Breast Imaging Reporting And Data System - NEET PG Surgery

Carcinoma of the breast is a type of cancer that arises from the cells in the breast tissue. It is one of the most common types of cancer that affects women, and the incidence is increasing globally. Breast Imaging Reporting and Data System (BI-RADS),  a standardized system is used by radiologists to classify breast imaging findings and provide recommendations for follow-up. 

For the NEET PG exam, it is essential to understand the various aspects of carcinoma breast, including its diagnosis, management, and treatment options. Furthermore, understanding the contraindications for BCS in carcinoma breast is crucial for making informed decisions about patient management and treatment. 

Read this blog further to get a quick overview of this important surgery topic for NEET PG/NExT exam preparations.

BREAST

Causes and types of nipple discharge                                              

ETIOLOGY
Bloody Nipple Discharge	Serous Nipple Discharge	Greenish/Blackish/Grumous/Pultaceous Nipple Discharge
Ductal papilloma (Most common cause) Carcinoma Duct Ectasia	Fibrocystic disease (Most common cause) Carcinoma Duct Ectasia	Duct Ectasia

Treatment

• Duct papilloma is a benign condition: Microdochectomy (Excision of involved duct only) 
• Duct Ectasia: Hadfield's Operation (Conical Excision of involved duct)

CARCINOMA BREAST 

• Generally, adenocarcinomas are more common in high socio-economic status and squamous cell carcinomas are more common in low socio-economic status
• Carcinoma Breast is adenocarcinoma, Most common in females belonging to high socioeconomic status 

Risk factors of Carcinoma Breast

• Advancing age 
• Western countries 
• High socio-economic status 
• Alcohol intake
• High fat diet leading to obesity 
• State of hyper-estrogenemia are
  • Early menarche 
  • Late Menopause 
  • Nulliparity 
  • Late first full-term pregnancy 
• Positive family history specially from maternal side 
• Genetic mutation 
  • BRCA-1: Mainly for female Breast-Carcinoma (Ladies First) 
  • BRCA-2: Mainly for male Breast-Carcinoma 
• Personal history of malignancy
  • Ovarian Carcinoma 
  • Endometrial Carcinoma 
• Hormone replacement therapy 
• Therapeutic radiation exposure 

Important Information

• OCP and Smoking are not the significant risk factors for Ca Breast
• Long duration of breast feeding is protective for Ca Breast.

DUCTAL CARCINOMA INSITU (DCIS)

• Though ducts are present in males and females it is common in both 
• It can progress to invasive ductal cancer
• On the basis of nuclear grade and necrosis ductal carcinoma insitu divided into 
  • Low grade 
  • High grade

Low grade	High grade
Cribriform	Solid
Papillary	Comedocarcinoma
Micropapillary	-

Investigations

• Sensitive investigation for diagnosis of microcalcification in DCIS is Mammography
• Sensitive investigation for diagnosis of DCIS is MRI 

Treatment 

• Non-palpable DCIS: Excision by needle localization with specimen mammography
• Low grade DCIS: Lumpectomy
• DCIS with limited disease: Lumpectomy + Radiotherapy

LOBULAR CARCINOMA INSITU          

• Lobules are present only in females so lobular carcinoma insitu is present only in females 
• It arises from terminal duct lobular units 
• It is multicentric and bilateral therefore there is increased risk of bilateral breast cancer

Pathology

• Cytoplasmic mucoid globules
• Hallmark: Indian file pattern

Clinical features 

• Lump with ill-defined margins 

Diagnosis

• Neighborhood calcification 

Treatment 

• Observation 
• Chemoprevention: Tamoxifen, Raloxifene
• Prophylactic B/L mastectomy
• Important Information
  • Most common Histological type: Adenocarcinoma 
  • Most common Histological subtype: Invasive ductal cancer
  • Least common Histological subtype: Papillary 
  • Most malignant Breast Carcinoma: Inflammatory Breast Carcinoma - (worst prognosis) 
  • Least malignant Breast Carcinoma: Tubular (best prognosis) 
  • Most common Site of breast cancer: Upper Outer Quadrant (Max Amount of Breast tissue) 
  • Least common area of Breast Carcinoma: Lower Inner Quadrant 
  • Breast Carcinoma is more common in Left Breast 
• Most common route of spread in breast cancer is Lymphatics 
• Most common site of Metastasis is BONES (Lumbar Vertebra > Femur > Thoracic vertebrae- "LFT")
• Carcinoma Breast is most common Malignancy causing Osteolytic & Osteoblastic secondaries in bones (Osteolytic >Osteoblastic) 
• Most common cause of Death in Carcinoma Breast is Malignant pleural Effusion 

• Most common primary for Leptomeningeal Metastasis is Carcinoma breast 
• Most common primary for Brain Metastasis is Carcinoma Lung > Carcinoma Breast 

Clinical features

• Most common presentation is Lump 
• In advanced cases
  • Architectural distortion 
  • Asymmetry
  • Skin fixity
  • Fixity to Chest Wall 
  • Involvement of nipple: Nipple Retraction / Deviation / Ulceration 

Signs and symptoms of metastasis  

• Backache
• Headache
• Dyspnea
• Jaundice
• Anorexia 
• Weight loss
• PEAU-D-ORANGE: Most Conspicuous Sign of Breast Ca, and it is due to cutaneous edema caused by permeation of lymphatics by tumor cells.
• Skin depression/ Dimpling
• Puckering (Fold/ wrinkling of Skin)
  • Both of these are due to involvement of ligament of cooper 
• Cancer - En - Cuirasse: Presence of multiple nodules and ulceration in the breast due to involvement of breast skin and chest wall.

Triple Assessment in Ca-Breast

• It has positive predictive value (PPV): 99.9%
• Components of Triple Assessment are
  • Clinical: Signs & Symptoms 
  • Imaging: Mammography/ USG
  • Tissue Sampling: Biopsy/ FNAC 

Also Read: Abnormalities in SMALL INTESTINE - NEET PG Surgery

Investigations

• 1^st Investigation done in suspected case of Breast Ca: Mammography 
• Investigation of choice for diagnosis of Carcinoma breast: Biopsy (true cut biopsy / core cut biopsy/ Needle biopsy)

Mammography

• Investigation of choice for Screening of Carcinoma Breast
• Age: 45 years (After that Annual Mammography)
• Bremsstrahlung X-rays are used
• Radiation Exposure: 0.1 Centi Gray/Study
• 1 Mammography = 4 Chest X-rays

 Reading of mammography

• Look for nipple: Normal or Retarded  
• Look for skin
• Focus on opacity-Calcification: Microcalcification (malignancy) & macrocalcification (benign) 
• The space between pectoralis major and breast tissue is retro mammary space 

Differentiation of Benign and Malignant Lesion on Mammography 

Benign	Malignant
Regular, smooth margin Homogenous Low density Thin halo	Opacity	Irregular Margins like Stellate Spiculate Comet tail Heterogeneous High density Wide halo
Macro Calcification > 0.5mm (Popcorn calcification seen in fibroadenoma)	Calcification	Micro (< 0.5 mm)
Absent	Associated changes	Present  Nipple retraction  Skin thickening  Obliteration of RIM space

BIRADS (BREAST IMAGING REPORTING AND DATA SYSTEM)

Category	Description
0	Incomplete Assessment, Additional Imaging is required: risk of malignancy NA
1	Negative, Annual Mammography recommended: 0% risk of malignancy
2	Benign, Annual Mammography recommended: 0% risk of malignancy
3	Probably Benign, Short term follow up:> 0-2% risk of malignancy
4	Suspicious of Malignancy  4A: Low Suspicion- >2-10 % risk of malignancy 4B: Moderate Suspicion- >10-50 % risk of malignancy 4C: High Suspicion- >50-95% risk of malignancy
5	Highly suggestive of Malignancy, Intervention is recommended:> 95% risk of malignancy
6	Biopsy Proven Malignancy

Role of MRI in Breast Cancer

• Investigation of choice for Screening of Breast Carcinoma in High-risk females with family history and BRCA mutation
• Investigation of choice for Implant Related Complications 
• Investigation of choice to differentiate scar from benign lesions

USG 

• 1^st investigation in female < 35 years with lump

Important Information

• Young female < 35 years have dense and glandular breast → which decrease the sensitivity of Mammography  

PET Scan 

• Investigation of choice for diagnosis of distant metastasis 
• Investigation of choice to differentiate scarring, necrosis, fibrosis from recurrence

Bone Scan 

• Investigation of choice for diagnosis of Bone metastasis 

BCS (Breast Conservative Surgery)                                          

• Done for early invasive breast cancer: I, IIA, IIB
  • Lumpectomy: Excision of lump
  • Wide local excision with 1 cm margin
  • Quadrantectomy: Excision of whole quadrant 

• In all patients of Breast Conservative Surgery we give Radiotherapy (if there is contraindication to Radiotherapy then there is contraindication to Breast Conservative Surgery)

Contraindication for Breast conservative Surgery  

Absolute	Relative
Pregnancy	H/o Collagen Vascular DiseaseSclerodermaActive lupus erythematosus
2 or > 2 tumors in different quadrants or diffuse malignant appearing microcalcifications	Multiple tumors in the same quadrant or indeterminate calcification
Persistently positive margins	Large tumor in small Breast
H/o Therapeutic radiation exposure	Large pendulous breast  Centrally located tumor

In early invasive breast cancer if there is contraindication for Breast conservative Surgery, we do simple or total mastectomy 

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