Mammography-The altered breast
Terms
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- What are examples of altered breast?
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Pregnancy
Lactation
Mastectomy/Lumpectomy
Radiation
Implants - What changes occur in the breast in the first few weeks of a pregnancy?
- Proliferation of ducts and lobules
- What are the typical mammographic changes during pregnancy?
- None. Some patients may develop increased density. Some may develop nodular changes.
- What are the typical mammographic changes during lactation?
- Increased density.
- What is effect of pregnancy on breast cancer?
- Decreases risk.
- Especially when?
- Early full term pregnancy
- Why?
- Increased breast density limits sensitivity.
- What is effect of pregnancy on an already present breast cancer?
- Associated with greater morbitity and mortality of the cancer.
- Why do breasts in lactation increase in density?
- There is proliferation of lobules, to the point that they crowd out stromal elements, and touch one another.
- What is protocol for mammographic screening during lactation?
- Don't do it.
- How are palpable abnormalities evaluated in the lactating patient?
- US
- What if a mammogram is indicated for evaluation of a lesion?
- The patient should nurse immediately before mammogram to allow for better compression.
- What is effect of fine needle aspiration of mammogram?
- Can produce hematoma and edema. Should wait at least 2 weeks before performing mammogram.
- What is effect of core needle biopsy?
- Frequent hematomas.
- When should post-biopsy hematoma be gone?
- Six months
- What about traumatic hematoma? What is the caveat here?
- If patient reports breast trauma and has findings classic for a hematoma, IT IS BREAST CANCER UNTIL PROVEN OTHERWISE, unless they have had prior mammogram.
- What is the deal with post biopsy scarring?
- If the lesion was BENIGN, the scar may be visible, but will most likely resolve by the next mammogram.
- What percent of patients with BENIGN biopsies have post biopsy scars that are notable (persisent spiculated abnormality) on subsequent mammography performed 2-3 years post biopsy?
- 3%
- When is early postbiopsy mammogram indicated?
- Only when there is concern that the lesion was not removed (i.e. palpable mass still present on exam).
- What if the 1 year post op mammo is still confusing (? residual effect from hematoma)
- Do 6 month followup. This is rarely necessary, though.
- What is a common post-biopsy change on mammo?
- Oil cyst
- What is the best way to judge where architectural distortion related to biopsy would be located?
- Not by looking at the skin scar marker, but at the site the lesion used to be on priors.
- If there is for some reason confusion about a lesion seen early in the post op period, post op changes vs. malignancy, how is it evaluated?
-
By following it over time on mammography. It should get smaller. If it doesn't, then be concerned. But this is very very unlikely to occur if the original lesion biopsied came back with benign pathology.
Doing ultrasound within the first 6 months is not likely to be useful for differentiation of post op changes vs. lesion. - If a patient returns a year post biopsy with a lesion in the biopsy bed that looks aggressive, and had benign pathology, what is done next?
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1) Review the pathology results again, to make sure there were no atypical changes that could have now developed into malignancy.
2) If not, do 6 month follow-up to look for further resolution.
Look at Kopans fig 17-15 for good example of rare 1 year residual post-op changes. - What is thought to be a predisposing factor in long term post-surgical scar?
- Post-biopsy hematoma formation
- How often are lucent centered calcifications related to fat necrosis seen after biopsies with benign pathology?
- Uncommonly
- What kind of suturing is used in the breast?
- Subcuticular stitches only, so that the hole will fill in with tissue, and not become distorted, like it does if the two walls are apposed together.
- How common are sutural caldification?
- Rare with uncomplicated benign biopsies. Occur more often in large surgeries or due to delayed healing related to radiation.