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  1. B-mode ultrasonography
    1. The main indications of breast US have been differentiation between cystic and solid lesions,
    2. Evaluation of a palpable lesion in a mammographically dense breast (for example young, pregnant or lactating patient),
    3. Evaluation of a lesion detected at mammography or mammographic asymmetry,
    4. Detection of an abscess in an infectious breast, evaluation after breast cancer treatment and breast augmentation,
    5. Evaluation of axillary lymph nodes and guidance for interventional procedures
    6. Ultrasound can detect mammographically occult cancers, but it is generally accepted that US is not suitable for screening.
    7. Microcalcifications with no associate mass are not usually reliably detectable at US.
    8. Currently, most solid breast lesions undergo a diagnostic or preoperative needle biopsy.  
  2. Magnetic resonance imaging 
    1. MR imaging has proved to be the most sensitive & specific method for the detection of invasive breast cancer. The detection is based on lesion enhancement after contrast agent administration.
    2. MRI indicated in post lumpectomy, breast scar and breast implant.

Differentiating feature between benign and malignant lupcep on MRI




Benign                                       Malignant
No enhancement Ring enhancement
Tiny stippled Spiculated
Smooth marginated Linear ductal
Lobulated Clumped globular
Septated Clumped globular interspersed with tiny
magnetic susceptibility  
  1. Diagnostic criteria
    1. The diagnostic criteria consist of both lesion morphology and enhancement kinetics.
    2. The morphologic criteria are comparable to those used at mammography.
    3. Well-defined margins indicate benignity, while ill-defined or spiculated lesions are suggestive of malignancy.
    4. Internal septations, if seen, are specific for fibroadenomas.
    5. Enhancement in benign lesions is homogeneous and proceeds centrifugally. Benign lesions also usually enhance less and do so more slowly than malignant lesions.
    6. In malignant lesions enhancement is often inhomogeneous or rim-like and tends to proceed centripetally.
    7. Enhancement kinetics can also be analyzed by the shape of time-signal intensity curve: a continuous increase in signal intensity is considered a benign finding, a rapid increase followed by a washout phenomenon is considered malignant.
  2. Other imaging modalities
    1. Computed tomography has not been recommended for breast imaging, mainly because of high radiation dose.
    2. It has been successfully used in regional staging of small breast cancer before breast conserving surgery.
    3. Electrical impedance scanning is a new technique, which is based upon the principle that malignant cells exhibit altered local dielectric properties and show measurably higher conductivity values.
  3. Image-guided needle biopsies
  4. Fine-needle aspiration biopsy
    1. Fine-needle aspiration biopsy, usually performed with a 20–25 gauge needle, is a widely used method for further evaluation of breast lesions other than microcalcifications.
    2. In qualified hands it decreases the need for surgical biopsies.
    3. The reported overall accuracy is from 81% to 98%.
    4. Lesions liable to misinterpretation include phyllodes tumor, lobular and tubular carcinomas.
    5. Most diagnostic investigation is biopsy
  5. Core needle biopsy
    1. Histologic examination is more likely than a cytologic examination to give a definitive diagnosis of a breast lesion.
    2. It is the only non-operative method that differentiates between an invasive and noninvasive tumor, and it has therefore become the preferred biopsy method.
    3. The reported sensitivities range from 89% to 100%, and the specificities from 96% to 100%
    4. Surgery is needed in case of atypical ductal hyperplasia or phyllodes tumor, radial scar, papillary lesions, atypical lobular hyperplasia and LCIS as well as in cases with suspicious microcalcifications despite a benign diagnosis at core biopsy.  
  6. Guiding methods
    1. The oldest and previously the most common guiding method is palpation, which is no longer preferred. US has emerged as the optimal guidance technique for percutaneous biopsies.
    2. The advantages of US over stereotactic x-ray guidance include:
      1. Real-time monitoring,
      2. The lack of ionizing radiation,
      3. The almost unlimited applicability to the lesion,
      4. The ability to use the shortest route to the lesion,
      5. The possibility of multidirectional sampling (FNAB)
    3. Mammographic stereotactic guidance is used for lesions not seen well at US, microcalcifications with no associated mass as the most important type 
  7. DCIS - Ductal Carcinoma In Situ Q
    Malignant cells proliferate within the pre-existing ductal structures and basement membranes to replace benign lining cells located within the ducts proximally and the lobules distally.  
  8. Gross Pathology of DCIS:
    1. By gross examination, most lesions of DCIS do not present with a distinct appearance.
    2. The background breast tissue may be fatty or fibrous, and slightly firm on palpation.
    3. Only extensive comedo type of DCIS depicts visible abnormality.
    4. The involved area has a granular character.
    5. By squeezing the area, necrotic material exudes from the ducts.
  9. Classification of DCIS
    Classification of DCIS is based on the microscopic characters of
    1. Architecture (growth pattern)
    2. Nuclear features  
  10. Classification of DCIS by the Predominant Architecture
    1. Papillary/micropapillary type
      1. Multiple isolated papillary projections, most of which lack fibrovascular stalks
      2. Papillae become fused to form Roman bridges and arches giving the impression of rigidity  
    2. Cribriform type
      1. Tumor cells are arranged in a sieve-like pattern, multiple small round glands growing in a larger gland or duct. These glands are confluent without fibrous walls.
      2. Most tumor cells have low nuclear grade 
    3. Solid type
      1. Tumor cells fill the ducts and ductules as solid sheets
      2. Nuclear grade is predominantly intermediate or high grade. Necrosis is usually focalQ
    4. Comedo type
      1. Central necrosis of the involved ducts is a prominent feature
      2. Calcification occurs within the necrosis
      3. High nuclear grade in most tumors.
  11. Prognosis of DCIS (by pathological analysis)
    1. Nuclear grade is more important than architecture (growth) pattern
    2. Status of surgical margin
    3. Lesion size

Salient Characteristics of In Situ Ductal (DCIS) and Lobular (LCIS) Carcinoma of the Breast




Age (years)






Clinical signs


Mass, pain, nipple discharge

Mammographic signs






Incidence of synchronous invasive carcinoma









Axillary metastasis



Subsequent carcinomas:







Interval to diagnosis

15–20 y

5–10 y

Histologic type





Mastectomy: Definitions of Standard Mastectomy Types

  1. Modified Radical Mastectomy(or Total Mastectomy with formal ipsilateral axillary dissection):
    1. This surgical procedure removes the entire breast parenchyma including the nipple-areolar complex.
    2. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins.
    3. An ipsilateral axillary dissection is included.               
  2. Simple Mastectomy (or Total Mastectomy):
    1. This includes removal of entire breast parenchyma including the nipple-areolar complex.
    2. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins.
    3. No axillary dissection is included.  
  3. Simple Mastectomy with Sentinel Lymphadenectomy:
    1. This surgical procedure removes the entire breast parenchyma including the nipple-areolar complex.
    2. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins.
    3. An ipsilateral sentinel lymphadenectomy is included.  
  4. Subcutaneous Mastectomy: The entire breast parenchyma is resected while preserving the nipple-areolar complex and its vascular viability. No axillary dissection is performed.  
  5. Skin Sparing Total Mastectomy (or reconstruction ready Mastectomy):
    1. This is the equivalent of a total mastectomy (with or without axillary dissection).
    2. The skin flaps however are designed to be long and the skin resection is minimal.
    3. The actual resection site for the mastectomy is a round incision.
    4. This mastectomy is used for immediate reconstruction with breast implants (Becker or standard).
Treatment summary as per stage.
  1. Stage I – BCS (Breast conservative surgery) or MRM
  2. Stage IIA / IIB – BCS or MRM
  3. Stage IIIA – MRM followed by chemotherapy and radiation if tumor is large, neoadjuvant chemo may be provided with or without harmone therapy.
  4. Stage IIIB – Neoadjuvent followed by lumpectomy or MRM followed by chemo, radiation Stage IIIB – inflammatory cancer.
    Treatment is quite similar to the treatment for stage IIIB or IV breast cancer, inaddition patient usually undergo chemo; harmone therapy and/or radiation. Patient who responds positively to systemic treatment may be candidates for mastectomy.
Structure preserve in MRM –
  1. Long Thoracic Nerve (Nerve to serratus anterior)
  2. Thoracodorsal Nerve
  3. Axillary vein.
  1. Complications
    1. Injury to the Intercostobrachial (Sensory) Nerve: It will result in a permanent numbness in the lateral aspect of the axillary and the inferior aspect of the arm.
    2. Injury to the Long Thoracic (Motor) Nerve: Seen in 10% of all cases. It will result in a palsy of the Serratus anterior muscle and clinically will create a classical winged scapula.
    3. Injury to the Thoracodorsal Nerve: Leads to palsy of the latissimus dorsi muscle.
    4. Lymphedema: This is a complication which occurs less frequently with the standard axillary dissections. However, it is commonly seen when an axillary dissection is combined with axillary radiation.
    5. Seroma

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