A 50-year-old woman felt a slightly painful nodule in her left breast. Comparison of mammograms from 1 year and 2 months ago showed an increase in density and volume of the nodule. Ultrasound, MRI and shear wave elastography of the breast and axilla revealed a 3 cm cancer close to the pectoral fascia and metastatic involvement of at least two axillary lymph nodes. High breast density can obscure cancers on mammography. Multiple modalities including ultrasound and MRI may be needed for screening in dense breasts. Shear wave elastography provides information on size and stiffness of cancers and lymph nodes beyond conventional ultrasound.

1. Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
dr. Masciotra
Case of the day n.1

2. 06/02/2014
 50 years old woman
 No familiar history for
breast cancer
 Menarche at age of 14
years
 2 normal pregnancies
with 18 months
overall breastfeeding
 Actually in menopause
since 6 months
 This mammography was
done 1 year ago,
considered normal,
besides very dense breast
tissue

3. 10/02/2015
 2 months ago she felt
something strange,
sligthly painful in upper
outer quadrant of her
left breast
 This mammography has
been done today

4. 06/02/2014 10/02/2015
 Images of left breast
axillary tail in the 2
exams are shown in
comparison
 The nodule in very dense
background shows an
increase in its density,
almost doubling of its
volume, but it seems
around 1 cm

7. Left breast 3D US
Skin and preglandular fat
Glandular tissue
Retroglandular fat tissue
Pectoral muscle and fascia
Cancer

8. Skin and preglandular fat
Glandular tissue
Retroglandular fat tissue
Pectoral muscle and fascia
Cancer
Left breast 3D US

9. Right and left axillary tails breast MRI

10. Right breast MRI
Skin and preglandular fat
Glandular tissue
Retroglandular fat tissue
Pectoral muscle and fascia

11. Left breast MRI
Skin and preglandular fat
Glandular tissue
Retroglandular fat tissue
Pectoral muscle and fascia
Cancer

12. First level
intramammary node

13.  At mammography and MRI the cancer seems far from skin and pectoral
fascia
 3D US give large higher morphological and spatial details, showing that
the posterior margin of the cancer is at only 1.3 mm from the pectoral
fascia

14. Left axilla

15.  At US the nodule is large wider than in
mammography (3 cm vs 1 cm)
 At shear wave elastography the stiff
tissue extends beyond the boundaries
of the nodule as seen in bidimensional
image and the mean stiffness is around
100 kPa
 At least 2 axillary nodes show marginal
nodule deforming the capsula, highly
suggestive for embolic metastasis
 At shear wave elastography the stiffness
of the node is homogeneous, with mean
value of around 16 kPa, large lower than
the 100 kPa of the primitive cancer

16.  At least 2 axillary nodes show marginal
nodule deforming the capsula, highly
suggestive for embolic metastasis
 At shear wave elastography the stiffness
of the node is homogeneous, with mean
value of around 16 kPa, large lower than
the 100 kPa of the primitive cancer
 At Color, Directional Powerdoppler and
Powerdoppler Imaging the feeding
vessels of the cortical nodule are clearly
shown

17. Keypoints of the case and ‘take home messages’
 One more time high breast density is an absolute risk factor for br. ca. by itself and often hides the
cancer
 This is the reason why an objective volumetric breast density measurement tool (Volpara) had to be
used for the quantification of the breast cancer risk and the best planning of the modalities to be
used in the screening of these women (considering the very low sensitivity shown by mammography)
by adding volumetric US and/or MRI
 One more time the size of a cancer at mammography in dense breast is smaller than the one shown
by Bidimensional US (echogenicity based) and by SWE (mechanical properties of tissue based).
 SWE shows that the cancer is even larger than in US B-scan and at MRI too (hence the question on
which one of these modalities is the more 'realistic' to correctly grade the 'T' feature in the TNM
staging).
 Very stiff primitive breast cancers not necessarily give stiff axillary nodes mets
 Axillary nodes status is possibly best assessed by high quality B-scan and CDI of the nodal vessels
(density, morphology, distribution and perhaps spectral analysis of the flow).

18. Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
dr. Masciotra
Case of the day n.1
Thanks for your attention