BREAST PROCEDURES AND PATHOLOGIES

CATINA CARR MSRS RRA RT(R)

MAMMOGRAPHY

Screening mammograms

Diagnostic mammograms

Spot compressions, magnification views

Stereotactic biopsy

Needle localizations

STEREOTACTIC BIOPSY

Architectural distortion

Micro-calcifications

Mass/lesion

NEEDLE LOCALIZATIONS MAMMOGRAPHY OR ULTRASOUND

• Calcifications that are too superficial or too deep to reach with stereotactic biopsy

• Positive biopsy

• Patient chooses excisional biopsy

• Fibroadenoma

• Radial scar

• Atypia

MAMMOGRAPHIC NEEDLE LOCALIZATION

ULTRASOUND GUIDED NEEDLE LOCALIZATION

• Clip migration

• Young patient

• Easily visualized lesion

• Difficult patient

• Chest wall/posterior lesions

NEEDLE LOCALIZATION

ULTRASOUND

• Cyst aspiration

• Abscess drain

• Biopsy

• Needle localization

ULTRASOUND

MRI

• MRI guided breast biopsy

• Abnormal breast MRI

• MRI guided needle localization

• MRI safe needles, devices, clips

MRI GUIDED BIOPSY

• MRI safe scalpel

• MRI Breast biopsy kit

• MRI safe light

GALACTOGRAPHY

• Ductogram

• Nipple discharge

• Papilloma

• Adenoma

• Duct ectasia

• Ductal debris

GALACTOGRAPHY

• Galactogram infusion set

• Angled or straight

• Scout mag views

• CC and ML

• Magnifier light

• Contrast

• Methylene blue ductogram

BREAST PROCEDURES

Wilton Medical Arts Breast Center/ Saratoga Hospital

Saratoga Springs New York

DUCTOGRAM

• 47 year old woman

• Clear left nipple discharge for 5 months

• One episode of brown/bloody discharge

• Comparison ultrasound

DUCTOGRAM

DUCTOGRAM

DUCTOGRAM

Patient underwent methylene blue ductogram

50/50 Isovue 300 and methylene blue

Surgical pathology returned intraductal papilloma

Filling defects in nipple were also papilloma’s

DUCTOGRAM

• 31 year old female

• Left nipple discharge

• Ultrasound-Mildly prominent debris

filled duct 9:00 position left breast

DUCTOGRAM

• One of the images is the diagnostic

ductogram, the other is the pre-op

methylene blue ductogram.

• Abrupt stoppage of contrast which

corresponds with ultrasound

findings.

• Pathology demonstrated intra-

ductal papilloma.

DUCTOGRAM

• 46 year old woman

• Increasing nipple discharge

• No family history

DUCTOGRAM

• Uncomplicated right ductogram. The duct in the middle, inferior portion of the contains

numerous filling defects. The canula fell out of the nipple and the duct was recannulated.

A second duct was opacified and demonstrates dilatation compatible with duct ectasia.

• Surgical pathology returned intraductal papilloma, apocrine metaplasia, small papillomas,

duct ectasia, microcysts , stromal fibrosis and patchy acute inflammation associated with

lobules. No evident malignancy.

62 YEAR OLD, LEFT BREAST PAIN FOR MONTHSDIAGNOSTIC MAMMO, US, +US BIOPSY

MRI BREAST BIOPSY

• US Cyst aspirate- malignancy consistent

with poorly differentiated carcinoma

• US Lymph node- metastatic ca.

compatible with breast primary

• MRI bx Suspicious for microinvasion

• Ductal carcinoma in situ

• Right breast atypical lobular hyperplasia

25 YEAR OLD PALPABLE MASS. BIRTH CONTROL PILLS 3 MONTHSENLISTED NAVY, TRAINING FOR MARATHON BI-RADS 4

ULTRASOUND GUIDED CORE BIOPSY-POORLY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA

ULTRASOUND BIOPSYPOST PROCEDURE MAMMOGRAM

STEREOTACTIC BIOPSY

• 47 year old screening, increased microcalcifications right breast, 3:00 anterior 1/3 of the

breast. Bi-rads 0

• Spot magnification views…. stereotactic biopsy

STEREOTACTIC BIOPSYMICROCALCIFICATIONS

MICROCALCIFICATIONS

• Stereotactic biopsy performed

• Post procedure mammogram showed anterior migration of the clip

• Pathology demonstrated Ductal Carcinoma In Situ

• Patient chose to go with breast conserving therapy

• Needle localization

NEEDLE LOCALIZATION

REDNESS, TENDER, FEVER, PALPABLE MASSDIAGNOSED WITH MASTITIS, 2 WEEKS OF ANTIBIOTICS, BOTH PATIENTS

PRESENTED TO ER AFTER ONLY A COUPLE OF DAYS ON MEDS

CONCLUSION

• Both women needed to undergo surgical drainage of collections

• 1- small pockets of necrotic tissue and scar tissue superficially, deep cavity with thin

purulent fluid

• 2- superficial sub-areolar abscess. In addition was a much deeper loculated collection over

a 15 cm area

Common denominator???????

ULTRASOUND GUIDED BIOPSY

• 23 year old female, mother deceased breast ca at age 42, maternal grandfather breast ca

• Bilateral palpable breast masses

• 6 month US follow up- typically follow every 6 months for 2 years to document stability

• Per the patient’s request because of family history and anxiety

• 6 breast biopsies

FIBROADENOMA

• All 6 biopsies returned Fibroadenoma

• Age of patient

• Birth control (hormone therapy)

• Bilaterallity

• Multiplicity

IMPORTANCE OF ANNUAL SCFREENING

• 71 year old female, h/o breast ca 5/2001, lumpectomy and radiation

• Annual screenings- area of scar, diffuse calcs

• 2011 breast biopsy at area of scar- fibrosis, calcification and granulation tissue

• 8/18 unchanged screening mammography

• 1/19 pt complains of pain and pressure at the scar

• Diagnostic mammography and ultrasound

2011

2015 2017 2019

ULTRASOUND GUIDED BIOPSY

ANGIOSARCOMA

• Pathology demonstrates Angiosarcoma of the breast

• MRI breast- no additional areas of abnormal enhancement

• Recommended treatment is surgical removal of all irradiated skin

• Angiosarcomas don’t typically travel to the lymph nodes

• Chest CT, smoking history, lung nodule follow up

ANGIOSARCOMA

• Patient chose to have mastectomy

• At the time of diagnosis- poor prognosis

• Status post mastectomy with clear margins, including skin

• Clinical stage 1

NOVEMBER 2016

• 24 year old female, 6 months pregnant, palpable lump

• US – 4x3x2 cm mass with lobular margins; adjacent 1.6x1x2.1 cm mass

• BI-RADS 4

• February 2017 Post delivery- 9.1x8.4x5.0 cm mass

• After biopsy, specimen was sent to Emory University

• ddx- metaplastic ca, spindle cell ca, malignant phyllodes sarcoma

• Mastectomy was performed prior to pathology results

POORLY DIFFERENTIATED HIGH-GRADE METASTATIC CARCINOMA, SPINDLE CELL TYPE

• Total mastectomy

• Clear margins

• Negative lymph node, no LVI

• Stage 2 B

• Staging CT chest abdomen and pelvis

• 4 rounds of chemotherapy

JANUARY 2018

• Screening right breast mammogram

• After chemotherapy treatments

• Follow up PET scan

• Lung nodule

• Subsequent CT guided lung biopsy

• Metastatic breast ca

PET CT APRIL 2018BIOPSY 2018

JUNE 17, 2018

Both biopsies showed

metastatic poorly

differentiated malignancy

with sarcomatoid features,

compatible with metaplastic

breast ca.

2018

• Further treatment with chemotherapy

• Increasing lung mets and mediastinal adenopathy

• Subsequent pleural effusion requiring thoracentesis x 3

• Change in chemo regimen, reduced lung lesions, mediastinal adenopathy

• Subsequent PET CT

FEBRUARY 2019

• PET CT shows continued decrease in lung mets and adenopathy

• New pelvic mass

• Biopsy demonstrates metastatic breast CA

MARCH 2019 NEW PELVIC MASS

SARATOGA SPRINGS NY

CLOSE TO NYC

CLOSE TO THE ADIRONDACKS

REFERENCES

• Clinical radiology, volume 73, issue 10

• Https://doi.org/10.1016/j.crad.2018.05.029

• Phil Fear MD

• Patricia Kennedy MD