Case History

A 56-year-old woman, status post–left lumpectomy, which was done at another institution, is seeking a second opinion. Microscopic examination suggests that the margins of the invasive malignancy are close to the surgical margins, so breast MRI is performed.

Physical Examination

• Left breast: healing lumpectomy site

• Right breast: normal

Fig. 34.1 After contrast injection, there is no abnormal enhancement associated with the rim of the left lumpectomy cavity. However, in the right upper outer quadrant, there is a 7 mm irregular, rapidly enhancing mass that appears as a spiculated solid mass on the T1 image, which does not have fat suppression (square). (A) Dynamic bolus T1-weighted, 2-minute subtraction axial bilateral breast MRI. (B) T1-weighted axial bilateral breast MRI.

• Left breast: reexcision of the lumpectomy cavity; no residual malignancy

• Right breast: radial scar

Management

• Right MRI enhancing mass: BI-RADS assessment category 4, suspicious; biopsy should be considered.

Suggested Reading

Berg WA. Radial scar. In: Berg WA, Birdwell RL, Gombos EC, Wang S-C, Parkinson BT, Raza S, Green GE, Kennedy A, Kettler MD, eds. Diagnostic Imaging Breast. Altona, Manitoba: Friesens; 2006:IV-2-84-89

Nunes LW, Schnall MD, Orel SG, et al. Correlation of lesion appearance and histologic findings for the nodes of a breast MR imaging interpretation model. Radiographics 1999;19:79–92

Pediconi F, Occhiato R, Venditti F, et al. Radial scars of the breast: contrast-enhanced magnetic resonance mammography appearance. Breast J 2005;11:23–28

Case History

A 51-year-old woman presents for screening MRI. She has the BRCA1 gene. She had right breast cancer 14 years prior and left breast cancer 15 years prior. She is status post–bilateral lumpectomy, radiation therapy, and axillary dissections. Her previous breast MRI (1 year prior) and bilateral mammograms (8 months prior) were negative.

Physical Examination

• Normal exam

Fig. 34.2 The patient has a lumpectomy scar in the left upper outer quadrant. (A) Left MLO mammogram. (B) Left CC mammogram.

Fig. 34.3 Bilateral contrast-enhanced axial breast high-resolution MRI, delayed image. At the 7 o’clock position of the left breast, there is a new enhancing oval mass (arrow).

Fig. 34.4 Left radial breast sonogram at the 7 o’clock position. This sonogram was performed as a result of the abnormal screening MRI. There is an oval hypoechoic solid mass, which corresponds to the screening MRI mass.

• Infiltrating ductal carcinoma, grade 3

Management

• Left breast MRI enhancing mass: BI-RADS assessment category 4, suspicious; biopsy should be considered.

Suggested Reading

Causer PA, Jong RA, Warner E, et al. Breast cancers detected with imaging screening in the BRCA population: emphasis on MR imaging with histopathologic correlation. Radiographics 2007;27(Suppl 1): S165–S182

Lee JM, Kopans DB, McMahon PM, et al. Breast cancer screening in BRCA1 mutation carriers: effectiveness of MR imaging—Markov Monte Carlo decision analysis. Radiology 2008;246:763–771

Lehman CD, Isaacs C, Schnall MD, et al. Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. Radiology 2007;244:381–388

Lynch HT, Lemon SJ, Marcus JN, Lehman C, Lynch J, Narod S. Breast cancer genetics: heterogeneity, molecular genetics, syndrome diagnosis, and genetic counseling. In: Bland KI, Copeland EM, eds. The Breast. 2nd ed. Philadelphia: WB Saunders; 1998:370-394

Riedl CC, Ponhold L, Flöry D, et al. Magnetic resonance imaging of the breast improves detection of invasive cancer, preinvasive cancer, and premalignant lesions during surveil-lance of women at high risk for breast cancer. Clin Cancer Res 2007;13): 6144–6152

Saslow D, Boetes C, Burke W, et al. American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75–89

Schrading S, Kuhl CK. Mammographic, US, and MR imaging phenotypes of familial breast cancer. Radiology 2008;246:58–70

Stavros AT. Ultrasound of solid breast nodules: distinguishing benign from malignant. In: Stavros AT, Breast Ultrasound. Philadelphia: Lippincott Williams & Wilkins; 2004:445-527

Willey SC, Cocilovo C. Screening and follow-up of the patient at high risk for breast cancer. Obstet Gynecol 2007;110:1404–1416

Case History

An 81-year-woman presents for screening mammography.

Physical Examination

• Normal examination

Mammogram

Fig. 34.5 In the left upper outer quadrant, there is a spiculated mass (square). (A) Right MLO mammogram. (B) Left MLO mammogram. (C) Right CC mammogram. (D) Left CC mammogram. (E) Left CC spot compression mammogram.

Fig. 34.6 Left radial sonogram. In the upper outer quadrant, there is a solid, hypoechoic, irregular solid mass with a hyperechoic haze and spiculations, which corresponds to the left mammographic spiculated mass.

Fig. 34.7 The left mammographic mass corresponds to a homogeneous irregular spiculated mass that exhibits fast initial enhancement that peaks at 2 to 3 minutes, then exhibits washout (type III kinetic curve). (A) Bilateral contrast-enhanced axial breast high-resolution MRI. (B) Signal-intensity time curve of the left MRI mass.

Fig. 34.8 In the right upper outer quadrant, there is an oval mass with irregular margins and homogeneous enhancement. This mass exhibits fast initial enhancement with a plateau curve in the later contrast phases (type II kinetic curve). (A) Bilateral contrast-enhanced axial breast high-resolution MRI. (B) Signal-intensity time curve of the right MRI mass.

Fig. 34.9 Right radial sonogram. This sonogram is performed to identify the MRI mass for sonographic biopsy. In the upper outer quadrant, there is a hypoechoic oval mass with a hyperechoic haze and spiculations, which corresponds to the right breast MRI mass. This mass was not identified mammographically.

• Left breast: invasive lobular carcinoma

• Right breast: invasive ductal carcinoma, grade 1

Management

• Left mammographic and sonographic mass: BI-RADS assessment category 5, highly suggestive of malignancy

• Right MRI and sonographic mass: BI-RADS assessment category 5, highly suggestive of malignancy