Foreword Introduction Breast anatomy

Introduction Gross anatomy Breast tissue Microscopic anatomy Vascular and lymphatic supply Development of the breast Changes in the breast with ageing

Clinical breast examination (CBE)

Breast cancer screening versus early diagnosis Performing a breast examination Practical tips when performing breast examinations Common abnormalities Interpretation: normal/negative cases Interpretation: abnormal/positive cases Documentation Pitfalls and limitations

Breast imaging

Introduction Evolution of breast imaging Techniques Principles of mammography Mammography technique

Mammography unit Basic functioning Mammography procedure

Scheduling a woman for mammography Obtaining mammographic images

Procedural steps Right MLO view Right CC view Left MLO view Left CC view

Technical adequacy of acquired mammographic views

Mediolateral oblique (MLO) view Craniocaudal (CC) view

Additional mammographic views

Introduction Spot compression magnification view 90 degrees lateral views Exaggerated craniocaudal view Cleavage view Axillary tail view Lumpectomy specimen mammography

Pitfalls

Incorrect MLO positioning Inadequate breast compression Screen artefacts on mammographic image Overstretched RCC and RMLO views Opacities from body parts causing artefacts in the examination field Breast tissue inadequately pulled onto the image receptor

Image processing

Mammography interpretation Breast ultrasound

Introduction Indications Equipment: Basic components and functioning Technique

Getting ready Procedural steps

Benefits Limitations Learning breast ultrasound

Normal anatomy Breast changes in special stages of life Breast changes in special stages of life (2) Interpreting the abnormalities

Ultrasound lexicon

Ultrasound lexicon Breast tissue composition Breast masses

Breast masses Shape Orientation Margin Echo pattern Posterior features

Calcifications Associated features

Associated features Architectural distortion Oedema Duct changes Skin changes Vascularity

Special cases

Special cases Cysts Mass in skin Foreign body Lymph nodes – Intramammary Lymph nodes – Axillary Postsurgical fluid collection Fat necrosis

Ultrasound-guided interventional procedures

Ultrasound-guided interventional procedures Advantages Fine-needle aspiration cytology (FNAC) Core needle biopsy of the breast

Reporting and final assessment categories

Standard reporting of breast imaging Report template Final assessment categories

Final assessment categories BI-RADS 0 BI-RADS 1 BI-RADS 2 BI-RADS 3 BI-RADS 4 BI-RADS 5 BI-RADS 6

Breast pathology

Introduction Cytopathology of the breast

Cytopathology of the breast Procedure for palpable breast masses

FNAC procedure Equipment Getting ready Locating the palpable breast lump Aspiration Smear preparation technique Fixation of the smears Staining procedure Additional points to remember in breast FNAC procedure Reporting terminology

Histopathology of the breast

Specimen types Processing of tissue for histopathology Specimen transport Specimen grossing Grossing of excision biopsy specimens Localization of lesion with mammography Histological techniques Histopathology reporting format Description and significance of the components of the report

Histological grade Histological subtype Tumour size Margins Features of DCIS Lymphovascular invasion Immunohistochemistry for biomarkers Pathological staging

Case studies

BI-RADS 1

ACR category a ACR category b ACR category c ACR category d

BI-RADS 2

Cystic

Simple cyst Complicated cyst

Solid

Fibroadenoma Phyllodes Adenosis

Fat-containing solid

Lipoma Hamartoma Galactocele

Calcified benign mass

Involuting fibroadenoma

Calcifications – typically benign

Skin Vascular Coarse or popcorn-like Large rod-like Round Rim Dystrophic Milk of calcium Suture Diffusely scattered calcifications bilaterally

Miscellaneous

Trauma Infection Inflammatory Granulomatous mastitis Intramammary node Fibrocystic changes Accessory breast Fat necrosis Oil cyst

BI-RADS 3

BI-RADS 3

BI-RADS 4

4A-Low suspicion for malignancy 4B-Moderate suspicion for malignancy 4C-High suspicion for malignancy

BI-RADS 5

IBC-Microcalcifications IBC-Skin thickening IBC-Skin retraction IBC-Nipple retraction IBC-Architectural distortion IBC-Spiculated margin IBC-Indistinct margin IBC-Obscured margin IBC-Microlobulated margin IBC-Metaplastic carcinoma IBC-Nipple erosion IBC–Occult primary in breast with nodal metastases IBC with metastatic intramammary node IBC with coarse heterogeneous calcifications IBC with Paget disease IBC with neuroendocrine differentiation IBC in neurofibromatosis Encapsulated papillary carcinoma Multifocal Multicentric Invasive cribriform carcinoma Infiltrating lobular carcinoma Inflammatory carcinoma Malignant phyllodes Medullary carcinoma Mucinous carcinoma Bilateral synchronous carcinoma Calcification of suspicious morphology

BI-RADS 6

BI-RADS 6

Miscellaneous cases

Post-operative breast Developing asymmetries Screen-positive TRAM flap Metastatic breast

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Atlas of breast cancer early detection

Breast imaging – Breast ultrasound – Ultrasound-guided interventional procedures – Fine-needle aspiration cytology (FNAC)

Indications for FNAC

Diagnostic

An abnormality that is suspicious for malignancy detected on clinical examination.
An abnormality that is suspicious for malignancy detected on diagnostic breast imaging performed to investigate any breast problem and/or abnormal clinical findings.
A non-palpable breast lesion detected on imaging during routine screening of an asymptomatic woman.
Inflammatory diseases (uncommon).
Suspected secondary or metastatic tumours in the breast (including haematological or lymphoid malignancies).
Suspected recurrence of malignancy after treatment.

Therapeutic

Evacuation of simple or inflammatory cysts.

Steps

Counsel the patient and obtain an informed consent.
Perform diagnostic breast imaging (mammography or ultrasound) to localize the lesion. Mark the suspicious finding for ultrasound-guided intervention.
Position the patient in dorsal decubitus and ask her to raise the arm ipsilateral to the lesion and rest it behind her head. An interior oblique position may be more suitable for a patient with large breasts or if the lesion is in an extremely lateral location. Patient position for ultrasound-guided FNAC is similar to that for diagnostic breast ultrasound.
The FNAC procedure and preparation of cytology smears are described in the section on Laboratory processing of breast specimens for cytology and histology.
Clean and drape the area of breast with a suspicious finding.
Clean and cover the ultrasound probe with a sterile probe drape.
Localize the non-palpable lesion and measure the skin depth to be traversed.
Stabilize the lesion with firm pressure of the ultrasound probe.
Select a 23G or 24G needle that is long enough to reach the centre of the lesion.
Introduce the needle under guidance parallel to the length of the ultrasound probe and advance it into the breast tissue up to the lesion.
View the needle in its entire length throughout the procedure and ensure that the lesion is hit and pierced towards its centre.
Document the position of the needle in the breast (mark the quadrant and the position of the transducer on the image). Save the first screenshot, and with the needle in the tumour, save the second image.
Pull the plunger back to create suction while holding the needle steady throughout the sampling procedure.
Move the needle backwards and forwards inside the lesion 10–20 times.
Release suction by letting go of the plunger.
Withdraw the needle.
Transfer the material onto the prepared slides. Ensure they are labelled with the patient’s unique identification details.
Keep compression on the area with a gauze pad to prevent the formation of haematoma.

Breast Pathology

Further details about the advantages and disadvantages of FNAC are given later.

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