Week 2 – Breast Pathology (Lecture notes)

Benign, malignant, cysts, fibroadenoma, carcinoma using BI-RADS, Mammo

CC & MLC correlation to US,

Benign Malignant
Shape Well defined Irregular
D:W Wider than tall Taller than wide
Margins Well circumscribed Irregular
Internal echos Homogenous Mixed
Post features Shadows
Disruptive Not Very
Compressible Yes Non compressible
Cysts Circumscribed, thin capsule, Internal echoes, septa, well
anechoic, non-disruptive, demarcated, debris,.
thin edge shadow,
compressible

Seroma/scar – post op if fluid adjacent to scar, can be aspirated if small.

Fibrocystic change – clinical lump, cyst formation, microscopic, fibrous stroma
Fibroadenoma – oval, smooth border, parallel, D:W <1, younger pt. (<30), occur during
malignant change/pregnancy.
Phyllodes (can be like fibroadenomas) – Well circumscribed, rapid growth, 1/3 malignant.
Biopsy this.
Abscess (non-lactating) – complex, irregular margin, enhancement, inflammation
Abscess (lactating) – mastitis, painful, red, tender.
Dilated ducts (lactating) – can be painful, increasing firmness as ducts are getting blocked.
Invasive ductal carcinoma – non mobile, non compressible, calcifications, hypo with
heterogenous int echoes, can cause duct obstruction, tall, lobulated, increased vasc.

BIRADS
1. Indication
2. Breast composition
3. Findings – mass asymmetry, architectural dist, calcifications, features
4. Comparison to prev studies
5. Category – management, comm with doctor

Category Management Ca likelihood

0 Additional Recall, + imaging n/a
imaging
1 Negative Routine 0%
screening
2 Benign Routine 0%
 screening
3 Probably benign Interval follow-up 0% - <2%
(6 month)
4 Suspicious Tissue diagnosis 4a. low suspicion
(>2% - <50%)
4b. Moderate sus
(>10% - 50%)
4c. High sus
(>50% - <95%)
5 Highly suggestive Tissue diagnosis >95%
of malig
6 Known biopsy Surgical excision n/a
proven

Boob Job
Old – smooth shell wall, liquid silicon or saline
Recent – textured shell, thicker (reduce rupture rate). Silicon now cohesive gel, will not ooze
in case of rupture.

Look all the way to the back of implant, as well as more superficial breast tissue.
Silicon – mammo radio-opaque (white)
Saline – Reverb, less radio opaque, plug and creases are visible.
Placement
 Sub glandular – posterior to breast tissue
 Sub pectoral – between pec maj and min

US
 Speed of sound slower in silicon. Post margin implant is 1.5 depper than reality ‘step
off sign’ diff between silicon and saline
 Sub glandular/sub pectoral? – scan from axillary tail/IUQ -> implant periphery. Thisll
tell you if it lies ant/post to pec muscle.
 Surface – Whole implant surrounded by echogenic line (up to 3). Single line –
implant with thick contracted fibrous capsule. III line – outler line = capsule, inner –
outer surface of shell, inner line = inner surface of shell.
 Internal structure – anechoic (both). Reverb, parallel to implant, move up and down
with presuue.
 Folds – echogenic bands that extend obliquely from implant surface, often originate
from dip in implant surface.
 Bulges/herniastions – Cont with anechoic interior, no separation from implant. Can
compress bulge, that may have presented as a palpable mass.
 Extra-capsular rupture – Snow-storm. Well defined ant borcer, obliterates all post
detail with ^ echogenicity.
Post mastectomy tissue implant
  Transverse rectus mycocytaneous FLAP
 TRAM FLAP – rectus abdominin muscles taken from skin and fat to form new
breast
 DIEP – modified version of TRAM
 Pedicelled mycocytaneous latissimus dorsi flat – w/wo implant.

Breast cancer - ^ risk

 Female
 ^ age
 FhX, Px of breast cancer
 Pre-menopausal B ca.
 Associated cancers
 Prolonged estrogen effect
 Early menarche
 Late menopause
 Nulliparity
 Late 1st pregnancy.

Breast cancer - ^ risk (males)

 Klinefelter sydrone
 Male – female trans
 Hx of chest wall irradiation
 Hx of orchitis or testicular tumour
 Liver Dx
 Genetic predisposition.

Gynaecomastia
 Hyperplasia of breast parenchyma
 Imbalance in effects of estrogen and testosterone in breast tissue
 Pain, swelling, variety of US appearances
 Causes – puberty, drugs, alcohol, thyroiditis, testicular + adrenal cancer, renal
disease, true hermaphrodism.
US – normal US adipose tissue replaces by hypo-reflective area, deep to nipple, irregular, ill
defined, spiculated with disrupted fat planes.

CC – time correlation in CC more predictable due to way its taken

MLO – more variable due to angle variation.

LN – intramammary, axillary
Normal intramammary – oval, circumscribed, hilar fat, UOQ, up to 1cm, thin cortex, ‘kidney’
look.

Axillary – similar to intramammary, up to 2 cm. can be over 2mm (thin run, lots hilar fat)