Fig. 23.1 a,b Sonography. Panoramic view of right and left breasts.

Fig. 23.2a,b Digital mammography, CC view.

Clinical Findings

Resistant parenchyma in the upper outer quadrants of both breasts, known and unchanged over a number of years. No circumscribed mass.

Fig. 23.3a,b Digital mammography, MLO view.

Fig. 23.4a–r Contrast-enhanced MR mammography. 18 consecutive subtraction images, cranial to caudal.

Fig. 23.5 Contrast-enhanced MR mammography. Maximum intensity projection.

Ultrasound

Panoramic views of the upper quadrants of both breasts are shown. Comparing both sides, suspect acoustic shadowing is in evidence on the right, while there are no notable ultrasound findings in the left breast. US BI-RADS right 3/left 2.

Mammography

Imaging showed bilaterally symmetric extremely dense parenchyma, ACR type 4. Considering these limiting conditions, no masses or densities could be identified. Mammograms demonstrated no architectural distortions or microcalcifications. BI-RADS right 1/left 1. PGMI: CC view P; MLO view M (inframammary fold not correctly depicted, pectoralis muscle does not reach nipple line).

MR Mammography

All presented subtraction images showed pathological multiple enhancement in the outer quadrants of the left breast. The morphology of the enhancing areas was highly pathological and their T2 signal was also suspect (intermediate signal, not shown). Signal-time curves also indicated malignancy (strong initial signal increase, washout; not shown).

MRI Artifact Category: 1

MRI Density Type: 2

Preliminary Diagnosis

Extended invasive carcinoma. No differential Diagnosis.

Procedure

Histopathological evaluation of the extensive enhancing areas in the lateral parts of the left breast with MR-guided core biopsy, because ultrasound did not provide clearly corresponding data. MR-guided vacuum biopsy in the upper outer quadrant of the left breast (11 gauge, 12 specimens). Additionally, MR-guided core biopsy in the lower outer quadrant of the left breast (16G, 8 specimens spaced 1 cm apart) to verify multicentricity.

Histopathology (all specimens)

Tubular breast cancer grade 1 -2.

Fig. 23.6a-d Digital mammography in 2 views from screening examination a year earlier, with identical findings.