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Mammography Principles

Mammography is 90% sensitive to find breast cancer.

Screening: Cranio-Caudal CC, Medio Lateral Oblique (MLO), XCCL - use when breast parenchyma extends beyond the edge on CC due to prominent tail of Spence extending to axilla
Diagnostic: problem solving, additional views:
- 90 degrees ML (triangulate lesion, milk of calc eval),
- Spot compression views with magnification (air gap, 1.5-2 x magnification, 0.1mm focal spot),
- SIO - Supero-Inferior Oblique,
- Axillary Tail (AT),
- Cleavage view (AT): Kleopatra view, valley view - eval of the far medial and posterior breast,
- Tangential (TAN),
- Roll (RL, RM): separate superimposed tissues - if the real abnormality is in the top half of the breast it will move medially on RM, lateral if it is in the bottom half and opposite is true for RL view,
- Caudocranial (FB) From Below:
Compression: improves image by reducing breast thickness, which reduces scatter and patient motion; 25-45 pounds.
Posterior Nipple Line PNL: axis of the nipple, line from the nipple equally bisecting the breast extending to pectoral muscle.
Inframammary skin fold.
The pectoral fold must extend to or below the PNL.

Needle Localization Excisional Biopsy NLBX: hooked wire into the lesion with wire passing out of the skin, pt to OR, surgeon will remove lesion w/ the hook wire still in the specimen. Specimen radiograph is made, results called to OR.
Vacuum assisted Core Needle Biopsy VCNB: 11G needle under US guidance into area of interest. Marker is deployed.
Gun needle devices: Core needle Bx w/o vacuum, under US; 14G hand held spring loaded; 5 passes required for adequate sampling; prone to sampling error
Fine Needle Aspiration FNA: 23G needle attached to a syringe w/ vacuum, multiple passes through a palpable abnormality; aspirate on slide, cytotechnologist or pathologist present
Incisional biopsy: surgical

Anatomy: 20 lobes, each lobe is connected by segmental duct to a lactiferous sinus. Each lobe contains thousands of lobules. Terminal duct and lobule = TDLU: Terminal Duct Lobular Unit. Invasive Ductal Carcinoma and Invasive Lobular Carcinoma originate from the TDLU.

Pathology and Histology:
ADH: Atypical Ductal Hyperplasia --> DCIS: Ductal Carcinoma In Situ --> IDC: Invasive Ductal Carcinoma. IDC w/ EIC - Extensive Intraductal Component ( > 25% DCIS component) means mastectomy rather than lumpectomy. DCIS and IDC NOS account for 85% of breast cancers.

DCIS: group of fine pleomorphic calcifications or linear branching calcs
- Cribriform: holes in ducts
- Solid: no holes
- Micropapillary: small finger-like projections
- Papillary: large finger like projection, 96% cure rate
- Intracystic papillary carcinoma: may obstruct the duct forming postobstructive cystic dilatation, may be large 1-2cm
- Comedo carcinoma: more aggressive DCIS, whitish colored necrotic debris

Calcifications represent tumor necrosis, linear, branching, chinese characters forming. These may remain relatively stable for many years. Do not follow calcifications. If they cannot be categorized as benign, they should be biopsied.

Invasive Ductal Carcinoma: Spiculated or Irregular mass
broke through the basement membrane, arises from TDLU
diffuse sheets, cords, nests, glands, tubules or individual cells
90% are poorly differentiated - Invasive Ductal Carcinoma, Not Otherwise Specified (NOS)
- Infammatory Breast Carcinoma: IDC NOS, peau d'orange, edematous skin changes, pain, warmth to touch; lymphatic channels infiltration by tumor cells --> obstruction --> edema

Better differentiated subtypes of IDC:
- Tubular carcinoma forms well differentiated ducts composed of malignant cells: presents as spiculated mass (spicules are reaction of surrounding tissues), all spiculated masses gets biopsy regardless of relative stability, best prognosis of all IDCs
- Mucinous (Colloid) carcinoma: older women, well circumscribed but at least a portion of the border will be indistinct, on spot compression view margins are ill-defined; US: hyoechoic mass with indistinct borders, angulations and posterior acustic enhancement, shadowing is uncommon (may look like fibroadenoma); MRI: very high signal on T2
- Medullary Carcinoma: well-circumscribed, lobular, round, oval in shape, may look like fibroadenoma, fast growth, younger females
- Papillary Invasive Carcinoma: circumscribed mass, important to differentiate between 4 papillary types: Papillary DCIS, Micropapillary DCIS, Intracystic Papillary DCIS and Invasive Papillary Carcinoma

Invasive Lobular Carcinoma
- < 10% of breast carcinomas, large portion of False Negatives
- Presents as spiculated mass without a mass or poorly defined asymmetric density with architectural distortion, No calcifications; commonly seen only on CC view
- Thin sheets of malignant cells resembling spiderweb; decrease compliance of breast tissue on physical exam; Shrinking breast (large ILC, decreased compressibility - smaller appearing breast on mammo, not clinically)
- Areas of shadowing on breast US
- Bilateral in up to 1/3 of cases
- Mets to peritoneum, retroperitoneum and gynecologic organs (ascites, hydronephrosis, pelvic mass)
- DDX: Radial Scar a.k.a Complex Sclerosing Lesion (30% incidence of adjacent ca)

LCIS: Lobular Carcinoma In Situ - Not a Cancer - Lobular Neoplasia
has no distinguishing features, multicentric, bilateral in 30%
10-12 fold risk for developing subsequent invasive carcinoma in both breasts (more likely IDC)

Phyllodes Tumor
more common in Hispanics born in latin America
round, relatively well circumscribed and firm, stromal hypercellularity (ddx: fibroadenoma), very fast growing, in middle aged and older women phyllodes tu is more likely, in younger female fast growing fibroadenoma is more likely
benign, low grade, high grade
Mets hematogeneously to the lung; do not spread through the lymphatic system - sentinel node bx is not indicated

Paget's disease of the nipple: neoplastic cells of DCIS may travel down the duct to the nipple forming a crusty appearance

Male Gynecomastia: Subareolar parenchymal density, flame shaped in appearance, uniformly distributed around the nipple. Any eccentricity is suspicious. Pseudogynecomastia is condioton of obese males.

Male Breast Carcinoma: rare IDC or DCIS, mean age 60, BRCA 2, painless firm mass eccentric to the nipple, bloody nipple discharge, calcs are rare, but any calcs in male breast are extremely suspicious

MQSA: Mammographic Quality and Standards Act
certified by FDA, accredited by State Accreditation Body, inspected annually by FDA inspector
all patients will receive a letter
overall assesment of finding
240 mammo interpretations in last 6 months (or 2 years if resident passed boards at the first attempt)
960 mammo interpretations over 24 month period, 15 category 1 CME over 36 months

Sickles criteria for BI-RAD 3:
1. Well-circumscribed lesion (at least 75% on the summtion of all views)
2. No clacifications
3. Non-palpable
4. Not a neodensity

<2% probability of malignancy

Multicentric disease: masses > 2 cm appart or in different quadrants
Multifocal disease: masses < 2 cm appart

ER, PR, Her 2 neu

Discordance of radiologic and pathologic findings:
1. Fibroadenoma with high degree of cellularity = phylloides tumor
2. Papilloma (papillary ca is difficult to exclude)
3. Radial Scar a.k.a Complex Sclerosing Ductal Lesion (30% incidence of adjacent ca)
4. ADH (cannot r/o adjacent DCIS or IDC)
6. No calcifications in specimen obtained for suspicious calcifications (use polarized light - calcium oxalate)
7. Mucous containing specimen: special stains
8. Hemangioma: undistinguishable from angiosarcoma