Breast Imaging Essentials

Transcription

1 Breast Imaging Essentials Module 5 Transcript 2016 ASRT. All rights reserved.

2 Breast Imaging Essentials Module 5 Pathology 1. ASRT Animation 2. Welcome Welcome to Module 5 of Breast Imaging Essentials Pathology. This module was written by Dana Aragon, R.T.(R)(M), CAE. 3. License Agreement 4. Objectives After completing this module, you will be able to: Define imaging terminology for breast pathology. Recognize examples of breast disease. Discuss systemic diseases and their mammographic appearances. Identify benign and malignant conditions and their mammographic appearances. Discuss male breast disease. Describe treatment options. 5. Breast Pathology Understanding breast pathology is an important part of breast imaging. By definition, pathology is the study of the nature and cause of disease. Pathology can also be defined as a condition produced by disease; that is the definition that we ll use for the purposes of this module. Pathology in breast imaging most often is a detectable variant that provides a clue in the diagnosis of breast disease. Recognizing the appearance of breast pathology on images helps mammographers produce quality mammograms and is an important component of the breast imaging skill set. 6. History of Breast Disease The recorded history of breast disease dates back to ancient Egypt more than 3,500 years ago. Breast inflammation, pain and changes in the breast were obvious signs that women have long been able to detect without the aid of modern imaging techniques. Until recently, breast disease was not openly discussed because of the stigma and embarrassment associated with the disease and the treatments used. Until the 1970s and early 1980s, treatment most often consisted of breast removal in the form of a total or radical mastectomy. Today, waiting until a symptom is apparent is a gamble many women are not willing to take. It has been said that early detection is the best protection when it comes to breast cancer diagnosis. Advances in diagnostic tools and treatment methods have led to improved care and better outcomes, and the public discussion of breast cancer no longer is taboo. Patients still may face embarrassment and other emotional issues, but today breast cancer is a more readily discussed and acceptable topic of conversation. 7. Breast Disease Awareness In the 1990s, efforts by organizations such as the American Cancer Society, or ACS, helped improve breast cancer outcomes by encouraging women to be proactive in their care. Women now talk about breast cancer, participate in advocacy and awareness campaigns and know to ask for and undergo annual screening mammography examinations. Cancer is not the only type of breast disease women may face, however. Benign conditions of the breast also can produce pain, discomfort and breast malformation. It s important that professionals who work in breast imaging understand and recognize breast disease in all its forms so that imaging techniques can be adjusted appropriately. 8. Breast Anatomy

3 The breast is made up of 6 different types of tissues: milk-producing glands called lobules, ducts that carry milk from the glands to the nipple, adipose or fatty tissue, connective tissue, blood vessels and lymph vessels. Breast disease can originate in any of these tissues, but the most common location for breast cancer is the lining of the ducts. Normally, the body's cells grow, divide and die in an orderly fashion. However, this process is disrupted in cancer cells. Instead of dying, cancerous cells continue to grow and reproduce abnormally, often at a rapid rate. Furthermore, cancerous cells have the ability to invade other tissues and overtake normal cells. 9. Breast Cancer Risk The ACS reports that more than 246,000 new cases of invasive breast cancer are diagnosed in the United States each year. The lifetime risk of developing breast cancer for women who reach age 95 is 1 in 8, and statistical data show that 1 in 36 women, about 3%, die from the disease. There are many potential causes of breast cancer, but no one factor has been identified as a single cause of the disease. A variety of risk factors have been identified over time and weighed as relative contributing factors for breast cancer development. Risk factors can be environmental, chemical, psychological, physiological or genetic elements that predispose a person to developing a disease. Breast cancer risk can be broken down into 2 categories: risk factors that can be modified and those that cannot. 10. Unmodifiable Risks Unmodifiable risk factors are those that a patient cannot control. The biggest risk factor for developing breast cancer is gender: women are 100 times more likely to develop breast cancer than men. The likelihood of developing breast cancer also increases with age. A woman s lifetime risk of developing breast cancer is 1 in 8; however, her risk at age 70 is estimated to be 1 in 26, compared with a risk of 1 in 1,674 for a woman in her 20s. Genetic factors such as the breast cancer susceptibility or BRCA genes and a family history of breast cancer can greatly increase risk, although an estimated 90 to 95% of women who develop breast cancer do not have an inherited genetic component. A personal history of breast cancer or any other type of cancer is a risk factor for new breast cancer or recurrence. Race and ethnicity play a role in breast cancer risk as well. Overall, white women tend to develop breast cancer more often than African-American women. Asian, Hispanic and Native American women have lower risks of developing the disease. Women with dense breasts that is, more glandular and fibrous tissue than fatty tissue have an increased risk of developing breast cancer compared to women with average breast density. The additional glandular tissue also makes it more difficult to identify breast lesions on a mammogram. Finally, the number of menstrual cycles a woman has over a lifetime impacts her risk for cancer development. Early menarche, or onset of menses before age 12, and late menopause after age 55 slightly increase breast cancer risk because of the increased exposure to the hormones estrogen and progesterone. 11. Genetic Mutations About 5 to 10% of breast cancers are believed to result from inherited genetic mutations. Breast cancer can arise from a change in a patient s DNA that causes normal cells to become malignant. Certain genes, such as BRCA1 and BRCA2, have been identified as tumor suppressor genes. Normally, tumor suppressor genes restrict cancer cell formation. However, if these genes become mutated, they may no longer stop the growth of cancerous cells. Patients with BRCA1 or BRCA2 mutations are more susceptible to breast cancer over their lifetime. 12. Family History

4 The incidence of breast cancer is higher among women with family members who have a history of breast cancer. Having close paternal or maternal blood relatives with the disease can increase the risk for family members. In particular, having a mother, sister or daughter with breast cancer can double a woman's risk. Still, over 85% of women who have breast cancer do not have a family history of the disease. 13. Modifiable Risk Factors Some breast cancer risk factors are considered to be modifiable. These factors involve a woman s life choices, and many are associated with her lifetime exposure to hormones such as estrogen. Hormones are thought to affect breast cancer risk because they increase cell proliferation, which subsequently may increase the possibility of DNA damage and stimulate the growth of potentially cancerous cells. Not having children, called nulliparity, having her first child at a later age, or not breastfeeding can contribute to a woman s breast cancer risk because of the increased exposure to hormones. Along the same lines, use of oral contraceptives and hormone replacement therapy also expose a woman to hormones such as estrogen for a longer period of time, which in turn may increase risk. Living a healthy lifestyle also can help prevent disease, and breast cancer is certainly no exception. Overweight and obesity, a sedentary lifestyle and frequent alcohol consumption can contribute to breast cancer development over a woman's lifetime. Because life choices seem to affect the probability of developing breast disease, physicians advise making healthy lifestyle changes part of breast cancer prevention. 14. Screening and Diagnostic Mammography Screening mammography is a crucial tool in the fight against breast cancer because a large percentage of cancer is treatable if it is found in its earliest stages. Screening mammography is performed on patients with no symptoms of breast cancer. A diagnostic mammogram is ordered by the physician to evaluate specific clinical indications, such as palpated lumps, or mammographic indications, such as asymmetry. Localized signs of breast cancer on mammography include masses, microcalcifications, architectural distortion and asymmetry or enlarged ductal structures. 15. Clinical Signs A clinical sign is based on or characterized by observable symptoms of disease, and certain clinical signs may indicate breast cancer. Mammographers should document and report to the radiologist any changes in the size, shape, condition or health of a patient's breast. Specific signs that should be noted include any palpable lump that is fixed to the skin or chest wall or a lump that is stony, hard and irregular on palpation. Lymph nodes that appear to be fixed in their location also can signal pathology. Skin dimpling is an area of retraction in the breast similar to an indentation or depression. In some instances, dimpling becomes more pronounced when the patient raises her arms. Any changes in skin color or texture also should be noted. Nipple retraction is a change occurring near the areola. In addition to the nipple being drawn inward, there can be lumps around the areola as well as reddening and thickening of the skin. Any type of unusual discharge from the nipple should be cause for concern. The discharge could be clear, cloudy, or bloody. Bloody nipple discharge can be a sign of breast cancer of the duct. 16. Documenting Clinical Signs These clinical signs are documented during the patient interview just before mammography is performed. Routine documentation consists of indicating any change on a diagram of the patient s breast or marking the area of concern with a lead marker before imaging. The mammographer should include any information about the sign, indicating the size and location of the area of concern, and how long the patient may have known about the condition.

5 17. Knowledge Check 18. Knowledge Check 19. Reporting Terminology As with any medical procedure, mammography uses common terminology to help describe a breast abnormality. Mammography reports describe areas of concern as masses, calcifications, architectural distortion, and asymmetries. Characteristics of these findings such as size, location, morphology and appearance help provide diagnostic clues. For example, a mass with a smooth, well-defined border often is labeled as benign by the radiologist depending on other factors such as risk, age, associated breast changes and patient history of previous cancer or surgery at the site. 20. Masses A mass is a three-dimensional lesion seen in two projections. To further define a mass, radiologists use descriptive terms to denote the shape, margin and density of the abnormality. For example, an oval shape has rounded edges but elongated height compared with the width. An irregularly shaped mass is suspicious because some forms of breast cancer have irregular borders. This means the edges lack symmetry and are not smooth or even. Although benign conditions such as fibroadenomas and cystic masses also can have irregular shapes, most irregular masses require further investigation. A mass with circumscribed margins has clear, distinct borders and is confined to a specific area. A mass that is described as well-circumscribed usually is benign. Conversely, a mass with indistinct margins is not well distinguished from surrounding tissues. A mass with spiculated margins appears star-burst in shape and exhibits sharp, finger-like projections. The star-burst pattern can indicate malignancy and a biopsy usually is recommended. A spiculated mass often is a hallmark sign of breast cancer. A mass that demonstrates low density compared to surrounding glandular tissue usually is benign, whereas a malignant mass typically demonstrates high density. 21. Calcifications Calcifications, which usually are small deposits of calcium or other minerals, are another type of abnormality that may or may not be associated with malignancy. Calcifications appear as small white specks with varying distribution on the mammogram. Calcifications might appear diffusely spread throughout the breast, regionally located in a large portion of the breast, grouped in small clusters, or in linear or segmental patterns, both of which suggest ductal deposits. The radiologist often requests magnification views or other additional projections to help evaluate the characteristics of calcifications, and they can be classified as typically benign or suspicious morphology. A biopsy usually is recommended for calcifications of suspicious morphology. 22. Suspicious Morphology Calcifications can take on many different forms and are described based on their appearance, or morphology. Approximately 40% to 50% of calcifications are associated with malignancy. Types of suspicious morphology include amorphous, meaning the calcifications lack apparent shape or organization, or have no real or apparent crystalline form. Coarse heterogeneous calcifications are irregular, conspicuous calcifications that are generally larger than 0.5 mm in diameter and tend to coalesce. Fine pleomorphic calcifications are more conspicuous than amorphous, have a discrete shape, and are typically less than 0.5 mm in diameter. Fine linear or fine-linear branching calcifications are thin, irregular linear calcifications, usually less than 0.5 mm in diameter, that may have branching forms. 23. Typically Benign Calcifications There are several types of calcifications with characteristics that are classified as typically benign. These include uniformly round, or punctate, calcifications less than 0.5 mm in diameter. Some calcifications can contain a fluid known as milk of calcium, which can solidify. These calcifications may demonstrate a tea cup sign, referring to a crescent shape or cup-like appearance seen on a lateral projection. This sign is usually a benign finding. Calcifications also can form in the skin. Indications of dermal or skin

6 calcifications include a lucent center or a peripherally located cluster only visible on 1 projection. A tangential projection of the breast may help determine the origin of the calcification. Other typically benign calcifications include vascular calcifications, coarse or popcorn-like calcifications, large rod-like calcifications, and rim calcifications, which can form along the margins of a benign mass. Dystrophic calcifications, which can form in degenerated tissue following trauma or irradiation, and suture calcifications, which can form on suture material following surgery, are typically benign as well. Benign calcifications usually remain stable over time. 24. Macrocalcifications Calcifications larger than 0.5 mm are called macrocalcifications. Typically described as larger and coarse in appearance, macrocalcifications most often indicate changes caused by the aging of the breast arteries, old injuries or sometimes inflammation. Macrocalcifications usually are related to noncancerous conditions and do not require a biopsy. Macrocalcifications can be found in about 1 in 10 women younger than age 50, and about half of women older than 50 have macrocalcifications in their breasts. 25. Asymmetries An asymmetry describes a unilateral area of more pronounced or thickened fibroglandular breast tissue that is seen on only one mammographic view. By definition, an asymmetrical finding also is not present in the contralateral, or opposite, breast. Many factors can cause breast asymmetry, including both malignant and benign conditions. A focal asymmetry is visible on two mammographic views, but still cannot be identified as a true mass. Further evaluation usually is recommended to exclude malignancy. 26. Architectural Distortion Architectural distortion describes changes in the normal appearance of the breast's structures. In a normal breast, the ductal structures are arranged as a pattern of radial lines that join at the nipple. When lines appear outside of this normal pattern, but no definitive mass is present, it is known as architectural distortion. Architectural distortion can include spiculations radiating from a point and focal retraction or distortion of the edge of the breast parenchyma. Architectural distortion can be associated with benign or malignant abnormalities, and a biopsy or additional imaging may be recommended depending on the patient s personal history, recent surgeries, and the location and size of the architectural distortion. 27. Breast Composition There are four types of breast composition, labeled a through d, which are categorized based on the amount of fibroglandular tissue and the possibility that a mass could be obscured by breast tissue. Composition a has the least amount of fibroglandular tissue and is described as almost entirely fatty. Mammography is highly sensitive for this type of breast tissue. Composition b demonstrates slightly more areas of x-ray attenuation and is described as having scattered areas of fibroglandular density. A heterogeneously dense breast, composition c, has a large enough proportion of fibroglandular tissue that small masses may be obscured. Lastly, composition d is described as extremely dense and has a significant amount of fibroglandular tissue. Mammography is less sensitive for extremely dense breasts. 28. Imaging Dense Breasts A breast with dense fibroglandular tissue is often difficult to image. The density can appear white on the image, especially in thick areas of breast tissue. Suspected pathology may not be adequately visualized on the mammogram, leading to a misdiagnosis. Hormonal factors and breast composition play roles in the appearance of dense breast tissue. It is most common in women before they reach menopause particularly in women who are younger than age 30. Because of the reduced diagnostic sensitivity of mammography for women with dense breasts, other imaging techniques may be used. Sonography and magnetic resonance (MR) imaging are useful tools to further evaluate dense breasts.

7 As women age, their breasts can display both glandular and fatty tissue on the same mammogram. A heterogeneously dense breast can present an imaging challenge because the mammographer must ensure that the x-ray beam penetrates dense areas adequately but does not overexpose the areas of fatty tissue. 29. Changes in Breast Composition As women continue to age, the glandular tissue eventually is replaced by fatty tissue in a process called lobular involution. Lobular involution results in a breast composed almost entirely of fatty tissue. This type of breast is usually the easiest to image because the glandular tissue is no longer present. Fatty breast tissue is typically found in women who are postmenopausal or who have gone through hormonal changes that affect breast composition. Other hormonal factors also can play a role in age-related changes of the breast. Because of this, it's important to document any new hormone therapy or changes in hormone treatment reported by patients. Even in a woman with mostly fatty breast tissue, hormone therapy can affect density and cause the breast tissue to become more prominent. Alternatively, increased density can be a sign of developing asymmetry. 30. Knowledge Check 31. Knowledge Check 32. Nonproliferative and Proliferative Lesions Histologically, benign breast lesions can be placed in 3 categories: nonproliferative, proliferative without atypia, and proliferative lesions with atypia, also called atypical hyperplasia. Nonproliferative lesions, such as breast cysts, are not caused by new cell growth and generally are not associated with an increased risk of cancer. Nonproliferative lesions are the most common finding in breast cancer screening biopsies. Proliferative lesions involve new cell growth by a rapid succession of cell divisions. Proliferative lesions without atypia show growth of new cells in the lobules or ducts of breast tissue. There is a slight increased risk for breast cancer associated with these lesions. The complex fibroadenoma, sclerosing adenosis, multiple papillomas and radial scars are examples of proliferative lesions without atypia. Proliferative lesions with atypia involve extensive cellular growth in the ducts or lobules of the breast tissue, and the growth does not appear normal. These types of lesions include atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ, depending on the location of cell growth. Atypical lesions are not considered premalignant, but they are associated with a higher future risk of developing breast cancer; the risk is reported to rise to about 4 to 5 times higher for women who have atypical hyperplasia. 33. Fibroadenoma There are many different types of benign breast conditions. One of the more common types is a fibroadenoma, a benign tumor or mass usually composed of stroma and epithelial tissues. Some fibroadenomas also contain coarse calcifications. They most often occur in premenopausal women; after menopause the fibroadenoma will atrophy, leaving calcifications behind. The fibroadenoma typically appears as a circumscribed oval or round shape on a mammogram. However, fibroadenomas can have many shapes, forms and positions within the breast and may be difficult to diagnose without a biopsy. Additional imaging modalities also may be used to confirm a fibroadenoma diagnosis, including sonography or MR. Other conditions can mimic the appearance of a fibroadenoma. For example, the phyllodes tumor can have a similar appearance, with smooth margins, internal cysts and septations, or separations, within the structure. Having a complex fibroadenoma indicates a slightly increased risk for breast cancer.

8 34. Cyst A cyst is a benign fluid-filled sac that has a distinct membrane and may develop abnormally in a body cavity or structure such as the breast. Patients often notice a cyst more readily than other types of pathology and may describe it as being tender, especially right before the beginning of a menstrual cycle. Some cysts also change size in response to hormonal fluctuations and may become larger right before menstruation. Liquid usually cannot be detected on mammography, so sonography often is used to verify the presence of fluid and to help distinguish a cyst from a solid lump. This distinction is important because cysts are benign, but a solid mass must be biopsied to rule out malignancy. If a cyst requires further evaluation, sonography also may be used to guide a needle aspiration procedure to sample the fluid for pathologic examination. 35. Galactocele A galactocele is a benign, cyst-like mass within the breast that contains milk or a milky fluid. The galactocele is caused by a blocked duct that prevents the milk from exiting the breast properly. Galactoceles are typically associated with recent lactation and breastfeeding. Once lactation has ended, the cyst usually resolves with no intervention. A galactocele is not likely to cause an infection because the milk is sterile. However, a physician may try to drain a galactocele if it becomes large and painful for the patient. 36. Lipoma A lipoma is a benign tumor or mass composed of fatty tissue. Fat cells grow within a thin, fibrous capsule, usually found just below the skin. Lipomas are the most common noncancerous soft tissue growth and can occur in many different locations of the body, including the breast. A patient might have multiple lipomas, but the masses usually do not require any type of surgical intervention unless they become painful or infected. Lipomas are slow growing, rarely cause pain, feel soft and somewhat rubbery and are mobile on palpation. Mammographically, lipomas typically appear as a radiolucent mass surrounded by a thin capsule. 37. Papilloma A papilloma is a benign tumor resulting from an overgrowth of epithelial or connective tissue. The intraductal papilloma is a wart-like growth that occurs in breast ducts. It usually can be palpated and can feel like lumps just under the nipple. A papilloma may be painful at times and may cause a bloody discharge from the nipple. The bloody discharge is likely the most alarming symptom for patients because it can also be a sign of malignancy. A physician might suggest removing the lump surgically to alleviate the symptoms and to perform a tissue biopsy. Papillomas appear most often in women between the ages of 35 and 55, and there are no known causes or risk factors. Occasionally, papillomas are involved with atypical cellular growth characteristic of ductal carcinoma in situ or atypical ductal hyperplasia. Papilloma with atypia is considered higher risk and is treated more aggressively than a benign papilloma. 38. Hamartoma A hamartoma is a benign, tumor-like growth consisting of a disorganized mixture of cells and tissues. Although rare, this growth is a mass of normal tissue that builds up in areas of the body, including the breast. A hamartoma may present as a soft, painless lump or a nonpalpable mass, usually in women older than age 35. Some hamartomas can be quite large and most appear as well-circumscribed, fatcontaining masses on mammograms. A biopsy may be required to confirm the benign diagnosis. 39. Hematoma

9 A hematoma is a buildup of blood in an injured area of the breast. Typically, the buildup can occur after biopsy, aspiration or surgery and appears as a collection of blood outside a vessel. A bruise is an example of a hematoma that forms because of a breast injury. Documenting the cause of injury and the length of time that has passed since the injury occurred is important in diagnosing a hematoma. A hematoma can appear on a mammogram as a well-defined, ovoid mass with relatively sharp margins. It tends to decrease in size over time and can leave behind an area of architectural distortion after it resolves. Proper documentation and imaging investigation can provide the diagnosis after resolution. A biopsy sometimes is indicated to verify the imaging results. 40. Fat Necrosis Fat necrosis is a benign inflammatory process associated with the death of fatty tissue. Fat necrosis typically is caused by irradiation, ductal ectasia from chronic mastitis, or by external breast trauma such as a breast biopsy or breast reduction surgery. Mammographically, fat necrosis can appear as a cluster of microcalcifications, a lipid cyst or as a focal mass, and might not be distinguishable from malignancy until a biopsy is performed. A fat necrosis usually has a rounded density with central fat and is surrounded by a capsule resembling an eggshell. Additionally, fat necrosis can cause formation of benign oil cysts. As fat cells die, they sometimes release their contents, which the body encapsulates in a cyst. 41. Abscess An abscess is a local accumulation of pus caused by an infection in the breast. Considered a benign mass, an abscess usually is tender and frequently feels mobile beneath the skin. The edge of the mass is typically regular and well defined. A serious infection may be signaled by a tender lump in the breast that does not decrease in size, particularly if the abscess is deep within the breast. If a patient has pus draining from her nipple or persistent fever, she may need additional treatment. The abscess or infected breast can look very similar clinically and on mammograms to inflammatory breast cancer, exhibiting skin thickening and increased breast density on the affected side. 42. Mastitis Mastitis is inflammation of breast tissue that usually occurs in women of childbearing age who are breastfeeding. If mastitis is left untreated, an abscess can develop in the breast tissue. It is difficult to image a lactating breast, so a course of antibiotics often is prescribed before attempting to perform mammography to determine whether signs and symptoms are caused by an infection or a malignancy. 43. Radial Scar A radial scar is a type of benign proliferative breast lesion. It has a central core consisting of fibrous tissue surrounded by tubular ducts or lobules. Despite its name, a radial scar is not associated with surgical scarring. There generally is no palpable mass associated with a radial scar; however, it usually is visible on a mammogram as a spiculated, rosette-like lesion with a radiolucent center. A radial scar often is surrounded by areas of adenosis, or enlarged breast lobules, hyperplasia, and numerous papillomas. These areas can obscure the normal ductal and lobular structures of the breast. The radial scar can mimic architectural distortion and possibly an invasive carcinoma on a mammogram; biopsy typically is recommended. A radial scar is considered a high risk lesion that slightly increases the risk of future breast cancer. 44. Knowledge Check 45. Knowledge Check 46. Systemic Breast Diseases

10 Many types of systemic diseases affect the breast and have visible mammographic signs. Systemic diseases of the breast often mimic malignancies and usually are investigated further with additional imaging studies or biopsies to provide a definitive diagnosis. A proper patient history of systemic disease is crucial to aid in the diagnosis of breast pathology and possibly prevent the patient from undergoing biopsy. 47. Ductal Ectasia Mammary duct ectasia is a widening of the milk ducts. It also has been referred to as periductal mastitis, plasma cell mastitis or comedo mastitis. It usually is found around the subareolar region and can cause clinical signs such as nipple retraction, nipple discharge or a palpable mass that is accompanied by pain or tenderness. Ductal ectasia is a benign condition most likely is caused by an anti-inflammatory reaction and fibrosis. Women who have ductal ectasia usually are perimenopausal or postmenopausal; however, the condition can occur in younger women. The stage of ductal ectasia affects mammographic findings. Patients in the chronic stage show signs of calcification that may appear as needle-like, tubular and cyst-like shapes. These signs most often are seen in the areas with dilated ducts. Both acute and subacute stages may cause the nipple to retract and possibly cause a subareolar density to develop. Sonography often is used to display the dilated and fluidfilled ducts that appear with ductal ectasia. Nipple discharge that is suspicious for malignancy is described as sanguineous (bloody), serosanguineous (without blood) or as clear discharge. Patients with unilateral, single-pore or spontaneous nipple discharge may require ductography or galactography to further investigate the discharge. On a galactogram, ductal ectasia may be represented by a dilated duct, obstruction, extravasation, epithelial irregularity, or architectural distortion. 48. Amyloidosis Amyloidosis is a systemic disease associated with extracellular deposits of various insoluble proteins; the deposits accumulate locally but cause few reported symptoms. The protein also can accumulate widely and involve multiple organs, leading to multiorgan failure. There are 3 main systemic forms of amyloidosis. Primary, or idiopathic, amyloidosis is the most common type in the United States. Some patients develop amyloidosis secondary to other diseases or conditions, such as various malignancies, rheumatoid arthritis and tuberculosis. The familial form of the disease is rare and consists of any inherited form of amyloidosis. An older patient may have clinical signs such as a suspicious, painless and solitary, firm mass called an amyloidoma. The mass consists of amyloid deposits in the fat, stroma or vessels of the breast. Mammographically, amyloidosis frequently appears as an irregular or spiculated mass with irregular or amorphous microcalcifications. These mammographic markers of malignancy may lead to an initial diagnosis of probable breast cancer until a biopsy can confirm amyloidosis. 49. Wegener Granulomatosis Wegener granulomatosis is a rare disease characterized by necrotizing tissue that is chronically inflamed. It is a type of vasculitis, or inflammation of the small- to medium-sized blood vessels. Inflammation can affect organs such as the lungs, kidneys, the eyes, skin, muscles, as well as the nervous system and heart. Wegener granulamatosis may mimic a malignancy on mammography because of its irregularly shaped, high-density masses. 50. Systemic Lupus Erythematosus Systemic lupus erythematosus is an autoimmune disease that rarely involves the breast, but when it does, it s called lupus mastitis. The cause of lupus is unknown, but it can affect multiple organs and the musculoskeletal system in the form of arthritis. Lupus resembles mastitis on a mammogram, with macrocalcifications appearing as curvilinear or diffuse coarse calcifications either bilaterally or unilaterally. Architectural distortion usually is not visible unless a previous biopsy has been performed on the breast. 51. Sarcoidosis

11 Sarcoidosis is a systemic disorder of unknown cause. It involves the lungs, eyes and musculoskeletal system. Sarcoidosis most notably appears in the form of a granuloma, or microscopic clump of inflammatory cells. On mammography, sarcoidosis is visualized as an irregular, ill-defined or spiculated mass that is suspicious for malignancy. Well-defined masses usually indicate intramammary lymph node involvement. 52. Other Systemic Diseases There are other systemic diseases that appear as pathology in the breast. Diabetic fibrous mastopathy is associated with insulin-dependent type 1 diabetes and can produce breast lesions. Dermatomyositis is a muscular disease with an inflammatory component that produces a rash and diffuse subcutaneous calcifications in the skin. Mammary tuberculosis can appear as a slow-growing, painless mass that can be either poorly defined or well circumscribed depending on the pattern of disease. The infection often develops into either a primary or secondary tuberculosis and is very rare. 53. Knowledge Check 54. Knowledge Check 55. ACR Report Standardization The American College of Radiology, or ACR, has established the Breast Imaging Reporting and Data System, known as BI-RADS, to standardize breast cancer diagnosis and reporting. BI-RADS provides guidance for the radiologist and referring physicians in organizing image interpretation and reporting. Several organizations contributed to the development of BI-RADS, including the National Cancer Institute, the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, the American Medical Association, the American College of Surgeons and the College of American Pathologists. 56. Breast Imaging Reporting and Data System (BI-RADS) Because BI-RADS has standardized reporting terminology, mammography data can be collected and analyzed to help improve breast imaging practice. The BI-RADS assessment categories are: Category 0 Incomplete - Needs additional imaging evaluation and/or prior mammograms for comparison. Category 1 Negative. Category 2 Benign. Category 3 Probably benign. Category 4 Suspicious. o Category 4A indicates low suspicion for malignancy. o Category 4B indicates moderate suspicion for malignancy, and o Category 4C indicates high suspicion for malignancy. Category 5 Highly suggestive of malignancy. Category 6 Known biopsy proven malignancy. Imaging reports delivered to patients and referring physicians generally reference the assigned BI-RADS category. The standardization of the reporting system has been a great value to patients, physicians, radiologists and mammographers because it provides a reliable system for determining a course of action. 57. Lymph Nodes The lymph node is important in breast imaging because its altered appearance can signal a possible metastatic disease from other sites. The size and consistency of the lymph node become important clues in determining a diagnosis. Normally sized and shaped lymph nodes are usually considered benign. A lymph node is a rounded mass surrounded by a capsule of connective tissue. Lymph nodes are found along the lymphatic vessels throughout the body. The lymph nodes contain numerous lymphocytes, which filter the clear fluid, or lymph, that drains through the node to remove impurities from the bloodstream. Enlarged nodes can be painful.

12 Lymph nodes at times may be visualized on a mammogram. MLO projections must include the axilla to ensure that breast tissue has not been missed; therefore, the axillary lymph nodes might appear on these images. The normal lymph node can contain a fatty, lucent area that is visible on mammograms. 58. Lymph Nodes In breast cancer, the lymph nodes can carry cancer cells from the breast to distant sites. A lymph node biopsy is typically performed in the breast cancer staging process to look for signs of malignancy. A sentinel lymph node biopsy or an axillary lymph node dissection checks the regional lymph nodes for cancer. The sentinel node is the first lymph node into which a tumor drains and is most likely to contain cancer cells if they have spread. Sentinel node mapping can be used to identify the sentinel lymph node for biopsy. In this procedure, a radiotracer is injected near the site of the tumor. A blue dye often is used in conjunction with the radiotracer to improve visualization of the lymph nodes. The radiotracer and dye are absorbed by the patient s lymphatic system, and a gamma detector is used to locate the sentinel node. A surgeon can then remove the sentinel node during the biopsy. 59. Breast Cancer Staging Staging is a classification system that describes the distinct periods in the course of a disease. Staging can help determine the patient s prognosis and is an important factor influencing treatment decisions. For breast cancer, the system helps describe the extent of disease and identify whether the malignancy has spread locally, regionally or distantly. The information helps physicians develop the optimal management plan to eradicate the cancer cells, minimize chance of recurrence and offer the patient the best possible options for survival and quality of life. The staging system for breast cancer ranges from stage 0 to stage IV. As with other forms of cancer, the lower-numbered stages indicate earlier phases of cancer and the higher numbers reflect later stages of the disease. 60. Stage 0 Stage 0 describes noninvasive, or in situ, breast cancer. It can occur in the ducts, where it is called ductal carcinoma in situ or DCIS, or it can occur in the lobules, called lobular carcinoma in situ or LCIS. Stage 0 breast cancer is usually detectable on mammography and confirmed by biopsy. A malignancy assigned stage 0 is confined within the walls of its originating structure. 61. Stage I Stage I indicates that there is no evidence of cancer cells spreading beyond the local area, or the invasion is early and microscopic. Stage I breast tumors are generally a very small mass, up to 2 cm. Ideally, screening mammography detects a malignancy at this stage because the major goal of mammography is to aid in the early detection of breast cancer. Finding a Stage I cancer through screening mammography is most likely if the patient participates in annual examinations and is proactive in her own care. 62. Stage II Stage II breast cancers are larger in size than stage I cancers and typically show signs of spread to the nearby lymph nodes. Lymph node involvement and the location of the lymph nodes can provide clues as to the extent of disease. Stage II also includes breast cancers that are larger than 5 cm but have not spread to axillary lymph nodes. Surgical and radiation therapy options for stage II tumors can be similar to those for stage I tumors. Postsurgical radiation therapy may be considered for tumors larger than 5 cm in stage II breast cancer. 63. Stage III By stage III, breast cancer is complex, and there are 3 subcategories, labeled A, B and C, which are based largely on spread to local sites. There may or may not be signs of a tumor in the breast, and cancer cells have not spread beyond the local-regional area to distant organs. A stage IIIA tumor has

13 spread to multiple axillary lymph nodes or multiple internal mammary lymph nodes, and the nodes are fixed to one another or to other structures. Stage IIIB is assigned to a tumor of any size that involves the tissues near the skin and chest muscles. It may have spread to lymph nodes within the breast or axilla. Inflammatory breast cancer usually is included in this stage. Stage IIIC includes breast tumors of any size. It includes cancers that have spread to the clavicular lymph nodes and may also have spread to the internal mammary lymph nodes. 64. Stage IV Stage IV breast cancer indicates that a distant metastasis has been detected. Usually, the distant spread is to organs such as the lungs, liver or brain or to the bones. Stage IV breast cancer carries the highest mortality rate of all stages because spread to vital organs has already occurred. Treatment options for stage IV include radiation, surgery and chemotherapy. 65. TNM Breast Cancer Staging To further clarify the breast cancer staging process, the American Joint Committee on Cancer uses the tumor, node, metastasis, or TNM classification system. The system consists of stage 0 to stage IV, but further clarifies breast cancer according to tumor size, lymph nodes involved and whether there is distant metastasis. 66. TNM Size Classification In TNM cancer staging, the T indicates the breast tumor size. The T is followed by a number from 0 to 4, which describes the size of the tumor and whether it has spread to the skin or chest wall under the breast. A higher number indicates a larger tumor and may describe more extensive spread to tissues surrounding the breast. TX indicates that the primary tumor cannot be assessed. T0 indicates that there is no evidence of a tumor. Tis means an in situ cancer such as DCIS or noninvasive Paget disease. T1 is used when the tumor is 2 cm or smaller at its greatest dimension. T2 is for a tumor that measures 2 to 5 cm. T3 indicates a tumor larger than 5 cm. T4 describes a tumor of any size that extends into the chest wall or the skin. 67. TNM Lymph Node Classification In TNM cancer staging, the N indicates the regional lymph nodes. The N is followed by a number from 0 to 3 that indicates whether the cancer is found in the lymph nodes near the breast. It also specifies whether the affected nodes are fixed to other structures under the arm. NX indicates that the lymph nodes cannot be assessed, for example, if the lymph nodes were previously removed. N0 indicates that the cancer has not spread to local-regional lymph nodes. N1 is used to describe cancer that has spread to the movable ipsilateral, or same-side, axillary lymph nodes. N2 indicates the cancer has spread to fixed ipsilateral axillary lymph nodes or to ipsilateral internal mammary nodes. The N3 cancer has spread to certain levels or combinations of the ipsilateral internal mammary lymph nodes, ipsilateral supraclavicular lymph nodes or ipsilateral infraclavicular lymph nodes. 68. TNM Metastasis Classification

14 In TNM cancer staging, the M stands for distant metastasis. The M is followed by numbers to indicate whether the cancer has spread to distant organs such as the lungs or bones. An additional classification indicates detection of microscopic cancer cells. M0 indicates that there is no evidence of distant metastasis to other organs. cm0(i+) is used to indicate microscopically detected tumor cells in areas of the body such as the blood, bone marrow or distant nodal tissue, in the absence of clinical or radiographic evidence. M1 is used when distant metastasis to other organs has been detected clinically, radiographically or histologically. 69. Knowledge Check 70. Knowledge Check 71. Invasive Cancers Invasive cancer indicates that the disease has spread beyond the structure in which it started. There are 3 different types of invasive cancers: inflammatory breast cancer, or IBC, invasive lobular carcinoma and invasive ductal carcinoma. IBC has the lowest incidence of the invasive breast cancers. Most breast cancers begin in the ductal structures, although cancer can develop in the lobules or in other breast tissues. Ductal cancers typically form into a mass, making them somewhat easier to identify. Lobular cancers tend to develop in several areas of the breast in a sheet-like pattern that sometimes makes them more difficult to locate. 72. Inflammatory Breast Cancer (IBC) The inflammation associated with IBC is caused by cancer cells blocking lymph vessels in the skin; it usually is clinically visible. Inflammatory breast cancer is similar in appearance to a breast infection. Clinical signs include a warm, red and swollen area of the breast that might look pitted or thick like an orange peel, called peau d orange. The breast may become firmer and larger, and the patient might report symptoms such as tenderness or itching. On a mammogram, the only IBC-related finding may be indications of skin thickening. Increased breast size also may be documented on the mammogram, but IBC is otherwise difficult to detect on mammography. Sonography, MR and positron emission tomography combined with computed tomography, or PET-CT, may provide additional assistance in diagnosing IBC. Examination of biopsied tissue by a pathologist is the only reliable confirmation of diagnosis. 73. IBC Treatment Because IBC is uncommon, this type of breast cancer often is misdiagnosed as mastitis and initially treated with antibiotics. However, the symptoms are caused by cancer and not an infection, so they do not improve after a course of antibiotics. Inflammatory breast cancer frequently is diagnosed at stage III or IV and is an aggressive type of breast cancer, so treatment usually involves a multimodality plan. Patients often receive chemotherapy first, to shrink the tumor, followed by surgery to remove the tumor and radiation therapy to the chest wall. A modified radical mastectomy is the standard surgical treatment; the surgeon removes the entire breast and the axillary lymph nodes. IBC can encompass much of the breast and skin, so a lumpectomy or skinsparing mastectomy generally is not an option. Compared to invasive ductal or lobular cancers, IBC can spread and grow more quickly and is associated with a poorer prognosis. However, it is believed that survival rates have increased with earlier diagnosis over recent years, in part because of the use of complementary imaging techniques. 74. Invasive Lobular Carcinoma (ILC) Invasive lobular carcinoma, also called infiltrating lobular carcinoma or ILC, originates in the lobular unit before spreading to surrounding breast tissue. ILC is the second most common type of breast cancer, accounting for 10% to 15% of invasive breast cancers. It is most likely to affect women in their mid-40s to

15 their mid-50s. ILC can appear in the breast as a general thickening of tissue, usually in the area above the nipple. ILC also can spread to other areas of the body including the ovaries and uterus. ILC is less likely to be detected on a mammogram because it can appear as an asymmetry when compared with the other breast. ILC can usually be treated with chemotherapy, hormonal therapy, surgery and radiation therapy, and the combination of these treatments depends on the stage and pathology of the cancer. 75. Invasive Ductal Carcinoma (IDC) Invasive ductal carcinoma, also called infiltrating ductal carcinoma or IDC, is the most common form of breast cancer, accounting for about 80% of all breast cancers. It originates in the milk ducts and then spreads to other areas of the breast. More than half of IDC cases occur in women older than age 65, partly because of increased overall lifetime risk. Clinically, IDC can present as a palpable hard lump that is anchored to the surrounding tissues. In comparison, a benign breast lump moves more freely when manipulated. In IDC, the skin over the affected area or the nipple may be retracted, which is another sign of possible breast cancer. On a mammogram, it may appear to have irregular borders and can look like a spiculated mass. It also can appear as a smooth-edged lesion or contain calcifications in the tumor area. 76. Noninvasive Cancers There are 2 types of noninvasive breast cancers: lobular carcinoma in situ, or LCIS, and ductal carcinoma in situ, or DCIS. The term in situ means the cancer remains in its original location. LCIS and DCIS often are referred to as premalignant because the cancer has not invaded other tissues. Of the two, DCIS is more common, making up about 20% of all breast cancers. 77. Lobular Carcinoma In Situ (LCIS) Lobular carcinoma in situ is considered the earliest possible and most treatable diagnosis of breast cancer. In fact, some experts don t consider LCIS to be a true form of cancer. No immediate treatment is recommended for most patients with LCIS, although a diagnosis of LCIS increases the risk of later developing invasive cancer. A regimen of intense surveillance that usually includes a yearly mammogram and a clinical breast examination is recommended because a woman with unilateral LCIS is at higher risk of developing cancer in the contralateral, or opposite, breast. Women with LCIS also may consider treatment that can reduce the risk of developing breast cancer. Tamoxifen, a type of hormonal therapy, blocks the activity of estrogen receptors that have been shown to increase the growth of some cancer cells and is thought to inhibit estrogen receptor-positive breast cancer. Some women with LCIS choose the prophylactic removal of both breasts to reduce their risk of developing invasive breast cancer. The women who choose this option usually have other risk factors, such as a strong family history or a personal history of breast cancer. Breast reconstruction is an option for these women either shortly after the mastectomy or later. 78. Ductal Carcinoma In Situ (DCIS) Ductal carcinoma in situ is a more common breast cancer in part because of advances in imaging techniques and equipment. DCIS frequently appears on mammograms as microcalcifications. A diagnosis of DCIS often is based on pathological evaluation of very small specimens collected using image-guided biopsy equipment. As part of the specimen evaluation, the pathologist also tests for the presence of estrogen receptors so that the physician can consider whether hormone therapy should be part of the treatment plan. DCIS tumors are staged as Tis, which indicates that the tumor has not yet spread, and a treatment stage of 0. Treatments for DCIS include localized surgical removal or lumpectomy, radiation therapy and hormonal treatment where indicated. Women with DCIS usually can choose a treatment option. Breast reconstruction procedures are available for women who undergo a surgical procedure such as simple mastectomy. If the DCIS is estrogen receptor-positive, postsurgical treatment with tamoxifen can reduce