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Breast Procedures and Pathologies

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Breast Procedures and Pathologies BREAST PROCEDURES AND PATHOLOGIES CATINA CARR MSRS RRA RT(R) Screening mammograms Diagnostic mammograms MAMMOGRAPHY Spot compressions, magnification views Stereotactic biopsy Needle localizations Architectural distortion STEREOTACTIC BIOPSY Micro- Mass/lesion calcifications 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 MONTHS DIAGNOSTIC 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 MONTHS ENLISTED NAVY, TRAINING FOR MARATHON BI-RADS 4 ULTRASOUND GUIDED CORE BIOPSY- POORLY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA ULTRASOUND BIOPSY POST 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 BIOPSY MICROCALCIFICATIONS 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 MASS DIAGNOSED 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 2018 BIOPSY 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 .
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