Monday, July 17, 2017

How To Perform A Ductogram / Galactogram

A ductogram is a minimally invasive exam performed by a radiologist for patients with nipple discharge. Also known as a galactogram, a ductogram should be reserved for patients (typically women) with unilateral, spontaneous clear or bloody nipple discharge. That type of discharge is worrisome for malignancy, specifically an intraductal papilloma. 

Indications: 
Women with bilateral nipple discharge should search for central causes first. A common cause would be a pituitary adenoma, which can be assessed with a prolactin level in conjunction with a contrast-enhanced MRI of the brain with sella-specific sequences.

Women with unilateral discharge that is green, yellow, brown or another color most likely have fibrocystic disease, with the discharge representing cystic contents that have been expelled into the ductal system.

Procedure:
Place the patient in a seated position next to the mammography machine. While some texts advocate performing the cannulation supine, the seated position minimizes risk of needle dislodgment when moving the patient.

After cleaning the nipple with an alcohol swap, ask the patient to express the discharge. If they cannot, consider a warm compress or rescheduling the procedure. Once discharge is evident, use a focal light and magnifying glass to attempt to place the needle. A straight or angled 30 gauge needle connected to a 1 cc tuberculin syringe or 3 cc syringe via tubing is utilized. The needle should slide right into the duct if the trajectory is correct. If not, gently re-orient the needle around the clock in 15-30 degree increments. There should not be any resistance or dimpling of the nipple; when the duct is cannulated, the needle will slide right in. This should be relatively painless for the patient.

Once in place, inject 0.3 to 0.5 cc of contrast. Inject S   L   O   W   L   Y, over a minute or more. This is key to preventing extravasation and opacifying the distal ducts.

After injecting, gently affix the needle to skin with Steristrips. Be careful not to affix too forcefully, as this will sidewall the needle. I recommend 1/8th inch strips if available.

Take CC and ML images to document your findings. Once complete, remove the needle and give the patient 2x2 gauze or similar pads to cover the nipple after discharge to capture the contrast that will leak out.

For further details about the procedure and common findings, please see this RadioGraphics article.


References:

       

Friday, July 7, 2017

Infectious Diseases of the Thorax

This post is derived from notes I took during training. Any images are copyright their respective owners.

  • Aspiration causes pneumonitis with lower pH causing worse reaction.
  • The term 'Pneumonia' is reserved for bacterial super infection with positive cultures
  • Tuberculosis (TB)
    • Findings: variable, can see necrotic lymph nodes
    • Rasmussen aneurysm: aneurysm associated with TB cavity, supplied by systemic bronchial arteries. Can cause massive hemoptysis
    • Reactivation can look like tree in bud nodules with +/- cavitation

  • Miliary TB: 1-2 mm nodules throughout lung
  • Mycobacterium avium complex (MAC)
    • Findings:
      • Elderly white females (Lady Windemere syndrome if suppress cough) get upper lobe cavitary
      • Middle aged males smoker/EtOH get Nodular bronchiectatic forms with clustered centrilobular nodules sparing pleura, irregular bronchiectasis with vol loss, predilection for RML and lingula
  • Fungal infections
    • Present with parenchymal necrotizing granulomatous lesions and regional LA. After acute phase, lung lesions may calcify.
    • Histoplasmosis: can cause large calcification in mediastinum (fibrosing mediastinitis)
  • Pulmonary mycetoma
    • Fungal ball, usually immunocompetent patients with fungal elements colonizing a cavity caused by other disease processes
    • Findings: upper lobes. Hemoptysis secondary to fragile bronchial circulation which feeds cavity wall
  • Allergic bronchopulmonary aspergillosis (ABPA)
    • Demographics: associated with asthma, cystic fibrosis
    • Pathology: Type I IgE and Type III hypersensitivity to aspergillus colonizing bronchial lumen causing inflammation, which releases enzymes that break down bronchial walls
    • DI: central bronchiectasis. Excess mucus production → mucoid impaction
  • Invasive aspergillosis
    • Occurs in immunosuppressed patients
    • Can see confluent nodules with surrounding ground glass halo sign (hemorrhage)


  • Pneumocystis carinii pneumonia (PCP)
    • Demographics: associated with HIV/immunosuppressed patients
    • Pathology: Caused by Pneumocystis jiroveci virus
    • Findings: bilateral perihilar reticular/ground-glass opacities, may consolidate after 10 days. Cysts - upper lobe. Can get spontaneous pneumothorax
    • Nuclear Medicine: Gallium positive
    • DDx: Kaposi (Gallium negative)

  • Viral pneumonia
    • DI: Miliary nodules with ground glass opacities


References:

     

Wednesday, July 5, 2017

What Is The Difference Between Epicondyle and Condyle?

This is a quick anatomy stub post on what is the difference between an epicondyle and a condyle?

First, some definitions:

Condyle: a rounded eminence at the end of long bones, often articulating with another bone. The term comes from the Greek for knuckle

Epicondyle: a bony covering that overlies a condyle, most often used in reference to the distal humerus at the level of the elbow

Anatomic relationships of epicondyles to condyles
Source: Wikipedia
At the elbow, the condyle form the trochlea which articulates with the ulna, and the capitulum, which articulates with the radius. As the image above shows, the epicondyles are medial and lateral to the condyles respectively, and do not have articulations.

The lateral epicondyle is often referenced in patients with tennis elbow, or lateral epicondylitis. The syndrome is an overuse injury of the common extensor tendon, first described in lawn tennis players.

The much less common medial epicondylitis, also known as golfer's elbow, is a similar phenomenon affecting the inner aspect of the elbow.

Findings for both entities are best described on MRI. As always, starting with basic anatomy from a text like Netter's Anatomy is very helpful.


Friday, March 17, 2017

Breast Finding Differential Diagnoses

This post is derived from notes I took during training. Any images are copyright their respective owners.


  • Well-circumscribed mass on mammogram (MG)
    • Most common: Cyst, fibroadenoma, lymph node
    • Also: Galactocele, papillary carcinoma
  • High risk lesions
    • Atypical ductal hyperplasia
    • Atypical lobular hyperplasia
    • LCIS
    • Phylloides
    • Radial scar (complex sclerosing lesions)
  • Fluid -containing lesion
    • Invasive cancer
    • Intracystic papillary carcinoma
    • Abscess, hematoma, galactocele, seroma
  • Bilateral breast edema
    • CHF
    • Renal failure
    • Liver disease
  • Unilateral breast edema
    • Subclavian vein occlusion
    • Inflammatory breast cancer
  • Skin thickening
    • Edema (CHF, ARF, liver failure)
    • Acute mastitis
    • Inflammatory carcinoma
    • Locally advanced carcinoma
    • Lymphatic obstruction
    • Radiation therapy


References:

                


     

Wednesday, March 15, 2017

Malignant Breast Disease

This post is derived from notes I took during training. Any images are copyright their respective owners.

  • Most invasive cancers arise from the terminal ductal lobular unit, which contain 100 acini draining into a terminal duct
    • Each breast has 15-18 lobes, each with 20 - 40 lobules
  • Ductal carcinoma in situ (DCIS)
    • Most common subtype
    • Findings: fine, linear, branching ca++ (BIRADS 5)
    • Prognosis: If untreated, 1% per year become invasive
  • Invasive Ductal Carcinoma (IDC)
    • MG: High density, spiculated mass with architectural distortion +/- pleomoprhic or fine linear branching ca++
  • Invasive lobular carcinoma (ILC)
    • Pathology: small monomorphic cells infiltrating stroma single file
    • Difficult to diagnose (21% MG false negative rate) because of infiltrating pattern
    • Findnigs: Spiculated ill-defined mass with architectural distortion; up to ⅓ are bilateral or multicentric (ie, exam contralateral breast well). Ca++ rare.
  • Phyllodes (cystosarcoma phyllodes)
    • Women 40-50s, with large, rapidly growing mass
    • Majority benign, but 25% malignant
    • MG: large, oval or lobular, circumscribed mass
    • US: smoothly marginated mass with heterogeneous echotexture
    • Treatment: wide surgical excision, often recurs
  • Tubular breast carcinoma
    • Pathology: low grade - proliferation of angulated, oval and elongated tubules lined by a single epithelial layer. Spreads through tissue without forming discrete mass - harder to diagnose. Difficult for pathologist to differentiate from radial scar (? spectrum)
    • Findings: small, irregularly shaped, spiculated margins, slow growing
  • Mucinous breast carcinoma
    • Findings: Low density circumscribed mass that can mimic fibroadenoma on US.
    • MR: T2↑
  • Medullary carcinoma
    • Younger women, rare, BRCA1 positive, locally aggressive
  • Papillary breast carcinoma
    • Malignant form of intraductal papilloma
    • Findings: well-circumscribed mass, most likely breast cancer to be associated with a cyst (called intracystic papillary carcinoma)

  • Adenoid cystic breast carcinoma
    • Very rare breast cancer presenting as palpable firm mass. Prognosis good
  • Inflammatory breast carcinoma
    • Presents with breast erythema, edema, firmness
    • Tumor invasion of dermal lymphatics
    • MG: affected breast larger, denser, skin thickening.
  • Lymphoma of the breast: Presents with palpable mass. DLBCL. DI: mass with indistinct margins. Treatment: Chemothearpy / radiation, not surgery
  • Paget disease of nipple:
    • DCIS that infiltrates epidermis of nipple, presents with erythema, ulceration, eczematoid changes
    • Palpable mass worsens prognosis
    • Treatment: breast conservation possible
  • Staging
    • I: Tumor less than 2 cm, negative lymph node (LN)
    • IIA: tumor 2 to 5 cm, negative LN
    • IIB: tumor 2 to 5 cm with ipsilateral LN *OR* >5 cm with neg LN
    • IIIB: any size involving chest wall +/- LN
  • Lymph nodes: based on relationship to pec minor
    • Level 1: lymph nodes lateral to pectoralis minor
    • Level 2: lymph nodes behind the pectoralis minor and interpectoral (Rotter's) nodes
    • Level 3: lymph nodes medial to pectoralis minor
    • Internal mammary chain lymph nodes are not included in this classification.
  • Breast cancer recurrences that occur within 3 yrs (75%) are most likely within original tumor bed; long-term risk 2% for first 10 years, then 1% per year after; mean time to recurrence is 3.5 yrs; most risk: pre-menopausal women with invasion, positive margins, multicentric



References:

                


     

Monday, March 13, 2017

Benign Breast Disease

This post is derived from notes I took during training. Any images are copyright their respective owners.

  • Simple cyst
    • Discard fluid after aspiration unless bloody (in which case, stop and send for cytology)
  • Fibrocystic change - may cause pain in menstruating woman, but essentially normal breast
  • Fibroadenoma - most common palpable mass in young women. Benign neoplasm. Can calcify
    • Giant form: greater than 8 cm
    • Tubular adenoma: variant form, lacks ca++. Circumscribed oval mass.
  • Hamartoma (fibroadenolipoma) - ‘breast within breast’ appearance. BIRADS 2.


  • Sclerosing adenosis - benign proliferative lesion caused by lobular hyperplasia, mimics DCIS
  • Mastitis
    • Nursing mothers or diabetics, presents with breast pain, induration, erythema.
    • Etiology: Most often S. aureus
    • Findings: diffuse skin thickening, edema, adenopathy
    • Treatment: antibiotics
  • Abscess
    • Typically due to S. aureus, can appear like mass
    • Treatment: antibiotics followed by US guided aspiration
  • Intraductal papilloma
    • most common cause of pathologic nipple discharge. 30-50 year old.
    • Benign tumor of lactiferous ducts.
    • Management: ductogram. An adequate ductogram relies on the presence of visible nipple discharge at the time of the procedure. If not seen, cancel and reschedule.
      • Look for filling defect within ducts
    • Treatment: Must excise because papillary carcinoma can appear identical on imaging
  • Periductal / plasma cell mastitis
    • Post menopausal women, due to irritation by intraductal lipids
    • DI: large, rod-like secretory ca++ (BIRADS 2)
  • Duct ectasia
    • A chemical mastitis, not pre-malignant
    • MG: ca++ can be rod-like or central lucencies due to ca++ forming around ducts (secretory ca++)
    • Prognosis: Not pre-malignant, do routine follow-up
  • Diabetic mastopathy
    • Long-term diabetics with firm, painful mass
    • Autoimmune reaction to matrix proteins from chronic hyperglycemia
    • MG: Asymmetry without ca++
    • US: hypoechoic mass
    • Treatment: Needs bx to exclude ca
  • Radial scar (complex sclerosing lesion)
    • MG: linear/radial spiculated appearance with hypolucent lesion
    • Differential diagnosis: carcinoma (dense center), post-surgical scar (not spiculated)
    • Treatment: resection because 30% pre-cancerous


  • Intramammary lymph node
    • Reniform with lucent / hyperechoic hilum, predominantly in upper outer breast
    • Unilateral axillary lymph nodes - exclude breast ca; bilateral enlarged, consider systemic prob
  • Pseudoangiomatous stromal hyperplasia (PASH)
    • Pathology: open slit-like spaces in dense collagenous stroma which are lined by a discontinuous layer of flat, spindle-shaped myofibroblasts with bland nuclei in hormonally active tissue
    • MG: benign mass up to 6cm with no ca++
    • Treatment/Prognosis: benign, but may recur after excisional biopsy
  • Mondor disease: breast superficial thrombophlebitis presenting as tender palpable cord, medial > lateral breast
  • Galactocele - younger pregnant/lactating women, well circumscribed rounded mass with possible fat-fluid level. No need for biopsy
  • Silicone Implants
    • On MR, radial folds extend to periphery, differentiating them from collapsed shell
    • Rupture
      • Intracapsular: MRI: multiple curvilinear low-signal intensity lines within silicone (linguine sign)
      • Extracapsular: US: “snowstorm” appearance of free silicone in breast or axilla (silicone granuloma)
  • Saline implants
    • If ruptured, breast shrinks and saline resorbed.
  • Gynecomastia
    • BIRADS 2 ductal proliferation, can be unilateral or bilateral
    • US: hypoechoic mass behind nipple with finger-like projections
    • MG: Flame-shaped
    • Differential: male breast cancer (lobulated borders, focal mass)
  • Male breast cancer - <1 all="" breast="" ca.="" of="">60s, presents with palpable mass.

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