhosis
• Inadequate estrogen clearance

90
Male Breast

• Male Breast Cancer
• Similar appearance and characteristics as female
  breast cancer
• Spiculated, ill- or well-defined,
  microcalcifications
• lt1 of all breast cancers occur in males
• 0.2 of male malignancies
• Risk Factors
• Age
• Exposure to ionizing radiation
• Cryptorchidism
• Klinefelter syndrome
• Treatment with estrogen hormones

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Classification and Differentials

• Spiculated Margins
• Breast carcinoma (93 of lesions with spiculated
  margins)
• Fat Necrosis
• Radial Scar
• Surgical Scar
• Mastitis
• Fibrocystic changes (focal fibrosis, sclerosing
  adenosis)
• Indistinct (ill-defined) Margins
• Breast carcinoma
• Breast abscess
• Hematoma
• Focal Fibrosis

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Classification and Differentials

• Circumscribed (well-defined) Margins
• From 2 to 5 of well-circumscribed masses on
  mammography may represent carcinomas
• Cysts (most common)
• Fibroadenoma
• Fibrosis
• Breast cancer
• Lymphoma
• Metastases
• Hematoma
• Organized Fat Necrosis

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Classification and Differentials

• Fat (lucent) Density
• Oil Cyst
• Lipoma
• Hamartoma
• Galactocele
• Mixed Fat and Water Density
• Galactocele
• Hamartoma
• Lymph Node
• Hematoma

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Classification and Differentials

• Large masses (gt5 cm)
• Hamartoma
• Phyllodes Tumor
• Giant fibroadenoma
• Multiple masses
• Cysts
• Fibroadenomas
• Papillomas
• Multifocal breast cancers
• Metastases (more often unifocal)

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BI-RADS Classification System

• Breast Imaging Reporting and Data System
• Final Assessment (BI-RADS 0 through 6)
• 0 Incomplete Assessment
• 1 Negative
• 2 Benign Findings
• 3 Probably Benign Findings
• 4 Suspicious Findings
• 5 Highly Suspicious for Malignancy
• 6 Known Malignancy Undergoing Therapy

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BI-RADS

• 0 Incomplete Assessment
• Priors for comparison
• Additional mammographic projections/views
• Ultrasound evaluation
• 1 Negative
• 2 Benign Findings
• 3 Probably Benign Findings
• Less than 2 risk of malignancy
• First follow-up in 6 months
• Noncalcified circumscribed solid mass
• Focal nonpalpable asymmetric parenchymal density
• Cluster of punctate calcifications
• Some suggest that palpable lesion should not be
  assigned this category

97
BI-RADS

• 4 Suspicious Findings
• Biopsy should be considered
• Wide range of probability of malignancy
• 5 Highly Suspicious for Malignancy
• gt95 probability of malignancy
• Spiculated mass
• Pleomorphic clusters of calcifications
• 6 Known Biopsy-Proven Malignancy
• Comment on breast composition
• Composed entirely of fat
• Scattered fibroglandular densities
• Heterogeneously dense (may lower sensitivity)
• Extremely dense (lowers sensitivity)

98
Breast Composition
Predominately Fatty ? Scattered Fibroglandular
Tissue ? Hetergenously Dense ? Extremely Dense
99
Interventional Procedures

• Image-guided localization of clinically occult
  lesion for excisional biopsy
• Performed under mammographic or ultrasound
  guidance
• Blue Dye Injection (less often used)
• Must avoid delay between time of injection and
  surgical excision to minimize diffusion of dye
• Needle-Wire system (most often used)
• Needle localization of lesion
• Wire inserted through needle and left in place
• Wire should be positioned slightly deep to the
  actual lesion
• Excised tissue should be sent for x-ray to ensure
  that the mammographic abnormality has been
  removed
• If unsuccessful (1-5), localization procedure
  may have to be repeated

100
Interventional Procedures

• Percutaneous Biopsy
• Fine-needle aspiration (FNA)
• Core biopsy
• Advantages of Core Biopsy over FNA
• Less dependence on specialized cytopathologist
  for cytologic (FNA) evaluation histologic (core)
  evaluation can be performed by all pathologists
• Greater sample of tissue obtained to increase
  likelihood of definitive diagnosis
• Better chance of differentiation of invasive from
  non-invasive cancers

101
Interventional Procedures

• Core biopsy should not be substitute for short
  interval follow-up of probably benign lesions
• Core biopsy not recommended for lesions
  suspicious of radial scars
• Core Biopsy Technique Overview
• Guidance
• Stereotactic Imaging
• Ultrasound
• MRI
• Needle
• 14-gauge automated push button biopsy gun
• 14- or 11-gauge vacuum-assisted needle

102
References

• Netter, Atlas of Human Anatomy, 2nd edition
• Pearson, et al AJR 174745
• Sickles Radiology 2151
• http//www.amershamhealth.com/medcyclopaedia
• http//sprojects.mmi.mcgill.ca/mammography/normal.
  htm
• http//www.miraluma.com/hcp/atlas_cases/cases/case
  2.htm
• http//www.mic.com.mt/screening_versus_diagnostic_
  mamm_Diagnositic.htm
• http//www.well-net.com/womenshealth/breast/breast
  selfexam-1.html
• http//www.cchs.net/health/health-info/PICTURES/br
  east20anatomy.gif
• http//www.breast-ultrasound.com/en/practice.cfm
• http//www.yalemedicalgroup.org/news/dxrad/ymg_bre
  astimaging.html
• http//herkules.oulu.fi/isbn9514270525/html/graphi
  c11.png (from Tabar)