Indication: Screening before planned breast reduction surgery.
History: Unremarkable.
Risk profile: No increased risk.
Age: 60 years.
Clinical Findings
Macromastia. No abnormalities.
Fig. 55.1a,b Ultrasound imaging between the upper quadrants of the right breast.
Fig. 55.2a,b Conventional mammography, MLO view [imaging not performed by authors].
Fig. 55.3a,b Conventional mammography, CC view [imaging not performed by authors].
Fig. 55.4a–c Contrast-enhanced MR mammography. Earliest subtraction.
Fig. 55.5a-c Contrast-enhanced MR mammography. Earliest subtraction.
Fig. 55.6 Contrast-enhanced MR mammography. Maximum intensity projection.
Fig. 55.7a,b Signal-to-time curves.
|
|
Please characterize ultrasound, mammography, and MRI findings. What is your preliminary diagnosis? What are your next steps? |
In view of the limited usefulness of mammography and sonography in this case, MR mammography was carried out on this patient in advance of planned bilateral reduction surgery.
Ultrasound
Ultrasound showed inhomogeneous echogenicity of the breast parenchyma. No suspicious lesions were seen in the initial ultrasound images. However, once the results of MR mammography were known, the sonographic examination was repeated and a hypoechoic mass measuring 8 mm with distal echo shadowing was depicted between the upper quadrants of the right breast. No architectural distortion. US BI-RADS right 3/left 1.
Mammography
Mammograms showed asymmetric, partially inhomogeneous dense parenchyma, ACR type 3. There were no suspicious findings and no microcalcifications. BI-RADS right 1/left 1. PGMI: CC view P; MLO view G (angle of pectoral muscle, inframammary fold).
MR Mammography
A solitary, partially ill-defined, spiculated mass of 1.5 cm diameter with homogeneous enhancement was found between the upper quadrants of the right breast. Initial signal increase was 120% followed by a postinitial plateau. There was a partially reduced signal of this lesion in T2-weighted imaging. No other suspect findings.
MRI Artifact Category: 1
MRI Density Type: 2
|
MRM score |
Finding |
Points |
|
Shape |
irregular |
1 |
|
Border |
spiculated |
1 |
|
CM Distribution |
homogenous |
0 |
|
Initial Signal Intensity Increase |
strong |
2 |
|
Post-initial Signal Intensity Character |
plateau |
1 |
|
MRI score (points) |
|
5 |
|
MRI BI-RADS |
|
4 |
Differential Diagnosis
Focal adenosis, radial scar, carcinoma (tubular?).
|
Clinical Findings |
right 1 |
left 1 |
|
Ultrasound |
right 3 |
left 1 |
|
Mammography |
right 1 |
left 1 |
|
MR Mammography |
right 4 |
left 1 |
|
BI-RADS Total |
right 4 |
left 1 |
Procedure
MR-guided vacuum biopsy. A US-guided biopsy could also be considered as an alternative. In the latter case, the correspondence between US and MRI findings must be very firmly established.
Histology
Invasive lobular carcinoma.
Fig. 55.8a–d MR-guided vacuum biopsy.
a Subtraction image reproducing the suspicious finding.
b Documentation of coaxial needle.
c Area of resection after biopsy.
d Final documentation following further contrast administration, showing enhancement due to bleeding.
Full access? Get Clinical Tree
