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

Quiz Acknowledgements Authors Suggested citation Copyright

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Atlas of breast cancer early detection

Breast pathology – Histopathology of the breast – Description and significance of the components of the report – Histological subtype

The International Classification of Diseases for Oncology, 3rd edition (ICD-O-3) published by IARC/WHO is internationally recognized as the definitive classification of neoplasms. ICD-O-3 is used principally in tumour or cancer registries for coding the site (topography) and the histology (morphology) of neoplasms, usually obtained from a pathology report. ICD-O-3 is a multi-axial classification of the site, morphology, behaviour, and grading of neoplasms.
The topography code describes the anatomical site of origin of the tumour.

ICD-O-3 topography site codes for breast

C50.0: Nipple
C50.1: Central portion of breast
C50.2: Upper inner quadrant of breast (UIQ)
C50.3: Lower inner quadrant of breast (LIQ)
C50.4: Upper outer quadrant of breast (UOQ)
C50.5: Lower outer quadrant of breast (LOQ)
C50.6: Axillary tail of breast
C50.7: Overlapping lesion of breast
C50.9: Breast, NOS (excludes skin of breast C44.5); multifocal neoplasm in more than one quadrant of the breast.

The WHO Classification of Tumours of the Breast, 5th edition is generally used classify tumours into various subtypes based on tumour architecture, cytonuclear features, and stromal features (WHO Classification of Tumours Editorial Board. Breast tumours. Lyon (France): International Agency for Research on Cancer; 2019. (WHO classification of tumours series, 5th edition; vol. 2))
A breast carcinoma showing a special histological pattern in more than 90% of the tumour is designated as a pure special type. Most breast cancers do not show such specific features and are designated as invasive breast carcinoma of no special type.
The histological subtypes of invasive breast carcinoma are as follows:

Invasive breast carcinoma of no special type
Microinvasive carcinoma
Invasive lobular carcinoma
Tubular carcinoma
Cribriform carcinoma
Mucinous carcinoma
Mucinous cystadenocarcinoma
Invasive micropapillary carcinoma
Carcinoma with apocrine differentiation
Metaplastic carcinoma
Encapsulated papillary carcinoma with invasion
Solid papillary carcinoma with invasion
Invasive papillary carcinoma
Rare and salivary gland type tumours
Neuroendocrine carcinoma.

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