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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Case number:	013
Age:	75
Clinical presentation:	Postmenopausal woman with average risk of breast cancer presented with a painless right breast lump of long duration. The lump had gradually grown to the present size. Examination revealed a large firm lump (> 10 cm) in the right breast.

Mammography:

Breast composition:	ACR category a (the breasts are almost entirely fatty)
Mammography features:

‣ Location of the lesion:	Right breast, upper quadrants at 2–9 o’clock, anterior, middle, and posterior thirds
‣ Mass:
• Number:	1
• Size:	11.0 × 5.0 cm
• Shape:	Oval
• Margins:	Circumscribed
• Density:	Fat-containing
‣ Calcifications:
• Typically benign:	None
• Suspicious:	None
• Distribution:	None
‣ Architectural distortion:	None
‣ Asymmetry:	None
‣ Intramammary node:	None
‣ Skin lesion:	None
‣ Solitary dilated duct:	None
‣ Associated features:	None

Ultrasound:

Ultrasound features: Right breast, upper quadrants at 2–9 o’clock

‣ Mass
• Location:	Right breast, upper quadrants at 2–9 o’clock
• Number:	1
• Size:	10.5 × 4.5 cm
• Shape:	Oval
• Orientation:	Parallel
• Margins:	Circumscribed
• Echo pattern:	Isoechoic
• Posterior features:	No posterior features
‣ Calcifications:	None
‣ Associated features:	None
‣ Special cases:	None

BI-RADS:

BI-RADS Category: 2 (benign)

Further assessment:

Further assessment advised: Referral for cytology

Cytology:

Cytology features:

‣ Type of sample:	FNAC
‣ Site of biopsy:
• Laterality:	Right
• Quadrant:	Upper half
• Localization technique:	Palpation
• Nature of aspirate:	Greasy, yellowish material
‣ Cytological description:	Smears show only adipose tissue fragments. Ductal epithelial cells not seen
‣ Reporting category:	Benign
‣ Diagnosis:	Only adipose tissue
‣ Comments:	None

Case summary:

Postmenopausal woman presented with a large painless lump on her right breast of long duration. Diagnosed as lipoma, BI-RADS 2 on imaging and as benign adipose tissue on cytology.

Learning points:

Nearly 15% of all mesenchymal tumours are lipomas.
Giant lipomas are defined as lesions with a diameter of at least 10.0 cm, as is seen in this case.

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