Ebook Breast imaging - A core review: Part 2

(BQ) Part 2 book “Breast imaging - A core review” has contents: Diagnostic breast imaging, breast pathology, and breast imaging findings; breast intervention; physics related to breast imaging.

D. BI-RADS 5

8 A 35-year-old female with a history of a left lumpectomy, radiation therapy, and chemotherapy at

age 29 presents for her annual diagnostic mammogram Based on the magnification images of thelumpectomy site, what is the most appropriate next step?

B. Irregular, microlobulated

C. Irregular, spiculated

D. Round, speculated

images are provided What is the most likely diagnosis?

B. Probable abscess, recommend drainage/aspiration

C. Probably benign, lactating adenoma, or fibroadenoma, recommend short interval follow-upultrasound in 6 months

All of the masses were similar in appearance sonographically so a single mass was selected tosample under ultrasound guidance Pathology demonstrates fibrous stromal proliferation andperivascular lymphocytic infiltrate consistent with diabetic mastopathy The correctradiologic/pathologic correlation is

for an abnormality seen on screening mammogram Mammogram demonstrated a circumscribedoval mass (not shown) Ultrasound image is shown The lesion was biopsied, and pathology

results were pseudoangiomatous stromal hyperplasia (PASH) Regarding PASH, which is the mostaccurate statement?

E. Annual diagnostic mammogram

66 A 60-year-old female presents for a diagnostic mammogram to workup calcifications in the lower

inner quadrant of the left breast seen on recent screening mammogram Skin calcifications aresuspected What is the most appropriate next step in determining the true nature of the

and ultrasound images, which one of the following is the most appropriate BI-RADS categoryassessment?

B. The mass should be categorized as BI-RADS 2, and continued risk-appropriate screeningshould be recommended

A. BI-RADS 2 Benign No further follow-up needed.

B. Most common cause of fat necrosis is surgery

C. Usually is seen in the upper inner quadrant on the right when the trauma is sustained by thedriver

Reference: Shah BA, Fundaro GM, Mandava S Breast Imaging Review: A Quick Guide to Essential Diagnoses 1st ed New

3b Answer B. Differential diagnosis for skin thickening includes unilateral edema (focal or

diffuse), mastitis, inflammatory carcinoma, postprocedural skin thickening, abscess, and

underlying malignancy Breast parenchymal enhancement may vary with the phase of the menstrualcycle, but skin thickening will not occur

4c Answer D. Color Doppler ultrasound demonstrates a solid, hypoechoic, oval, circumscribed,

vascular mass with long axis parallel to the skin surface that has an appearance of a

fibroadenoma The most common solid benign tumor in young female is a fibroadenoma Juvenilefibroadenoma occurs usually been in the age of 10-20, rare above the age of 45 Because juvenillefibroadenomas can grow to a large size, they can be called a giant fibroadenomas However, notall giant fibroadenomas are juvenile fibroadenomas The appearance of fat necrosis on ultrasoundevolves over time The sonographic spectrum can range from anechoic, echogenic, irregular

differential diagnosis of intraductal lesions leading to nipple discharge but are less common thanintraductal papillomas

Reference: Stavros AT Breast Ultrasound Philadelphia, PA: Lippincott Williams & Wilkins; 2004:157–160.

6a Answer A. The images demonstrate round and smudgy calcifications on the CC view that have a

curvilinear appearance on the ML view These are representative of milk of calcium, which arebenign Milk of calcium is sedimented calcium oxalate calcifications within microcysts and

hypoechoic cortex and an echogenic fatty hilum On color or power Doppler, a feeding arteryentering the hilum can be seen The outer cortex should be smooth, without eccentric thickening.The appearance of the lymph node in this image is benign A palpable lymph node, which is

benign in appearance by ultrasound, does not require additional workup or biopsy

Reference: Stavros AT Breast Ultrasound Philadelphia, PA: Lippincott Williams & Wilkins; 2004: 838–845, 855–870.

8 Answer C. On initial review of the images, the pleomorphic microcalcifications near the

lumpectomy bed are the most obvious finding These were new compared to the prior study, andimages of the prior study were not provided However, on more careful inspection, there is a focalasymmetry associated with the calcifications, making the findings even more concerning for

malignancy The findings are concerning for malignancy; therefore, an annual screening

mammogram, annual diagnostic mammogram, and 6-month follow-up are inappropriate MRI may

be beneficial after the biopsy is performed if there is a concern for multicentric disease Of theanswer choices provided, stereotactic core biopsy of the calcifications is the most appropriateanswer

References: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:0–4.

Kopans D Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:989.

10a Answer C. Masses are described by both their shape and margins Terms used to describe the

shape of a mass included round, oval, lobular, and irregular (mneumonic: “ROLI”) Terms used todescribe the margins of a mass include circumscribed, obscured, microlobulated, indistinct, andspiculated (mneumonic: “COMIS”) In this case, the best description of the shape would be

irregular, meaning the shape cannot be characterized by any of the other descriptors The bestdescription of the margins would be spiculated, meaning there are thin lines radiating from themargin of the mass An irregular mass with spiculated margins is a concerning finding and

Reference: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:0-10–IV:0-11.

10c Answer B. Elastography measures the stiffness of a lesion compared to the surrounding tissues.

Cysts are typically less stiff than the surrounding tissue, while solid masses are typically morestiff than the surrounding tissue On the image provided, the color image is the elastography image.The scale to the right of the image has the abbreviation SF at the top of the scale, meaning soft.The abbreviation HD at the bottom of the image means hard The mass in question is blue on

elastography, which corresponds to hard or stiff on the elastography scale Therefore, this mass ismore stiff than the surrounding breast tissue and represents a solid mass requiring biopsy

References: Burnside ES, Hall TJ, Sommer AM, et al Differentiating benign from malignant solid breast masses with US strain

mimicking new or recurrent malignancy when the macroscopic fat content is low In these

situations, biopsy may be necessary for diagnosis On mammogram, fat necrosis can present ascalcifications, usually curvilinear or eggshell but can mimic linear pleomorphic calcificationsearly in development Fat necrosis can also present on mammography as lipid cysts, focal

References: Kopans D Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2006:89, 579–603.

Litton JK, Theriault RL, Gonzalez-Angulo AM Breast cancer diagnosis during pregnancy Womens Health 2009;5(3):243–249.

Trop I, Dugas A, David J, et al Breast abscesses: Evidence-based algorithms for diagnosis, management, and follow-up.

Radiographics 2011;31:1683–1699.

MLO image The differential diagnosis for unilateral adenopathy includes metastases, reactiveadenopathy from inflammation or infection, or silicone from an implant rupture or leak The

differential diagnosis for bilateral axillary adenopathy includes HIV, lymphoproliferative

disorders such as lymphoma or leukemia, rheumatoid arthritis and other collagen vascular

diseases, and tuberculosis or sarcoidosis This lymph node was biopsied and was consistent withmetastases from ovarian carcinoma The ovarian malignancy was known prior to the mammogramand was the reason this diagnostic mammogram was performed

Reference: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:3–31.

14a Answer C.

14b Answer D. On the axial T1-weighted image, we can see the pectoral muscle clearly, indicating

that this is a prepectoral implant The second image is a water-saturated image, but the implantstill has high signal, indicating that this is a silicone implant The keyhole sign is present,

consistent with intracapsular rupture In addition, silicone is noted outside the implant capsuleposterior, indicative of extracapsular rupture as well

References: Berg WA, Caskey CI, Hamper UM, et al Diagnosing breast implant rupture with MR imaging, ultrasound and

prostate cancer Males with breast cancer typically have a worse prognosis due to a later stage atthe time of diagnosis Approximately 35% to 50% of male breast cancer is associated with DCIS.Approximately 50% have axillary adenopathy at the time of diagnosis

Reference: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:5-54–IV:5-57.

16 Answer A. By convention, rolled CC views are performed with the superior half of the breast

rolled medial (CCRM) and lateral (CCRL) prior to convention These are performed when alesion is seen on the CC view but not the MLO view and are useful to determine if a lesion is realand to locate in the sagittal plane

Reference: de Paredes ES Atlas of Mammography (electronic resource) 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:37.

17 Answer A. The classic appearance of an extracapsular silicone rupture on ultrasound is the

snowstorm appearance, in which the extracapsular silicone creates dirty shadowing The

extracapsular silicone can form silicone granulomas, which may present as palpable masses Thepresence of extracapsular silicone does imply that there is a simultaneous or preexisting

intracapsular rupture, though this may not be visualized by ultrasound On this single image, theextracapsular silicone is visualized by the dirty shadowing; however, the intracapsular rupture isnot visualized

References: Berg WA, Birdwell RL, eds Diagnostic Imaging: Breast Salt Lake City, UT: Amirsys; 2008;IV:4-28–IV:4-31.

Stavros AT Breast Ultrasound Philadelphia, PA: Lippincott Williams & Wilkins; 2004:838–845, 240–243.

18 Answer B. A lateral-medial (LM) view would be preferred because the calcifications would be

projection, the sternalis muscle is not identified on the MLO view It is a thin accessory muscle inthe chest that runs in a craniocaudal direction, parallel and adjacent to the sternum The reportedprevalence of the sternalis muscle ranges from 1% to 11% and varies by population It can be seenbilaterally but more commonly presents unilaterally The sternalis muscle is a normal variant thatcan mimic breast pathology and create a diagnostic dilemma Confirmatory imaging with CT orMRI may corroborate the presence of this muscle

palpable breast mass, classically eccentric to the nipple The subareolar region is the most

common site of involvement Invasive ductal carcinoma is the most common type of cancer inmen, accounting for 99% of cases Imaging findings and staging are the same as in women Breastcancer in males is rare and accounts for ~1% of all breast cancers

References: Cardeñosa G Clinical Breast Imaging: A Patient Focused Teaching File Philadelphia, PA: Lippincott Williams &

Wilkins; 2007:308–309.

Weiss JR, et al Epidemiology of male breast cancer Cancer Epidemiol Biomarkers Prev 2005;14:20–26.

patients with type I diabetes mellitus It can mimic malignancy both clinically and

radiographically and typically requires a biopsy While thought of as being a rare disorder, somestudies have shown prevalence as high as 13% in long-standing type I diabetic patients

gynecomastia, one of which is drug related In this patient with multiple comorbidities, obtaining afull past medical and drug history is crucial This patient was on prednisone, Zoloft, and a

/hypothyroidism, liver disease, renal failure, COPD, and diabetes are physiologic causes of

References: Kang BL, Jung JI, Park C, et al Breast MRI findings after modified radical mastectomy and transverse rectus

fibroadenomas is dark internal septations Simple cysts also do not demonstrate enhancement.Hamartomas are usually diagnostic mammographically, and MRI is generally not necessary fordiagnosis When imaged on MRI, the glandular elements within hamartomas show slight

internal echoes and irregular thick walls may represent various entities in each process Historyhelps distinguish an abscess if there is increased redness, tenderness, warmth to the area, and skinthickening A common presentation is a post- or peripartum female A malignancy will likely havevascularity in the soft tissue components of a complex mass Hematomas may present after a

1699.

31 Answer D. Tubular carcinoma is slow growing and the most likely diagnosis of the given

options when a very small (5 mm) spiculated lesion is found by mammography The majority of

Reference: Kopans DB Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:860.

32 Answer C. There are many types of calcifications with the breast, some of which are classically

benign These include skin calcifications, oil cysts or fat necrosis, milk of calcium, and vascularcalcifications Skin calcifications are lucent-centered and usually distributed medially Oil cystsare rim or eggshell calcifications that may be due to previous trauma Milk of calcium is a

precipitate that layers in cystically dilated acini of lobules On the CC view, they appear as

amorphous, smudgy calcifications, while on the lateral view, the layering of calcifications becomemore crescentic in shape, sometimes referred to as “teacup” shaped Vascular calcifications occuralong the walls of arterial vessels and have a parallel “train track” appearance In a young (under

extracapsular rupture If there was only intracapsular rupture of the implant shell, the siliconewould likely have been contained by the fibrous capsule without definitive mammographic

evidence of the implant integrity abnormality Implant contour irregularity is an unreliable sign ofrupture

No mass is present in this case, although free silicone can eventually lead to a silicone

granuloma Calcifications around the implant can often be seen, although the important finding inthis case is the free silicone

36b Answer B. Although a mammographic abnormality is identified, the ruptured implant with

resultant free silicone in the breast tissue does not indicate a malignancy BI-RADS assessment isfor evidence of malignancy, which there is not in this case

References: Berg WA, et al Diagnosing breast implant rupture with MR imaging, US, and mammography Radiographics

1993;13:1323–1336.

Kopans DB Breast Imaging 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

37 Answer A. According to the BI-RADS Manual, fourth edition, high-risk lesions include atypical

ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS),peripheral duct papillomas, and phyllodes tumor (not specified as malignant) Intracystic

papilloma and intraductal papilloma are benign and papillary carcinoma in situ is malignant

Reference: American College of Radiology (ACR) ACR BI-RADS—Mammography ACR Breast Imaging Reporting and Data System, Breast Imaging Atlas 4th ed Reston, VA: American College of Radiology; 2003:300.

38a Answer B.

38b Answer D. According to well-established sonographic criteria for simple cysts and the BI-RADS lexicon description for simple cysts set forth by Stavros, a mass is classified as a simplecyst when these features are met: anechoic, well circumscribed with a thin echogenic capsule,increased through transmission (or posterior acoustic enhancement), and thin edge shadows (sharpborder) A simple cyst confers an assessment of BI-RADS 2, benign finding, and the patient canreturn to routine screening or ageappropriate follow-up

surgical excision

References: Camuto PM, Zetrenne E, Ponn T Diabetic mastopathy: A report of 5 cases and a review of the literature Arch Surg

2000;135:1190–1193.