Breast procedures and pathologies
Transcript of Breast procedures and pathologies
BREAST PROCEDURES AND PATHOLOGIES
CATINA CARR MSRS RRA RT(R)
MAMMOGRAPHY
Screening mammograms
Diagnostic mammograms
Spot compressions, magnification views
Stereotactic biopsy
Needle localizations
STEREOTACTIC BIOPSY
Architectural distortion
Micro-calcifications
Mass/lesion
NEEDLE LOCALIZATIONS MAMMOGRAPHY OR ULTRASOUND
• Calcifications that are too superficial or too deep to reach with stereotactic biopsy
• Positive biopsy
• Patient chooses excisional biopsy
• Fibroadenoma
• Radial scar
• Atypia
MAMMOGRAPHIC NEEDLE LOCALIZATION
ULTRASOUND GUIDED NEEDLE LOCALIZATION
• Clip migration
• Young patient
• Easily visualized lesion
• Difficult patient
• Chest wall/posterior lesions
NEEDLE LOCALIZATION
ULTRASOUND
• Cyst aspiration
• Abscess drain
• Biopsy
• Needle localization
ULTRASOUND
MRI
• MRI guided breast biopsy
• Abnormal breast MRI
• MRI guided needle localization
• MRI safe needles, devices, clips
MRI GUIDED BIOPSY
• MRI safe scalpel
• MRI Breast biopsy kit
• MRI safe light
GALACTOGRAPHY
• Ductogram
• Nipple discharge
• Papilloma
• Adenoma
• Duct ectasia
• Ductal debris
GALACTOGRAPHY
• Galactogram infusion set
• Angled or straight
• Scout mag views
• CC and ML
• Magnifier light
• Contrast
• Methylene blue ductogram
BREAST PROCEDURES
Wilton Medical Arts Breast Center/ Saratoga Hospital
Saratoga Springs New York
DUCTOGRAM
• 47 year old woman
• Clear left nipple discharge for 5 months
• One episode of brown/bloody discharge
• Comparison ultrasound
DUCTOGRAM
DUCTOGRAM
DUCTOGRAM
Patient underwent methylene blue ductogram
50/50 Isovue 300 and methylene blue
Surgical pathology returned intraductal papilloma
Filling defects in nipple were also papilloma’s
DUCTOGRAM
• 31 year old female
• Left nipple discharge
• Ultrasound-Mildly prominent debris
filled duct 9:00 position left breast
DUCTOGRAM
• One of the images is the diagnostic
ductogram, the other is the pre-op
methylene blue ductogram.
• Abrupt stoppage of contrast which
corresponds with ultrasound
findings.
• Pathology demonstrated intra-
ductal papilloma.
DUCTOGRAM
• 46 year old woman
• Increasing nipple discharge
• No family history
DUCTOGRAM
• Uncomplicated right ductogram. The duct in the middle, inferior portion of the contains
numerous filling defects. The canula fell out of the nipple and the duct was recannulated.
A second duct was opacified and demonstrates dilatation compatible with duct ectasia.
• Surgical pathology returned intraductal papilloma, apocrine metaplasia, small papillomas,
duct ectasia, microcysts , stromal fibrosis and patchy acute inflammation associated with
lobules. No evident malignancy.
62 YEAR OLD, LEFT BREAST PAIN FOR MONTHSDIAGNOSTIC MAMMO, US, +US BIOPSY
MRI BREAST BIOPSY
• US Cyst aspirate- malignancy consistent
with poorly differentiated carcinoma
• US Lymph node- metastatic ca.
compatible with breast primary
• MRI bx Suspicious for microinvasion
• Ductal carcinoma in situ
• Right breast atypical lobular hyperplasia
25 YEAR OLD PALPABLE MASS. BIRTH CONTROL PILLS 3 MONTHSENLISTED NAVY, TRAINING FOR MARATHON BI-RADS 4
ULTRASOUND GUIDED CORE BIOPSY-POORLY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA
ULTRASOUND BIOPSYPOST PROCEDURE MAMMOGRAM
STEREOTACTIC BIOPSY
• 47 year old screening, increased microcalcifications right breast, 3:00 anterior 1/3 of the
breast. Bi-rads 0
• Spot magnification views…. stereotactic biopsy
STEREOTACTIC BIOPSYMICROCALCIFICATIONS
MICROCALCIFICATIONS
• Stereotactic biopsy performed
• Post procedure mammogram showed anterior migration of the clip
• Pathology demonstrated Ductal Carcinoma In Situ
• Patient chose to go with breast conserving therapy
• Needle localization
NEEDLE LOCALIZATION
REDNESS, TENDER, FEVER, PALPABLE MASSDIAGNOSED WITH MASTITIS, 2 WEEKS OF ANTIBIOTICS, BOTH PATIENTS
PRESENTED TO ER AFTER ONLY A COUPLE OF DAYS ON MEDS
CONCLUSION
• Both women needed to undergo surgical drainage of collections
• 1- small pockets of necrotic tissue and scar tissue superficially, deep cavity with thin
purulent fluid
• 2- superficial sub-areolar abscess. In addition was a much deeper loculated collection over
a 15 cm area
Common denominator???????
ULTRASOUND GUIDED BIOPSY
• 23 year old female, mother deceased breast ca at age 42, maternal grandfather breast ca
• Bilateral palpable breast masses
• 6 month US follow up- typically follow every 6 months for 2 years to document stability
• Per the patient’s request because of family history and anxiety
• 6 breast biopsies
FIBROADENOMA
• All 6 biopsies returned Fibroadenoma
• Age of patient
• Birth control (hormone therapy)
• Bilaterallity
• Multiplicity
IMPORTANCE OF ANNUAL SCFREENING
• 71 year old female, h/o breast ca 5/2001, lumpectomy and radiation
• Annual screenings- area of scar, diffuse calcs
• 2011 breast biopsy at area of scar- fibrosis, calcification and granulation tissue
• 8/18 unchanged screening mammography
• 1/19 pt complains of pain and pressure at the scar
• Diagnostic mammography and ultrasound
2011
2015 2017 2019
ULTRASOUND GUIDED BIOPSY
ANGIOSARCOMA
• Pathology demonstrates Angiosarcoma of the breast
• MRI breast- no additional areas of abnormal enhancement
• Recommended treatment is surgical removal of all irradiated skin
• Angiosarcomas don’t typically travel to the lymph nodes
• Chest CT, smoking history, lung nodule follow up
ANGIOSARCOMA
• Patient chose to have mastectomy
• At the time of diagnosis- poor prognosis
• Status post mastectomy with clear margins, including skin
• Clinical stage 1
NOVEMBER 2016
• 24 year old female, 6 months pregnant, palpable lump
• US – 4x3x2 cm mass with lobular margins; adjacent 1.6x1x2.1 cm mass
• BI-RADS 4
• February 2017 Post delivery- 9.1x8.4x5.0 cm mass
• After biopsy, specimen was sent to Emory University
• ddx- metaplastic ca, spindle cell ca, malignant phyllodes sarcoma
• Mastectomy was performed prior to pathology results
POORLY DIFFERENTIATED HIGH-GRADE METASTATIC CARCINOMA, SPINDLE CELL TYPE
• Total mastectomy
• Clear margins
• Negative lymph node, no LVI
• Stage 2 B
• Staging CT chest abdomen and pelvis
• 4 rounds of chemotherapy
JANUARY 2018
• Screening right breast mammogram
• After chemotherapy treatments
• Follow up PET scan
• Lung nodule
• Subsequent CT guided lung biopsy
• Metastatic breast ca
PET CT APRIL 2018BIOPSY 2018
JUNE 17, 2018
Both biopsies showed
metastatic poorly
differentiated malignancy
with sarcomatoid features,
compatible with metaplastic
breast ca.
2018
• Further treatment with chemotherapy
• Increasing lung mets and mediastinal adenopathy
• Subsequent pleural effusion requiring thoracentesis x 3
• Change in chemo regimen, reduced lung lesions, mediastinal adenopathy
• Subsequent PET CT
FEBRUARY 2019
• PET CT shows continued decrease in lung mets and adenopathy
• New pelvic mass
• Biopsy demonstrates metastatic breast CA
MARCH 2019 NEW PELVIC MASS
SARATOGA SPRINGS NY
CLOSE TO NYC
CLOSE TO THE ADIRONDACKS
REFERENCES
• Clinical radiology, volume 73, issue 10
• Https://doi.org/10.1016/j.crad.2018.05.029
• Phil Fear MD
• Patricia Kennedy MD