Mammography Casebook E-Book

Uwe Fischer

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 246

Veröffentlichungsjahr: 2005

Beschreibung

Mammography Casebook presents 100 complex breast imaging cases in a question and answer format, ideal for self-testing and review. Each case is presented in a concise way, with two pages devoted to review of the patient's imaging studies and the following two pages to analysis and categorization of findings. The clinician will benefit from thorough review of the relevant standard views as well as from discussion of the usefulness of techniques, such as spot compression and coned views. The author classifies image findings using BI-RADS criteria and provides differential diagnoses and commentary on eventual histological results that will help the radiologist manage all clinical situations. Additional image sequences illuminate concepts in advanced procedures, such as MR-guided core biopsy or specimen radiography. Features: Succinct descriptions and consistent presentation that enhances ease of use Key points highlighted in easy-to-reference blue boxes More than 1,700 high-quality images From initial screening to histology to treatment options, this casebook will help the radiologist develop the knowledge and skills needed to examine for and accurately diagnose both common and rare breast tumors.

Leseprobe

The bookmark included with this book lists the most important parameter in breast diagnosis(desctiption of lesions, xray, MR mammography and sonography criteria, BI-RADS categorization, MRI score etc.). Please note that this data is also repeated on page 1.

Library of Congress Cataloging-in-Publication Data

Fischer, Uwe, 1949-

[Trainer mammadiagnostik. English]

Mammography casebook / Uwe Fischer, Friedemann Baum.

p.; cm.

Authorized translation of: Trainer mammadiagnostik, 2005. ISBN 3-13-140351-9 (alk. paper) -ISBN 1-58890-350-8 (alk. paper)

1.Breast-Radiography-Case studies.

2.Breast-Imaging-Case studies.

3.Breast-Diseases-Diagnosis-Case studies.

4.Breast-Cancer-Diagnosis-Case studies.

[DNLM: 1. Breast Neoplasms-diagnosis-Case Reports. 2. Diagnosis, Differential-Case Reports. 3. Mammography-methods-Case Reports. WP 870 F536t 2006a] I. Baum, Friedemann. II. Title.

RG493.5.R33F5713 2006618.1′907572-dc22

2005028398

This book is an authorized translation of the German edition published and copyrighted 2005 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Trainer Mammadiagnostik. Fallsammlung - 100 kommentierte Kasuistiken.

Illustrator: Barbara Gay, Stuttgart

© 2006 Georg Thieme VerlagRüdigerstraße 1470469 StuttgartGermany

http://www.thieme.deThieme New York 333 Seventh AvenueNew York, NY 10001 USAhttp://www.thieme.com

Cover photo background: Photo Alto, Paris Typesetting by Ziegler und Müller, Kirchentellinsfurt Printed in Germany by Karl Grammlich GmbH, Pliezhausen

ISBN 3-13-140351-9 (GTV)

ISBN 1-58890-350-8 (TNY)                                                                                                                1 2 3 4 5

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Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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Preface

Breast cancer is one of the most common malignant tumors among women in many parts of the world today. In addition, it is also one of the leading causes of cancer death. In contrast to the situation for many other malignant tumors, modern imaging modalities allow the early diagnosis of breast cancers, most often in asymptomatic women. Generally, the earlier a cancerous lesion is detected, the better the prognosis. The early detection of a suspicious lesion is not only, however, the conclusion of the diagnostic work-up. In many situations it is important to further clarify the nature of the lesion by performing additional imaging and/or percutaneous biopsy. Furthermore, in the case of malignancy, it is necessary to rule out or verify the presence of additional cancerous manifestations. A complete diagnostic work-up is the prerequisite for achieving the best possible individual outcome on the one hand, and for reducing the number of unnecessary open biopsies on the other.

Terminology and strategic proceedings in breast diagnostics have changed to a greater extent than in other diagnostic imaging areas over the last years. The limitations of certain imaging techniques can often be compensated for by the performance of additional procedures. To attain the maximum of relevant diagnostic information, it is important to be aware and informed about the strengths and weaknesses of the physical examination, x-ray mammography, ultrasonography, and MR mammography. Numerous studies have evaluated the efficiency and limitations of each of these components of breast diagnostics. X-ray mammography remains the primary technique in the early diagnosis of breast cancer. It allows the detection of breast carcinoma in its earliest stages, when prognosis is best, through the visualization of minimal tumor induced changes. In addition, when mammography is performed in asymptomatic women, it allows the detection of occult carcinomas. For these reasons, mammography continues to be indispensable. Screening programs in European countries and the USA, however, have shown the performance of x-ray mammography alone to have major limitations. Its sensitivity in women with dense breast tissue, a relevant number, is significantly reduced.

The complementary performance of breast ultrasonography in women with dense breast tissue can often compensate for the limitations of mammography in these cases. Especially in the hands of an experienced examiner, ultrasonography allows the visualization of mammographically inaccessible areas of the breast due to dense tissue. Furthermore, ultrasound has no known health risks and is the standard imaging method used for examining younger women, and is also obligatory in the work-up of a patient with an indeterminate palpable lesion. In contrast to mammography and ultrasound, MR mammography not only provides information on the morphology of breast lesions, but also investigates vascularization as a metabolic-dependant characteristic. As with x-ray mammography, however, MR mammography is a widely standardized procedure which allows the acquisition of comparable image sets over time. Specialized image post-processing accentuates suspicious findings for the viewer.

In addition to the importance of the appropriate application of the various examination modalities in the diagnostic work-up of breast lesions, examination techniques, image analysis, assessment, and the ensuing therapeutic consequences should be in agreement with national and international standards. The image quality of mammography, for example, has been categorized according to the PGMI-criteria of the British national health service breast screening program (NHSBSP). The basis for terminology and lesion assessment used in mammographic image analysis was presented in the BI-RADS ™ lexicon by the American College of Radiology (ACR), and has since been firmly established in the German speaking countries of Europe. An analogous US-BIRADS lexicon serving as the basis for breast ultrasound image analysis was presented by the breast sonography work group of the “Deutsche Gesellschaft für Ultraschall in der Medizin” (DEGUM, German Society for Medical Ultrasound Applications). For the interpretation and assessment of MR mammograms there is the so-called “Goettinger Score” and its derivative, the MRM-BIRADS-categorization. New aspects con-sidered in MR mammographic interpretation pertain to the degree of contrast enhancement seen in the normal parenchyma (MRM-Density-Type 1 - 4), and the extent of motion artifacts in the subtraction image (MRM-Artifact-Score 1-4). Both parameters represent a measure of the diagnostic sensitivity of the examination. Pictorial representations of the relevant classifications are included in this book in tabular form as a removable appendix.

The detection of a suspicious lesion in the breast usually requires the performance of further diagnostic procedures. In the presented clinical cases we show examples where the interventional diagnostic work-up usually conforms with the well-established guidelines and standards. In some cases, however, deviations from the standard course of action are shown to illustrate alternative procedures when the individual case demands it, or to allow for patients' wishes.

This book offers the reader the opportunity to make deliberations and decisions on 100 example cases in breast diagnostics. Each case includes information about patient complaints, personal history, risk profile, and clinical findings. The reader is able to view the relevant image material at his/her leisure and come to his/her own conclusions. He/She is able to practice analyzing and describing the images, as well as making an assessment after taking the possible differential diagnoses into account. On the pages following each case, an explicit commentary explains which diagnostic procedures were performed and the actual, often histologically verified diagnosis is revealed. In this way the interested reader is able to achieve a maximal training effect.

Because most of the presented images in this book are digital, the printed images are of high quality without loss of image information. This provides the reader with image material that allows a realistic evaluation. There are only a few exceptions when patients presented in our clinic with recently performed conventional mammograms. When not otherwise indicated as examinations not performed by the authors, all breast sonograms were performed with a Logic 5 (General Electric MS). The digital mammograms were performed using the full field digital mammography system Se-nograph 2000D (General Electric MS). MR mammography and MR interventions were performed using the Echospeed system (General Electric MS; MRI Device). Stereotactic interventions were performed on the Lorad-Premium intervention table (Medicor). The Vacora System (Bard) was used for stereotactic vacuum biopsies.

Our special thanks for helping make this book possible go to the team at the Diagnostisches Brustzentrum Goettingen: Anja El Hajab, Doris Hermes, Gudrun Meyer, Jutta Rüschoff, and Christina Vujecic.

Uwe Fischer

Friedemann Baum

Contents

Numbers in bold type refer to case numbers, normal type refers to page numbers.

Adenoma

Adenoma tubular

Adenomyoepithelioma

Adenosis

- focal

- sclerosing

- tumorous

Angiosarcoma

Arteriosclerosis

Artifact cream

- hair

- paint

Atheroma

Burn trauma

Carcinoma

- ductal minimally invasive

- invasive ductal

- invasive lobular

- lobular in situ

- medullary

- multicentric

- papillary

- tubular

Carcinosarcoma

Cysts

- complicated

- oil

DCIS

- multifocal

Fat necrosis

Fibroadenoma

- giant

- myxoid

- pericanalicular

Galactography

Gel bleeding

Gout

Gynecomastia

Hamartoma

Hematoma

Insect bite

Lipoma

Local relapse

- invasive ductal

- invasive lobular

Lymphadenitis

Mastitis focal

- postoperative

Mastopathy fibrocystic

Mucinous carcinoma

Paget disease

Papilloma intraductal

Papillomatosis intraductal

Prosthesis rupture

Radial scars

Abbreviations

ACR

American College of Radiology

ADH

atypical ductal hyperplasia

BCT

breast conservation therapy

BIRADS

Breast Imaging Reporting and Data System (ACR)

CI-5

cytology classification of malignancy 1-5

CC

craniocaudal (view)

LCIS

lobular carcinoma in situ

CM

contrast medium

DC

ductal carcinoma

DCIS

ductal carcinoma in situ

EIC

extensive intraductal component

FNAP

Fine needle aspiration punction

G1-4

tumor cell grade 1-4

C

good (PGMI)

I

intermediate (PGMI)

IDC

invasive ductal carcinoma

ILC

invasive lobular carcinoma

IR

inversion recovery

LH

lobular hyperplasia

LM

lateromedial (view)

M

moderately good (PGMI)

MO-1

hematomatous metastases

MIP

maximum intensity projection

ML

mediolateral (view)

MLO

mediolateral oblique (view)

MR

magnetic resonance

MRI

magnetic resonance imaging

MRM

magnetic resonance mammography

OPTIPACK concept

digital dose-reduced one-view-mammography plus contrast-enhanced MR imaging of the breast

P

perfect (PGMI)

PGMI

UK system of mammogram classification: P (Perfect), G (Good), M (Moderate), I (Inadequate)

pN

lymph node status classification (histologically verified)

PT

tumor size classification (histologically verified)

pTis

histologically verified intraductal carcinoma

RO-2

residual tumor classification 0-2

R1

microscopic residual tumor (incomplete tumor resection)

ROI

region of interest

SN

Sentinel node activity at axillary dissection

TC

tubular carcinoma

US

ultrasound/ultrasonography

VB

vacuum biopsy

VNPI

Van Nuys Prognostic Index

TNM Classification of Breast Carcinomas

Breast cancers are classified based on histopathology of the primary tumor (T stage), regional nodal status as confirmed by histopathology (N stage), and distant metastases (M stage).

In case multiple simultaneous carcinomas exist in one breast, T stage is determined by the carcinoma with the highest T stage. If carcinomas exist in both breasts, each breast is staged separately. The size of invasive carcinomas is determined based on the size of the invasive component only.

TX

Primary tumor cannot be assessed (for example: no histology available)

TO

No primary tumor detected (p is added if tissue was his-topathologically assessed)

pTis

ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS) or Paget's disease of the nipple without DCIS, LSIS or invasive tumor in the breast. (If invasive tumor, DCIS, or LCIS is detected in the breast, the disease is staged based on these entities.)

pTl

tumor < 20 mm

Tlmic

microinvasion: The basal membrane has been exceeded in one or more foci. No focus exceeds 1 mm in size

pTla

<5mm

pTlb

5mm < tumor < 10 mm

pTlc

10mm < tumor < 20 mm

pT2

20mm < tumor < 50 mm

pT3

tumor>50 mm

pT4

tumor of any size that invades skin or chest wall*

pT4a

invasion of chest wall*

pT4b

skin edema, ulceration, or cutaneous satellite nodule**

pT4c

T4a + b

pT4d

inflammatory carcinoma (inflammatory carcinoma without proof of in-breast tumor and with negative skin biopsy is classified as pTX)

N

concerns histopathologic staging of the regional lymph nodes (lymph node groups, see Appendix 2). So far this included at least sampling of>six lymph nodes of level 1.

NX

regional lymph nodes cannot be assessed (for example: had been removed before or were not sampled)

pN0

no regional lymph-node metastases

pNl

mobile metastatic lymph node(s) of the ipsilateral axilla

pNla

only micrometastases (<2 mm)

pNlb

at least one metastasis>2 mm

i

one ore more metastases in 1 -3 lymph nodes all < 20 mm

ii

≥ 4 lymph nodes with all foci < 20 mm

iii

metastatic involvement exceeds lymph-node capsule, but all foci < 20 mm

iv

metastatic focus or foci>20 mm

pN2

metastatic lymph nodes located in the ipsilateral axilla and fixed to one another or to surrounding structures

pN3

metastatic involvement of internal mammary lymph nodes

Ml

involvement of supraclavicular, cervical, or contralateral lymph nodes distant metastases

References

Heywang-Köbrunner et al. Diagnostic Breast Imaging. Stuttgart, New York: Thieme; 2001.

* The chest wall includes ribs and intercostal muscles, but not the pectoral muscles.

** Skin retraction alone does not lead to a T4 classification.

Lesions (all modalities)

Shape

Border

Mammography

PGMI image classification

P

perfect

G

good

M

moderately good

I

inadequate (imaging should be repeated)

Parenchymal Density Type

ACR1

predominantly lipomatous tissue

ACR2

fibroglandular tissue

ACR3

inhomogeneously dense tissue

ACR4

extremely dense tissue

Lesion density

Microcalcifications/Distribution

Architectural distortion

BI-RADS Categorizations (all modalities)

BI-RADS 1 no findings

(risk of cancer 0%)

BI-RADS 2 benign findings

(risk of cancer 0%)

BI-RADS 3 probably benign findings

(risk of cancer < 2%)

BI-RADS 4 probably malignant findings

(risk of cancer~30%)

BI-RADS 5 highly suspect findings

(risk of cancer~95%)

BI-RADS 6 histologically verified cancer

Ultrasound of the Breast

Lesions

Echo pattern comparison

Surroundings

anechoic - hypoechoic - isoechoic - hyperechoic

Acoustic transmission

diminished - indeterminate - increased - mixed

Compressibility

good - low - absent

Internal structure

homogeneous - inhomogeneous

Lesion axis

horizontal - vertical - indeterminate

Surrounding structures

intact - displaced - disrupted

Mobility

good - low - immobile

Calcifications

macrocalcifications - microcalcifications

Perfusion

increased - slightly increased - not increased

MR Mammography

MRI Artifact Category

MRI Artifact Category 1

no motion/subtraction artifacts

MRI Artifact Category 2

minor motion/subtraction artifacts

MRI Artifact Category 3

distinct motion/subtraction artifacts

MRI Artifact Category 4

unacceptable motion/subtraction artifacts

Density Type

MRI Density Type 1

no enhancement of the parenchyma

MRI Density Type 2

patchy enhancement of the parenchyma

MRI Density Type 3

widespread patchy enhancement of the parenchyma

MRI Density Type 4

strong enhancement of the parenchyma

MRI scoring system (Göttingen score)

MRI BI-RADS

0 Points

MRI BI-RADS 1

1-2 Points

MRI BI-RADS 2

3 Points

MRI BI-RADS 3

4-5 Points

MRI BI-RADS 4

6-8 Points

MRI BI-RADS 5

Case 1

Indication: Palpable mass in the left breast, upper outer quadrant, discovered 8 weeks prior to examination.

History: Unremarkable.

Risk profile: No increased risk.

Age: 78 years.

Fig. 1.1 Sonography of the left breast. Panoramic view.

Clinical Findings

Dense, mobile mass of diameter 2 cm in the upper outer quadrant of the left breast. Ptosis of the left breast.

Fig. 1.2a,b Digital mammography, MLO view.

Fig. 1.3 Magnification view of the upper outer quadrant of the left breast, CC view.

Fig. 1.4a—c Contrast-enhanced MRI of the breasts.

Fig. 1.5 Contrast-enhanced MR mammography. Maximum intensity projection.

Fig. 1.6a, b Signal-to-time curve.

Please characterize the ultrasound, mammography and MRI findings.

What is your preliminary diagnosis?

What are your next steps?

This case describes the imaging findings in an older symptomatic woman. Clinical findings strongly suggest the diagnosis of invasive breast cancer in the left breast.

Ultrasound

Corresponding to the palpable mass, ultrasound demonstrates a suspect lobulated lesion with predominantly ill-defined borders and a hyperechoic marginal area. This lesion disturbs ligaments and leads to retraction of the surrounding parenchyma. Close to this lesion, ultrasound shows a pathologically enlarged lymph node. Assessment: US BI-RADS left 5.

Mammography

Mammography shows symmetric lipomatous breast tissue of ACR type 1. There are no pathological findings in the right breast. In the upper outer quadrant of the left breast, there is a lobulated mass (2 cm diameter) with ill-defined borders. A bridge of dense tissue is seen between the lesion and a prepectoral lymph node about 2 cm away. There is a further partially visible, enlarged lymph node in the left upper axilla. No microcalcifications are detectable (BI-RADS right 1/left 5). PGMI: G (the inframammary fold was not clearly discernible).

MR Mammography

MRI shows a mass 2 cm in diameter in the upper outer quadrant of the left breast. There is a second small nodule nearby. After administration of contrast the tumor shows marked initial enhancement, followed by washout. There is ductal enhancement extending from the primary tumor to the lateral parts of the left breast (Fig. 1.7; arrow). MIP demonstrates pathological enhancement of the prepectoral lymph node as well as the bridge like connection between tumor and lymph node.

Fig. 1.7 Contrast-enhanced MR mammography. Magnification view of the left breast, upper outer quadrant.

Caution: Other linear structures with increased vascularization correlate with contrast-enhanced veins (broken arrow).

MRI Artifact Category: 2

MRI Density Type: 1

MRM score

Finding

Points

Shape

lobulated

0

Border

ill-defined

1

CM Distribution

inhomogeneous

1

Initial Signal Intensity Increase

strong

2

Post-initial Signal Intensity Character

wash-out

2

MRI score (points)

6

MRI BI-RADS

5

Preliminary Diagnosis

Invasive breast cancer of the left breast with lymph node metastases, stage T2. No differential diagnosis.

BIRADS categorization

Clinical Findings

right 1

left 5

Ultra sound

right 1

left 5

Mammography

right 1

left 5

MR Mammography

right 1

left 5

BI-RADS Total

right 1

left 5

Next step according guidelines

US-guided core biopsy of the palpable mass in the left breast

Performed step (departing from guidelines)

Due to the age of the patient and the clear findings in all imaging modalities, and in response to the patient's own request, a US-guided core biopsy for preoperative histopathological diagonsis was not performed. The tumor was examined histopathologically following mastectomy.

Histology

Medullary carcinoma of the left breast.

MC pT2 (2.5 cm), pN1 a (2/18), G2.

Treatment

Mastectomy (subsequent radiation therapy was declined by the patient).

This case shows a typical breast cancer in all imaging modalities.

But beware: The following cases are trickier!

Case 2

Indication: Screening.

History: Hodgkin disease 20 years ago. Supradiaphragmal irradiation therapy. No relapse.

Risk profile: Irradiation therapy of the chest. No increased familial risk.

Age: 42 years.

Fig. 2.1 a,b Digital mammography, MLO view.

Clinical Findings

Slightly increased parenchymal resistance in the upper quadrants of the right breast, compared to left. No palpable mass.

Fig. 2.2 Magnification view of the central region of the right breast.

Fig. 2.3a,b Sonography (comparison of upper outer quadrants bilaterally).

Fig. 2.4a–c Contrast-enhanced MRI of the breasts.

Fig. 2.5 Contrast-enhanced MR mammography. Maximum intensity projection.

Fig. 2.6a,b Signal-to-time curves.

Please characterize ultrasound, mammography, and MRI findings.

What is your preliminary diagnosis?

What are your next steps?

Presented here are all the imaging studies of a younger woman who presented for screening and has a markedly increased risk of breast cancer due to radiation therapy to the mantle field 20 years previously.

Ultrasound

There is a marked difference in the calibers of the milk ducts (right > left), a sign of possible duct ectasia in the right breast. No circumscribed lesion. US BI-RADS right 3/left 1.

Mammography

Asymmetric inhomogeneous dense parenchyma of ACR type 4. No opacities. Polymorphous (round, linear, v-shaped) microcalcifications within the dense parenchyma of the right breast visible in the enlarged view. BI-RADS right 5/left 1). PGMI: P.

MR Mammography

MRI shows no suspect findings on Tl -weighted images and on water-sensitive IR sequence. There is a suspicious segmental dendritic signal enhancement in the upper quadrants of the right breast after administration of contrast medium. Signal-time curve is unspecific. However, in cases with a dendritic enhancement pattern, the placement of an adequate region-of-interest (ROI) is difficult or impossible. MRI shows no circumscribed enhancing masses. MRI of the left breast is normal.

MRI Artifact Category: 2

MRI Density Type: 1

MRM score

Finding

Points

Shape

irregular

1

Border

ill-defined

1

CM Distribution

dendritic

1

Initial Signal Intensity Increase

strong

2

Post-initial Signal Intensity Character

plateau

1

MRI score (points)

6

MRI BI-RADS

5

Preliminary Diagnosis

Extensive intraductal, possibly partially microinvasive tumor of the right breast.

Differential Diagnosis

Segmental adenosis, inflammation (both very unlikely).

BI-RADS Categorization

Clinical Findings

right 3

left 1

Ultrasound

right 3

left 1

Mammography

right 5

left 1

MR Mammography

right 5

left 1

BI-RADS Total

right 5

left 1

Procedure

Stereotactic vacuum core biopsy of the right breast to obtain histological confirmation of preliminary diagnosis. Compression with the probe of one of the tissue samples retrieved in the area of a calcification, visible here, produced “blackhead”-like emissions from the core. This is evidence of the presence of intraductal tumor.

Fig. 2.7 Specimen radiography of some of the core biopsies with positive findings of microcalcifications (arrows).

Fig. 2.8a–c Specimen of a single core biopsy before and after compression of the tissue including the microcalcification. Photography of the necrotic comedo tissue (arrow) after compression.

Histology of the specimen

Comedo-type DCIS, Grade 2.

Histology of the right breast

Tricentric intraductal breast carcinoma in the central part of the right breast including the nipple (see the linear enhancement in MRI reaching the nipple region).

pTis (Paget disease), pN0 (sentinel Node 0/2), G2, R1 (upper inner quadrant), VNP110 points.

Treatment

Mastectomy of the right breast with subsequent resection in the upper inner quadrant (primary Rl resection).

Earlier radiation therapy near the area of the breasts carries an increased risk of breast cancer developing

up to 15-25 years later.

Case 3

Indication: Screening.

History: Unremarkable.

Risk profile: Postmenopausal breast cancer in mother, premenopausal in an aunt, postmenopausal in a second cousin.

Age: 40 years.

Clinical Findings

No findings.

Sonography

No findings (not shown).

Fig. 3.1 a,b Digital mammography of both breasts, MLO view.

Fig. 3.2a–c Contrast-enhanced MRI of the breasts.

Fig. 3.3 Contrast-enhanced MR mammography. Maximum intensity projection.

Fig. 3.4a,b Signal-to-time curves.

Please characterize mammography and MRI findings.

What is your preliminary diagnosis?

What are your next steps?

These are the imaging studies of a younger woman presenting for screening with a high risk profile due to three relatives having breast cancer.

Ultrasound

Ultrasound showed no suspicious changes (not shown).

Mammography

Bilaterally symmetric, extremely dense parenchymal pattern, ACR type 4. Within the limitations of these conditions, there were no abnormal findings in the left breast central area-where MRI findings are significant-or anywhere else. There is no hyperdensity, no mass, no architectural distortion. No microcalcifications corresponding to the linear enhancement observed in MRI (BI-RADS right 1/left 1). PGMI: MLO view P.

MR Mammography

There is linear and partially dendritic enhancement, likely representing a milk duct, visible in the central sections of the left breast. Signal-time curves are nonspecific. No further observations.

MRI Artifact Category: 1

MRI Density Type: 1

MRM score

Finding

Points

Shape

linear

1

Border

ill-defined

1

CM Distribution

homogeneous

0

Initial Signal Intensity Increase

strong

2

Post-initial Signal Intensity Character

plateau

1

MRI score (points)

5

MRI BI-RADS

4

Preliminary Diagnosis

DCIS.

Differential Diagnosis

Segmental papillomatosis, inflammation of the milk ducts.

BI-RADS Categorization

Clinical Findings

right 1

left 1

Ultrasound

right 1

left 1

Mammography

right 1

left 1

MR Mammography

right 1

left 4

BI-RADS Total

right 1

left 4

Procedure

Histological verification of the suspicious findings in MRI, preferably with MR-guided percutaneous vacuum biopsy to avoid open biopsy.

Fig. 3.5a–d Documentation of the MR-guided vacuum biopsy: T1-weighted precontrast image of the left breast positioned within the stereotactic device (a). Precise reproducibility of the linear enhancement in subtraction image (b). Position of the biopsy needle after removal of 20 core biopsies (11 gauge) (c). Documentation of parts of the enhancing area in a second contrast-enhanced MRI sequence (subtraction image) (d).

Histopathological result of the left breast

Chronic fibrocystic mastopathy with a single intraductal papilloma. Low-grade sclerosing adenosis. No malignancy.

Treatment

None. One follow-up MRI after 6 months.

Suspicious findings visible on MRI only can be reliably corroborated with MR-guided vacuum core biopsy.

This strategy helps avoid a large number of unnecessary open

Case 4

Indication: Screening.

History: Unremarkable.

Risk profile: No increased risk.

Age: 52 years.

Clinical Findings

Normal.

Fig. 4.1 a, b Sonography.

Fig. 4.2a,b Digital mammography, CC view.

Fig. 4.3a,b Digital mammography, MLO view.

Fig. 4.4 Zoomed view of upper outer quadrant of the left breast, CC view.

Fig. 4.5a-c

Fig. 4.6a-c

Fig. 4.7a-c

Fig. 4.8a,b Signal-to-time curves.

Fig. 4.9a,b Signal-to-time curves.

Fig. 4.10a,b Signal-to-time curves.

Fig. 4.5-4.10 Contrast-enhanced MR mammography.

Fig. 4.11 Contrast-enhanced MR mammography. Maximum intensity projection.

Please characterize ultrasound, mammography, and MRI findings.

What is your preliminary diagnosis?

What are your next steps?

This asymptomatic woman presented for screening mammography. There was no increased familial risk.

Ultrasound

There is a lobulated hypoechoic lesion with microlobulated borders and partially peripheral hyperechogenicity as well as a disruption of a ligament structure in the upper outer quadrant of the right breast. Moreover, there is a round hypoechoic lesion with partially ill-defined borders and disruption of the continuity of a ligament in the outer upper quadrant of the left breast. Neither lesion shows any pathological distal echo alteration. US BI-RADS right 5/left 4.

Mammography

Both breasts show inhomogeneous dense tissue, ACR type 3. There is a hyperdense round lesion 1 cm in diameter with spiculated borders within the dense parenchyma in the upper outer quadrant of the right breast. There are no associated microcalcifications. In the upper outer quadrant of the left breast, there is also a hyperdense round lesion (1 cm) with spiculated borders. There are microcalcifications in the region of this lesion (BI-RADS right 5/left 5). PGMI: CC view P; MLO view M (inframammary fold, pectoral angle < 20°).

MR Mammography

Corresponding to ultrasound and digital mammography findings, there is a round hypervascularized tumor of 1 cm diameter in the upper outer quadrant of each breast. Additionally, MRI shows another small hypervascularized tumor in the caudal area of the right breast (in line with the nipple) with a stronger contrast uptake in the early subtraction phase compared to the surrounding tissue. All lesions showed intermediate signal intensity in water-sensitive IR sequence.

MRI Artifact Category: 2

MRI Density Type: 2

Preliminary Diagnosis

Multicentric invasive breast cancer of the right breast. Invasive breast cancer of the left breast, probably with an extensive intraductal component (EIC, see microcalcifications).

BI-RADS Categorization

Clinical Findings

right 1

left 1

Ultrasound

right 5

left 4

Mammography

right 5

left 5

MR Mammography

right 5 (suspected MCC)

left 5

BI-RADS Total

right 5 (suspected MCC)

left 5

Procedure

Histological verification of the suspect lesion in the upper outer quadrants of both breasts with US-guided core biopsy. Additionally, histology of the suspect lesion in the caudal area of the right breast with MR-guided vacuum biopsy.

Fig. 4.12a–c MR-guided vacuum biopsy of the right breast (caudal lesion). Reproducibility of the lesion (arrow) (a). Misplacement of the coaxial needle with deviation toward the thoracic wall (b). Repositioning of the coaxial needle and documentation of its correct position after excision of the tissue specimen, (c).

Histology

Histology of US-guided core biopsy, upper outer quadrant, right breast: IDC.

Histology of US-guided core biopsy upper outer quadrant, left breast: IDC.

Histology of MR-guided vacuum biopsy right caudal lesion: ILC.

Histology

Right breast: IDC and ILC pT1c (multicentric: 12 mm +7 mm), pNO (0/11)*, G1 + G2.

Left breast: IDC pT1 b (8 mm) + pTis (EIC 4 mm + mm), pNO (0/5 sn), G1.

*