Chapter 21 Breast 2 PPT First 1/2

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3

40

35-40

40

  • Breast self examinations:
    • Performed monthly by women of all ages
  • Clinical Breast Examination
    • Performed by a physician every __ years for women 20-40
    • Every year for women over __
  • Mammography
    • Baseline study for women _____
    • Mammogram yearly after age __
2

40

BSE

FIBROUS RIDGE

Breast self examination:

  • Includes a visual inspection and palpating the breasts in both a standing or upright position as well as lying down.
  • Breast cancer may develop in women younger than ___
  • Most of these cancers are found by either ____ or by clinical breast examination performed by the patients physician.
  • A commonly palpable structure in the breast is a ____ _____. This is often mistaken for a mass.
3

most important

absorb; scatter

Mammography

Mammography:

  • Currently the ____ _____ breast imaging method.
  • Can be highly effective in the diagnosis of breast cancer
  • Mammograms are made by directing radiation through the breast tissue onto a film or digital detector.
  • The breast tissues _____ or ____ the x-rays at varying degrees.
  • Radiologists who interpret mammograms look for patterns made of dark gray, light gray, and white to detect breast cancers.
  • _____ detects more small breast cancers than any other modality.
4

radiation

To obtain high quality mammograms at the lowest _____ dose possible, the equipment must be inspected and maintained.

Breast imaging standards of the mammography quality standards act of 1992 and the American College of Radiology help ensure that mammography is safe and diagnostic.

5

equally

slightly

scattering

motion

overlap

Compression: Compression is important for high quality mammographic imaging

  • Compression should be applied ____ to both breasts.
  • If applied properly, compression should be ____ uncomfortable.
  • Compression Helps:
    • Thin the breast for even x-ray exposure
    • Reduce radiation _____ by decreasing thickness of the breast
    • Reduce ____
    • Prevent tissue ____
6

Two

two

Mammographic Views:

  • ___ projections or views of each breast should be obtained for the screening mammogram.
  • Additional views may be needed when abnormalities are found or an area needs further investigation.
  • Screening mammogram
    • ___ standard views are obtained
  • Diagnostic mammogram
    • additional views are obtained to further investigate certain areas
7

most valuable

axilla; inframmmary

pectoralis

30 and 60

medial to lateral or side to side.

Medio-Lateral Oblique (MLO View):

  • The ____ ____ mammographic view.
  • Allows imaging from high in the ____, down to the _____ fold, and all the way back to the chest wall.
  • The nipple should be imaged in profile in order to not be mistaken for a mass.
  • The _____ muscle should be included in this view as well.
  • Angulation of the mammography unit for the MLO view will vary between ___ ____ degrees depending on the patient.
  • In this view the breast tissue is compressed from ____ ____ or ___ ____
8

most valuable

perpendicular

superior to inferior or top to bottom.

Cranio-caudal or CC View

  • The next ___ ____ view
  • Mammography unit is adjusted to place the x-ray beam _____ to the floor.
  • The nipple should be seen in profile in this view as well
  • The breast tissue is compressed from ____ ____ or ____ ____
9

parallel

medial/lateral or lateromedial

accurately

Lateral View:

  • The lateral view is a true lateral view with the x-ray beam ____ to the floor.
  • It can be performed as a ______ ______ projection.
  • This view most ______ shows pathology located in the superior or inferior quadrants
10

magnification

smaller

overlap

Spot Compression:

  • Views performed with or without _____
  • These are used to focus in on specific _____ areas of the breast
  • This view uses greater compression and utilizes a paddle to press tissues flat
  • Often this view alleviates tissue ____ and obtains a close up view to evaluate the questionable area
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medial

medial

Cleavage View:

  • View of the _____ or inner portions of both breasts.
  • It is valuable when there is a lesion suspected in the most _____ portion of the breast.
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MLO; tail of spence

backward

Other Views:

  • Axillary tail
    • Similar to the ____. More focused on the ____ of _____
  • Rolled views
    • Attempts to displace the breast tissues to confirm a lesion
  • Implant views
    • Displaced view: the implant is pushed _____ to image the breast tissue
13

superior

inferior

lateral or medial

Rules for Evaluating a Mammogram:

  • ML view
    • Above the nipple is the ____ region
    • Below the nipple is _____.
    • There is no knowledge of _____ _____.
    • If the mass is on the line between superior and inferior, the mass is located at either 3:00 or 9:00 on the breast.
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lateral

medial

superior and inferior

axilla

CC View:

  • From the nipple to the top of the film or marker is ____
  • From the nipple away from the marker is ____
  • We have No knowledge of _____ _____.
  • The marker is always located at the _____ in the CC view
  • If a mass is located on the line between the lateral and medial sections, the mass is located at 12:00 or 6:00 on the breast.
15

...

Measuring from the Nipple:

  • You can further pinpoint the location of a mammographic finding by measuring the distance in cm from the nipple.
  • There are many ways that this can be done.
  • My favorite: Place a ruler at the nipple or nipple marker. Measure straight back until you line up with the location of the lesion. Draw an imaginary line from the lesion to the ruler and note the cm marking on the ruler.
  • In my experience, this method is more accurate with a CC view than an MLO view
16

oblique

higher

higher

lower

  • When locating a lesion on an MLO view you must remember that an MLO view is not a true lateral view and is slightly _____.
  • This can cause lesions in the medial portion to be actually located slightly _____ than they appear.
  • On a CC view if a lesion is medial, you must consider that it may actually be ______ than it appears on the MLO view.
  • If the lesion appears lateral on the CC view, one must consider that it may be _____ than it appears on the MLO view.
  • Medial UP, Lateral Down : MULD
17

not

  • It is __ possible to distinguish normal and abnormal tissue based on density alone.
  • One cannot distinguish cysts, from solid tissues, or benign vs. malignant tumors based on a mammogram.
  • We must consider other diagnostic features just as we do in sonography.
18

asymmetrical

center

Shape

  • Round
  • Oval
  • Lobulated
    • Undulations or scalloped edges
  • Irregular
    • Angles and straight lines, _____
  • Spiculated
    • Lines radiate from ____ of the tumor.
19

Circumscribed

large

small

Margins

  • Smooth
    • _____ (clear borders)
  • Macrolobulated
    • gentle ____ lobulations.
  • Microlobulated
    • Multiple _____ lobuations
20

poorly

highly

malignancy

  • Ill defined
    • Obscured or indistinct margins that are _____ defined. (usually means invasion into surrounding tissues)
  • Angular
    • Irregular, jagged margins (_____ suggestive of malignancy)
  • Spiculated
    • straight lines radiate out from center (most specific characteristic for _____)
21

darker

middle

light

white

Density: The density of a lesion or structure provides the least predictive ability in determining benign vs. malignant findings

  • Fat densities (radiolucent – ____ gray)
    • Fat, cysts, lipomas
  • Mixed fat and water densities (____ gray)
    • Lymph nodes, galactocele, fibroadenolipoma
  • Water density structures (radiopaque – ____ gray)
    • Glandular tissue, connective tissue, lactiferous ducts, pectoral muscles, cysts, hematoma, fibroadenoma, phyllodes tumors, malignant tumors
  • Calcium density – radiopaque – ____
    • Benign and malignant calcifications
22

fibroglandular

limited

decrease; replacement

HRT

  • Sometimes, dense _____ tissue can hide tumors on mammography
  • Screening mammography with dense breasts may be ____
  • Normally, fibroglandular tissue will ____ with age. This is called fatty _____.
  • In some cases, tissue will increase in women taking ____ and women with marked weight loss.
23

consistently

benign; malignant

benign

Calcifications:

  • Mammography is the only modality that can identify calcifications ______.
  • Calcifications can be ___ or _____.
  • Statistically, calcifications are more associated with _____ processes.
  • There are several types of calcifications.
24

vessels

popcorn; 1; fibroadenoma

ducts

  • Vascular
    • Appear as calcified tubes associated with ____
  • Large coarse
    • Also known as _____ calcifications. Usually larger than __ mm. Commonly caused by a degenerating _____
  • Rod shaped
    • Calcium deposits within the ____
  • Rim or eggshell
    • Crescent or rim shape, or round with a radiolucent center. Represents calcium deposit in a cyst, milk of calcium cysts, sebaceous cysts, hemorrhagic cysts, or fat necrosis.
25

.5

malignant

malignancy

Suspicious calcifications:

  • Punctate or microcalcs
    • Very small, less than __ mm. Pinpoint calcifications. Associated with fibrocystic changes, fibroadenoma, sclerosing adenosis, malignancy
  • Flake shaped calcifications
    • Small indistinct and fuzzy – tend to be _____
  • Linear branching
    • Fine interrupted linear calcifications within the ducts (almost exclusively associated with _____)
26

benign

malignancy

malignancy

malignancy

Calcification Patterns:

  • Diffuse
    • Scattered randomly, associated with ____ lesions
  • Clustered microcalcifications
    • Usually associated with fibroadenoma or _____
  • Segmental
    • Suggest calcifications follow a ductal system – associated with _____
  • Regional
    • Calcifications cover a segment or quadrant of the breast – associated with ___
27

menopause

hormonal

Breast Cysts:

  • A simple cyst of the breast is very common and generally occurs in women between 35 and 50.
  • Simple cysts typically regress after _____
  • Cysts result from obstructed lactiferous ducts due to fibrosis or proliferative changes in the ducts epithelium.
  • Cysts can also result from _____ dilatation.
  • Ultrasound can accurately diagnose simple cysts. No further intervention is required unless the cyst is large, painful etc. Then aspiration can be performed.
28

...

Cysts can be:

  • Single or multiple
  • Unilateral/bilateral
  • Variable in size
  • Palpable or non palpable
  • Silent or painful
  • Moveable
  • compressible
29

...

Mammographically, simple cysts appear

  • Round or oval
  • Smooth or well circumscribed margins
  • Radiopaque (water density)
  • Halo sign – lucent rim of fat
30

...

Sonographically simple cysts appear:

  • Round or oval
  • Anechoic
  • Smooth margins
  • Sharp borders
  • Acoustic enhancement
  • May have edge shadowing
  • Occasionally lobulated
  • Compressible
  • No internal Doppler signal
31

Debris

Fatty

Hemorrhagic

Complex Cysts: Cysts that contain internal echoes or abnormal walls are considered complex.

  • Types of complex cysts:
    • _____-filled
      • Cellular debris, epithelial cells, apocrine cells, foam cells and cholesterol crystals fill the cyst
    • ____ cyst
      • Filled with fat and protein
    • _____ cyst
      • Filled with blood cells
32

Abscess

Galactocele

Milk

Sebaceous

  • Inflammatory cyst
    • Inflammatory cells, purulent fluid, may have thick walls
  • _____
    • Purulent fluid, may have thick walls
  • ______
    • Milk cyst
  • ____ of calcium cyst
    • Calcium in gravity dependent portion
  • _____ or epidermal inclusion cyst
    • Sebum – greasy substance
33

Fibrous

wall

thick

  • Oil cyst
    • Oil cells
  • Septated cyst
    • ____ stromal cells
  • Calcified cyst
    • Calcium deposits in the ____ of the cyst
  • Malignant cyst
    • Malignant neoplastic cells, may have ____ walls
34

Heterogeneous

Gravity

Wall

calcification

Sonographically, complex cysts may demonstrate:

  • Low to medium level echoes
  • _____ internal appearance
  • ____ dependent fluid/fluid levels
  • Septations
  • ____ thickening
  • Total or partial wall _____
  • Partial enhancement or shadowing
35

No

complex

  • It may sometimes be difficult to differentiate a complex cyst from an intraductal papilloma or carcinoma.
  • Color Doppler may be helpful in assessment of complex cysts. ___ Doppler flow will be detected in a cyst.
  • If ______ cysts are painful, recurrent, associated with inflammation, or appear suspicious aspiration can be performed. Cytology will reveal the true nature of a cyst.
36

Milk; lactiferous

subareolar

Hypoechoic

Galactocele:

  • ___ filled cyst caused by the obstruction of a ____ duct.
  • Usually associated with breast feeding/childbirth/lactation
  • The cyst is usually located in the _____ region
  • Sonograpically it appears:
    • Round, oval or lobulated
    • ____ to isoechoic
    • Homogeneous
    • Acoustic enhancement
    • No internal Doppler signal
    • May also see dilated ducts, mastitis, and abscess
37

sebaceous

oily

inframammary

Round

Superficial

Sebaceous Cysts:

  • Results from obstructed ______ gland within the skin
  • Cyst contains sebum, an ___ substance
  • Commonly associated with Montgomery glands of the areola or found at the _____ fold
  • Patients usually present with a superficial palpable nodule
  • Sonography will show:
    • ____, well defined mass
    • Hypoechoic to isoechoic
    • _____ location
    • No doppler signal
    • enhancement