docUncommon Signs of Malignancy
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Uncommon Signs of Malignancy
Armed Forces Institute of Pathology www.radpath.com Armed Forces Institute of Pathology Breast Disease www.radpath.org Armed Forces Institute of Pathology Uncommon Signs of Breast Cancers Leonard M. Glassman MD FACR American College of Radiology Breast Imaging Scientist Armed Forces Institute of Pathology Washington DC Washington Radiology Associates, PC Washington DC glassmanl@afip.osd.mil Uncommon Signs Are Rare • 90% of cancers present as calcifications or masses or both • 10% of cancers present as an uncommon sign • Less than 10% of uncommon signs represent cancer Uncommon Signs • • • • • • Asymmetry Architectural distortion Paget’s disease Thickened skin pattern Isolated dilated duct Nipple/skin retraction Asymmetric Findings • More normal tissue on one side • Normal finding usually – The larger the asymmetry the more likely it is benign Asymmetric Findings • Global asymmetry – More than one quadrant involved – Almost always benign except when palpable • Asymmetry (seen in one view) – Almost always benign • Focal asymmetry – Asymmetry with similar shape in 2 views – One quadrant or less – Usually benign Global Asymmetry Asymmetry Seen in One View • Focal area seen on one view only – Not 3 dimensional • Seen on one side only • Almost always benign except if new or enlarging Focal Asymmetry • Area seen on two or more views which lacks all the signs of a mass – Usually benign but more often significant than global asymmetry Focal Asymmetry Focal Asymmetry Focal Asymmetry - Malignant Common Benign Causes of Asymmetry, Focal Asymmetry, Neodensity and Developing Density • Change in mammographic technique • Hormone replacement therapy • Fibrocystic change Change in Technique • Low to high contrast examination – Film to digital • Change in positioning – Usually the oblique view • Involution Change in Technique • Film • Digital Hormone Replacement Therapy • • • • • All types of HRT 25% of patients exhibit some change Usually bilateral Stabilizes usually within 1 year Decreases in 3 months with cessation of HRT Hormone Replacement Therapy Neodensity Developing Density - Carcinoma Asymmetric Findings • Is it palpable? – If it should be palpable and is not it is benign – Does not work for small deep densities Asymmetric Findings • Does it have bulging borders? – Concave borders suggest benign process – Convex borders suggest mass Asymmetric Findings • Does it have fat running through it? – All lesions that contain fat are benign Asymmetric Findings • Is it hypoechoic on ultrasound – Cancers are hypoechoic – Benign tissue is usually echogenic Asymmetric Findings • Are calcifications present within it? – Are they benign or malignant appearing Architectural Distortion • Change in orientation of tissue – Especially Cooper’s ligaments • Classically without a mass – Can be associated with a mass, calcification or asymmetry • Common causes – Scar from prior biopsy – Radial scar (sclerosing papillary lesion) – Cancer • All unexplained distortions need biopsy Architectural Distortion Scar Architectural Distortion • Radial scar • Tubular carcinoma Architectural Distortion • Invasive ductal cancer Paget's Disease • • • • • Red nipple and areola Scaling eczematoid reaction 50% have a palpable mass Must have Paget's cells in skin Has underlying breast carcinoma Paget’s Disease Paget’s Disease Paget’s Disease Thickened Skin Pattern • • • • • Edema Mastitis Inflammatory carcinoma Post-radiation change Obstruction to lymphatic drainage in the axilla or superior mediastinum • Lymphoma Thickened Skin Pattern Mastitis Thickened Skin Pattern Mastitis Thickened Skin Pattern Radiation Therapy Thickened Skin Pattern Mediastinal Obstruction Thickened Skin Pattern Inflammatory Carcinoma Inflammatory Carcinoma • Clinical findings – – – – Heavy firm breast Red skin Warm skin Peau d’orange • Can not differentiate from acute mastitis Inflammatory Carcinoma Inflammatory Carcinoma • Far advanced local disease • 50% five year survival – Pre-op chemo, mastectomy and radiation Breast Imaging Findings • • • • • Skin thickening Diffuse increased density Trabecular thickening Adenopathy Signs of carcinoma – Mass, calcification, asymmetry, distortion Inflammatory Carcinoma Inflammatory Carcinoma • Axillary nodes • Supraclavicular node Inflammatory Carcinoma Inflammatory Carcinoma Lymphoma Dilated Duct (Asymmetric Tubular Structure) • Usually inflammatory disease • May be papilloma or papillary carcinoma • History is critical – Should have spontaneous bloody or clear nipple discharge to be suspicious – Bilateral discharge is not cancer • Sonography helpful to exclude mass in large ducts Normal Ducts Normal Ducts Mammography Sonography • Inflammation • Papilloma Results • Fibrocystic change • DCIS Sonography • Papillary carcinoma Evaluation of Nipple Discharge • History – Bilateral or unilateral – Bloody or non bloody • Green is usually inflammatory • Black is usually cystic – Spontaneous or only with pressure • Is there a trigger point? Evaluation of Nipple Discharge • Mammography – Spot views helpful to get clear view – Is there a solitary dilated duct? • Sonography – Most useful with solitary dilated duct – Is a mass present? • Cytology – 18% false negative rate for carcinoma • Ductography Ductography • Papilloma • Papilloma Ductography • DCIS Nipple/Skin Retraction • Invasive ductal carcinoma Nipple/Skin Retraction Conclusion • Asymmetric findings are the most common of the uncommon signs of breast cancer • Most examples of uncommon signs do not represent cancer Conclusion • All unexplained architectural distortions need a biopsy • Paget’s disease of the breast “always” has an underlying carcinoma • The major differential diagnosis of thickened skin pattern is mastitis vs. inflammatory carcinoma • Isolated dilated duct is usually benign • New skin/nipple retraction is suspicious Conclusion • Most cancers show common signs • Most examples of uncommon signs represent benign processes • Many cancers missed on mammography represent examples of uncommon signs
