Wk 3, Case 1 - Review

HISTORY: 39-year-old woman with a history of recently diagnosed locally advanced right breast cancer with skin invasion and axillary nodal metastases.

Summary of prior imaging:

Mammography: Patient presented with a palpable abnormality in the right breast and axilla. Diagnostic mammogram demonstrated a 57 x 42 x 67 mm oval mass with circumscribed margins and associated skin thickening at 11:00 anterior depth.

Ultrasound: Subsequent ultrasound demonstrated a correlating 57 x 53 x 57 mm irregular, hypoechoic mass with angular margins at 11:00 5 cm from the nipple. The mass invades the dermis. Morphologically abnormal axillary lymph nodes are also identified.

Previous Breast MRI:
Extending from 9 to 12:00 in the upper outer right breast anterior to middle depth, there is a 6.3 cm (CC) irregular mass with irregular margins and rim internal enhancement. Worst curve kinetics are initial phase rapid and delayed phase washout. There is central decreased enhancement compatible with necrosis. The mass invades the adjacent dermis. There is focal susceptibility artifact at the superior lateral aspect of the mass compatible with a biopsy clip. There are two small adjacent masses or intramammary lymph nodes at the posterior superior aspect of the mass compatible with satellite lesions. There are multiple abnormal level I axillary lymph nodes, the largest of which contains focal susceptibility artifact compatible with a biopsy clip. Abnormal level II axillary adenopathy is also demonstrated.

FINDINGS

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

Background Parenchymal Enhancement: Moderate

Amount of Fibroglandular Tissue: Heterogenous glandular tissue

LEFT BREAST
Narrative: Negative. No suspicious enhancement or lymphadenopathy.

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: description, ☐ Abnormal internal mammary: description

RIGHT BREAST

Narrative:
Marked decrease in size of the biopsy proven right breast malignancy, with minimal remaining enhancement. The mass measures up to 2.4 cm (AP). There is trace remaining skin enhancement, and minimal skin retraction. The right axillary adenopathy has normalized with all previously identified abnormal nodes, now normal in appearance. There is a left chest wall port in place.

Right breast lesion 1
Lesion type: Mass
2.4 cm. Upper outer Quadrant. 10:00 Radian. 5 cm from the nipple
Mass/post-surgical change: Shape:Irregular. Margins:Not circumscribed-irregular, Enhancement: Heterogeneous. Kinetics: Does not meet threshold

BI-RADS:6: Known biopsy-proven malignancy – Appropriate action should be taken

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: ☐ Abnormal internal mammary

Extramammary findings: Left chest wall port.

SUMMARY:
1) Marked interval decrease in size and enhancement of the biopsy-proven malignancy in the right breast compatible with treatment effect, now measuring up to 2.4 cm with trace remaining skin enhancement and retraction.
2) Resolved right axillary adenopathy.

RECOMMENDATIONS: Follow up with the surgeon or medical oncologist is recommended.

RIGHT BI-RADS: 6: Known biopsy-proven malignancy: Surgical excision when clinically appropriate
LEFT BI-RADS: 1: Negative: Routine breast MRI screening if cumulative lifetime risk =>20%