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 .