Case Presentation

Radiology HMC

PATIENT PROFILE

Age
Gender Address Profession

: 50yr
: Female : Peshawar : House wife

CHIEF COMPLAINTS

Mass in right breast Pain in right breast

8 months 1 month

 PAST MEDICAL/ SURGICAL Hx MENSTRUAL/OBSTETRICAL Hx DRUG Hx FAMILY Hx

LUMP EXAMINATION
Location Size Upper inner quad. 3x2 cm

Appearance
Temperature Tenderness Margins Consistency Motility

Normal
Normal Present Irregular Hard Immobile

AXILLARY LYMPH NODES

Palpable nodes

In right axilla
Anterior group 1-2 cm size

ULTRASOUND BREAST

Well defined, rounded lesion 2.2x2 cm Heterogenous parenchyma Irregular margin Echogenic foci--- microcalcifications

MAMMOGRAPHY

Superiomedial Well defined round Radiopaque Foci of calcification + parenchymal distortion Microcalcifications dispersed in parenchyma

DIAGNOSIS ???

MALIGNANT BREAST LESION.

RISK FACTORS
Female gender Aging Genetic factors
BRCA 1&2 P53 PTEN CHEK2

 Family history of breast ca Past hx of breast cancer

Breast diseases
Atypical hyperplasia Carcinoma in situ

 Menstrual hx
Early menarche, late menopause

Nulliparous Lack of breast feeding Late age pregnancy

 Drugs
Oral contraceptives Diethlystilbesterol

Chest radiation Metabolic

Obese Alcohol Fat

RADIOLOGICAL TOOLS IN DIAGNOSING

Ultrasound Mammography MRI PET Complex cyst aspiration FNAC Core biopsy Ductography

ULTRASOUND
INDICATIONS
Symptomatic breast lumps in women aged less than 35 years. Breast lump developing during pregnancy or lactation. Assessment of mammographic abnormality ( further mammographic views)

 Assessment of MRI or scintimammography detected lesions. Clinical breast mass with negative mammograms. Breast inflammation. The augmented breast (together with MRI).

 Breast lump in a male (together with mammography). Guidance of needle biopsy or localisation. Follow-up of breast cancer treated with adjuvant chemotherapy.

Benign Characteristics
Ellipsoid shape
Thin definable capsule Two or three lobulations Hyperechogenicity.

Malignant Characteristics
Solid
Irregular shape Irregular borders Almost anechoic

Angular margin Taller than wide Thick echogenic rim Posterior shadowing

BENIGN
Shape Oval/ellipsoid

MALIGNANT
Variable

Alignment

Wider than deep; aligned parallel to tissue planes Smooth/thin echogenic pseudocapsule 2-3 gentle lobulations

Deeper than wide

Margins

Irregular or spiculated; echogenic 'halo'

Echotexture

Variable to intense hyperechogenicity

Low-level Marked hypoechogenicity

Homogeneity of internal echoes Lateral shadowing Posterior effect

Uniform

Non-uniform

Present Minimum attenuation/posterior enhancement --------------

Absent Attenuation with obscured posterior margin Calcification Microlobulation

Other signs

Intraductal extension
Infiltration across tissue planes

Increased echogenicity of surrounding fat

Fibroadenoma Homogeneous internal echoes with an ovoid shape and circumscribed margins benign There is posterior acoustic enhancement..

A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.

Invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.

Inflammatory breast cancer with secondary signs. increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.

A power Doppler image of invasive grade 3 breast cancer. irregular tortuous vessels penetrating into the centre of the lesion.

Mammography
INDICATIONS
Screening asymptomatic >50yrs Screening high risk asymptomatic >35yrs

Symptomatic >35yrs with lump/ cancer

 Surveillance after excision of cancer Evaluation after augmentation mammoplasty Suspicious breast lump in man

CHARACTERISTICS
SPICULATE MASS
Commonest appearance of invasive Ca Central soft tissue tumor

Spicules extending to surrounding

Lateral view

Localized compression magnification view

Spiculate mass due to invasive carcinoma

 ARCHITECTURAL DISTORTION
Numerous straight lines 1 to 4 cm long Radiating towards centre

Stellate lesion due to invasive tubular carcinoma

ASYMMETRICAL SOFT TISSUE DENSITY Areas of

Low soft tissue density

Lucency Curvilinear margins

Soft tissue density with irregular margins

CIRCUMSCRIBED MASS

DENSITY
Radiopaque

CONTOUR
Ill defined

NUMBER
Solitary

Circumscribed soft tissue mass showing intracystic carcinoma

Phyllodes tumor. Circumscribed mass with lobulated outline

1. Poorly defined spiculate mass.. Invasive ductal Ca 2. Circumscribed soft tissue mass..mucinous Ca

Circumscribed retroareolar mass, poorly defined posterior margin Invasive ductal Ca

MICROCALCIFICATIONS Ductal
Variable in density. Variable in shape like linear, casting, branching, irregular Distribution With in one lobe/segment

Ductal Carcinoma in situ ,irregular linear branching calcifications

Ductal Carcinoma in situ Irregular pleomorphic calcification

EDEMATOUS BREAST
Thickened skin Increased density Coarse trabecular pattern Enlargement of breast

MRI
INDICATIONS
Staging biopsy-proven primary breast carcinoma Detecting an occult primary breast cancer in a patient with proven axillary node involvement but negative results on mammography and ultrasonography

 Ascertaining the extent of disease after lumpectomy with positive margins or close margins Investigating suspected pectoralis muscle invasion Assessing response to chemotherapy, including preoperative chemotherapy

 Looking for suspected recurrent disease, such as in a postsurgical scar A compelling clinical presentation with negative or equivocal imaging results Problem solving, ie, workup of uncertain imaging findings that could not be resolved even after special mammographic and ultrasonographic techniques were used

 Needle localization and guided biopsy Known or suspected rupture of breast implants Screening patients with certain welldefined risk factors for breast cancer.

Dense breast tissue

Two lesions on contrast enchanced MRI

Biopsy proven case of breast carcinoma

Pre contrast

Post contrast

Sagittal T1 weighted gradient-echo images with fat saturation Intravenous gadolinium-DTPA. 2 malignant masses Typical heterogenous and rim enhancement of larger mass Involvement of prepectoral fascia,pectoralis major and skin by inferior mass

BI-RADS
Breast Imaging Reporting And Data System Made by American college of radiology Importance
Diagnostic Therapeutic Prognostic Epidemiologic Standardized words in mammographic reporting Improved communication

BI-RADS assessment categories

Category 0 Category 1 Category 2

Category 3
Category 4 Category 5 Category 6

Category 0
Assessment incomplete Further workup needed e.g Screening mammogram shows a nodule.. Till further workup its labelled as category 0

Category 1
Negative mammogram shows No grouped or suspicious microcalcifications No well-formed mass,

A symmetrical glandular structure

No change from any previous exam

Category 2
definitely benign and a routine screening It include: Round opacities with macrocalcifications (typical calcified fibroadenoma or cyst) Round opacities corresponding to a typical cyst at ultrasonography

 Oval opacities with a radiolucent center Fatty densities or partially fatty images (lipoma, galactocele, oil cyst, hamartoma ) Vascular calcifications

 Scattered macrocalcifications (fibroadenoma, cyst, cytosteatonecrosis, secretory ductal ectasia);

Breast implants,silicone granuloma.

Surgical scar

Category 3
Probably Benign
Positive predictive value less than 1% a follow-up of 6 months is usually recommended.

Findings include: Clusters of tiny calcifications if round or oval

Non-calcified solid nodules (no size limitation but non palpable), round, ovoid, well-defined,

 Selected focal asymmetric areas of fibroglandular density (not palpable): Miscellaneous focal findings, such as a dilated duct, or post biopsy architectural distortion without central density Generalized distribution in both breasts. For example, multiple similar lesions with tiny calcifications or nodules distributed randomly

 In some scenerios a percutaneous biopsy might be considered,even with category 3. For example, extreme patient anxiety, or plans for pregnancy, plans for breast augmentation or reduction surgery, or if synchronous carcinoma is present

indeterminate BI-RADS 3 and not BI-RADS 2, because of the poorly defined, fuzzy edge.

Category 4
Suspicious or Indeterminate abnormality The positive predictive value (the chance of a real cancer) 20-40%. Commonly fibrocystic changes

A biopsy should be recommended.

It is often subdivided into three smaller sub-categories:

"A" for low suspicion of malignancy, "B" for moderate suspicion,

"C" for high suspicion.

Findings include: Asymmetric, localized or evolving hyperdensities with convex contours. Indeterminate microcalcifications appearing amorphous, indistinct particularly if in a cluster or heterogeneous and pleomorphic Round or oval non cystic opacities with microlobulated or obscured contours

Category 5
Highly suggestive of malignancy A biopsy should be taken immediately.

Positive predictive value 95%

Finding include : Typically malignant microcalcifications; e.g.linear with branching pattern;

 Clusters of microcalcifications with a segmental or galactophorous distribution Evolving microcalcifications or associated with an architectural distortion or opacity Poorly circumscribed opacities; Spiculated opacities with radio-opaque center.

Category 6
Known Cancer Proven by biopsy. Used when patients undergoing breast cancer treatment have follow-up mammograms.

THANKS