Clues You Can Use: Core

Breast Imaging Division March 2018 BI-RADS® Assessment Categories

o Assessments are divided into incomplete Category 0 and final assessment categories Categories 1-6 o Overall assessment based on the most worrisome finding or the need for immediate additional evaluation o Screening mammograms may be assigned Category 0,1,2 BI-RADS® Assessment Categories

o BI-RADS® Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON o BI-RADS® Category 1: NEGATIVE o BI-RADS® Category 2: BENIGN o BI-RADS® Category 3: PROBABLY BENIGN o BI-RADS® Category 4: SUSPICIOUS o BI-RADS® Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY o BI-RADS® Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY Management Recommendations

o Management recommendations on a per Assessment basis o Wording emphasizes recall, routine screening, tissue diagnosis, surgical excision o Management recommended wording for tissue diagnosis is: “Biopsy should be performed in the absence of clinical contraindications.” o Management recommended wording for BI-RADS® 6 is : “Surgical excision when clinically appropriate.” o Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON Recall for additional imaging and/or comparison with prior examinations o Category 1: NEGATIVE Routine mammography screening o Category 2: BENIGN Routine mammography screening o Category 3: PROBABLY BENIGN Short interval 6 month follow-up OR continued surveillance o Category 4: SUSPICIOUS ABNORMALITY Biopsy should be performed in the absence of clinical contraindications o Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY Biopsy should be performed in the absence of clinical contraindications o Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY Surgical excision when clinically appropriate BI-RADS® Assessment Categories

o BI-RADS® Category 0: INCOMPLETE - NEED ADDITIONAL IMAGING EVALUATION AND/OR PRIOR MAMMOGRAMS FOR COMPARISON o BI-RADS® Category 1: NEGATIVE o BI-RADS® Category 2: BENIGN o BI-RADS® Category 3: PROBABLY BENIGN <2% chance CA o BI-RADS® Category 4: SUSPICIOUS 2-95% chance CA o BI-RADS® Category 5: HIGHLY SUGGESTIVE OF MALIGNANCY >95% chance CA o BI-RADS® Category 6: KNOWN BIOPSY-PROVEN MALIGNANCY BI-RADS® Category 3 Assignment

NO ! MAYBEEE

➢ Screening mammogram ➢ MUST complete diagnostic ➢ Solitary dilated duct (B-R 4) workup prior to assigning BI- RADS® 3 ➢ BI-RADS® Atlas older edition so- called indeterminate ➢ Solitary solid mass with benign calcifications (B-R 4) mammogram and ultrasound features ➢ Developing asymmetry ➢ Focal asymmetry with negative ➢ Any mass with mammogram or ultrasound features of CBE and ultrasound malignancy (B-R 4) ➢ calcifications ➢ Masses in BRCA gene mutation ➢ Young women with palpable pts (B-R 4) mass, imaging = FA ➢ Multiple bilateral circumscribed masses (B-R 2) Screening Mammography

o Standard projections MLO and CC o If Baseline risk pt: Begin age 40 and annual thereafter o High risk screening pt: test or tests determined by her specific risk parameters ie mammo+US/MR o SEARCH! Screening mammogram hallmarks of malignancy: suspicious mass, calcifications, site of architectural distortion, asymmetry Asymmetries

Unilateral deposits of fibroglandular tissue not conforming to the definition of a radiodense mass. Four types:

1. ASYMMETRY - visible in only one mammographic projection. Typically summation artifact 2. GLOBAL ASYMMETRY - large amount of fibroglandular-density tissue over a substantial portion of breast at least a quadrant compared to contralateral breast. Usually normal variant 3. FOCAL ASYMMETRY - relatively small amount of fibroglandular-density tissue over a confined portion of breast < a quadrant. Concave borders and interspersed fat distinguish from mass. DDx Superimposition of two normal structures, Mass 4. DEVELOPING ASYMMETRY - focal asymmetry that is new, larger, or more conspicuous than previously. 15% are CA Architectural Distortion defined

o Normal breast architecture is distorted with no definite mass o Thin straight lines of spiculations radiating from a point; focal retraction, distortion, straightening at the anterior or posterior edge of the parenchyma o May also be seen in association with asymmetry or calcifications o Determine if concordant history of trauma or surgery o DDx = Cancer, Radial scar, Posttraumatic/Surgical scar The Abnormal Screening Mammogram

Abnormal screening mammogram is assigned BI-RADS® CATEGORY 0 and is called back for a Diagnostic breast imaging workup o For mass/asymmetry: compression magnification views in MLO and CC possibly followed by targeted ultrasound o For architectural distortion: compression magnification views in MLO and CC possibly followed by targeted ultrasound o For calcifications: compression magnification views in TL 90 and CC o PPV1 based on abnormal screening exam 3-8% o PPV2 when biopsy - surgical, FNA, or core - recommended 20-40% The Abnormal Screening Mammogram

ACR BI-RADS® 5th ed Desirable Medical Audit #s for interpreting radiologists o Cancer detection rate per 1000 exams >2% o Abnormal interpretation ie recall rate 5-12% o Sensitivity >75% o Specificity 88%-95% o PPV1 based on abnormal screening exam 3-8% o PPV2 when biopsy -surgical, FNA, or core - recommended 20-40% Classic Benign

Fibroadenoma Simple Cyst o Most common in o Occur in 10% of all women patients <35 yo o May be palpable, painful, o Contain stromal tissue and breast grow/regress quickly ductules o Anechoic mass, imperceptible wall, o Sensitive to hormone changes - eg pregnancy posterior enhancement o Oval parallel circumscribed o Painful cysts can be aspirated under hypoechoic ultrasound - benign type fluid is o May contain calcifications yellow, green o Biopsy is recommended for newly palpable or increasing in size or demonstrating suspicious features on exam Classic Benign Breast Disease

Complicated Cyst Clustered Microcysts o Homogeneous low level internal o Etiologies include fibrocystic echoes change and apocrine metaplasia o May have a layered appearance o Lesion consists of cluster of tiny anechoic foci, individually smaller o Fluid-debris levels may shift than 3 mm with pt position o Present as asx mammogram mass, o May also contain brightly occasionally palpable echogenic foci that scintillate as o Thin intervening septations and no they shift discrete solid component for B-R 3 o NOT complex cystic and solid vs B-R 2 mass echo mass o Complex cystic and solid mass B-R 4 mass Classic Benign Breast Disease

Fat Necrosis Papilloma o Benign condition o Solitary intraductal papillomas usu o Trauma-induced may be surgical, located centrally or in the although patient may have no retroareolar region knowledge of precipitating event o Present with bloody or clear o Typically presents as palpable mass discharge - oil cyst o Most commonly observed in o Occasionally present as irregular symptomatic perimenopausal mass or calcifications that merit patients in the past CNB o Now presenting as mass on mammogram in younger asx o Round or oval circumscribed masses, may be complex, intraductal, calcifications Classic Benign Breast Disease

Lactating Adenoma o Unique to pregnant and lactating pt o Unique to pregnant and lactating pt o Fibroadenoma mimicker o Typically present as fluctuating o Oval parallel circumscribed mass in pt who recently ceased hypoechoic breastfeeding o <3cm and contain stromal tissue o Round or oval parallel and breast ductules circumscribed mass. May be an- hypo- or hyperechoic, depending o May contain calcifications on fat content. Mammo TL proj for o May infarct and present with fat fluid level enlarging mass o Tend to regress spontaneously and o Tend to regress after cessation of most do NOT require aspiration breastfeeding o May be aspirated FA appearance in pregnant? Fat fluid levels Think LA! true lat Classic Breast Disease

Phyllodes DCIS o Fibroepithelial - histologically o Accounts for 20-25% CA similar to fibroadenoma o Confined to the ducts o Typically present as rapidly o Increased risk in pts with family enlarging mass history, elevated BMI o Appearance is similar to large postmenopausal, dense fibroadenoma o Mortality is extremely low and o May be complex and contain cystic related to IDC 8-10 years post spaces diagnosis of DCIS o 10% malignant - no distinguishing o Mammographically detected features o May also present with mass, nipple o Excision of benign discharge, Paget disease AND malignant o On MRI - NME o Recurrence is local. with delayed peak Rare lung, bone, enhancement liver mets kinetic Mammo Calcifications BI-RADS® AtAWord

BENIGN SUSPICIOUS o All ‘typically benign’: Round, Rim, o Fine linear and fine linear Dystrophic, Coarse ie Popcorn, branching 70% risk Milk of Calcium, Large Rod-Like ie o Fine pleomorphic 29% Secretory, Skin, Vascular, Suture o Amorphous 21% 0% risk o Coarse heterogeneous 13% o Diffuse o Segmental 62% o Linear 60% CA % RISKS reported are in BOLD o Grouped 31% o Regional 26% Mammo Mass BI-RADS® AtAWord

BENIGN SUSPICIOUS Mass Mass

Shape: Oval Round Shape: Irregular Margin: Circumscribed Margin: Spiculated Indistinct Density: Fat Low Microlobulated Density: High Equal Associated Features: Skin retraction Nipple retraction Skin thickening Trabecular thickening Axillary adenopathy US Mass BI-RADS® AtAWord

BENIGN SUSPICIOUS

Mass Mass

Shape: Irregular Shape: Oval Orientation: Not parallel Orientation: Parallel Margin: Not circumscribed Margin: Circumscribed Echogenicity: Echogenicity: Anechoic Hypoechoic Isoechoic Hyperechoic Complex cystic and solid Posterior Features: Enhanced Heterogeneous Posterior Features: None Shadowing Combined MR Mass BI-RADS® AtAWord

BENIGN SUSPICIOUS

Mass Mass Shape: Oval Shape: Irregular Margin: Circumscribed Margin: Spiculated Enhancement: Irregular Enhancement: Heterogeneous Homogeneous Rim Dark internal septations NME Heterogeneous NME Homogeneous Clumped Multiple Clustered ring Diffuse Segmental Linear Classic Malignant Breast Disease

Invasive Mammary (Ductal) Invasive Lobular o Accounts for 50-75% invasive o Accounts for 10-15% CA cancers o Lobule rather than duct origin o Heterogeneous group of tumors o Women in early 60s slightly older without sufficient histologic than IDC features to be classified more o Present as thickening specifically o Present as asymmetry, architectural o Ductal origin distortion, even calcifications but o Present as mass, size varies may be mammographically occult o Mammogram, US, and MR evident o Bilateral, multifocal, multicentric, o Indistinct mass on US o MRI may be required Special Types Breast CA

Re Special subtypes - all account for <1-5% of CA: ➢ Asymmetry and architectural distortion - think lobular ➢ Small spiculated mass mimicking radial scar - think tubular ➢ Favorable prognosis round-ish circumscribed-ish mass - think papillary, medullary, mucinous ➢ T2 bright enhancing mass - think mucinous ➢ BRCA1 and BRCA2 patients - think medullary ➢ Large and extremely dense - think metaplastic ➢ Nipple eczematous or erythematous change - think Paget

Tu Mu Med Met Pa MR Characteristics of Breast Masses

Breast BenignT1 Pre T1 Pre T1 PostSuspicious Mass NonFatSat T2 STIR FatSat FatSat Distinguishing Features Mass Mass FA Shape: Ovaldark bright dark brightShape: Irregulardark internal septation Simple Cyst dark bright dark darkMargin: Spiculatedimperceptible wall Margin: Circumscribed Complicated Cyst dark bright dark may be brightIrregularrim enhancement Enhancement:dark except Enhancement: Heterogeneous LN hilum bright dark bright fatty hilum Type III curve Homogeneous Rim Papilloma bright bright bright bright homogenous enhancement Dark internal septations NME Heterogeneous Oil Cyst bright dark dark dark Clumped Fat NecrosisNME Homogeneousbright dark dark may be bright variable enhancement Clustered ring CA - IBC NST Multipledark dark dark bright Type III or II enhancement Segmental CA - Mucinous Diffusedark bright dark bright homogenous enhancement Linearheterogeneous rim Type III CA - TNBC dark dark dark bright enhancement From Special Types Breast CA on to . . . Special Types Clinical Presentations Each of these are assigned up to 5% on Core but more importantly, are common scenarios presenting to clinic!

➢ - distinguish clinical presentation ➢ Male breast - distinguish and breast CA ➢ Axillary lymphadenopathy - distinguish unilateral and bilateral ➢ Implants - distinguish saline and silicone ruptures ➢ Inflammatory disease - distinguish differential diagnoses ➢ Breast conserving therapy - distinguish normal and recurrence

LN Si EIC BCT rim Gynecom Nipple Discharge

BENIGN PATHOLOGIC o Usually bilateral, multiductal o More likely unilateral, uniductal o Yellow, orange, green, milky o Bloody, clear o Occurs with breast manipulation o Occurs spontaneously o Age<40yo o Age >40yo o Etiologies: pregnancy, lactation, o May be associated with mass physiologic, drug-related o Duct ectasia, abscess, papilloma, high-risk lesion, DCIS, invasive cancer o Isolated papillomas are usually benign, but can harbor areas of atypia or DCIS o Solitary dilated duct 9% chance of malignancy ie no longer BI-RADS 3 Male Breast Disease

Gynecomastia Rule of 3s Male Breast Cancer o Unilateral o Male breast CA: soft or firm o 3 times for gynecomastia: neonate, nontender mass, nonmobile or puberty, senescence mobile; unilateral; eccentric to nipple, typical mammogram o 3 types gynecomastia: nodular, dendritic, diffuse irregular hyperdense mass may have calcifications, skin thickening, o 3+ etiologies gynecomastia: nipple retraction, axillary LN, ie physiologic, drugs, hyperestrogen, secondary features systemic diseases cirrhosis, CRF o Histologies: IDC NOS, DCIS, Invasive o Gynecomastia: soft tender mass, papillary mobile, bilateral, central to nipple, typical mammogram flame-shaped o NOT ILC appearance with no secondary o Males > 60 years features, no axillary LN o Account for <1% new breast CA diagnoses and may be associated with BRCA2 gene mutation Male Breast Disease

Pseudogynecomastia Abscess o Usually bilateral o Male breast abscess - typically o No palpable mass present as tender palpable mass with erythema and warmth o Excessive fat deposition in the breasts o Rx male breast abscess is similar to female o Results from genetic normal variant, truncal obesity, and occasionally in neurofibromatosis Breast Other Masses o Antecedent trauma or o Epidermal inclusion cyst anticoagulant therapy o IMLN o Mass or ie skin involved o Papilloma o Complex cystic and solid mass o Mesenchymal tumors including lipoma, granular cell tumor, myofibroblastoma Axillary Lymphadenopathy

BI-RADS® Category 4 BI-RADS® Category 2 o Unilateral o Bilateral o DDx breast carcinoma, o Frequently reactive in metastatic melanoma, ovarian inflammatory ds and HIV CA, other CA o Sarcoid, SLE, psoriasis, o Careful eval ipsilateral breast analogous ds o Bilateral axillary US to o Known dx Lymphoma - add determine if uni/bilateral wording “known lymphoma” o (Clinical eval for , o When bilateral LN new or breast abscess, skin infx, cat increasing - rethink BI-RADS® 4 scratch fever ie convert to 2) and include pass for flow o Proceed to FNA or CNB cytometry (saline or RPMI) Breast Implants Rule of 2s o 2 types Saline, Silicone o 2 locations Retropectoral, Subglandular o 2 indications Cosmesis, Reconstruction o 2 postoperative complications Early: hematoma and infection Late: capsular contraction and implant rupture o 2 Si ruptures Intracapsular, Extracapsular o 2 x 2 signs Si rupture Intracapsular - ladder, teardrop, keyhole, salad oil and linguini signs Extracapsular - snowstorm and free silicone/silicone granuloma Also, 2 extracapsular implant rupture are current or prior implant rupture and silicone injections o 2 MRI frequencies to suppress for silicone Fat suppression and Water suppression Mastitis Abscess

o Common etiologies lactation, o Progression of mastitis most post trauma common etiology o Localized breast erythema, o Delayed or inadequate antibiotic warmth, induration, tenderness treatment o May have associated fever and o Staph aureus in puerperal nursing mass woman, also strep o US study of choice for diagnosis o Nonpuerperal abscesses typically and surveillance contain mixed flora S aureus, o Breast parenchyma hyperechoic streptococcal species and hypervascular, skin edema, anaerobes reactive lymphadenopathy o Pain, erythema, edema, mass o Delayed or inadequate antibiotic o Round or irregular complex mass, treatment can progress to fluid-debris levels or mobile abscess debris DDx: Epidermal inclusion cyst o US study of choice for diagnosis Mondor disease and IR guidance Puerperal mastitis, abscess Nonpuerperal mastitis, abscess o US surveillance Inflammatory breast cancer Post Breast Conserving Therapy

Normal ie BI-RADS® Category 2,3 Abnormal BI-RADS® Category 4,5 o Lumpx or axillary node site o Recurrence - at lumpx site but complex cystic fluid collection rare until 2 yr mark o Trabecular thickening (breast o New or increasing asymmetry, edema) AND skin thickening peak mass, linear pleomorphic at 6 months post radiation then amorphous calcifications all improve thereafter and attain concerning stability at 2-3 yrs o Metachronous tumor - other o Lumpx and axillary node sites quadrants of ipsilateral and in benign architectural distortion contralateral breast (with central lucencies) stabilize by o Radiation-induced malignancies 2 yrs esp (angio)sarcoma o Fat necrosis calcifications both dystrophic and rim oil cysts Breast IR etcetera

1. Sentinel node injection Nonmigration of isotope: injection into malignant mass, injection into hematoma/seroma, lymphatic obstruction or alteration in the setting of bulky axillary LAN or prior lymph node surgery, morbid obesity, CHF/severe CVD, idiopathic

2. US CNB guidance US-guided biopsy preferred offers several advantages over stereotactic and MR imaging-guided CNB o real-time procedure allows visualization and verification of accurate targeting with faster procedure times o requires no breast compression and allows more comfortable positioning for the patient o no ionizing radiation is used compared with stereo CNB and no modality- based contraindications as compared with MR imaging Stereotactic CNB Tips & Targeting Stereotactic CNB Tips & Targeting

Stereotactic Tips: o Axes are X (horizontal), Y (vertical), and Z (depth) o Stereotactic are paired 15 degree off midline. Scout image -> X and Y, Stereos -> Z o Stroke margin is distance from postfire needle tip to the distal surface of breast o Negative stroke margin indicates risk postfire needle will strike image receptor distally Specimen Radiograph - 3 types

1. Core needle biopsy specimen - confirm adequate sampling of the specific calcifications of concern on prebiopsy mammograms. a must for stereotactic biopsy procedures

2. Surgical sample specimen - confirm excision of the localized abnormalities, to include the specific mass/calcifications/architectural distortion/other, metallic localizer clip, and intact localization wire in entirety. also adequacy of surgical margins

3. Paraffin blocks specimen - directs pathologist to detailed review of biopsy or surgical specimen blocks in case of subtle finding Recommend further tissue sampling due to:

High Risk and Etcetera o Atypical ductal hyperplasia ADH o Lobular neoplasia: Atypical lobular hyperplasia ALH Lobular carcinoma in situ LCIS o Flat epithelial atypia FEA o Papilloma with atypia o Radial scar and Complex sclerosing lesion If discordant results are returned, o Phyllodes arrangements for repeat image o Locally aggressive benign (mesenchymal) guided biopsy or surgical biopsy should be made. If the pathology o Discordance results are malignant, review of o Insufficient tissue the entire case should be performed, including index and opposite breast, axilla to determine if other findings now require closer scrutiny or bx