Wk 2, Case 2 - Review

HISTORY: 65-year-old female presenting from an outside facility with recently biopsied left axillary mass and node demonstrating grade 3 invasive ductal carcinoma (ER+, PR-, HER2+). Evaluate extent of disease.

Summary of prior imaging:

Mammography: Incompletely visualized left axillary mass with circumscribed margins measuring at least 38 mm.

Ultrasound: Targeted ultrasound of the left axilla demonstrates a markedly abnormal lymph node with cortical thickness of 12 mm, but a preserved fatty hilum. There is an adjacent oval mass with indistinct margins measuring up to 28 mm.

Breast MRI: NA

FINDINGS

Quality control issues: ☒None ☐Poor/lack contrast bolus ☐Poor fat suppression
☐Susceptibility ☐Movement ☐Other

Background Parenchymal Enhancement: Minimal

Amount of Fibroglandular Tissue: Scattered fibroglandular tissue

LEFT BREAST

Narrative: At 2:00 anterior depth, approximately 6 cm from the nipple, there is an irregular mass with irregular margins which measures 1.1 cm (AP). There is homogeneous internal enhancement. Worst curve kinetics are initial phase rapid and delayed phase plateau. There is an additional mass measuring 0.6 cm (CC) which is 0.6 cm inferior and lateral to the mass described above. In total the two masses span a distance of 2.2 cm.

There are markedly large abnormal level I and II conglomerate lymph nodes. Two foci of susceptibility artifact are identified within this nodal conglomerate compatible with biopsy clips. The nodal conglomerate abuts and partially surrounds the pectoralis minor muscle, but there is no evidence of pectoral invasion. Superiorly, the nodal conglomerate abuts the axillary veinand abnormal infraclavicular nodes are demonstrated.

Left breast lesion 1
Lesion type: Mass
1.1 cm. Upper outer Quadrant. 2:00 Radian. 6 cm from the nipple

Mass/post-surgical change: Shape:Irregular. Margins:Not circumscribed-irregular.

Enhancement: Homogenous. Kinetics: upslope -Fast, delayed-Plateau

BI-RADS:4: Suspicious abnormality – Biopsy should be considered

Left breast lesion 2
Lesion type: Mass
0.6 cm. Upper outer Quadrant. 2:00 Radian. 5 cm from the nipple

Mass/post-surgical change: Shape:Irregular. Margins:Not circumscribed-irregular.

Enhancement: Homogenous. Kinetics: upslope -Fast, delayed-Plateau

BI-RADS:4: Suspicious abnormality – Biopsy should be considered

Associated findings LEFT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin
retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory,
☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings LEFT breast: ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☒Signal void from clips

Fat containing lesions LEFT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative
seroma/hematoma with fat

Lymph nodes LEFT: ☐Normal axillary, ☒Abnormal axillary: Markedly enlarged abnormal level I and II lymph nodes, ☐ Abnormal internal mammary

RIGHT BREAST

Narrative: Negative. No suspicious enhancement or lymphadenopathy.

Associated findings RIGHT breast: ☐Nipple retraction, ☐Nipple involvement, ☐Skin retraction, ☐Skin thickening, ☐Skin invasion-direct, ☐Skin invasion-inflammatory, ☐Pectoral muscle invasion, ☐Chest wall invasion, ☐ Architectural distortion

Non-enhancing findings RIGHT breast: ☐High ductal signal pre contrast T1, ☐Cyst(s), ☐Hematoma/seroma, ☐Post therapy skin/trabecular thickening, ☐Non-enhancing mass, ☐Architectural distortion, ☐Signal void from clips

Fat containing lesions RIGHT: ☐Fat necrosis, ☐Hamartoma, ☐Post-operative
seroma/hematoma with fat

Lymph nodes RIGHT: ☒Normal axillary, ☐Abnormal axillary: description, ☐ Abnormal internal mammary

Extramammary findings: None

SUMMARY:
1. Two adjacent masses in the left breast at 2:00 anterior depth, which measure up to 2.2 cm on MRI in total. BI-RADS:4: Suspicious abnormality – Biopsy should be considered

2. Markedly abnormal level I and II axillary nodal conglomeration, previously biopsied demonstrating malignancy. Superiorly, there are abnormal infraclavicular lymph nodes and the nodal conglomerate appears to abut the axillary vein. The nodal conglomerate abuts but does invade the pectoralis minor muscle.

RECOMMENDATIONS: Image-guided biopsy of one of the adjacent masses in the left breast
at 2:00.