Malignant breast lesion

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Malignant breast lesion

  1. 1. CaseCase PresentationPresentation Radiology HMCRadiology HMC
  2. 2. PATIENT PROFILE • Age : 50yr • Gender : Female • Address : Peshawar • Profession : House wife
  3. 3. CHIEF COMPLAINTS • Mass in right breast 8 months • Pain in right breast 1 month
  4. 4. • PAST MEDICAL/ SURGICAL Hx • MENSTRUAL/OBSTETRICAL Hx • DRUG Hx • FAMILY Hx
  5. 5. LUMP EXAMINATION Location Upper inner quad. Size 3x2 cm Appearance Normal Temperature Normal Tenderness Present Margins Irregular Consistency Hard Motility Immobile
  6. 6. AXILLARY LYMPH NODES • Palpable nodes • In right axilla • Anterior group • 1-2 cm size
  7. 7. ULTRASOUND BREAST
  8. 8. Well defined, rounded lesion 2.2x2 cm Heterogenous parenchyma Irregular margin Echogenic foci--- microcalcifications
  9. 9. MAMMOGRAPHY
  10. 10. Superiomedial Well defined round Radiopaque Foci of calcification + parenchymal distortion Microcalcifications dispersed in parenchyma
  11. 11. DIAGNOSIS ???DIAGNOSIS ???
  12. 12. MALIGNANT BREAST LESION.
  13. 13. RISK FACTORSRISK FACTORS • Female gender • Aging • Genetic factors • BRCA 1&2 • P53 • PTEN • CHEK2
  14. 14. • Family history of breast ca • Past hx of breast cancer • Breast diseases • Atypical hyperplasia • Carcinoma in situ
  15. 15. • Menstrual hx • Early menarche, • late menopause • Nulliparous • Lack of breast feeding • Late age pregnancy
  16. 16. • Drugs • Oral contraceptives • Diethlystilbesterol • Chest radiation • Metabolic • Obese • Alcohol • Fat
  17. 17. RADIOLOGICAL TOOLS INRADIOLOGICAL TOOLS IN DIAGNOSINGDIAGNOSING – Ultrasound – Mammography – MRI – PET – Complex cyst aspiration – FNAC – Core biopsy – Ductography
  18. 18. ULTRASOUNDULTRASOUND INDICATIONS • Symptomatic breast lumps in women aged less than 35 years. • Breast lump developing during pregnancy or lactation. • Assessment of mammographic abnormality (± further mammographic views)
  19. 19. • Assessment of MRI or scintimammography detected lesions. • Clinical breast mass with negative mammograms. • Breast inflammation. • The augmented breast (together with MRI).
  20. 20. • Breast lump in a male (together with mammography). • Guidance of needle biopsy or localisation. • Follow-up of breast cancer treated with adjuvant chemotherapy.
  21. 21. BenignBenign CharacteristicsCharacteristics • Ellipsoid shape • Thin definable capsule • Two or three lobulations • Hyperechogenicity.
  22. 22. MalignantMalignant CharacteristicsCharacteristics • Solid • Irregular shape • Irregular borders • Almost anechoic
  23. 23. •Angular margin •Taller than wide •Thick echogenic rim •Posterior shadowing
  24. 24. BENIGN MALIGNANT Shape Oval/ellipsoid Variable Alignment Wider than deep; aligned parallel to tissue planes Deeper than wide Margins Smooth/thin echogenic pseudocapsule 2-3 gentle lobulations Irregular or spiculated; echogenic 'halo' Echotexture Variable to intense hyperechogenicity Low-level Marked hypoechogenicity
  25. 25. Homogeneity of internal echoes Uniform Non-uniform Lateral shadowing Present Absent Posterior effect Minimum attenuation/posterior enhancement Attenuation with obscured posterior margin Other signs -------------- Calcification Microlobulation Intraductal extension Infiltration across tissue planes Increased echogenicity of surrounding fat
  26. 26. Fibroadenoma Homogeneous internal echoes with an ovoid shape and circumscribed margins – benign There is posterior acoustic enhancement..
  27. 27. A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.
  28. 28. Invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.
  29. 29. Inflammatory breast cancer with secondary signs. increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.
  30. 30. A power Doppler image of invasive grade 3 breast cancer. irregular tortuous vessels penetrating into the centre of the lesion.
  31. 31. MammographyMammography INDICATIONS • Screening asymptomatic >50yrs • Screening high risk asymptomatic >35yrs • Symptomatic >35yrs with lump/ cancer
  32. 32. • Surveillance after excision of cancer • Evaluation after augmentation mammoplasty • Suspicious breast lump in man
  33. 33. CHARACTERISTICS • SPICULATE MASS – Commonest appearance of invasive Ca – Central soft tissue tumor – Spicules extending to surrounding
  34. 34. Spiculate mass due to invasive carcinoma Lateral view Localized compression magnification view
  35. 35. • ARCHITECTURAL DISTORTION – Numerous straight lines – 1 to 4 cm long – Radiating towards centre
  36. 36. Stellate lesion due to invasive tubular carcinoma
  37. 37. ASYMMETRICAL SOFT TISSUE DENSITY Areas of • Low soft tissue density • Lucency • Curvilinear margins
  38. 38. Soft tissue density with irregular margins
  39. 39. CIRCUMSCRIBED MASS • DENSITY – Radiopaque • CONTOUR – Ill defined • NUMBER – Solitary
  40. 40. Circumscribed soft tissue mass showing intracystic carcinoma
  41. 41. Phyllodes tumor. Circumscribed mass with lobulated outline
  42. 42. 1. Poorly defined spiculate mass.. Invasive ductal Ca 2. Circumscribed soft tissue mass..mucinous Ca
  43. 43. Circumscribed retroareolar mass, poorly defined posterior margin Invasive ductal Ca
  44. 44. MICROCALCIFICATIONS • Ductal – Variable in density. – Variable in shape like linear, casting, branching, irregular – Distribution With in one lobe/segment
  45. 45. Ductal Carcinoma in situ ,irregular linear branching calcifications
  46. 46. Ductal Carcinoma in situ Irregular pleomorphic calcification
  47. 47. EDEMATOUS BREAST • Thickened skin • Increased density • Coarse trabecular pattern • Enlargement of breast
  48. 48. MRIMRI INDICATIONS • Staging biopsy-proven primary breast carcinoma • Detecting an occult primary breast cancer in a patient with proven axillary node involvement but negative results on mammography and ultrasonography
  49. 49. • Ascertaining the extent of disease after lumpectomy with positive margins or close margins • Investigating suspected pectoralis muscle invasion • Assessing response to chemotherapy, including preoperative chemotherapy
  50. 50. • Looking for suspected recurrent disease, such as in a postsurgical scar • A compelling clinical presentation with negative or equivocal imaging results • Problem solving, ie, workup of uncertain imaging findings that could not be resolved even after special mammographic and ultrasonographic techniques were used
  51. 51. • Needle localization and guided biopsy • Known or suspected rupture of breast implants • Screening patients with certain well- defined risk factors for breast cancer.
  52. 52. Dense breast tissue Two lesions on contrast enchanced MRI Biopsy proven case of breast carcinoma
  53. 53. Pre contrastPre contrast Post contrastPost contrast Sagittal T1 weighted gradient-echo images with fat saturationSagittal T1 weighted gradient-echo images with fat saturation Intravenous gadolinium-DTPA.Intravenous gadolinium-DTPA. 2 malignant masses2 malignant masses Typical heterogenous and rim enhancement of larger massTypical heterogenous and rim enhancement of larger mass Involvement of prepectoral fascia,pectoralis major andInvolvement of prepectoral fascia,pectoralis major and skin by inferior massskin by inferior mass
  54. 54. BI-RADSBI-RADS • Breast Imaging Reporting And Data System • Made by American college of radiology • Importance – Diagnostic – Therapeutic – Prognostic – Epidemiologic – Standardized words in mammographic reporting – Improved communication
  55. 55. BI-RADS assessmentBI-RADS assessment categoriescategories • Category 0 • Category 1 • Category 2 • Category 3 • Category 4 • Category 5 • Category 6
  56. 56. Category 0Category 0 • Assessment incomplete • Further workup needed • e.g Screening mammogram shows a nodule….. • Till further workup its labelled as category 0
  57. 57. Category 1Category 1 • Negative • mammogram shows – No grouped or suspicious microcalcifications – No well-formed mass, – A symmetrical glandular structure – No change from any previous exam
  58. 58. Category 2Category 2 • definitely benign and a routine screening • It include: – Round opacities with macrocalcifications (typical calcified fibroadenoma or cyst) – Round opacities corresponding to a typical cyst at ultrasonography
  59. 59. – Oval opacities with a radiolucent center – Fatty densities or partially fatty images (lipoma, galactocele, oil cyst, hamartoma ) – Vascular calcifications
  60. 60. – Scattered macrocalcifications (fibroadenoma, cyst, cytosteatonecrosis, secretory ductal ectasia); – Breast implants,silicone granuloma. – Surgical scar
  61. 61. Category 3Category 3 • Probably Benign • Positive predictive value less than 1% • a follow-up of 6 months is usually recommended.
  62. 62. Findings include: • Clusters of tiny calcifications if round or oval • Non-calcified solid nodules (no size limitation but non palpable), round, ovoid, well-defined,
  63. 63. • Selected focal asymmetric areas of fibroglandular density (not palpable): • Miscellaneous focal findings, such as a dilated duct, or post biopsy architectural distortion without central density • Generalized distribution in both breasts. For example, multiple similar lesions with tiny calcifications or nodules distributed randomly
  64. 64. • In some scenerios a percutaneous biopsy might be considered,even with category 3. For example, extreme patient anxiety, or plans for pregnancy, plans for breast augmentation or reduction surgery, or if synchronous carcinoma is present
  65. 65. indeterminate BI-RADS 3 and not BI-RADS 2, because of the poorly defined, fuzzy edge.
  66. 66. Category 4Category 4 • Suspicious or Indeterminate abnormality • The positive predictive value (the chance of a real cancer) 20-40%. • Commonly fibrocystic changes • A biopsy should be recommended.
  67. 67. It is often subdivided into three smaller sub-categories: – "A" for low suspicion of malignancy, – "B" for moderate suspicion, – "C" for high suspicion.
  68. 68. Findings include: • Asymmetric, localized or evolving hyperdensities with convex contours. • Indeterminate microcalcifications appearing amorphous, indistinct particularly if in a cluster or heterogeneous and pleomorphic • Round or oval non cystic opacities with microlobulated or obscured contours
  69. 69. Category 5Category 5 • Highly suggestive of malignancy • A biopsy should be taken immediately. • Positive predictive value 95% Finding include : • Typically malignant microcalcifications; e.g.linear with branching pattern;
  70. 70. • Clusters of microcalcifications with a segmental or galactophorous distribution • Evolving microcalcifications or associated with an architectural distortion or opacity • Poorly circumscribed opacities; • Spiculated opacities with radio-opaque center.
  71. 71. Category 6Category 6 • Known Cancer • Proven by biopsy. • Used when patients undergoing breast cancer treatment have follow-up mammograms.
  72. 72. THANKS

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