High Risk Breast Lesions

Breast Malignancy

DCIS (90% with IDC)

  • Cancer confined to the duct

  • Multiple filling defects in a duct (note that papilloma will present as a solitary filling defect)

  • Paget’s

    • Associated with high grade DCIS

    • Need to also biopsy the skin - wedge biopsy

    • Involvement of skin does not upgrade the cancer

  • Comedo form - more aggressive

  • Non-comedo form

  • 10% = mass without calcs

  • MG

    • Fine linear branching, fine pleomorphic calcs

  • US

    • Microlobulated hypoechoic mass

    • Ductal extension

    • Normal acoustic transmission

  • MRI

    • Non-mass like enhancement

  • Galactography

    • Multiple intraductal masses/filling defects on galactogram

Invasive lobular carcinoma (8%)

  • Seen in older patients

  • Commonly only seen in one view (usually CC as there is better compression)

  • Mets to axilla = less common vs ductal carcinoma

  • Washout less common on MRI vs ductal carcinoma

  • Prognosis similar to ductal carcinoma

    • Exception = pleomorphic ILC = very bad

  • More often bilateral and multifocal vs ductal carcinoma

  • Shrinking breast appearance on mammogram

    • The affected breast looks asymmetrically small

    • But may look normal on physical exam

  • Breast wont compress because its infiltrated and fucked up

  • Dark star appearance

    • Architectural distortion without definitive central mass on MG

  • Shadowing on US without evidence of definitive mass

  • Invasion of the overlying skin is not uncommon

    • Note that you may get this confused with mastitis or inflammatory breast cancer because of the skin involvement but in mastitis or inflammatory breast cancer the breast should really be enlarged and will have lymphadenopathy, in invasive lobular carcinoma the breast is typically asymmetrically smaller and the nodes may be normal or not very impressive

Dark Star DDx

  • Architectural distortion without definitive mass

  • Invasive lobular carcinoma

  • Radial scar

  • Postsurgical scarring

  • IDC-NOS subtype

Paget disease of Breast

  • Carcinoma in situ of the nipple epidermis

Inflammatory Breast Cancer

  • Skin thickening

  • Swollen red breast - think mastitis vs inflam breast cancer

  • Horrible prognosis

  • Treat with chemo then surgery

  • Note the inflammation may improved with Abx but will not RESOLVE

    • If does not go away completely = cancer

  • If cannot find a mass and you see this = get skin biopsy

  • Note skin thickening on left picture

Metastatic Disease to the Breast

  • Typically round, circumscribed and non-calcified (not typically spiculated)

  • Typically hematogenous spread from

    • Melanoma,

    • Lymphoma

    • Lung

    • Others

  • In males, prostate most common source (> lung)

General

  • Lesions that are associated with cancer and usually require an excision when they show up on biopsy

  • Atypical ductal hyperplasia (ADH)

  • ALD

  • LCIS

  • Radial scar

  • Papilloma

Breast Cancers

  • Ductal carcinoma in situ (DCIS)

  • Invasive ductal carcinoma

  • Invasive lobular carcinoma

Atypical Ductal Hyperpalsia

  • Basically the precursor to DCIS

  • By definition, partial involvement of <2 duct sites and measures < 2mm

  • Most commonly found from biopsy of calcifications

Radial Scar

  • Dense fibroelastic core with stellate entrapped ducts

  • Associated with tubular cancer

  • Dark star appearance

  • Biopsy recommended

Lymph nodes

  • Measure area of cortex to hilum in short axis of thickest part

  • If >2.5-3 mm = abnormal

  • Non-hilar blood flow is highly suspicious finding

References:

Pleomorphic LCIS

  • Basically precursor to invasive lobular carcinoma

  • Cells are more atypical with necrosis and calcifications

Lobular Neoplasia

  • General term for epithelial atypia of cells lining the lobular portion of the TLDU

  • Includes

    • Atypical lobular Hyperplasia (<50% of acini with atypia)

      • 4% chance of becoming malignancy

    • Classic lobular carcinoma in situ (LCIS) (>50% of acini with atypia)

      • 10% chance of becoming full on malignanct

    • Difference between this is for path not us

  • Most commonly found from biopsy of calcifications

Invasive Ductal Carcinoma

  • Histopath subtypes

  • Not otherwise specified

    • Most common

    • Worse prognosis of those listed here

  • Mucinous

    • Rare

    • High T2 signal 2/2 high mucin content (note ILC is T2 hypo)

  • Medullary

    • BRCA association

    • Seen in younger patients

    • Bulky lymphadenopathy

  • Tubular

    • Spiculated & Small masses

    • Good prognosis

    • Has a radial scar

  • Papillary

    • Complex cystic & solid

    • Older patients

    • Rare to have lymphadenopathy

    • Basically opposite of medullary

Notice not only the focal mass but how asymmetrically smaller the left breast is compared to the normal right breast

Bilateral Disease

  • Genetic disease - BRCA

  • Multicentric disease

  • Lobular malignancy

Papilloma

  • Most common intraductal mass

  • Most common cause of bloody nipple discharge

  • Solitary filling defect on galactography

  • Usually within 1 cm of nipple

  • Central papillomas more like to be benign than peripheral papillomas