Case History

A 63-year-old woman presents with a palpable left breast lump.

Physical Examination

• Firm lump in outer left breast near the 3 o’clock position

Mammogram

Fig. 35.1 In the outer quadrant, there is an ill-defined oval mass. (A) Left MLO mammogram. (B) Left exaggerated craniocaudal (XCC) mammogram.

Fig. 35.2 Left breast antiradial sonogram. The mammographic mass and palpable lump correspond to an irregular hypoechoic solid mass near the 3 o’clock position that is associated with spiculations. The mass also distorts the Cooper’s ligament and surrounding glandular architecture.

Fig. 35.3 Dynamic bolus T1-weighted, 2-minute subtraction axial bilateral breast MRI. The MRI is performed to further stage the tumor. The primary malignancy is a rapidly enhancing irregular mass in the left 3 o’clock position (arrow).

Fig. 35.4 Dynamic bolus T1-weighted, 2-minute subtraction axial bilateral breast MRI. The MRI identifies an abnormal enhancing left axilla (arrow).

Fig. 35.5 Dynamic bolus T1-weighted, 2-minute subtraction axial bilateral breast MRI. An abnormally enlarged internal mammary lymph node is evident (arrow).

Fig. 35.6 Maximum projection intensity (MIP) positron emission tomography (PET) image. The PET exam demonstrates the primary malignancy (B) and confirms the presence of abnormal axillary nodes (A) and an internal mammary node (arrow).

• Invasive ductal carcinoma

Management

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

Suggested Reading

Eubank WB, Mankoff DA, Takasugi J, et al. ¹⁸Fluorodeoxyglucose positron emission tomography to detect mediastinal or internal mammary metastases in breast cancer. J Clin Oncol 2001;19(15):3516–3523

Greco M, Crippa F, Agresti R, et al. Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management. J Natl Cancer Inst 2001;93(8):630–635

van der Hoeven JJM, Krak NC, Hoekstra OS, et al. ¹⁸F-2-fluoro-2-deoxy-D-glucose positron emission tomography in staging of locally advanced breast cancer. J Clin Oncol 2004;22(7):1253–1259

Wahl RL, Siegel BA, Coleman RE, Gatsonis CG; PET Study Group. Prospective multicenter study of axillary nodal staging by positron emission tomography in breast cancer: a report of the staging breast cancer with PET Study Group. J Clin Oncol 2004;22(2):277–285

Case History

A 73-year-old woman presents for screening mammography.

Physical Examination

• Normal exam

Mammogram

Fig. 35.7 Right MLO spot compression mammogram. There is an oval mass with ill-defined, irregular margins in the upper outer quadrant of the right breast.

Fig. 35.8 The mammographic mass corresponds to a sonographically solid, hypoechoic, mildly lobulated mass. The margins are mildly irregular on the antiradial image. (A) Right radial breast sonogram. (B) Right antiradial breast sonogram.

Fig. 35.9 Because the patient’s tumor histologically is aggressive, a PET scan is performed, which demonstrates abnormal uptake in the liver (L), right supraclavicular lymph node (S), and right breast (B). The liver and nodal appearance is consistent with metastatic disease. (A) Axial positron emission tomography–computed tomography (PET-CT) of upper chest. (B) Axial PET-CT of lower chest. (C) Axial PET-CT of the abdomen. (D) Maximum intensity projection (MIP) PET image.

Pathology

• A 3.6 cm, high-grade infiltrating ductal carcinoma, estrogen and progesterone receptor negative, with overexpression of HER-2/neu (c-erb-B2)

Management (Mammography and Ultrasound Findings)

• Right mammographic and sonographic mass: BI-RADS assessment category 4, suspicious; biopsy should be considered.

Suggested Reading

Eubank WB, Mankoff D, Bhattacharya M, et al. Impact of FDG PET on defining the extent of disease and on the treatment of patients with recurrent or metastatic breast cancer. AJR Am J Roentgenol 2004;183(2):479–486