Indication: Raised tumor marker level.
History: Breast conservation therapy and radiation therapy for a breast carcinoma 3 years previously (right breast).
Risk profile: Increased by earlier incidence of breast cancer.
Age: 64 years.
Fig. 67.1 a,b Ultrasound images from the area of the scar in the upper outer quadrant of the right breast.
Clinical Findings
Normal scar. No findings at palpation.
Fig. 67.2 a,b Digital mammography, MLO view.
Fig. 67.3 a,b Digital mammography, CC view.
Fig. 67.4 a-c Contrast-enhanced MRI of the breasts
Fig. 67.5 a-c Contrast-enhanced MRI of the breasts.
Fig. 67.6 Contrast-enhanced MR mammography. Maximum intensity projection.
Fig. 67.7 a,b Signal-to-time curves.
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Please characterize ultrasound, mammography, and MRI findings. What is your preliminary diagnosis? What are your next steps? |
This case investigates increased tumor marker levels discovered during monitoring of the patient following lumpectomy and radiation therapy for an invasive ductal carcinoma (stage pTlc) 3 years previously.
Ultrasound
There was an ill-defined, hypoechoic lesion in the upper outer quadrant of the right breast. The surrounding ligamental structures were not displaced. The margins were not hyperechoic and there was no distal echo shadowing. US BI-RADS 3.
Mammography
The parenchyma was bilaterally symmetric and fibroglandular in texture, ACR type 2. Slight postoperative architectural distortion was seen in the upper outer quadrant of the right breast. There were no suspicious masses or densities and no microcalcifications. BI-RADS right 3/left 1. PGMI: CC view I (lateral superimposition of the shoulder, imaging not repeated); MLO view M (inframammary angle, pronounced abdominal skin fold, pectoralis).
MR Mammography
MRI demonstrated a segmental, ill-defined inhomogeneously enhancing mass measuring 2 cm between the outer quadrants of the right breast. This lesion showed marked initial signal increase, postinitial washout, and decreased signal in T2-weighted imaging.
Note: Because of the ptosis of the large breasts and the prone position of the examination, the areola is depicted at the level of the lumpectomy scar in the upper outer quadrant of the left breast.
MRI Artifact Category: 1
MRI Density Type: 1
|
MRM score |
Finding |
Points |
|
Shape |
irregular/segmental |
1 |
|
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) |
|
7 |
|
MRI BI-RADS |
|
5 |
Differential Diagnosis
Local tumor relapse, focal (e.g., granulomatous) mastitis, focal adenosis.
|
BI-RADS Categorization | ||
|
Clinical Findings |
right 1 |
left 1 |
|
Ultrasound |
right 3 |
left 1 |
|
Mammography |
right 3 |
left 1 |
|
MR Mammography |
right 5 |
left 1 |
|
BI-RADS Total |
right 5 |
left 1 |
Procedure
MR-guided vacuum biopsy of the lesion in the upper outer quadrant of the right breast.
Histology
Invasive ductal carcinoma.
Fig.67.8 a-e MR-guided vacuum biopsy of the right breast.
a Precontrast TI-weighted image.
b Reproducibility of the segmental enhancement in subtraction image.
c Coaxial needle after local anesthesia.
d Findings after biopsy in precontrast TI-weighted image.
e Subtraction image after further contrast administration with enhancement due to bleeding. No residual enhancing tumor component.
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