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

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Breast pathology – Histopathology of the breast – Description and significance of the components of the report – Pathological staging (according to the 2017 TNM classification of malignant tumours, 8th edition; UICC)

Classification of tumour, node, and metastasis (TNM) by pathological examination of the resected tissue is denoted by use of a lowercase ‘p’ prefix:

pT1: Tumour 2 cm or less in greatest dimension.
pT2: Tumour more than 2 cm but not more than 5 cm in greatest dimension.
pT3: Tumour more than 5 cm in greatest dimension.
pT4: Tumour of any size with direct extension to chest wall or skin.
pN0: No regional lymph node metastasis.
pN1: Metastasis in 1–3 ipsilateral axillary lymph node(s), and/or in internal mammary nodes with microscopic metastasis detected by sentinel lymph node dissection but not clinically apparent.
pN2: Metastasis in 4–9 ipsilateral axillary lymph nodes, or in clinically apparent ipsilateral internal mammary node(s) in the absence of axillary lymph node metastasis.
pN3: Metastasis in 10 or more ipsilateral axillary lymph nodes, or in infraclavicular lymph nodes; or in clinically apparent ipsilateral internal mammary nodes in the presence of 1 or more positive axillary lymph node metastasis or in more than 3 axillary lymph nodes with clinically negative, microscopic metastasis in internal mammary nodes; or in ipsilateral supraclavicular lymph nodes.
pM1: Distant metastasis (applicable only if biopsy positive at metastatic site).

The following TNM descriptors are required only if applicable:

m (multiple): In cases of multiple simultaneous tumours in one breast, the tumour with the highest T category should be classified and the multiplicity or the number of tumours should be indicated in parentheses, e.g. T2(m) or T2(5).
r (recurrent): When a tumour is staged after a documented disease-free interval.
y (post-treatment): Applies to staging following initial multimodality (e.g. after neo-adjuvant therapy) therapy. Add as prefix to the pTNM descriptor, e.g. ypTNM.
In simultaneous bilateral cancers, each tumour is classified independently.

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