Answer for CoW 28 May 2017
INFILTRATIVE DUCTAL ADENOCARCINOMA OF LEFT BREAST.
Findings
T2 hypointense lesion with lobulated margins seen in upper outer quadrant of left breast. It just abutts the skin Lesion shows diffusion restriction with low ADC values . On contrast administration, it shows heterogenous enhancement with type 3 kinetic pattern of TIC ( Time intensity curve).
Discussion
There are two main approaches to image interpretation: lesion morphology assessment of enhancement kinetics. Benign lesions tend to be well defined with smooth margins, whereas malignant lesions are poorly defined and may show spiculation or parenchymal deformity. Malignant lesions usually show a rapid uptake of contrast agent in the initial phase of the examination, followed by a washout or plateau in the intermediate and late periods after injection, whereas benign lesions exhibit a steady increase in signal intensity throughout the time course of the examination. The use of the breast imaging reporting and data system (BIRADS) lexicon aids in reporting.Using this system, lesions can be characterised into one of three morphological groups: (1) a focus (a lesion <5 mm, rarely worthy of further investigation); (2) a mass (>5 mm); and (3) non-mass enhancement (an area of enhancement without a morphological correlate). Normal breast tissue may enhance and this enhancement is in part dependent on the phase of the menstrual cycle. The optimum time for performing a breast MRI is during the second week of the menstrual cycle (between days 7 and 13) when background glandular enhancement should be least intense. If a mass is irregularly shaped, it has a 32% chance of being malignant. Spiculated margins are frequently a feature of malignant breast lesions and radial scars. If a mass has spiculated margins, it has an 80% chance of being malignant. Bright signal on T2 fat-suppressed images are benign except colloid carcinoma.Moderate and low signal intensities can be caused by cancer. LEXICON Density background enhancement none/minimal: <25% mild: 25-50% moderate: 50-75% marked : >75% focus < 5 mm: cannot characterize margins, etc mass enhancement shape: round, oval, lobulated, irregular margins: smooth, irregular, speculated internal: homogenous, heterogenous , rim, internal septations, central (target) non mass enhancement focal, linear ductal, linear clumped, segmental patchy/clumped, regional, diffuse stippled, punctate, bilateral symmetric - it is important to scan both breasts for comparison linear enhancement enhancement kinetics: washout, plateau, persistent ~ 70% of invasive cancers wash out ~ 9% of DCIS washes out INDICATIONS FOR BREAST MRI Local staging of primary breast cancer. MRI is the most accurate technique for sizing invasive breast carcinoma . MRI is used in mammographically occult lesions and dense breasts. Patients whose carcinomas have lobular features. Lobular carcinomas are more likely to be multifocal compared with ductal carcinoma. Another important role of MRI is identifying an occult primary tumour in women presenting with malignant axillary lymphadenopathy with a normal mammogram and breast ultrasound MRI is also useful in the postsurgical breast, differentiating surgical scarring from tumour recurrence. MRI can help to assess the response to treatment in women receiving neoadjuvant chemotherapy . MRI can be used to plan the extent of surgical resection in positive responders, with successful breast conservation. MRI has become an important tool for screening younger women with a high familial risk of breast cancer. Time intensity curve or Kuhl enhancement curves. type I curve: progressive enhancement pattern typically shows a continuous increase in signal intensity throughout time usually considered benign with only a small proportion of (~9%) of malignant lesions having this pattern type II curve: plateau pattern initial uptake followed by the plateau phase towards the latter part of the study considered concerning for malignancy type III curve: washout pattern has a relatively rapid uptake shows reduction in enhancement towards the latter part of the study considered strongly suggestive of malignancy/
References:
Virginia Molleran, MD*, Mary C. Mahoney, MD The BI-RADS Breast Magnetic Resonance Imaging Lexicon Magn Reson Imaging Clin N Am 18 (2010) 171–185. Basak Erguvan-Dogan1 Gary J. Whitman1 Anne C. Kushwaha1,2 Michael J. Phelps1,3 Peter J. Dempsey WOMEN’S IMAGING BI-RADS–MRI: A Primer AJR 2006; 187:W152–W160 0361–803X/06/1872–W152 GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY A Textbook of Medical Imaging , 6TH EDITION
Findings
T2 hypointense lesion with lobulated margins seen in upper outer quadrant of left breast. It just abutts the skin Lesion shows diffusion restriction with low ADC values . On contrast administration, it shows heterogenous enhancement with type 3 kinetic pattern of TIC ( Time intensity curve).
Discussion
There are two main approaches to image interpretation: lesion morphology assessment of enhancement kinetics. Benign lesions tend to be well defined with smooth margins, whereas malignant lesions are poorly defined and may show spiculation or parenchymal deformity. Malignant lesions usually show a rapid uptake of contrast agent in the initial phase of the examination, followed by a washout or plateau in the intermediate and late periods after injection, whereas benign lesions exhibit a steady increase in signal intensity throughout the time course of the examination. The use of the breast imaging reporting and data system (BIRADS) lexicon aids in reporting.Using this system, lesions can be characterised into one of three morphological groups: (1) a focus (a lesion <5 mm, rarely worthy of further investigation); (2) a mass (>5 mm); and (3) non-mass enhancement (an area of enhancement without a morphological correlate). Normal breast tissue may enhance and this enhancement is in part dependent on the phase of the menstrual cycle. The optimum time for performing a breast MRI is during the second week of the menstrual cycle (between days 7 and 13) when background glandular enhancement should be least intense. If a mass is irregularly shaped, it has a 32% chance of being malignant. Spiculated margins are frequently a feature of malignant breast lesions and radial scars. If a mass has spiculated margins, it has an 80% chance of being malignant. Bright signal on T2 fat-suppressed images are benign except colloid carcinoma.Moderate and low signal intensities can be caused by cancer. LEXICON Density background enhancement none/minimal: <25% mild: 25-50% moderate: 50-75% marked : >75% focus < 5 mm: cannot characterize margins, etc mass enhancement shape: round, oval, lobulated, irregular margins: smooth, irregular, speculated internal: homogenous, heterogenous , rim, internal septations, central (target) non mass enhancement focal, linear ductal, linear clumped, segmental patchy/clumped, regional, diffuse stippled, punctate, bilateral symmetric - it is important to scan both breasts for comparison linear enhancement enhancement kinetics: washout, plateau, persistent ~ 70% of invasive cancers wash out ~ 9% of DCIS washes out INDICATIONS FOR BREAST MRI Local staging of primary breast cancer. MRI is the most accurate technique for sizing invasive breast carcinoma . MRI is used in mammographically occult lesions and dense breasts. Patients whose carcinomas have lobular features. Lobular carcinomas are more likely to be multifocal compared with ductal carcinoma. Another important role of MRI is identifying an occult primary tumour in women presenting with malignant axillary lymphadenopathy with a normal mammogram and breast ultrasound MRI is also useful in the postsurgical breast, differentiating surgical scarring from tumour recurrence. MRI can help to assess the response to treatment in women receiving neoadjuvant chemotherapy . MRI can be used to plan the extent of surgical resection in positive responders, with successful breast conservation. MRI has become an important tool for screening younger women with a high familial risk of breast cancer. Time intensity curve or Kuhl enhancement curves. type I curve: progressive enhancement pattern typically shows a continuous increase in signal intensity throughout time usually considered benign with only a small proportion of (~9%) of malignant lesions having this pattern type II curve: plateau pattern initial uptake followed by the plateau phase towards the latter part of the study considered concerning for malignancy type III curve: washout pattern has a relatively rapid uptake shows reduction in enhancement towards the latter part of the study considered strongly suggestive of malignancy/
References:
Virginia Molleran, MD*, Mary C. Mahoney, MD The BI-RADS Breast Magnetic Resonance Imaging Lexicon Magn Reson Imaging Clin N Am 18 (2010) 171–185. Basak Erguvan-Dogan1 Gary J. Whitman1 Anne C. Kushwaha1,2 Michael J. Phelps1,3 Peter J. Dempsey WOMEN’S IMAGING BI-RADS–MRI: A Primer AJR 2006; 187:W152–W160 0361–803X/06/1872–W152 GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY A Textbook of Medical Imaging , 6TH EDITION
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!