Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Sonographic Appearance of Lymph Nodes

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The sonographic appearance of a normal lymph node:
    • Is elliptical with a thin, hypoechoic cortex and an isoechoic to hyperechoic fatty hilum (Image)
Normal axillary lymph node
  • Metastatic carcinoma in a lymph node:
    • Would usually have an asymmetric thick cortex or have near-total or total obliteration of the hilum:
    • Resulting in a rounded, hypoechoic mass (Image)
Node with metastatic carcinoma
  • Axillary adenopathy can occur in association with rheumatoid arthritis:
    • But the sonographic findings would usually be a symmetrical, mild thickening of the cortex:
      • Usually with preservation of the hilum
  • Silicone granulomas:
    • Classically create a snowstorm appearance:
      • Which allows a definitive diagnosis by ultrasound alone
Silicone Granulomatous
  • The mass in the image has a rounded anterior border and “dirty” incoherent shadowing that obscures the posterior border of the lesion:
    • Nothing other than silicone can cause this sonographic appearance:
      • But it is difficult to distinguish free silicone that has migrated to the axilla from a node that has been replaced with silicone
  • In different stages of development, silicone extravasation can also mimic complex cysts or fibrotic nodules, depending on the amount of silicone extravasated and the amount of time from extravasation:
    • If a large amount of silicone is released into the tissue, the ultrasound pattern is that of a complex cyst
  • Silicone’s presence in tissues can cause a local inflammatory reaction:
    • Which may cause tissue fibrosis and a fibrotic nodule:
      • This is a late finding seen following extravasating
  • References:
    • Berg WA, Caskey CI, Hamper UM, Anderson ND, Chang BW, Sheth S, et al. Diagnosing breast implant rupture with MR imaging, US, and mammography. Radiographics. 1993;13(6):1323-1336.
    • Juanpere S, Perez E, Huc O, Motos N, Pont J, Pedraza S. Imaging of breast implants‒a pictorial review. Insights Imaging. 2011;2(6):653-670.

Mammographic Images in Diffusely Invasive Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Diffusely invasive carcinoma:
    • Has a mammographic appearance of:
      • Diffuse architectural distortion
    • Usually involving a large area:
      • Often larger than a lobe:
        • With no central tumor mass and no calcifications
    • It sometimes has the appearance of:
      • A “spider’s web” (Image 1)
    • The diffusely infiltrating cancer forms concave contours with the surrounding fat in a manner similar to normal fibroglandular tissue (Images 2 a-b)
Image 1: Mediolateral oblique and craniocaudal projections.
Mastectomy slice radiographs (a) and large format 3D histology image (b) showing concave contours similar to normal breast
  • The imaging findings of diffusely infiltrating breast cancer:
    • Are strikingly different from the imaging findings of breast cancers originating either from the terminal ductal lobular units (TDLUs) or the lactiferous ducts:
      • Suggesting that it may have a different site of origin
  • It has been recently proposed that diffusely infiltrating breast cancers may originate from:
    • Mesenchymal stem cells (progenitors):
      • Through a complex process of both epithelial-mesenchymal transformation and more frequently, mesenchymal-epithelial transformation
    • The clinical presentation is typically a:
      • Recently detected, extensive, firm lesion:
        • Often appearing as an interval cancer following a previous mammogram which was interpreted as normal
    • On clinical breast examination:
      • The cancer does not have a distinct tumor mass or focal skin retraction seen in other cancers:
        • But rather an indistinct “thickening” and eventually a shrinkage of the breast
    • In order to make the diagnosis before the development of a palpable mass and a decrease in size of the breast:
      • The radiologist and breast surgeon must have a high level of suspicion and a thorough knowledge of the underlying pathophysiology
    • The subgross (3D) histopathology images:
      • Show how growth of the mesenchymal tissue distorts the normal, harmonious connective tissue framework by causing nonuniform thickening of the fine sheets of connective tissue (Images 3a -b)
Large format subgross (3D) histology images of a diffusely infiltrating breast cancer
  • The predominance of mesenchyme in the diffusely infiltrating breast malignancy:
    • Allows it to be imaged with greater sensitivity by ultrasound than by mammography
  • The thin sheets or veils of tissue reflect the ultrasound waves, but are relatively easily penetrated by x-rays:
    • The structural / architectural distortion, while difficult to detect mammographically:
      • Is readily detectable on 2-mm thick coronal sections of automated breast ultrasound (Image 3c)
    • The hypoechoic changes can also usually be seen on hand-held ultrasound (Image 4).
3D automated ultrasound images. The 2-mm thick multi-slice series demonstrate the extensive architectural distortion, corresponding to the 3D histology
Hand-held ultrasound of diffusely infiltrating carcinoma
  • The growth pattern and cell type of diffusely invasive breast cancer:
    • Is very similar to that of diffuse gastric carcinoma (linitis plastica):
      • Both of these diseases can be associated with a deleterious mutation in the CDH1 gene:
        • Which is located on chromosome 16q22:
          • It codes for e-cadherin protein (Image 5a, Image 5b)
Large format histology slide of diffusely infiltrating breast cancer similar to growth pattern of linitis plastica
High-power histology of pleomorphic infiltrating breast cancer with cell type similar to linitis plastica.
  • References
    • Hansford S, Kaurah P, Li-Chang H, Woo M, Senz J, Pinheiro H, et al. Hereditary diffuse gastric cancer syndrome: CDH1 mutations and beyond. JAMA Oncol. 2015;1(1):23-32.
    • Tot T. The diffuse type of invasive lobular carcinoma of the breast: morphology and prognosis. Virchows Arch. 2003;443(6):718-724.
    • Tot T. Diffuse invasive breast carcinoma of no special type. Virchows Arch. 2016;468(2):199-206.
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Evaluation of a Breast Mass on Ultrasound

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • You first evaluate the lesion for any of the 10 malignant signs:
    • Shadowing
    • Hypoechoic echotexture
    • Spiculation
    • Angular margins
    • Thick echogenic halo
    • Microlobulation
    • Taller than wide
    • Duct extension
    • Branching pattern
    • Calcifications
  • Finding none, you move on to the second step in the evaluation process:
    • Specifically look for one of the 3 strictly defined benign signs:
      • If any of them are found, the lesion can be considered BIRADS 3
    • The 3 benign findings defined by Stavros are:
      • A purely hyperechoic lesion with no hypoechoic area larger than a normal duct or lobule
      • Elliptical, wider than tall, well-circumscribed and thin echogenic capsule
      • Gently lobulated, wider than tall, well-circumscribed and thin echogenic capsule
    • Combining the elliptical or gently lobulated shapes with the presence of a complete, thin echogenic capsule:
      • Is necessary because many circumscribed carcinomas and most ductal carcinoma in situ are encompassed in a thin, echogenic capsule:
        • However, the shape of circumscribed invasive carcinoma or pure ductal carcinoma in situ is rarely elliptical or gently lobulated
  • BIRADS 3:
    • A 6-month follow-up ultrasound would be appropriate unless the anxiety of the patient makes core biopsy a better option
  • References
    • Madjar H, Mendelson EB. The Practice of Breast Ultrasound. 2nd ed. Thieme; 2008;141-144.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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Ultrasound Appearance of Axillary Lymph Nodes

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Abnormal lymph node with eccentric cortical thickening
  • This axilla ultrasound shows a case of severe eccentric compression and displacement of the hilum to the edge of the node:
    • Favoring metastatic disease
  • Typical lymph node ultrasound appearances include:
    • Uniformly mildly thickened cortex
      • Typical of inflamed or reactive lymph node
    • Eccentric cortical thickening:
      • Favors metastatic disease (Image)
    • Convex indentations of the hilum:
      • Favors metastatic disease
    • Severe compression of the hilum to slit-like configuration:
      • Can occur in metastatic or severely inflamed lymph node
    • Severe eccentric compression and displacement of the hilum to the edge of the node:
      • Favoring metastatic disease
    • Complete obliteration of the hilum and rounding of the node:
      • Favoring metastatic disease:
        • Can also occur in severe necrotizing lymphadenitis
    • Perinodal invasion by metastasis:
      • The outer thin echogenic capsule cannot be identified:
        • Angular margins
Severe eccentric compression and displacement of the hilum to the edge of the node.
  • References
    • Stavros AT. Evaluation of regional lymph nodes in breast cancer patients. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:858-859.
    • AIUM curriculum for fundamentals of ultrasound physics and instrumentation. JUltrasound Med 2019;38(8):1933-1935. https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15088. Accessed July 16, 2020.
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Types of Calcifications 1

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Ductal calcifications:
    • Have a wide variety of presentations depending upon the underlying process that created them
  • When coarse rod-like ductal calcifications are diffuse, bilateral, and not confined to a single lobe:
    • They can be confidently assumed to result from plasma cell mastitis, and do not require further evaluation or biopsy (Image)
  • The process is called secretory disease:
    • Because there is a stagnant, viscous fluid that eventually petrifies and results in the smooth contoured calcifications
    • Some of them are branching and look like malignant casting type calcifications:
      • But the key distinguishing feature is the diffuse, multilobe, bilateral nature of the process:
        • Calcifications become much more worrisome when they are confined to a single lobe
  • The most frequent malignant, ductal “casting type” calcifications are:
    • Fragmented, linear, and branching, and they are the most reliable mammographic sign of malignancy (Image)
Casting type calcification.
  • The presence of fragmented and / or dotted casting type calcifications on the mammogram restricted to one lobe:
    • Is a pathognomonic sign of a diffuse, grade 3 breast cancer subtype that originates in the major ducts and usually has a solid or micropapillary pattern:
      • Traditionally, this subtype has been called “comedo carcinoma”
    • The cancer cells either produce a viscous, proteinaceous fluid, which gradually concentrates and eventually calcifies, or they undergo necrosis (apoptosis) followed by calcification:
      • In both instances, the intraluminal pressure increases, distending the ducts considerably
  • Dotted casting type calcifications:
    • Have been referred to as “snakeskin-like calcifications” and they accumulate in the fluid produced by either micropapillary or solid cancer cell growth patterns (Image)
    • The tips of the micropapillary growths may become detached and eventually calcify, contributing to the intraluminal calcifications (Image)
Snakeskin type calcifications.
The micropapillary growths break off and calcify in the lumen, resulting in the individual dots of calcification (the dark, almost black stained structures).
  • Occasionally, malignant ductal calcifications present in a manner that can be easily mistaken for a benign process:
    • It occurs when fluid production, rather than necrosis, dominates the picture
    • The intraductal carcinoma can be grades 1, 2, or 3 and a micropapillary and/or cribriform architecture is present

Dense Breast Screening

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Debate on adjunct screening in women with dense breasts:
    • Has resulted from legislation mandating that women be informed if their mammograms show dense breast tissue, including informing them that other screening modalities are available
  • In addition to MRI and molecular imaging:
    • Both tomosynthesis and breast ultrasound are additional techniques for enhanced screening in patients with dense breasts
  • Multiple studies show significant benefits from the addition of tomosynthesis to conventional digital mammography alone in screening programs:
    • Ciatto et al:
      • Found an increase in detection rate of invasive breast cancer:
        • From 5.3/1000 to 8.1/1000
      • While also decreasing the recall rate by 17%
    • Skaane et al:
      • Found a 40% increase in the detection of invasive cancers with a 15% reduction in false negatives
    • Rose et al.3 and Haas et al:
      • Showed statistically significant relative reductions in recall rates of 37% and 30%, respectively
    • A recent retrospective review of 454,850 examinations in 13 screening centers in the United States:
      • Demonstrated a 41% increase in invasive cancer detection, a 15% reduction in call backs, and a 49% increase in the positive predictive value for recall
  • Implementation of tomosynthesis:
    • Did not lead to a significant reduction in biopsy rates as compared to digital mammography screening
  • As yet, there are no data that show a reduction in mortality with enhanced screening in dense breasts
  • A prospective multicenter study compared tomosynthesis with bilateral physician hand-held ultrasound screening in 3,231 asymptomatic patients with mammography-negative dense breasts:
    • In all, 24 additional cancers were detected, 23 of which were invasive
    • Tomosynthesis detected 13 cancers, and ultrasound detected 23
    • These data suggest that even though tomosysthesis significantly increases the number of cancers found in dense breasts, in the hands of a skilled breast radiologist, ultrasound may be even better
  • References
    • Ciatto S, Houssami N, Bernardi D, Caumo F, Pellegrino M, Brunelli S, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583-589.
    • Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47-56.
    • Haas BM, Kalra V, Geisel J, Raghu M, Durand M, Philpotts LE. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology. 2013;269(3):694-700.
    • Rose SL, Tidwell AL, Bujnoch LJ, Kushwaha AC, Nordmann AS, Sexton R Jr. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR Am J Roentgenol. 2013;200(6):1401-1408.
    • Friedewald SM, Rafferty EA, Rose SL, Durand MA, Plecha DM, Greenberg JS, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499-2507.
    • Tagliafico AS, Calabrese M, Mariscotti G, Durando M, Tosto S, Monetti F, et al. Adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts: interim report of a prospective comparative trial. J Clin Oncol. 2016;34(16):1882-1888.
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Tissue Harmonic Imaging in Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Tissue harmonic imaging:
    • Creates images derived solely from higher frequencies
  • The ultrasound beam:
    • Is transmitted centered at 1 frequency, e.g., 6 MHz
    • Received centered at a multiple of the transmitted frequency, e.g., 12 MHz
  • Different techniques can be used to process the received signals so that only the returning high-frequency harmonic signal is used to produce the image:
    • Whereas echoes from the fundamental / lower frequencies are rejected
  • THI increases signal-to-noise ratio:
    • Resulting in better tissue contrast
  • THI reduces reverberation, clutter, and speckle artifacts:
    • Improving contrast resolution
    • It accentuates real echoes in addition to suppressing artifactual echoes
    • The suppression of speckle artifact by coded harmonics makes solid nodules more hypoechoic and conspicuous than they are with fundamental imaging (Images a and b)
A. Infiltrating ductal carcinoma with fundamental imaging.
B. The same infiltrating ductal carcinoma as 2a with coded harmonic imaging.
  • It makes the thin, echogenic capsule that surrounds most benign lesions appear to be thinner, more echogenic and more complete than with fundamental imaging
  • THI cannot be combined with simultaneous color Doppler imaging because the resulting frame rate would be unacceptable:
    • When Doppler is required, the image that is interlaced with Doppler must be constructed at fundamental rather than harmonic frequencies
  • THI is of limited value in differentiating benign from malignant lesions.
  • Another method of reducing artifactual echoes, improving contrast, and making the thin, echogenic capsule more conspicuous is real time spatial compounding of images:
    • In conventional imaging, each frame is created by a single sweep of the beam at a 90 degree angle to the long axis of the transducer
    • In compound imaging, there are multiple sweeps of the beam from different angles, creating a spatially and temporally compounded image from multiple angles over time
    • Among other things, the lateral borders of lesions can be seen better with compound imagin
  • References
    • Mesurolle B, Helou T, El-Khoury M, Edwardes M, Sutton EJ, Kao E. Tissue harmonic imaging, frequency compound imaging, and conventional imaging use and benefit in breast sonography. J Ultrasound Med. 2007;26(8):1041-1051.
    • Cha JH, Moon WK, Cho N, Kim SM, Park SH, Han BK, et al. Characterization of benign and malignant solid breast masses: comparison of conventional US and tissue harmonic imaging. Radiology. 2007;242(1):63-69.
    • Stavros AT. Breast ultrasound equipment requirements. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:16-41.
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Calcifications Identified on Mammogram

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Straight lateral magnification view. “Milk of Calcium” Calcifications.
  • The images clearly show benign “milk of calcium” type calcifications:
    • Which do not warrant biopsy or interval follow-up regardless of how many are present
  • In fibrocystic change:
    • An apocrine metaplastic cell layer lines the cystically dilated acini:
      • Which are filled with fluid and contain numerous psammoma body-like calcifications
    • The appearance of the calcifications on the mammogram:
      • Will depend on the shape of the summation of the calcified particles in the cystically dilated acini
    • When the shape happens to be “teacup-like” (i.e., crescent-shaped on the mediolateral projection and low density, circular/oval on the craniocaudad projection):
      • The diagnosis of fibrocystic change can be made with confidence
Images a and b show a galactogram performed on a woman with greenish cloudy nipple discharge. The ducts are distended by fluid (duct ectasia) and the acini of a single terminal ductal lobular unit are cystically distended. The contrast media shows a teacup-like appearance, seen from the side (Image a) and seen from above (Image b).
Images a-c show 3D histology images of the aggregate of the psammoma body-like calcification corresponding to the mammogram. The impression is that the teacup-like calcification is a single calcification, but Image c shows that it is the summation / aggregate of many tiny psammoma body-like calcifications.
  • Benign and malignant type calcifications:
    • Can increase or decrease in number and density, or even remain unchanged for years:
      • So changes in the appearance on follow-up examination do not constitute a reliable way to exclude malignancy
  • In general, calcifications should be determined to be benign by:
    • Their appearance and distribution or they should have a large bore core needle biopsy
  • Six month follow-up mammography is not a good way to determine if calcifications are benign
  • In fibrocystic changes:
    • The most frequently occurring calcifications are the psammoma body-like calcifications that float in fluid in microcysts:
      • They should cause little diagnostic confusion
    • When the calcifications are imaged in a craniocaudad projection:
      • The calcifications are spread out over the entire microcyst yielding a smudgy image of the calcifications
    • In a straight lateral image:
      • The microcysts are imaged in a vertically oriented direction, and gravity causes the calcium rich fluid to settle to the bottom of the cysts yielding the teacup-like appearance of the calcifications
        • When these images are present, the diagnosis of benign milk of calcium is secure.
  • Low-grade in situ carcinoma:
    • Would cause powdery calcifications
  • Intermediate grade in situ carcinoma:
    • Would cause crushed stone-type calcifications on the mammogram
  • References
    • Monda LA. Differentiation of breast calcifications. Radiol Technol. 2001;72(6):532-544.
    • Baldwin P. Breast calcification imaging. Radiol Technol. 2013;84(4):383M-404M.

How to Evaluate a Breast Nodule on Ultrasound of the Breast?

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • You first evaluate the lesion for:
    • Any of the 10 malignant signs:
      • Shadowing
      • Hypoechoic echotexture
      • Spiculation
      • Angular margins
      • Thick echogenic halo
      • Microlobulation
      • Taller than wide
      • Duct extension
      • Branching pattern
    • Calcifications
  • Finding none:
    • You move on to the second step in the evaluation process:
      • Specifically look for one of the 3 strictly defined benign signs:
        • If any of them are found:
          • The lesion can be considered BIRADS 3:
            • A 6-month follow-up ultrasound would be appropriate unless the anxiety of the patient makes core biopsy a better option
    • The 3 benign findings defined by Stavros are:
      • A purely hyperechoic lesion:
        • With no hypoechoic area larger than a normal duct or lobule
      • Elliptical, wider than tall, well-circumscribed and thin echogenic capsule
      • Gently lobulated, wider than tall, well-circumscribed and thin echogenic capsule
      • Combining the elliptical or gently lobulated shapes:
        • With the presence of a complete, thin echogenic capsule:
          • Is necessary because many circumscribed carcinomas and most ductal carcinoma in situ are encompassed in a thin, echogenic capsule:
            • However, the shape of circumscribed invasive carcinoma or pure ductal carcinoma in situ:
              • Is rarely elliptical or gently lobulated:
  • References:
    • Madjar H, Mendelson EB. The Practice of Breast Ultrasound. 2nd ed. Thieme; 2008;141-144.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #Surgeon #Doctor #MountSinaiMedicalCenter #MSMC #Miami #Mexico

Breast Calcifications on Mammogram

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Screening mammography:
    • Is important in identifying breast cancer at an early stage
  • Calcifications have many forms:
    • The characteristics of the calcifications help identify whether they are associated with a benign or malignant process:
      • Smooth, round, large and layering calcium are generally associated with benign findings
      • Fine, irregular, punctate, linear and branching, and pleomorphic calcifications are characteristics generally associated with malignant findings
  • Magnification views of the calcifications:
    • Are essential in helping to evaluate the calcifications to determine the appearance and to be able to accurately interpret the findings
  • References
    • Brant W, Helms C. Fundamentals of Diagnostic Radiology, 5th Edition. Lippincott, Williams & Wilkins; 2019
    • Baldwin P. Breast calcification imaging. Radiol Technol. 2013;84(4):383M-404M.
#Arrangoiz #Doctor #Surgeon #CancerSurgeon #SurgicalOncologist #BreastSurgeon #BreastCancer #MountSinaiMedicalCenter #MSMC #Miami Mexico