Breast

1. Lymph nodes
2. Nipple: asymmetric enhacement of nipple suggests Paget's disease.
3. Vessels
4. Glandular tissue:
- increased glandular tissue in pregnancy which has increased blood flow.

- Typically located in the axilla but may be located in the breast (intramammary lymph node).
- Oval/round in shape
- Circumscribed margins
- Central fatty hilum
- Enhancement characteristics: rapid uptake and wash out.

Treatment related enhancement can be seen with:
1. Scars (post-surgical or biopsy): Surgical bed and/or biopsy tract may enhance for a while after the procedure. However, old scars should not enhance.
2. XRT: increased enhancement is seen for 6-16 mos after radiation therapy which decreases over time.
3. Ablation

- Can be any shape and can show any type of kinetics.
- Acute fat necrosis does not show fat SI.
- Chronic fat necrosis has fat signal.
- Look for history of trauma, XRT, surgery.

Lobular shape, dark internal septations, and markedly hyperintense on T2WI.
Kinetics: usually persistent pattern.

1. Inflammatory mass caused by foreign body reaction to extracapsular silicone gel in tissue.
2.
- Hyperechoic lymph nodes, the posterior aspect of which is obscured by acoustic noise.
- Gives the pathognomic appearance of a "snowstorm".
3. When the shell of the implant fails (i.e., ruptures), the gel is contained by the fibrous scar or capsule the body forms around the implant. The implant maintains its shape as it is contained by the fibrous capsule. Intracapsular ruptures are hard to diagnose with physical exam or mammography. MRI reveals the "linguini sign" in intracapsular rupture. When the scar tissue fails to contain the gel (i.e., "extracapsular rupture"), silicone gel can migrate and be taken up in lymph nodes or be walled off by fibrosis. This is easily detected by physical exam and mammogram.
4. Radial fold represents an infolding of the silicone implant which appears thicker than the ruptured capsule and only partially traverses the implant. It can mimic an intracapsular rupture.

1. Inflammatory breast cancer: 2/2 non-compressible breast. On physical examination, the affected breast is actually larger.
2. Infiltrating lobular carcinoma
3. Post-radiation

- bilateral marked parenchymal densities that are hard to distinguish from breast cancer.
- presents as hard breast masses in an insulin dependent diabetic.

Inflammatory breast cancer
Mastitis
Radiation dermatitis

- carcinoma in situ involving the nipple epidermis
- associated with a local inflammatory response with pruritus and excoriation (misinterpreted as a dermatologic condition). Therefore, wedge biopsy should be performed of any skin lesion of the nipple-areolar complex that does not resolve promptly with topical therapy.
- Most cases of Paget disease are associated with ductal carcinoma in situ (DCIS); uncommonly, there can be underlying invasive carcinoma as well.

1. Benign papilloma is the most common cause of nipple discharge. Malignant causes include DCIS and papillary carcinoma.
2.
- Most often central, near the nipple.
- Frond-like configuration of the mass is typical.
- Multiple small filling defects within multiple ducts is called papillomatosis.
3. Irregular duct wall with cutoff &/or irregular intraductal masses on galactography.
4. Mammogram. If the mammogram is positive, then follow up ultrasound and biopsy. If mammogram is negative, then do a ductogram.

- most common near the nipple
- usually due to skin organisms
- diabetes, recent surgery, human immunodeficiency virus (HIV), or nursing mothers are at risk
- If < 3 cm in size, they can usually be treated successfully with oral antibiotics (Cephalexin or Azithromycin) and US-guided drainage.
- If > 3 cm, open incision and drainage, or placement of a drainage catheter, may be required.

1. Causes of gynecomastia include hormonal (relative excess of estrogen in relation to testosterone), drug-induced (marijuana), systemic (liver disease), and idiopathic.
2.
- Centered behind the nipple.
- Tapers peripherally on imaging (i.e. flame shaped).
3.
- Eccentric to the nipple.
- Peripherally convex/nodular.
4. If there are no suspicious findings on mammogram, then ultrasound is not indicated. Ultrasound should be performed in a man when the mammographic findings are not classic for gynecomastia and you suspect a mass is present.

1.
- 20% = malignant (DCIS/IDC)
- 20% = atypical ductal hyperplasia
- 60% = fibrocystic changes (milk of calcium)
2. Calcium deposits in fat necrosis develops 1.5-5 yrs (or later) after trauma and coarsen over time. Calcifications seen within the 1st year after surgery at the lumpectomy site in a patient with prior cancer are more likely residual carcinoma and should prompt biopsy.
3. If ultrasound guided biopsy shows atypical ductal hyperplasia, there is a 15-20% risk of DCIS and thus excisional biopsy is performed.
4. milk of calcium, secretory calcifications, dystrophic calcifications, and vascular calcifications.

Triangular shaped density seen in the posterior-medial aspect of the breasts on the CC view.

Steatocystoma multiplex is an uncommon disorder, which consists of multiple cutaneous intradermal cysts mainly on the trunk and upper extremities. These may mimic a galactocele in appearance with fat/fluid levels. Clinical history will help distinguish.

Rupture is more common with subpectoral than subglandular implants and is generally more common the longer the implant has been in place. Intracapsular silicone implant rupture, as in this case, has no known clinical significance, though implant manufacturers typically recommend replacement if the implant is known to be ruptured and most insurance will cover surgery for known implant rupture (imagers may be asked to determine implant integrity). MR is more sensitive than ultrasound to intracapsular rupture, especially when there is only partial collapse of the shell (rather than complete as in this case), and mammography typically cannot show intracapsular rupture. Extracapsular silicone can be identified on mammography as dense masses outside the implant and show a "snowstorm" appearance on ultrasound.

BI-RADS 3 (probably benign) is most frequently used on a baseline exam when there are no priors for comparison. A BI-RADS 3 finding is usually followed for 2 years (6, 12, and 24 months) on the modality that best depicts the finding, assuming stability at each examination. If there is suspicious change (new irregular margin) or excessive growth (> 20% in 6 months) at any follow-up, biopsy should be performed.

1. 20 gauge
2. 14 gauge
3. 11 gauge

1. In a galactocele, the debris is lipid-rich and is seen in the nondependent portion of the collection.
NOTE: debris in a complicated cyst is located in a DEPENDENT location.

- IDC
- ILC
- Radial scar (architectural distortion with central lucency on mammography)

Reorganization of the breast tissue with band-like densities along the expected course of the incisions in the lower posterior portions of both breasts.

regional or diffuse increase in density in 1 breast compared to a similar area in opposite breast

- Architectural distortion
- Focal asymmetry
- Shrunken breast with direct involvement of the overlying skin.
- Often diagnosed at a larger size and more advanced stage than infiltrating ductal carcinoma because the tumor cells invade as single file columns more than forming a discrete mass.

Palpable mass in pregnant or lactating woman
Indistinguishable from FA clinically, as both may enlarge in pregnancy
Indistinguishable from FA on US
Circumscribed, oval or gently lobulated, hypoechoic mass
Posterior acoustic enhancement
Echogenic septations
Core needle biopsy often needed to distinguish from other pathology

Nonspecific, similar to FA on US, biopsy needed to confirm diagnosis
Well-circumscribed, oval or lobular, hypoechoic mass
Posterior enhancement, minimal vascularity

MULTICENTRIC TUMORS
- in different quadrants of the breasts
- separated by at least 4-5 cm
- requires mastectomy instead of lumpectomy.
MULTIFOCAL TUMORS
- multiple primary breast cancers in the same quadrant, typically the same duct system
- within 4-5 cm of each other.

Spot compression/magnification views are important in the work-up of extent of disease. Even when you have already decided to biopsy the lesion, it is important that you make sure there are no subtle calcifications elsewhere in the breast, especially in the segment between the mass and the nipple. Finding more extensive disease may mean a mastectomy instead of a lumpectomy. Also, for dcis it is important to define the anterior and posterior extent of the calcifications as all calcifications need to excised.

A 6-month follow-up exam should be performed for all benign needle biopsies becuause of a small risk of sampling error.

1. Non-mass like density that is seen on two views (if seen only on one view, it is called an asymmetry).
2. Focal asymmetry may represent asymmetric breast tissue or a breast mass. Therefore, you would give a focal asymmetry a birads 0 and recommend spot compression views and ultrasound.
3. If diagnostic workup reveals only breat tissue, a birads 3 category is used to document stability as it may represent an infiltrating cancer.

1. Usually obtained on biopsies of suspicious calcifications.
2. Surgical excision is recommended as 15% of ADH harbor DCIS.

The positive biopsy rate that is published as a general guideline of what is appropriate in standard screening practice is about 30%. Thus, 2 of every 3 biopsies yield benign results. This is for a screening population only.

- Papillomas can have diffuse calcifications. NOTE: when papilloma with diffuse calcifications is seen, it mimics metastatic ovarian cancer.
- Fibroadenomas have pop-corn or coarse calcifications

- DCIS is treated like a cancer.
- Following the diagnosis of DCIS, the patient will get a breast MRI to further asses the extent of disease.
- Surgery can be either lumpectomy to obtain clean margins followed by radiation therapy OR mastectomy without radiation therapy.
- A specimen radiograph is obtained before closing to confirm that the target has been removed. In addition, if the specimen radiograph shows a close margin, the surgeon will be able to excise that margin at the time of lumpectomy. This decreases the chances of re-operation for positive margins. Many sites perform 2 orthogonal views of the specimen to more completely assess margins.

- review previous mammograms and decide on the shortest distance from the skin. We measure the distance to pick the right length of the needle.
- place a bb on the skin overlying the lesion
- place breast in alphanumeric grid
- verify the target is in place
- after cleansing the skin, we advance the needle the appropriate length making sure the hub of the needle is directly orthogonal.
- then we obtain an orthogonal view, making sure the needle traverses the region of interest.
- then we advance a wire into the lesion
- we obtain two orthogonal views after wire placement and annotate the images.

- a bb is placed on the skin overlying the calcifications.
- the patient lies prone on the table with the breast hanging out from a hole in the table.
- using the bb as a guide, the breast is immobilized with a compression paddle.
- then we make sure that the target is in place. After identifying the target, we make 2 additional exposures 15 degrees from the midline. The computer calculates the depth of the lesion.
- after making a small nick in the nick, we advance the vacuum assisted biopsy gun the appropriate depth into the breast.
- We then take samples while rotating the biopsy gun. We take 12 samples.
- Following the biopsy we place a clip in the breast.
- we radiograph the samples to make sure we see calcifications in our sample
- we obtain post-procedure mammogram to document the position of the clp.

- Firm, mobile, nontender, well-circumscribed; avg size of 5cm - Phyllodes often exhibit rapid growth and are >2cm at presentation
- Can look exactly like a fibroadenoma. Sometimes have cystic spaces
- 90% of phyllodes are benign; 10% malignant - A VERY SKILLED pathologist is needed to tell benign from malignant phyllodes Pathologists look for high cellularity and atypia to determine if malignant
- Malignant tumors metastasize hematogenously - Do not require lymph node dissection - Malignant phyllodes requires wide excision with 1 cm margins
- Recurrent tumors are more aggressive than the presenting lesion - Most common site for mets is the lungs
- There is NO role for chemo or radiation