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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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