Interactive Clinical CasesDr. Alice Pocklington and Dr. Anjum Mahatma

Consultant Radiologists

CASE 1

Case 1. 33y. One stop

• PC – dent in right breast. – Re-presentation after 3/12 as getting worse.

• OE – indentation LIQ right breast when arm elevated. No palpable mass. P3.

• (Left breast and both axillae normal clinical exam).

• Right breast US – U1

AUDIENCE POLLWhat would you do next?

1. Reassure and discharge

2. Mammogram

3. Other

Mammogram – M1

AUDIENCE POLL

What would you do next?

1. Reassure and discharge

2. MRI

3. Other

Case 1

• MRI – right breast: LIQ 6 x 4 mm enhancing mass which demonstrates a type II (equivocal) curve on the dynamic contrast enhanced sequences. High signal on T2 and could represent a benign lesion.

• MRI 3

• 2nd look USS and tomosynthesis - normal

• MRI – guided core Bx

AUDIENCE POLL

Most likely diagnosis?

1. Normal fibrotic stroma

2. Fibrocystic change

3. Fibroadenoma

4. Invasive malignancy

5. None of the above

Case 1- PATHOLOGY

• focal proliferation of oval and spindle cells. Ki-67 1%.

• features raise the possibility of fibromatosis however, further clinicopathological and radiological correlation is needed.

• The background breast shows ducts and lobules embedded in focally dense fibrous stroma.

• There is no evidence of in-situ or invasive malignancy (B3).

Case 1 – WLE Pathology

• the excision contains a spindle cell proliferation adj. to biopsy tract changes.

• infiltrative margin with no excess mitotic activity.

• features are consistent with fibromatosis.

• 5mm in max. dimension. Biopsy tract changes are frequently difficult to distinguish from the lesion but margins are considered clear by >2mm.

FIBROMATOSIS OF THE BREAST

• also termed desmoid-type fibromatosis - rare neoplasm (

FIBROMATOSIS OF THE BREAST• Similar clinical presentation to a malignant lesion – mass or

skin dimpling• treatment of choice is primary surgical excision with clear

margins.• characterised by being locally aggressive but not

metastasising.• high rate of recurrence after surgical excision.

• Management of recurrent breast fibromatosis remains controversial because of the low incidence and, in consequence, the limited data.

CASE 2

Case 2. 42y. One stop

• PC – pain and swelling left breast. Several months

– ? a/w trauma. Pt unclear.

• OE – 4cm P5 mass inner left breast. No skin changes. Normal axilla and contralateral breast.

• MG

• US

Imaging -

• Ultrasound guided core biopsy of the palpable abnormality:

• B1

• AUDIENCE POLL – what next?1. Reassure and discharge

2. Rpt US biopsy

3. Further imaging

T2W

Contrast MRI• Left LIQ area of non-Mass enhancement

measuring approx. 44 mm in maximum dimension. It appears to almost completely fill the posterior two thirds of the quadrant.

• Anteromedially within this region, there is a 6 mm more avidly enhancing focus.

• Normal nodes• MRI 4

AUDIENCE POLL

Next step?

1. 2nd look USS and tomosynthesis

2. MRI-guided biopsy

2nd look USS and tomo• No additional abnormality demonstrated.

• Biopsy repeated in area of high vascularity.

AUDIENCE POLL - Most likely diagnosis?1. Fibrotic glandular tissue

2. Diabetic mastopathy

3. DCIS

4. Inflammatory carcinoma

5. None of the above

Low grade Angiosarcoma• Mastectomy specimen shows low grade

angiosarcoma as described on the previous (2nd) biopsy.

• Tumour measures at least 36mm in one section but macroscopically across the slices measures 70mm in maximum dimension. 2mm from the nearest deep margin.

• no evidence of epithelial malignancy

ANGIOSARCOMA OF THE BREAST• Angiosarcoma is a rare soft tissue tumour of the breast.

– primary - without a known precursor– secondary - a/w history of irradiated breast tissue.

• Adjuvant radiotherapy is a major risk factor for SBA. Most cases occur in the surrounding area of the irradiation region and may be associated with chronic lymphatic oedema.

• Primary is usually younger (30-50y). • Both forms have a malignant behaviour and a poor prognosis.

CASE 3

Case 3 – 49y

• Prevalent screening mammogram

• No history of breast disease given

AUDIENCE POLL

NBSS Entry?1. RR

2. Recall - Asymmetry

3. Recall - distortion

4. Recall - Spiculate mass

5. Recall - Calcification

Distortion more apparent on the true lateral, so also had tomosynthesis.(not shown)

US-guided core biopsy• Breast cores showing dense and monotonous

lymphocytic infiltrate. Focal calcification is seen. There is no in-situ neoplasia or evidence of breast carcinoma.

Axillary FNA :• lymphoid cells representing lymph node sampling.

No malignant cells seen. (C2)

Supplementary report (after lymphoma panel performed)

• CONCLUSION:

• Grade 2 follicular lymphoma in the breast biopsy.

• Follicular lymphoma is a systemic malignancy and this patient needs further staging investigations.

AUDIENCE POLL

What further imaging?1. CT

2. MRI

3. PET/CT

4. All of the above

5. None of the above

PET/CT

• Focal parenchymal thickening in the left upper outer quadrant

• Mildly elevated SUV

• No avid lymph nodes

• Low grade uptake in the left breast in keeping with solitary extranodal lymphoma

• Treated with radiotherapy only.

Follicular lymphoma of the breast• Primary breast lymphomas are rare:

< 1 % of all the non-Hodgkin’s lymphomas

• Usually few symptoms or none at all.

• Most frequently painless adenopathy.

• Occ. B symptoms: weight loss, fevers, night sweats, fatigue

CASE 4

Screening – 58y

• Recalled for new calcification right lower outer quadrant.

• Mag views performed

• Clinical exam and USS normal

Stereocore performed

• These cores show duct ectasia, apocrine metaplasia, dilated ducts and cysts; features of fibrocystic change. There are benign microcalcifications some of which of Weddelite type. There is no evidence of in situ or invasive malignancy (B2).

5/7 post procedure

• ED referral - painful mass lower right breast –

• ?abscess

AUDIENCE POLLHow would you manage this?

• US-directed external compression

• Thrombin injection into the pseudoaneurysm

• Surgical intervention

• Attempts at US directed external compression unsuccessful due to pain.

• Surgeons advised no surgical intervention as no longer enlarging.

• Gradually improved over several weeks.

Pseudoaneurysm of the breast• Well recognised complication of diagnostic IR techniques –

esp after femoral or radial artery puncture.• Control often gained with US-guided external compression• Rare but acknowledged complication of breast intervention• Usually a/w core biopsy but has also been documented

secondary to FNA.• Previous case reports documented active surgical

management. Only one managed conservatively.

CASE 5

CASE 5 – 38y• PC: lumpiness left UOQ

• Past history: known benign breast condition, Juvenile Papillomatosis

• OE: lumps left UOQ - P2. Another lower left breast, P2, feels glandular

• F/H Mother had breast cancer

• No recent previous breast imaging available for comparison

• M3 and Tomo 3 left breast,

• U3 left breast, lower left breast more glandular

• Known clinical lump was a normal looking lymph node

• An U/S guided core biopsy performed through inferior left breast as previous biopsy was performed long time ago

Histology

• cores of breast tissue showing small intraductal papillary lesions with focal sclerosis.

• No in situ or invasive malignancy is seen in the material examined (B3).

AUDIENCE POLL

What do you do next?1. Discharge

2. Breast MRI

3. U/S follow up

4. VAE of B3 lesion

5. Surgical excision of B3

• VAE not performed as she was known to have Juvenile Papillomatosis

• Baseline MRI performed due to known risk of breast cancer in her condition

AUDIENCE POLLWhat is your diagnosis?

1. Multiple fibroadenomata

2. Fibrocystic disease

3. Juvenile Papillomatosis

4. Intracystic papillary carcinomatosis

5. Phyllodes tumour

Juvenile papillomatosis

• JP is an infrequent disorder among young women

• mean age at diagnosis - 19 years .

• Approximately 26-58% of the patients have a family history of breast cancer

• The most frequent clinical presentation is a palpable nodule, similar to a fibroadenoma, usually unilateral

• Ultrasound appearance is a well or ill-defined mass with multiple small cysts, especially at the periphery

• On MRI, the most specific finding is the presence of numerous small cysts on T2WI. Contrast enhanced T1WI with fat suppression permits a proper visualisation of contour and internal matrix. Contrast media uptake pattern is that of a benign disease, with type 1-2 curves and high diffusion.

Juvenile papillomatosis• Macroscopically - multicystic mass without capsule, and its size ranges

from 1 to 8 cm

• consists of a localised benign proliferative lesion of the breast also known as “Swiss Cheese”-disease due to its fibrocystic appearance .

• Despite its benign nature, JP has been associated with an increase in the incidence of breast cancer.

ref: Eurorad (cases published in 09/10/17)

CASE 6

Case 6 -34 Y F

• PC: lumpiness left breast, redness, lump left axilla

• CH: 22 weeks pregnant

• OE: P5 mass left axilla, breast enlarged and erythematous

AUDIENCE POLLNext possible investigations?

1. Only U/S

2. Mammogram and U/S

3. U/S and Clinical biopsy

• Mammogram: M3 left , M1 right

• Ultrasound: U3

• An U/S guided core biopsy of left axillary lymph node was performed

Imaging Report Summary• MG - generalised thickening of skin overlying the left

breast. There is subtle increase in density but no discrete mass seen. No focal abnormality in the right breast.

• Classification: M3 left breast, M1 right breast

• US guided core biopsy of left axillary lymph node performed.

AUDIENCE POLL

Likely diagnosis?1. Mastitis with reactive adenopathy

2. Mastitis with axillary tail abscess

3. Invasive malignancy with nodal spread

4. Inflammatory cancer with nodal spread

Histology

• Cores show a lymph node almost completely effaced by metastatic carcinoma

AUDIENCE POLL

Next investigation?1. Another U/S to look for index mass

2. MRI Breasts dynamic with contrast

3. Diffusion weighted imaging WB

4. Staging CT

5. PET

6. All of the above

WB diffusion imaging

Diffusion weighted imaging

• 2.5cm left breast carcinoma with extensive ipsilateral nodal disease only

• No distant metastases - liver, lung, brain and bones are clear.

AUDIENCE POLL

What do you do next?1. Second look U/S of left breast

2. Punch biopsy

3. Proceed with neoadjuvant chemotherapy and further treatment

U/S report

• There is an irregular hypoechogenicity in the upper outer left breast at approximately 1:00 A position. There is some ductal involvement which crosses the midline associated with this mass.

• The total extent measures approximately 43 x 18 mm.

• U4

Histology –US-guided Bx

• A. Cores of breast tissue showing Grade 3 invasive ductal carcinoma with high nuclear grade DCIS. No definite lymphovascular invasion is seen in this specimen (B5b).

• B. Punch biopsy of skin with tumour emboli in the lymphatics, confirming the clinical finding of inflammatory carcinoma.

Discussion - Whole Body DWI• Is a potential investigation and problem solving tool when local and distal

staging cannot be performed in case of pregnancy or where contrast administration is contraindicated due to deranged renal function/ contrast allergy

• In this case, we were also able to localise the index breast carcinoma on 2nd look U/S

Ref: 1.Whole body MRI for systemic staging of breast cancer in pregnant women , The Breast, July 2017 2. Difficulties with diagnosis of malignancies in pregnancy,Clinical Obstetrics and Best Practice & Research Gynaecology, 2016

CASE 7

Case 7- 62y• PC - Left breast now smaller with puckering and thickening in

lower pole.

• PMHx - bilateral LD-implant reconstruction for ?DCIS left side 19 y ago.

• OE - thickening lateral right breast - left breast is smaller

• Bilateral breast US performed

AUDIENCE POLL

What do you do next?1. Follow up ultrasound in few weeks

2. U/S guided FNA of mass

3. U/S guided biopsy of mass

4. MRI breasts with implant protocol

5. MRI breasts with contrast

FNA

• An ultrasound-guided FNA of the lesion within the muscle in the medial right breast.

Cytology

• smears show lymphoid cells in various stages of maturation.

• features are consistent with a reactive lymph node. No malignant cells are seen (C2).

→Implant protocol MRI

Report: Implant Protocol MRI• Appearances suggest bilateral intracapsular rupture, with a 41 mm

mass between layers of right breast implant has an unusual appearance .

AUDIENCE POLL Most likely diagnosis?1. Silicone-induced granuloma2. Odd appearance of implant rupture3. Implant associated Anaplastic Large cell lymphoma4. Cancer of breast origin

MIP images of both breasts

RIGHT LEFT

Report: MRI breasts with contrast

• Whilst the lateral aspect of the mass in the medial reconstructed right breast may represent a silicone granuloma, the avid enhancement in the medial half is suspicious

• Classification:

• left breast -MRI 2; right breast - MRI 4

AUDIENCE POLLWhat do you do next?

1. U/S guided core biopsy

2. Surgical implant removal

3. PET scan

• She had ultrasound guided core biopsy of mass

• Histology: features are consistent with the known history of ruptured implant (B1/B2)

• No neoplastic process seen

Silicone induced granuloma• An intracapsular mass - usually has a high heterogeneous signal in T2-

weighted sequences and hyposignal in T1-weighted sequences• It has hyposignal of the rim on dynamic scans• Delayed enhancement

• Slow-growing mass that has a compressive effect on the breast implant

• Its main differential diagnosis is intracapsular haematoma, which makes the use of intravenous contrast essential

• Ref: Breast magnetic resonance imaging: tips for the diagnosis of silicone-induced granuloma of a breast implant capsule (SIGBIC) : Insights into imaging 2017

CASE 8

Case 8- 34 year old F

• PMHx: High risk screening previously treated with radiotherapy for Hodgkins Lymphoma

• She was having yearly screening MRI

Imaging in 2014

MRI 3 right breast, MRI 1 left breast

Further assessement

• MG: M1

• U/S: Well defined mass which was benign looking but biopsied. No other abnormality seen

• Histology: B2

MRI report

• MRI 4 right breast, MRI 1 left breast

AUDIENCE POLL

What do you do next?1. Return back to screening

2. Assessment

3. MRI guided biopsy

Assessment• Mammogram: Normal• U/S nil focalAUDIENCE POLL• What do you do next?

1. Early follow up MRI2. MRI guided biopsy3. Return back to screening

MRI guided biopsy

Histology:

Breast tissue showing high nuclear grade DCIS of solid, cribriform and comedo morphology.

No evidence of invasive malignancy in the sections examined.

Discussion

• Asymmetrical non mass enhancement in High risk group should be interpreted with caution

• Correlating with T2 weighted imaging is important, to see if there is fibrocystic change in area of enhancement

• Low threshold for recall, and for MRI guided biopsy helps in arriving at early diagnosis

To ConcludeWe have presented:

• Salient features of some uncommon breast diseases

• Diseases with complex diagnostic pathways

• A rare post-procedural complication, to remind us that they do occur.