Imaging the Symptomatic Patient. Avice M.O Connell MD,FACR,FSBI Professor of Imaging Sciences Director, Women s Imaging University of Rochester

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1 Imaging the Symptomatic Patient Avice M.O Connell MD,FACR,FSBI Professor of Imaging Sciences Director, Women s Imaging University of Rochester

2 The four most common symptoms Mass Pain Discharge Infection /inflammation

3 and Anxiety!

4 Remember anxiety is a real symptom Concern for cancer Whatever the symptoms

5 Do we worry too much?

6 Put risk in perspective Lifetime risk 1 in 8 20s risk is 1 in 1700 for breast cancer 30 s 1 in s 1 in s 1 in s 1 in 29 70s 1 in 26 BREASTCANCER.ORG

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9 Presenting complaint Lump or thickening - self discovered or other Pain -unilateral,bilateral,cyclical or persistent Nipple discharge -spontaneous or elicited Skin or nipple redness or eczema Infection/inflammation

10 Breast cancer-how it presents Mass or thickening Discharge Inflammatory changes Paget s disease -nipple Axillary LN s,metastasis CT/MRI/PET finding (Calcifications -screening mammography) (Asymmetry or neodensity-screening finding)

11 ACR Appropriateness criteria Mass under age 30 Mass age Mass age 40 and older Pain (Nipple discharge) Mass in a male

12 Mass under 30 what to do first?

13 Benign US Features Margins-Circumscribed Parallel orientation

14 U/S probably benign

15 Ultrasound of Fibroadenoma Single or multiple Oval or lobular Up to 4 gentle lobulations Hypoechoic May calcify

16 Fibroadenoma Commonest breast mass in young women Arises in TDLU Epithelial and stromal elements Single or multiple Asian and African predisposition

17 > 3 cm Rapid growth Biopsy if More than 4 lobulations Any unusual features(irregular border or internal heterogeneity)

18 Benign finding under 30 (cyst)

19 Cyst

20 Cysts Need classic sonographic findings Not complicated or complex cysts Aspirate if symptomatic or not classic Otherwise reassure and counsel

21 under 30 U/S negative

22 Ultrasound is negative Examine the patient(palpate) Reassure Answer questions

23 Under 30-Initial suspicious

24 U/S suspicious for malignancy

25 Palpable Age 30-39

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27 Palpable mass per ACR over 40

28 Findings in a 2010 surgical survey Despite screening mammography 43% of breast cancers presented as a mass or other symptomatic presentation 57% screen detected Palpable more likely if no previous screening (67% vs 39%) Palpable were younger Mathis et al J Am Coll Surg 2010;210:

29 Palpable mass over 40

30 Over 40-Initial suspicious

31 mammogram suspicious

32 Diagnostic

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34 Ultrasound 3 cm mass

35 Initial probably benign

36 Over 40 mammo probably benign

37 43 year old 43 year old female - screening mammogram Also reports a palpable mass in the right breast for many years.

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42 Probable fibroadenoma short interval ultrasound follow up 42

43 Breast Masses: Mammo evaluation Rule of multiplicity (Legacy article in Radiology) *Sickles EA. Radiology 1989; 173 issue( 2 ):

44 Over 40- initial mammogram benign

45 Over 40 benign mammogram

46 > 40 Initial mammogram negative

47 Palpable over 40 mammo negative

48 44-year-old female with right breast palpable lump for one week.

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52 right breast 1:00 3cm FN

53 Metastatic melanoma

54 72yo with Palpable Abnormality

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57 Targeted ultrasound

58 PATHOLOGY INVASIVE MAMMARY CARCINOMA WITH LOBULAR FEATURES 58

59 Diagnostic 49 y/o with a palpable mass in the right breast.

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62 Right Breast 5:00 3 cm FN

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64 Pathology Multicentric invasive ductal carcinoma - Right breast Benign cyst - Left 64

65 Mastodynia (breast pain)

66 Pain Cyclical Persistent Diffuse Focal

67 Non cyclical focal pain < 30

68 Pain focal non cyclical -over 30

69 Pain, cyclical under age 40

70 Pain non cyclical under 40

71 Pain - over 40 cyclical

72 Pain over 40

73 43 year old Baseline mammogram Complains of bilateral breast tenderness L>R and new left breast nipple discharge

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76 Pathology results:

77 Extensive calcifications- left Pleomorphic Segmental Stereotactic biopsy: DCIS 77

78 DCIS Previously: all symptomatic <5% (before routine mammography) Now: 20-30% of cancers diagnosed (mostly screenings)

79 Discharge

80 Discharge Common Bilateral / unilateral clear, yellow, green Only spontaneous,single duct is pathologic If bilateral think hormonal (elevated prolactin) Malignant etiology ~7% * Significant discharge not always bloody *Hou MF.Radiology1996;195:

81 Pathologic discharge Mammogram-diagnostic Ultrasound-retroareolar Ductogram

82 79 year old Spontaneous blood-tinged nipple discharge for several weeks on the right side.

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87 Ductogram

88 Ductogram 30g cannula Omnipaque (Atropine) Magnifying glasses and light

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90 Post Ultrasound Guided Biopsy

91 37 yr old Right nipple discharge Diagnostic Mammogram Ultrasound

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97 Pathology Pathology : intraductal papillary neoplasm

98 Inflammatory conditions

99 Abscess 21 year old with history of nipple piercings presents with a palpable painful lump

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101 Screening mammogram Screening mammography. Age 49.

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104 Skin thickness 0.8cm

105 Inflammatory cancer

106 70 year old Inflammatory cancer History: spider bites

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108 The male breast Mass or enlargement Pain 108

109 Male with painful breast enlargement

110 under 25 with palpable breast mass

111 Male over 25 with palpable mass

112 Male > 25 mammogram indeterminate

113 Male- clinically suspicious mass

114 50 year old pain and mass x6 weeks He reports taking Paxil for the last 3 years.

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119 80 year old man 80 y/o old male with positive BRCA 2 Palpable left breast lump just superior to the left nipple and left nipple retraction. Patient's daughter had breast cancer.

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124 The symptomatic patient-summary Diagnostic appointment Careful history and examination Initial Imaging per ACR appropriateness criteria Biopsy if not benign or probably benign (BIRADS 2 or 3) Finally, talk to the patientassess anxiety level and understanding 124

125 Thank you!