Wk 4, Case 4 - Review
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This is a patient who had invasive ductal
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carcinoma diagnosed in the left breast.
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We'll start with the left breast,
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and we'll move on to the right.
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So this is the post-GAD non-subtracted
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images, and it has this large area of nod,
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I would call this non-mass enhancement.
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Some people might call it a mass,
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but I think this is all regional
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clumped non-mass enhancement.
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It goes from almost all the way to the
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chest wall, and it goes up into the nipple.
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So this is somebody who's not
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going to be a surgical, uh, a
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lumpectomy candidate on this side.
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Um, there's a couple of nodes that look
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a little suspicious on that side as well.
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They're a little lumpy-bumpy.
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Um, we can talk about nodes
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if you, um, want afterwards.
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You know, that nipple involvement is
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important to identify for the surgeon.
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So that's the ipsilateral breast, which
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I knew about, although I don't think
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they knew it was quite so extensive.
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And then in the right breast, which
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was mammographically normal, there
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were four different abnormalities.
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There were two masses.
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Here's one.
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And then here's that other little
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mass that's pretty adjacent to, and
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one of those was biopsied and shown
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to be invasive ductal carcinoma.
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And then there are two areas of non-mass
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enhancement, this linear area medially here,
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and
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this area inferiorly here,
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which is more segmental.
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Non-mass enhancement, pretty
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homogeneous in that case.
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Um, and this was biopsied and
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it came back as being DCIS.
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So, you know, this was the learning
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point from this case is that we
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do see contralateral malignancies.
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In, um, it depends on the study, three to 5%.
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Um, we did a study that was
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5%, others around three.
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So somewhere in that area, you're going
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to find a contralateral malignancy.
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And of course, that is one of the huge that is
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not otherwise, um, seen on conventional imaging.
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Um, and that is, of course, one of the huge
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advantages of using breast MRI for staging.
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Um, it remains a controversial area.
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Using breast MRI for staging.
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Um, there are proponents and there are
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people who don't feel that it's helpful.
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Um, we, at my institution, every patient
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who has breast cancer, who is, um, under the
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age of 80, um, has a breast MRI, virtually
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a hundred percent, if they can have it.
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You do need to work these up.
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You should never buy RADS 3, a contralateral
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abnormality in a patient who has an ipsilateral
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malignancy, who is likely to be undergoing
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any form of chemo or hormonal therapy.
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The reason being is, you know, if you, um, you
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know, say this patient has a mastectomy and has
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chemotherapy afterwards, or has tamoxifen or
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something, um, and then these areas disappear,
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well, you don't know if they were real or not.
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So you don't know if they were cancer or not.
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So always, um, you should never buy RADS
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3, a contralateral breast in a patient with
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ipsilateral breast cancer for staging.
Petra J Lewis, MBBS
Professor of Radiology and OBGYN
Dartmouth-Hitchcock Medical Center & Geisel School of Medicine at Dartmouth
Sheryl G. Jordan, MD
Professor, Department of Radiology
University of North Carolina School of Medicine
Ryan W. Woods, MD, MPH
Assistant Professor of Radiology
University of Wisconsin School of Medicine and Public Health
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