breast procedures and pathologies
TRANSCRIPT
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BREAST PROCEDURES AND PATHOLOGIES
CATINA CARR MSRS RRA RT(R)
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MAMMOGRAPHY
Screening mammograms
Diagnostic mammograms
Spot compressions, magnification views
Stereotactic biopsy
Needle localizations
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STEREOTACTIC BIOPSY
Architectural distortion
Micro-calcifications
Mass/lesion
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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
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MAMMOGRAPHIC NEEDLE LOCALIZATION
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ULTRASOUND GUIDED NEEDLE LOCALIZATION
• Clip migration
• Young patient
• Easily visualized lesion
• Difficult patient
• Chest wall/posterior lesions
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NEEDLE LOCALIZATION
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ULTRASOUND
• Cyst aspiration
• Abscess drain
• Biopsy
• Needle localization
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ULTRASOUND
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MRI
• MRI guided breast biopsy
• Abnormal breast MRI
• MRI guided needle localization
• MRI safe needles, devices, clips
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MRI GUIDED BIOPSY
• MRI safe scalpel
• MRI Breast biopsy kit
• MRI safe light
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GALACTOGRAPHY
• Ductogram
• Nipple discharge
• Papilloma
• Adenoma
• Duct ectasia
• Ductal debris
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GALACTOGRAPHY
• Galactogram infusion set
• Angled or straight
• Scout mag views
• CC and ML
• Magnifier light
• Contrast
• Methylene blue ductogram
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BREAST PROCEDURES
Wilton Medical Arts Breast Center/ Saratoga Hospital
Saratoga Springs New York
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DUCTOGRAM
• 47 year old woman
• Clear left nipple discharge for 5 months
• One episode of brown/bloody discharge
• Comparison ultrasound
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DUCTOGRAM
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DUCTOGRAM
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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
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DUCTOGRAM
• 31 year old female
• Left nipple discharge
• Ultrasound-Mildly prominent debris
filled duct 9:00 position left breast
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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.
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DUCTOGRAM
• 46 year old woman
• Increasing nipple discharge
• No family history
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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.
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62 YEAR OLD, LEFT BREAST PAIN FOR MONTHSDIAGNOSTIC MAMMO, US, +US BIOPSY
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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
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25 YEAR OLD PALPABLE MASS. BIRTH CONTROL PILLS 3 MONTHSENLISTED NAVY, TRAINING FOR MARATHON BI-RADS 4
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ULTRASOUND GUIDED CORE BIOPSY-POORLY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA
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ULTRASOUND BIOPSYPOST PROCEDURE MAMMOGRAM
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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
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STEREOTACTIC BIOPSYMICROCALCIFICATIONS
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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
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NEEDLE LOCALIZATION
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REDNESS, TENDER, FEVER, PALPABLE MASSDIAGNOSED WITH MASTITIS, 2 WEEKS OF ANTIBIOTICS, BOTH PATIENTS
PRESENTED TO ER AFTER ONLY A COUPLE OF DAYS ON MEDS
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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???????
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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
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FIBROADENOMA
• All 6 biopsies returned Fibroadenoma
• Age of patient
• Birth control (hormone therapy)
• Bilaterallity
• Multiplicity
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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
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2011
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2015 2017 2019
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ULTRASOUND GUIDED BIOPSY
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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
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ANGIOSARCOMA
• Patient chose to have mastectomy
• At the time of diagnosis- poor prognosis
• Status post mastectomy with clear margins, including skin
• Clinical stage 1
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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
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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
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JANUARY 2018
• Screening right breast mammogram
• After chemotherapy treatments
• Follow up PET scan
• Lung nodule
• Subsequent CT guided lung biopsy
• Metastatic breast ca
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PET CT APRIL 2018BIOPSY 2018
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JUNE 17, 2018
Both biopsies showed
metastatic poorly
differentiated malignancy
with sarcomatoid features,
compatible with metaplastic
breast ca.
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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
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FEBRUARY 2019
• PET CT shows continued decrease in lung mets and adenopathy
• New pelvic mass
• Biopsy demonstrates metastatic breast CA
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MARCH 2019 NEW PELVIC MASS
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SARATOGA SPRINGS NY
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CLOSE TO NYC
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CLOSE TO THE ADIRONDACKS
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REFERENCES
• Clinical radiology, volume 73, issue 10
• Https://doi.org/10.1016/j.crad.2018.05.029
• Phil Fear MD
• Patricia Kennedy MD