1. Radiological imaging of
malignant breast diseases.
Dr/ ABD ALLAH NAZEER. MD.

2. Breast cancer is a malignant tumor that starts in the cells of
the breast. A malignant tumor is a group of cancer cells that
can grow into (invade) surrounding tissues or spread
(metastasize) to distant areas of the body. The disease occurs
almost entirely in women, but men can get it, too.
Breast cancer.
Most breast cancers begin in the cells that line the ducts
(ductal cancers). Some begin in the cells that line the lobules
(lobular cancers), while a small number start in other tissues.
The lymph (lymphatic) system of the breast.
Most lymphatic vessels in the breast connect to lymph nodes
under the arm (axillary nodes). Some lymphatic vessels
connect to lymph nodes inside the chest (internal
mammary nodes) and those either above or below the
collarbone (supraclavicular or infra-clavicular nodes).

6. Carcinoma:
This is a term used to describe a cancer that begins in the lining layer
(epithelial cells) of organs like the breast. Nearly all breast cancers are
carcinomas (either ductal carcinomas or lobular carcinomas).
Adenocarcinoma:
An adenocarcinoma is a type of carcinoma that starts in glandular
tissue (tissue that makes and secretes a substance). The ducts and
lobules of the breast are glandular tissues (they make breast milk),
so cancers starting in these areas are often called adenocarcinomas.
Carcinoma in situ:
This term is used for an early stage of cancer, when it is confined to the
layer of cells where it began. In breast cancer, in situ means that the
cancer cells remain confined to ducts (ductal carcinoma in situ). The
cells have not grown into (invaded) deeper tissues in the breast or
spread to other organs in the body. Ductal carcinoma in situ of the
breast is sometimes referred to as non-invasive or pre-invasive breast
cancer because it might develop into an invasive breast cancer if left
untreated.

7. When cancer cells are confined to the lobules it is called lobular
carcinoma in situ. This is not actually a true cancer or pre-cancer, and is
discussed more in the section, “What are the risk factors for breast
cancer?”
Invasive (infiltrating) carcinoma:
An invasive cancer is one that has already grown beyond the layer of
cells where it started (as opposed to carcinoma in situ). Most breast
cancers are invasive carcinomas—either invasive ductal carcinoma or
invasive lobular carcinoma.
Sarcoma (Fibrosarcoma, liposarcoma, leiomyosarcoma and malignant
fibrous histiocytoma):
Sarcomas are cancers that start in connective tissues such as muscle
tissue, fat tissue, or blood vessels. Sarcomas of the breast are rare.
Paget disease of the nipple(1%):
Rare manifestation of breast cancer.
Primary carcinoma of mammary duct that invaded the skin.
Chronic eczematoid lesion of the nipple.
It present with erythematous eruption and purities.

8. Breast lymphoma.
Breast lymphomas can be either primary or secondary. Both are rare
accounting for 0.3 - 1.1 % of all breast malignancies.
Primary lymphoma of the breast is less common than secondary
lymphoma, and is typically a B cell type of non-Hodgkin's lymphoma
(NHL). Primary non-Hodgkin’s lymphoma of the breast represent only
about 0.12 - 0.53% of all reported malignant breast tumors.
Secondary lymphoma of the breast, is also more frequently NHL than
Hodgkin's lymphoma.
The axillary nodes are often large. It may present either as a palpable
mass or as diffuse thickening of the breast.
Inflammatory carcinoma of the breast(1.5-3%).
Inflammatory carcinoma of the breast (or inflammatory breast cancer -
IBC) is a relatively uncommon but aggressive form of invasive breast
carcinoma which has a characteristic clinical presentation and unique
radiographic appearances. Any pathological sub-type of breast cancer
may be involved .

9. Non-invasive carcinoma:(10%).
1- Ductal carcinoma in situ (DCIS; also known as intraductal
carcinoma) is considered noninvasive or pre-invasive breast cancer.
DCIS means that cells that lined the ducts have changed to look like
cancer cells. The difference between DCIS and invasive cancer is that
the cells have not spread (invaded) through the walls of the ducts
into the surrounding breast tissue. DCIS is considered a pre-cancer
because some cases can go on to become invasive cancers. Right
now, though, there is no good way to know for certain which cases
will go on to become invasive cancers and which ones won’t. About
1 in 5 new breast cancer cases will be DCIS. Nearly all women
diagnosed at this early stage of breast cancer can be cured.
2- Lobular carcinoma in situ.
This is not a true cancer or pre-cancer, and is discussed in the
section “What are the risk factors for breast cancer?”
3- Paget's disease.

10. Invasive breast carcinoma(85%, 5%-year survival rate).
There are some special types of breast cancer that are sub-types of invasive
carcinoma.
These are often named after features seen when they are viewed under the
microscope, like the ways the cells are arranged.
Some of these may have a better prognosis than standard infiltrating ductal
carcinoma.
These include:
· Adenoid cystic (or adenocystic) carcinoma
· Low-grade adenosquamous carcinoma (this is a type of metaplastic
carcinoma)
· Medullary carcinoma(4%).
· Mucinous (or colloid) carcinoma(3%).
· Papillary carcinoma(2%).
· Tubular carcinoma(2%).
Some sub-types have the same or maybe worse prognosis than standard
infiltrating ductal carcinoma. These include:
· Metaplastic carcinoma (most types, including spindle cell and squamous)
· Micropapillary carcinoma
· Mixed carcinoma (has features of both invasive ductal and lobular).

15. Ductal Carcinoma in Situ.
Seen as microcalcifications on mammogram
Confined to ductal cells.
No invasion of the underlying basement membrane.
Chance of recurrence 25-50% in 5 years, of these 50% will be invasive
Ductal carcinoma in-situ (DCIS).

16. Ductal carcinoma in-situ (DCIS) with enlarged axillary lymph nodes.

17. Comparison of ss-DWI and rs-DWI in a 40-year-old woman with DCIS. Significantly
stronger geometric distortion, image blurring and ghosting artifacts can be seen on ss-
FDWI (a) compared with rs-FDWI (b). Rs-FDWI (b) also provides significantly higher
anatomic detail than ss-FDWI (a) because of reduced T2* blurring. Arrows=DCIS

18. DCIS. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal linear nonmasslike high signal
intensity in the medial lower quadrant of left breast (arrows). DCE-MRI (e) shows linear
nonmasslike enhancement. Significantly stronger geometric distortion, image blurring and
ghosting artifacts (arrowheads) can be seen on ss-DWI (a) and ss-FDWI (c). Rs-DWI (b) and rs-
FDWI (d) show higher anatomic detail similar to DCE-MRI because of reduced T2* blurring

19. Lobular Carcinoma in Situ.
Not detectable on mammography
Most commonly found incidentally
Risk of invasive breast cancer in 20 years is 15-20% bilaterally.

20. Invasive lobular carcinoma with lobular carcinoma in situ.

22. Paget’s Disease.
Uncommon
Usually involves the nipple
Histologically, vacuolated cells are seen in the epidermis of the nipple and
result in an eczematous dermatitis of the nipple.
It is generally associated with an underlying intraductal or invasive
carcinoma.
Mammography should be performed
About 30% of patients have axillary node metastasis at diagnosis.
Mastectomy is the standard of treatment
80% have a 10 year survival rate if there is no mass present and no
axillary nodes are involved.

23. Paget’s disease of the nipple.

24. Paget’s disease of the nipple.

25. Invasive breast cancer is cancer that spreads outside the membrane
of the lobule or duct into the breast tissue. The cancer can then spread into
the lymph nodes in the armpit or beyond.
When breast cancer cells are found in other parts of the body, the cancer is
called metastatic breast cancer.
The two most common types of invasive breast cancer include:
Invasive ductal carcinoma (IDC). With IDC, cancer cells start in a milk
duct, break through the duct walls, and then invade fatty breast tissue.
IDC can remain localized, which means it stays near the site where the
tumor originated. Or the cancer cells may enter the bloodstream or
lymphatic system and metastasize -- spread -- anywhere in the body.
Invasive ductal carcinoma is the most common type of invasive breast
cancer. It accounts for 80% of invasive cancers.
lobular carcinoma (ILC). This cancer accounts for about 10% to 15% of
Infiltrating (invasive) invasive breast cancers. ILC starts in the lobules or
milk glands. It then spreads in a way similar to IDC. With ILC, most women
feel a mass or thickening instead of a breast lump.
There are mixed types of IDC and ILC and other less common types of
invasive breast cancer.

27. T1, axial, postcontrast source (non-subtracted) images were obtained at 3T with
75-second temporal resolution (every second slice through lesion shown). The
irregular mass shows classic rim enhancement and a signal void is noted (arrow),
placed at the time of prior percutaneous needle core biopsy. The irregular shape
and rim enhancement are characteristic of malignancy -- in this case, a high-
grade invasive ductal cancer (IDC), triple-negative subtype.

28. High-grade intra-ductal carcinoma(IDC).

33. Irregular shaped hyperdense mass with spiculated margin in Rt. UOQ. (arrow) US: About
1.7cm sized microlobulated round mass is seen in Rt. breast 11o’clock direction, 5cm from
nipple. MRI : Irregular margined and shaped mass (arrowhead) is seen in Rt. LIQ, about
2.2cm in maximal diameter. On dynamic study, the mass shows steady enhancement.

34. Left breast ILC. (a) This lesion as irregular margins and low signal intensity on axial
T2-weighted images (arrow), and (b) show enhancement on axial dynamic studies. (c)
In Diffusion weighted sequence (b=1000), water restriction produces hyperintensity in
the tumor area , matching the low signal in the ADC map (d).

35. On MRI, the ILC corresponds to a mass with irregular margins and low
signal intensity septa on axial T2-weighted images (arrows), (b) showing
enhancement on axial dynamic studies and (c) axial subtraction images

36. On MRI, the ILC corresponds to a mass with irregular margins and low signal intensity
septa on axial T2-weighted images and enhancement on axial dynamic studies .

37. Invasive ductal carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal high signal intensity
mass (arrows) without intraductal spread in the lateral portion of right breast. DCE-MRI (e) shows
masslike enhancement with heterogeneous internal enhancement and smooth margin. Significantly
stronger geometric distortion, image blurring and ghosting artifacts (arrowheads) can be seen on ss-DWI
(a) and ss-FDWI(c) compared with rs-DWI (b) and rs-FDWI (d). Rs-DWI (b) and rs-FDWI (d) provide
significantly higher anatomic detail than ss-DWI and FDWI because of reduced T2* blurring.

38. Invasive ductal carcinoma of bilateral breasts in a 52-year-old woman. Ss-DWI (a), rs-DWI
(b), ss-FDWI (c) and rs-FDWI (d) reveal an irregular high signal intensity mass (arrows) in
the lateral portion of left breast and a minimally irregular high signal intensity mass
(arrowheads). DCE-MRI (e) shows the irregular enhancing mass in the left breast (arrow)
and the minimally irregular enhanced mass in right breast (arrowhead) . Rs-DWI (b) and rs-
FDWI (d) provide significantly higher anatomic detail than ss-DWI (a) and ss-FDWI (c)
because of reduced T2* blurring. However, signal intensity of right breast lesion on ss-DWI
(a) and ss-FDWI (c) is higher than that of left breast on rs-DWI (b) and rs-FDWI (d).

39. Invasive lobular carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal segmental
nonmasslike high signal intensity in the central portion of right breast. DCE-MRI (e) shows
segmental nonmasslike enhancement. Rs-DWI (b) and rs-FDWI (d) show significantly higher
anatomic detail than ss-DWI (a) and ss-FDWI (c) because of reduced T2* blurring

40. Right (a) CC (craniocaudal) and (b) MLO (mediolateral oblique) views show at 12
o’clock, a low-density circumbscribed mass with irregular margins (arrows). (c)
On US scan this mass show heterogeneous echogenicity and posterior acoustic
enhancement. Core needle biopsy revealed a mucinous carcinoma.

41. Right breast mucinous carcinoma. (a) This lesion has high signal intensity on
axial T2-weighted images (ellipse), and show progressive enhancement on
(b) axial dynamic studies and on (c) axial and (d) sagittal subtraction images.

42. Mucinous carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c), rs-FDWI (d) and STIR (e) reveal marginal
high signal intensity mass (arrows) in the lateral portion of right breast. DCE-MRI (f) shows
marginal enhancement with heterogeneous internal enhancement (arrow). Significantly stronger
geometric distortion and image blurring can be seen on ss-DWI (a) and ss-FDWI(c) compared with
rs-DWI(b) and rs-FDWI (d) . Rs-DWI (b) and rs-FDWI (d) provide significantly higher anatomic detail
than ss-DWI (a) and ss-FDWI (c) because of reduced T2* blurring. However, incomplete fat
suppression can be seen on rs-DWI(b) and rs-FDWI (d) (arrowhead).

43. Invasive lobular carcinoma of the breast.

44. Invasive lobular carcinoma of the breast.

45. Two cases of invasive lobular carcinoma

48. Invasive lobular carcinoma

49. Left (a) CC and (b) MLO mammographic views show a large and relatively circumscribed
ovalar lesion in the upper outer quadrant, with high-density. (c) On US scan it consists
on a complex cyst (*) with a parietal ill-defined mass (arrows). US-guided core needle
biopsy of the intracystic mass revealed a malignant phyllodes tumor.

50. Mammographic MLO projection shows a large irregular mass in the superior
right breast (arrow) and enlarged axillary lymph nodes. This mass is also seen on
the sagittal contrast-enhanced MR image (arrow) and on the axial angiomap
(arrow). Contrast enhancement is also evident in the chest wall muscles shown
on the sagittal MR image (circle) and the axial angiomap (circle), indicating
chest wall invasion. Muscle or chest wall enhancement is indicative of invasion

51. The images above are from a recent breast MRI patient that detail a
cancerous lesion in the left breast. The graph to the right is called a
washin/washout curve. When it spikes rapidly, this generally indicates cancer.

52. Inflammatory breast carcinoma (IBC), a rare and
aggressive form of breast cancer, has an incidence in the United
States of between 1% and 6% . Primary IBC is characterized by
the rapid development of aggressive inflammatory skin
changes and tumor growth in a previously healthy breast. The
clinical presentation of IBC is predominantly defined by the
inflammatory component and has been extensively described.
The diagnostic criteria for IBC as defined by the American Joint
Committee on Cancer include nonspecific findings of diffuse
erythema, edema, or peau d’orange changes in the breast,
frequently without an underlying palpable mass or primary
breast lesion identified by imaging and with the biopsy
diagnosis of invasive cancer. The most characteristic pathologic
feature of tumor emboli within dermal lymphatic vessels is not
always detected on skin biopsy.

54. Right inflammatory breast carcinoma. Axial contrast-enhanced T1-
weighted VIBRANT MP (GE Healthcare) (top) and subtraction (bottom)
images show enlarged right breast with global skin thickening and
asymmetric diffuse non mass like parenchymal enhancement (arrows).

55. Inflammatory breast carcinoma. Sagittal unenhanced T2-weighted
image with fat suppression shows hyperintensity of breast parenchyma
and chest wall (arrows) as a result of diffuse tissue edema.

56. Inflammatory breast carcinoma. Sagittal contrast-enhanced T1-weighted VIBRANT MP
image shows enhancing lesions (arrows) within thickened skin. Time–signal intensity
curve shows delayed persistent enhancement of skin lesion on delayed phase.

57. Inflammatory breast carcinoma and locoregional metastatic adenopathy. A, Sagittal
maximum-intensity-projection image of left breast after IV contrast administration shows
multiple heterogeneous enhancing breast masses (long arrows) and enlarged left axillary
lymph node (short arrow). B, Left lateromedial mammogram shows neither mass nor
architectural distortion. C, Extended-FOV ultrasound image shows multiple hypoechoic
masses (long arrows) and marked overlying subcutaneous edema (short arrows).

58. Inflammatory breast carcinoma. Sagittal contrast-enhanced T1-weighted
VIBRANT image shows mass lesion (arrows) with irregular shape, spiculated
margins, and heterogeneous internal enhancement.

59. Colloid carcinoma.

60. Sarcoma with osseous differentiation.

61. Metaplastic carcinoma .

62. Breast lymphoma.
Breast lymphomas can be either primary or secondary. Both are rare
accounting for 0.3 - 1.1 % of all breast malignancies.
Primary lymphoma of the breast is less common than secondary
lymphoma, and is typically a B cell type of non-Hodgkin's lymphoma
(NHL). Primary non-Hodgkin’s lymphoma of the breast represent only
about 0.12 - 0.53% of all reported malignant breast tumors.
For a tumour to be labeled as a primary breast lymphoma it is required to
fulfill the following criteria :
disease should be in the breast or in close proximity to breast tissue
no evidence of widespread disease should be there
no previous history of lymphoma
ipsilateral lymph nodes may be involved if developing simultaneously with
primary breast tumor.
Secondary lymphoma of the breast, is also more frequently NHL than
Hodgkin's lymphoma.
The axillary nodes are often large. It may present either as a palpable
mass or as diffuse thickening of the breast.

63. Core biopsy shows diffuse
large B-cell lymphoma of
right breast.

64. Lymphoma of Both breast

65. HIV infection with bilateral breast lymphoma.

66. Metastatic Neuroendocrine carcinoma to the breast

67. Metastases to the breast.
Metastases to the breast from non-mammary primary tumours are
uncommon and account for 0.5-2.0% of all breast malignancies.
Primary sites:
The most frequent source of a metastatic breast lesion is the
contralateral breast .
The most common extra-mammary cancers that metastasise to breast
are:
lymphoma / leukaemia: most common extra mammary source.
melanoma
sarcomas
prostate cancer: considered on the most frequent primary sites in men.
lung cancer
gastric cancer
ovarian cancer
renal cell cancer

68. Metastatic cervical carcinoma.

69. Metastatic Malignant melanoma to the breast

70. Metastatic Non-Hogkin Lymphoma to the breast.

71. Metastatic Rhabdomyosarcoma to the breast.

72. Metastatic Multiple
Myeloma to the
breast.

73. Monitoring of Neoadjuvant Chemotherapy by MR Spectroscopy.

74. pre- and post-chemotherapy MRI appearance of breast
cancer in a patient who had complete response to therapy.

78. Pet scan showing breast cancer )(red arrows)

80. Thank You.