QUESTION-1:
40 year old s/p reduction mammoplasty 10 years ago. Palpable lump noted shortly after reduction and :
Correct Answer: Epidermal inclusion cyst
- May occur after reduction mammoplasty
- Epithelial elements retained within the infolded dermo glandular structures or at any skin closure site
- Epithelial cysts can occur in absence of prior trauma or surgery
Assessment & Recommendation:
- Mass increase in size and no visible pore
- Suspicious abnormality
- Biopsy should be considered
Epithelial (Sebaceous) Cysts :
Etiology Unknown:
- Formed by downgrowth and cystic expansion of epidermis or of epithelium forming the hair follicle.
- Cysts filled with keratin, lipid-containing debris.
Clinically:
- Dermal or sub circumscribed moveable mass
- Communicating pore/ blackhead visible on skin
Differential Diagnosis:
- Cyst
- Fibroadenoma
- Cancer
- Epidermal cyst
- Others - phyllodes tumor, hematoma, metastasis, etc.
Circumscribed Mass:
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Correct Answer Explanation
QUESTION-2:
45 year old with no new complaint or prior surgical intervention:
Correct Answer: Invasive ductal carcinoma
- Highly suggestive of malignancy
- Appropriate action should be taken
Finding:
- Irregular spiculated mass in right breast at 2:00 to 3:00
Differential Diagnosis:
- Cancer
- Post surgical scar/ Fat necrosis (pt has no history of prior surgery)
- Radial Scar
- Granular cell tumor
- Fibromatosis (Desmoid tumor)
- Abscess
Pearls:
- Stability does not exclude cancer
- Beware of densities in expected locations of predominantly fatty tissue
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QUESTION-3:
Palpable left breast lesion:
Correct Answer: Hamartoma
- Scattered fibro glandular densities
- Finding – oval partially fat containing mass in left sub areolar region near 9:00 to 10:00
Case 6
Differential Diagnosis:
- Hamartoma, fibroadenolipoma
- Galactocele
- Intermammary lymph node
- Oil cyst
- Lipoma
Fat containing Mass
Pearls:
- Circumscribed fat containing masses always benign.
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QUESTION-4:
49 y.o. Screening mammogram:
Correct Answer: Birads 4
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QUESTION-5:
50 year-old female with abnormal physical exam:
Correct Answer: Intraductal papilloma
- Benign ductal neoplasm with fibrovascular stalk
- Females > 50 years old
- Mams are usually negative, possible calcifications in the mass and a dilated duct
- Ultrasound and duct gram show intraluminal mass
- Ultrasound may show complex cyst with nodule
- Core biopsy, excise if atypia is present
Differential Diagnosis:
- Papillary carcinoma
- Intraductal debris
- DCIS
- Ductal carcinoma NOS
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QUESTION-6:
62 year-old woman with breast implants:
Correct Answer: Extracapsular implant rupture
Pearls:
- The “snowstorm” sign is one of the most well-recognized signs of implant rupture, which represents the presence of free silicone droplets mixed with breast tissue. Snowstorm sign on breast ultrasound may be seen within either the breast parenchyma or even the axillary lymph nodes.
- This phenomenon is considered to be the most reliable sign of extracapsular breast implant rupture. This is thought to be a sensitive and statistically significant sign of extra-capsular rupture. Silicone implant rupture can be classified as intracapsular or extracapsular depending on the location of ruptured silicone with respect to the fibrous capsule. Most implant ruptures are intracapsular.
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QUESTION-7:
48 year-old female with a palpable mass:
Correct Answer: Complicated mass; Birads 4/biopsy
Differential Diagnosis:
- Complicated cystic breast masses demonstrate both anechoic (cystic) and echogenic (solid) components. US is used to identify and characterize such masses and to guide percutaneous biopsy.
- Common atypical findings include atypical ductal hyperplasia, atypical papilloma, atypical lobular hyperplasia, and lobular carcinoma in situ.
- Malignant findings include ductal carcinoma in situ, infiltrating ductal carcinoma, and infiltrating lobular carcinoma.
- New palpable lesion, US-guided percutaneous biopsy may be used effectively to diagnose and to guide management of complex cystic masses.
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QUESTION-8:
75 year-old woman with onset of breast pain and palpable abnormality:
Correct Answer: Mondor’s disease
- Thrombophlebitis of a superficial vein
- Tender, cord-like, erythema
- Beaded cord on mammography and ultrasound, mammogram is often negative
- Limited benign condition, resolves spontaneously
- No treatment necessary
Differential Diagnosis:
- Dilated duct from intraductal papilloma
- Intraductal Carcinoma
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QUESTION-9:
The MLO view is limited for which part of the breast? :
Correct Answer: Inner
“On the MLO projection the most common location to fail to image a lesion is the medial area because this part of the breast is further away from the film and more likely to slip out from under the compression plate. The CC views can be positioned to be certain to include these tissues.”
Source: Kopans 2nd ed. p.271-272; Bassett p. 50.
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QUESTION-10:
52 y.o. Screening:
Correct Answer: Milk of Calcium
Pearls:
- Mammographic appearance is pathognomonic of this benign entity when there is dependent calcium layering within breast cysts.
- Characteristically, calcium particles within cysts produce linear, "tea cup" or "crescent shaped" calcifications on a true lateral. On a CC view, these calcifications can appear smudged, where the beam is oriented more vertical with respect to the calcifications.
- Sometimes the microcystic milk of calcium cannot be seen at all on the CC view or just look like a vague smudge appearance. This is a very reassuring sign for benign breast disease.
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QUESTION-11:
The usual range of kVp used in mammography is::
Correct Answer: 24-28
The 24-28 kVp range is best suited for mammography. 25 kVp is optimal without a grid, 26-27 kVp with a grid, 22-24 kVp for specimens and 26-27 kVp for magnification views. Source: Dähnert p.545; Bassett p. 31.
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QUESTION-12:
New palpable lump, BRCA1+:
Correct Answer: Invasive ductal carcinoma
- Invasive ductal CA – enhancement extends to but does not appear to involve the chest wall; slight washout from 1st to 3rd pass.
- Invasive ductal carcinoma shows up most commonly as a speculated and nodular growth but since it is the most common cancer (70% ) it is the most common circumscribed cancer (Diagnostic Breast Imaging 2nd ed. Pg 276) even though that is the typical appearance of Medullary and Colloid Ca.
Differential Diagnosis:
- Enhancement kinetics: early enhancement with washout - not 100%
- Vocabulary: Lesion Type: Mass
- Mass Type: Single
- Shape: irregular
- Margins: spiculated
- Mass Enhancement: rim enhancement, enhancing internal septations
Pearls:
- Invasive Lobular carcinoma (a second most common type of breast Ca) has 1% of cases that will show as a round/ovoid mass with regular borders (Dähnert pg 460).
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