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1 Armed Forces Institute of Pathology

2 Armed Forces Institute of Pathology Breast Disease

3 Armed Forces Institute of Pathology Uncommon Signs of Breast Cancers Leonard M. Glassman MD FACR American College of Radiology Breast Imaging Scientist Armed Forces Institute of Pathology Washington DC Washington Radiology Associates, PC Washington DC

4 Uncommon Signs Are Rare 90% of cancers present as calcifications or masses or both 10% of cancers present as an uncommon sign Less than 10% of uncommon signs represent cancer

5 Uncommon Signs Asymmetry Architectural distortion Paget s disease Thickened skin pattern Isolated dilated duct Nipple/skin retraction

6 Asymmetric Findings More normal tissue on one side Normal finding usually The larger the asymmetry the more likely it is benign

7 Asymmetric Findings Global asymmetry More than one quadrant involved Almost always benign except when palpable Asymmetry (seen in one view) Almost always benign Focal asymmetry Asymmetry with similar shape in 2 views One quadrant or less Usually benign

8 Global Asymmetry

9 Asymmetry Seen in One View Focal area seen on one view only Not 3 dimensional Seen on one side only Almost always benign except if new or enlarging

10 Focal Asymmetry Area seen on two or more views which lacks all the signs of a mass Usually benign but more often significant than global asymmetry

11 Focal Asymmetry

12 Focal Asymmetry

13 Focal Asymmetry - Malignant

14 Common Benign Causes of Asymmetry, Focal Asymmetry, Neodensity and Developing Density Change in mammographic technique Hormone replacement therapy Fibrocystic change

15 Change in Technique Low to high contrast examination Film to digital Change in positioning Usually the oblique view Involution

16 Change in Technique Film Digital

17 Hormone Replacement Therapy All types of HRT 25% of patients exhibit some change Usually bilateral Stabilizes usually within 1 year Decreases in 3 months with cessation of HRT

18 Hormone Replacement Therapy

19 Neodensity

20 Developing Density - Carcinoma

21 Asymmetric Findings Is it palpable? If it should be palpable and is not it is benign Does not work for small deep densities

22 Asymmetric Findings Does it have bulging borders? Concave borders suggest benign process Convex borders suggest mass

23 Asymmetric Findings Does it have fat running through it? All lesions that contain fat are benign

24 Asymmetric Findings Is it hypoechoic on ultrasound Cancers are hypoechoic Benign tissue is usually echogenic

25 Asymmetric Findings Are calcifications present within it? Are they benign or malignant appearing

26 Architectural Distortion Change in orientation of tissue Especially Cooper s ligaments Classically without a mass Can be associated with a mass, calcification or asymmetry Common causes Scar from prior biopsy Radial scar (sclerosing papillary lesion) Cancer All unexplained distortions need biopsy

27 Architectural Distortion Scar

28 Architectural Distortion Radial scar Tubular carcinoma

29 Architectural Distortion Invasive ductal cancer

30 Paget's Disease Red nipple and areola Scaling eczematoid reaction 50% have a palpable mass Must have Paget's cells in skin Has underlying breast carcinoma

31 Paget s Disease

32 Paget s Disease

33 Paget s Disease

34 Thickened Skin Pattern Edema Mastitis Inflammatory carcinoma Post-radiation change Obstruction to lymphatic drainage in the axilla or superior mediastinum Lymphoma

35 Thickened Skin Pattern Mastitis

36 Thickened Skin Pattern Mastitis

37 Thickened Skin Pattern Radiation Therapy

38 Thickened Skin Pattern Mediastinal Obstruction

39 Thickened Skin Pattern Inflammatory Carcinoma

40 Inflammatory Carcinoma Clinical findings Heavy firm breast Red skin Warm skin Peau d orange Can not differentiate from acute mastitis

41 Inflammatory Carcinoma

42 Inflammatory Carcinoma Far advanced local disease 50% five year survival Pre-op chemo, mastectomy and radiation

43 Breast Imaging Findings Skin thickening Diffuse increased density Trabecular thickening Adenopathy Signs of carcinoma Mass, calcification, asymmetry, distortion

44 Inflammatory Carcinoma

45 Inflammatory Carcinoma Axillary nodes Supraclavicular node

46 Inflammatory Carcinoma

47 Inflammatory Carcinoma

48 Lymphoma

49 Dilated Duct (Asymmetric Tubular Structure) Usually inflammatory disease May be papilloma or papillary carcinoma History is critical Should have spontaneous bloody or clear nipple discharge to be suspicious Bilateral discharge is not cancer Sonography helpful to exclude mass in large ducts

50 Normal Ducts

51 Normal Ducts

52 Mammography

53 Sonography Inflammation Papilloma

54 Results Fibrocystic change DCIS

55 Papillary carcinoma Sonography

56 Evaluation of Nipple Discharge History Bilateral or unilateral Bloody or non bloody Green is usually inflammatory Black is usually cystic Spontaneous or only with pressure Is there a trigger point?

57 Evaluation of Nipple Discharge Mammography Spot views helpful to get clear view Is there a solitary dilated duct? Sonography Most useful with solitary dilated duct Is a mass present? Cytology 18% false negative rate for carcinoma Ductography

58 Ductography Papilloma Papilloma

59 Ductography DCIS

60 Nipple/Skin Retraction Invasive ductal carcinoma

61 Nipple/Skin Retraction

62 Conclusion Asymmetric findings are the most common of the uncommon signs of breast cancer Most examples of uncommon signs do not represent cancer

63 Conclusion All unexplained architectural distortions need a biopsy Paget s disease of the breast always has an underlying carcinoma The major differential diagnosis of thickened skin pattern is mastitis vs. inflammatory carcinoma Isolated dilated duct is usually benign New skin/nipple retraction is suspicious

64 Conclusion Most cancers show common signs Most examples of uncommon signs represent benign processes Many cancers missed on mammography represent examples of uncommon signs

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