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BI-RADS 4 – New Diagnosis Right Breast Cancer, Nodes on Right

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So our next case is a 42 year old woman

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with a recent diagnosis of right breast cancer, which was initially discovered

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on a baseline screening mammogram as a right retroareolar mass.

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And that mass was biopsied and found to be

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an invasive ductal carcinoma, which was kind of a surprise.

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And she had fairly dense breasts on mammography.

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The size of the tumor was a little bit

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unclear based on the mammogram and ultrasound.

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So MRI was requested for evaluation of extent of disease.

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So here's the patient's MIP,

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which really shows a lot going on here in the right breast.

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So the area behind the nipple that had been biopsied was just this mass.

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But you can see that there's a lot more going on in the right breast.

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There's some non mass enhancement.

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There may be other masses.

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There's a suggestion of a lymph node here in the axilla,

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and she has a fair amount of background parenchymal enhancement as well.

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So we'll go ahead and look at this a little bit more closely.

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We'll pull in our T1 and our post contrast sub,

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and you can see that this patient has a lot of fibroglandular tissue,

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and on a mammogram, that would manifest as breast tissue density.

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So she does have heterogeneously dense to dense breasts on mammography,

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and that was making it difficult to interpret her mammogram.

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But on her MRI, you can see that even in places with denser tissue or more

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fibroglandular tissue, she doesn't really enhance very much.

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But then on the right breast, she has a lot of enhancement.

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So the area that was biopsied was this mass.

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So that's an invasive ductal carcinoma.

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But then she had

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sort of this surprising amount of non mass enhancement in the lateral right breast,

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kind of extending from front to back, and then another mass or masses posteriorly.

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Most of her issue is here in the central

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breast to upper breast, but it does extend lower as well.

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And there are a few other masses

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in the medial breast as well here, anteriorly and posteriorly.

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And she also has multiple large lymph nodes

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in the right axilla that are enhancing, several large lymph nodes.

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So we looked at this with our source images as well, T1,

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pre and post contrast, and you can see the same findings,

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particularly these large axillary lymph nodes.

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So we read this as a BI-RADS 4, because what we wanted to do was biopsy or

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do a second look ultrasound and biopsy of one of those right axillary lymph nodes.

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And there was some discussion before

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reading this, as to whether she would need anything else done in the breast

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on the right. All of this enhancement was suspicious

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on the right kind of BI-RADS 4/5, almost certainly cancer.

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We elected not to do additional biopsies in the right breast because it was felt

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that this would probably be needing to be a mastectomy.

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And we went ahead and did a biopsy, ultrasound guided biopsy of a lymph node

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in the right axilla, and that showed metastatic disease.

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So this was BI-RADS 4.

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And, you know,

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I think in some of these cases, there's a fine line between BI-RADS 4 and 5.

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This is almost certainly going to be a cancer.

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So BI-RADS 4 or 5 would be appropriate here.

Report

Description

Faculty

Lisa Ann Mullen, MD

Assistant Professor; Breast Imaging Fellowship Director

Johns Hopkins Medicine

Tags

Women's Health

Neoplastic

MRI

Breast

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