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Mammo Guide to the Boards

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Mammo Guide to the Boards

  1. 1. Oral Boards Simplified
  2. 2. How to take a case
  3. 3. Systematic approach to every breast case Breast density Finding BIRADS (0 or 2) ---------------------------------------------- Workup Specific findings Final Impression and BIRADS (2 or 4)
  4. 4. Systematic approach to every breast case Breast density Fatty Scattered Hetereogenously dense Extremely dense
  5. 5. Systematic approach to every breast case Breast density Finding Mass Asymmetry / Focal asymmetry Calcifications Architectural distortion
  6. 6. Systematic approach to every breast case Breast density Finding BIRADS (0 or 2) ---------------------------------------------------------
  7. 7. Systematic approach to every breast case Breast density Finding BIRADS (0 or 2) ---------------------------------------------- Workup Additional views / modalities
  8. 8. Systematic approach to every breast case Breast density Finding BIRADS (0 or 2) ---------------------------------------------- Workup Specific findings
  9. 9. Systematic approach to every breast case Breast density Finding BIRADS (0 or 2) ---------------------------------------------- Workup Specific findings Final Impression and BIRADS (2 or 4)
  10. 10. What to say
  11. 11. “The breasts are heterogenously dense” “There is a focal asymmetry in the superior and central right breast” “This is a BIRADS 0, additional evaluation is required”
  12. 12. ------------------------------------------------------------------------------------------------ “I would do a lateral view, spot compression and an ultrasound” “The focal asymmetry persists on the lateral and spot views. Ultrasound demonstrates an irregular hypoechoic mass with posterior acoustic shadowing” “This is a suspicious mass. BIRADS 4, biopsy is recommended.”
  13. 13. Final BIRADS at Boards Avoid BIRADS 3 All cases will be BIRADS 2 Benign or BIRADS 4 Suspicious
  14. 14. 15 Must-Know Cases Workups Aunt Minnies Special 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5
  15. 15. Case 1
  16. 16. Case 1: Solid mass 1. Specific diagnosis is not important 2. How to workup the finding is the key 3. Be consistent – Suspicious descriptors  BIRADS 4 Benign descriptors  BIRADS 2
  17. 17. Mass Workup Lateral Spot Mag Ultrasound
  18. 18. Mass descriptors - Mammo Shape (round, oval, lobular, irregular) Margins (well-circumscribed, microlobulated, partially obscured, indistinct, spiculated) Density (high density, isodense, low density, fat-containing)
  19. 19. Mass descriptors - US Shape (oval, round, irregular) Echogenicity (anechoic, hyperechoic, complex/mixed, hypoechoic, isoechoic) Margins (well-circumscribed, indistinct, angular, microlobulated, spiculated) Orientation (wider than tall, taller than wide) Posterior features (shadowing, increased thru transmission, none)
  20. 20. For the boards: We biopsy all new solid masses
  21. 21. Case 2
  22. 22. You can use the mouse as a magnifying glass during the exam
  23. 23. Case 2: Suspicious calcifications
  24. 24. Calcifications Lateral Mags in CC / 90 (Full or spot)
  25. 25. Case 3
  26. 26. Case 3: Suspicious focal asymmetry
  27. 27. Focal asymmetry / Architectural distortion Lateral Spot Compression +/- Ultrasound Same workup for architectural distortion as for focal asymmetry
  28. 28. Case 4
  29. 29. Rolled views
  30. 30. Case 4: Suspicious asymmetry Boards cases will not be this subtle
  31. 31. Asymmetry Only on CC Rolled CC’s Spot compression Only on MLO Lateral Spot compression
  32. 32. Case 5
  33. 33. Case 5: Suspicious palpable mass Always look for a BB on the skin = palpable
  34. 34. Palpable Workup Put BB on skin Lateral Spot in tangent Ultrasound * Any patient < 30 years old, start with ultrasound *
  35. 35. 15 Must-Know Cases Workups Aunt Minnies Special Mass Calcs Focal asym/arch dist Asymmetry Palpable
  36. 36. Case 6
  37. 37. Case 6: Skin Calcifications BIRADS 2
  38. 38. How to do a skin localization Place alpha- Keep patient in Remove from numeric grid compression. compression. Take over Place BB on skin image with BB in calcifications & directly over the tangent to prove image. calcs & image. calcs are in the skin
  39. 39. Milk of Calcium Skin calcifications Secretory calcifications Hyalinized fibroadenoma Other Benign Calcifications
  40. 40. Case 7
  41. 41. Case 7: Breast Hamartoma BIRADS 2
  42. 42. Fat containing breast masses = BIRADS 2 Lipoma Hamartoma Oil cyst
  43. 43. Case 8
  44. 44. Case 8: Bilateral intracapsular & left extracapsular implant rupture Linguine or keyhole sign = Intracapsular rupture Free silicone = Extracapsular rupture
  45. 45. Intracapsular Extracapsular
  46. 46. Intracapsular Extracapsular Stepladder sign Snowstorm sign
  47. 47. Case 9
  48. 48. Case 9: Fat Necrosis BIRADS 2
  49. 49. Fat Necrosis = oil cysts or coarse dystrophic calcs
  50. 50. Case 10
  51. 51. Case 10: Sternalis muscle BIRADS 2
  52. 52. 15 Must-Know Cases Workups Aunt Minnies Special Mass Benign calcs Calcs Fat containing Focal asym/arch dist Implant rupture Asymmetry Sternalis Palpable Fat necrosis
  53. 53. Case 11
  54. 54. Case 11: Complex cyst BIRADS 4
  55. 55. Simple Complicated Complex BIRADS 2 BIRADS 3 BIRADS 4
  56. 56. Case 12
  57. 57. Case 12: Unilateral axillary adenopathy
  58. 58. Bilateral DDx Unilateral DDx Lymphoma Mets – breast 1⁰ Rheumatoid/Autoimmune Mets – non-breast 1⁰ Granulomatous/Sarcoid Infection Systemic processes
  59. 59. Case 13
  60. 60. Case 13: Multiple round masses BIRADS 2
  61. 61. Multiple round masses = BIRADS 2 Must be: Bilateral At least 3 masses Nonpalpable No new or suspicious findings
  62. 62. Case 14
  63. 63. Case 14: Suspicious left breast mass w/ pec invasion + axillary nodes
  64. 64. Mass NMLE
  65. 65. Main MRI finding will be obvious Look for secondary findings - multifocal disease - contralateral disease - axillary or IM adenopathy - pectoralis or skin involvement
  66. 66. Mass NMLE Shape Distribution (round, oval, lobulated, irregular) (focal, linear, ductal, segmental, regional, diffuse) Margins (smooth, irregular, spiculated) Enhancement Pattern (homo, hetero, stippled, clumped) Enhancement (homo, hetero, rim, internal septations)
  67. 67. Case 15
  68. 68. Case 15: Male IDC
  69. 69. Gynecomastia Male IDC Signs of Male IDC: - Eccentric mass - Skin thickening - Skin retraction
  70. 70. 15 Must-Know Cases Workups Aunt Minnies Special Mass Benign calcs Cysts Calcs Fat containing Axillary adenopathy Focal asym/arch dist Implant rupture Mult round masses Asymmetry Sternalis MRI Palpable Fat necrosis Male breast
  71. 71. Your Name Here American Board of Radiology

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