1) A 74-year-old woman underwent an unenhanced CT scan of the chest for cough and dyspnea that incidentally found a 3 cm solid mass in her right breast. Further imaging with mammography, ultrasound, and shear wave elastography provided details of the mass's irregular margins, infiltrating growth, and stiff mechanical properties. 2) A follow-up CT scan with contrast found the mass had a contrast enhancement pattern between Type 1 and Type 2 curves on MR, which is not highly indicative of malignancy based on kinetics. Density increments were also relatively low. 3) The CT scan also incidentally found endometrial cancer, and total body CT was done for staging. Incidental breast

1. Breast cancer as incidental finding on CT scan of the chest
Antonio Pio Masciotra
Campobasso – Molise – Italy
Email
antoniomasciotra@yahoo.it
Website
www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
Sometimes while you're looking for something
you find something different and unexpected…………….

2. Clinical Case
74 years old woman undergoing
unenhanced CT scan of the chest for the
evaluation of cough ad dyspnea

3. Incidental finding of a solid mass of
about 3 cm in max diameter in her
right breast, inhomogeneous with
irregular margins and infiltrating
growth.

4. Mammography gives the same
morphologic information
(irregular margins and infiltrating
growth).

7. US and Shear Wave elastography
particularly in 3D show the features
of the mass in its morphology,
growth pattern (with spiculae) and
mechanical properties.
All with a great detail.

9. We have always to well consider that in SWE images what appears ‘black colored’ is so cause one of 2 possible phenomena :
 Black area contains fluid in which Shear Waves don’t propagate
(and sometimes the necrotic part of a tumor becomes almost fluid, like the pus in an abscess)
 Black area contains tissue too stiff generating shear waves so fast that the detection US cannot ‘see’ them
(like an autovelox calibrated to a maximum speed of 200 km/h doesn’t see a car passing at a speed of 300 km/h)

10. Colorscale 0-180 kPa
Tuned on factory preset
Colorscale 0-85 kPa
Tuned on highest mean value
Colorscale 0-130 kPa
Tuned on highest maximum value
The factory preset of colorscale (0-180 kPa) for breast in my opinion can be misleading cause the eye is conditioned to consider mainly the blue
part of the scale, toward an erroneously ‘soft’ judgment.
I think that a better ‘immediate’ perception of the real stiffness in the ROI can be given tuning the colorscale on highest mean value (red image)
or on the highest maximum value (green image) of the stiffness.
Another ‘trick’ with equivalent result for the eye could be found in shifting the ‘opacity’ tool to the maximum, like in the different case below.

11. PHASE
ROI 1
ROI 2
ROI 3
Unenhanced
29,0
31,8
33,7
Arterial phase
40,2
41,2
42,8
Late enhancement (6 min)
46,2
46,6
46,5
Then a total body and head CT scan with
contrast enhancement was performed
for the staging of the disease.
In comparation to the classic features
of contrast enhancement pattern and
kinetics in MR study of breast
cancer…………………………..

12. MR contrast enhancement pattern of a breast mass
Dark internal septations
is uniform and confluent enhancement throughout the mass
refers to non-enhancing septations in an enhancing mass.
These are typical for fibroadenomas, especially when the lesion has
smooth or lobulated margins.
Heterogeneous enhancement
Enhancing internal septations
is nonuniform enhancement, which varies within the mass
are usually a feature of malignancy.
Rim enhancement
Central enhancement
Homogeneous enhancement
is enhancement mainly concentrated at the periphery of the mass.
This type of enhancement is frequently a feature of high-grade invasive
ductal cancer, fat necrosis, and inflammatory cysts. A lesion with rim
enhancement that is not a typical cyst has a 40% chance of malignancy.
is pronounced enhancement of a nidus within an enhancing mass.
Central enhancement has been associated with high-grade ductal
cancer. Central enhancement has been associated with high-grade
ductal cancer.
MR non-mass contrast enhancement
Non-mass enhancement is enhancement without three-dimensional characteristics.
It is important because it occurs in a significant number of cancers.
You need to look at its distribution, its enhancement pattern and its symmetry or
asymmetry.
The table on the left summarizes the terms used to describe the distribution of nonmass enhancement in the breast.

13. Temporal Resolution - Kinetic Analysis (Curves)
Type 1
On the image on the left is a type 1 curve.
There is a slow rise and a continued rise with time.
A lesion with a type 1 curve has a chance of 6% of
being malignant.
Type 2
Then there is the type 2 curve, which is in the
middle: a slow or rapid initial rise followed by a
plateau in the delayed phase, which is allowed a
variance of 10% up or down.
The chance of a lesion with a type 2 curve being
malignant lies somewhere between the 6% of the
type 1 curve and the 29-77% of the type 3 curve.
Many physicians will biopsy lesions with type 2
curves.
Type 3
The type 3 curve shows a rapid initial rise, followed
by a drop-off with time (washout) in the delayed
phase.
A lesion with this type of curve is malignant in 2977%.

14. PHASE
ROI 1
ROI 2
ROI 3
29,0
31,8
Compared to MR CE kinetics curve, the CT CE of
this case would be intermediate between Type 1
and Type 2 (relatively not indicative of malignancy
despite all clear morphologic features).
33,7
Breast cancer CT contrast enhancement pattern
40,2
41,2
42,8
Arterial phase
46,2
Late enhancement (6 min)
46,6
46,5
HU
Unenhanced
50,0
45,0
40,0
35,0
30,0
25,0
20,0
15,0
10,0
5,0
0,0
ROI 1
ROI 2
ROI 3
0 min
2 min
6 min
29,0
31,8
33,7
40,2
41,2
42,8
46,2
46,6
46,5
In this case also the density increment (only
about 17 HU) is relatively not indicative of
malignancy and closer to the one more typical of
benign lesions (11-24 HU) than to the one more
typical of DCIS (56-62 HU) or IDC (52-60 HU).

15. But total body CT shows the presence of an endometrial cancer too (a well known possible concurrent disease)

16. Main features of malignancies found in CT scan of the chest
•
The largely most prevalent malignancies are female primitive breast cancers, although
it’s important to take in account that breasts could be the site of metastasis, of
lymphomas and of primitive cancer in males too
•
The overall prevalence of incidentally CT detected breast malignancies varies from 1%
to 2%
•
The detectability of malignancies at CT like in mammography also in CT is conditioned
by the background density of the surrounding parenchima
•
So it’s easier to detect it in adipose background while in dense fibroglandular
background malignancies can be detected only at contrast enhanced scans and often
share the pattern of non-mass-like-enhancement well known in breast MR

17. Galileo Galilei
"Any problem that wants
to be solved
starts with curiosity."
Johann Wolfgang von Goethe
"Knowing is not enough,
we must apply.
Willing is not enough,
we must do."

18. Breast cancer as incidental finding on CT scan of the chest
Sometimes while you're looking for something
you can find something different and
unexpected…………….
But remember that your eyes can detect it only
if your mind is trained to search for it!
Antonio Pio Masciotra
Campobasso – Molise – Italy
Email
antoniomasciotra@yahoo.it
Website
www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ