Wk 4, Case 4 - Review

HISTORY: 49 year old woman presented with recently diagnosed invasive ductal carcinoma with micropapillary features grade 2 left breast cancer presented to evaluate extent of disease

Summary of prior imaging

Mammography: In the setting of extremely dense breasts, there is global asymmetry in the upper outer quadrant of the left breast anterior and middle depths. There is an incompletely visualized enlarged left axillary lymph node.

Ultrasound: Poorly delineated architectural distortion and hypoechoic masses with posterior acoustic shadowing is noted in the left breast from 10:00 to 3:00 1-7 cm from the nipple at the site of palpable mass. There are 2 enlarged left axillary lymph nodes.

Breast MRI: None

FINDINGS

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

Background Parenchymal Enhancement: Mild
Amount of Fibroglandular Tissue: Extreme fibroglandular tissue

LEFT BREAST

Narrative: There is clumped enhancement spanning 10 cm in confluent manner in the upper outer quadrant and upper inner quadrant anterior and middle depths. Abnormal enhancement abuts the lateral areolar margin anteriorly and measures 3 mm from the superficial pectoralis fascia posteriorly. The enhancement extends into the lower outer quadrant to lesser degree.

Type III kinetics predominate. There is no associated nipple retraction or skin enhancement. There are 4-5 enlarged level I axillary lymph nodes.

Left breast lesion 1
Lesion type: Non-mass enhancement
10 cm. Multicentric Upper outer and Upper inner and Lower outer Quadrant, to within less than 1 cm from the nipple

Non mass enhancement: Distribution: Diffuse, Internal enhancement: Clumped, Kinetics: delayed- Washout

BI-RADS:6: Known biopsy-proven malignancy: Surgical exicision when clinically appropriate

Associated findings LEFT: ☒NONE, ☐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: ☐NONE, ☒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: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

Lymph nodes LEFT: ☐Normal axillary, ☒Abnormal axillary: abnormal level 1 lymph nodes, 4-5 in number, ☐ Abnormal internal mammary

RIGHT BREAST

Narrative: There are adjacent enhancing irregular masses in the upper inner quadrant middle depth measuring 1.2 and 0.7 cm, overall 1.7 x 1.3 cm with Types II and III kinetics. There is NME in linear distribution in the lower inner quadrant middle depth measuring 2.1 cm with Type II kinetics. There is NME in regional distribution in the lower outer quadrant middle depth measuring 4.4 cm with Type I kinetics.

Right breast lesion 1
Lesion type: Mass
1.2 cm. Upper inner Quadrant. 2:00 Radian. 4.0 cm from the nipple

Mass/post-surgical change: Shape:Irregular. Margins:Not circumscribed-irregular.
Enhancement: Homogenous. Kinetics: delayed- Washout

BI-RADS: 5: Highly suggestive of malignancy: Tissue diagnosis

Right breast lesion 2
Lesion type: Mass
0.7 cm. Upper inner Quadrant. 2:00 Radian. 5.5 cm from the nipple

Mass/post-surgical change: Shape:Irregular. Margins:Not circumscribed-irregular.
Enhancement: Homogenous. Kinetics: delayed- Washout

BI-RADS: 5: Highly suggestive of malignancy: Tissue diagnosis

Right breast lesion 3
Lesion type: Non-mass enhancement
2.1 cm. Lower inner Quadrant. 3:30 Radian. 6.0 cm from the nipple

Non mass enhancement: Distribution: Linear, Internal enhancement: Homogenous, Kinetics: delayed- Cannot assess

BI-RADS: 4: Suspicious abnormality: Tissue diagnosis

Right breast lesion 4
Lesion type: Non-mass enhancement
4.4 cm. Lower outer Quadrant. 7:00 Radian. 5.5 cm from the nipple

Non mass enhancement: Distribution: Regional, Internal enhancement: Heterogenous, Kinetics: delayed- Progressive

BI-RADS: 2: Benign: Routine breast MRI screening if cumulative lifetime risk =>20%

Associated findings RIGHT breast: ☒NONE, ☐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: ☒NONE, ☐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: ☒NONE, ☐Fat necrosis, ☐Hamartoma, ☐Post-operative seroma/hematoma with fat

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

Extramammary findings: None

SUMMARY:

LEFT BI-RADS: 6: Known biopsy-proven malignancy: Surgical excision when clinically appropriate.

RIGHT BI-RADS: 5: Highly suggestive of malignancy: Tissue diagnosis

RECOMMENDATIONS: Recall for second look ultrasound to assist pre-biopsy planning right breast upper inner quadrant masses and lower inner quadrant NME.