This document presents a case study of a 50-year-old female patient presenting with a mass in her right breast. On examination, an irregular, hard lump was found. Ultrasound and mammography revealed an irregular, heterogeneous lesion with microcalcifications. Based on the radiological findings, the diagnosis was likely a malignant breast lesion. Risk factors for breast cancer and the roles of various radiological tools such as ultrasound, mammography, and MRI in diagnosing breast lesions are also discussed.

1. CaseCase
PresentationPresentation
Radiology HMCRadiology HMC

2. PATIENT PROFILE
• Age : 50yr
• Gender : Female
• Address : Peshawar
• Profession : House wife

3. CHIEF COMPLAINTS
• Mass in right breast 8 months
• Pain in right breast 1 month

4. • PAST MEDICAL/ SURGICAL Hx
• MENSTRUAL/OBSTETRICAL Hx
• DRUG Hx
• FAMILY Hx

5. LUMP EXAMINATION
Location Upper inner quad.
Size 3x2 cm
Appearance Normal
Temperature Normal
Tenderness Present
Margins Irregular
Consistency Hard
Motility Immobile

6. AXILLARY LYMPH NODES
• Palpable nodes
• In right axilla
• Anterior group
• 1-2 cm size

7. ULTRASOUND BREAST

8. Well defined, rounded lesion 2.2x2 cm
Heterogenous parenchyma
Irregular margin
Echogenic foci--- microcalcifications

10. MAMMOGRAPHY

11. Superiomedial
Well defined round
Radiopaque
Foci of calcification + parenchymal distortion
Microcalcifications dispersed in parenchyma

14. DIAGNOSIS ???DIAGNOSIS ???

15. MALIGNANT BREAST LESION.

16. RISK FACTORSRISK FACTORS
• Female gender
• Aging
• Genetic factors
• BRCA 1&2
• P53
• PTEN
• CHEK2

17. • Family history of breast ca
• Past hx of breast cancer
• Breast diseases
• Atypical hyperplasia
• Carcinoma in situ

18. • Menstrual hx
• Early menarche,
• late menopause
• Nulliparous
• Lack of breast feeding
• Late age pregnancy

19. • Drugs
• Oral contraceptives
• Diethlystilbesterol
• Chest radiation
• Metabolic
• Obese
• Alcohol
• Fat

20. RADIOLOGICAL TOOLS INRADIOLOGICAL TOOLS IN
DIAGNOSINGDIAGNOSING
– Ultrasound
– Mammography
– MRI
– PET
– Complex cyst aspiration
– FNAC
– Core biopsy
– Ductography

21. 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)

22. • Assessment of MRI or scintimammography
detected lesions.
• Clinical breast mass with negative
mammograms.
• Breast inflammation.
• The augmented breast (together with
MRI).

23. • Breast lump in a male (together with
mammography).
• Guidance of needle biopsy or localisation.
• Follow-up of breast cancer treated with
adjuvant chemotherapy.

24. BenignBenign
CharacteristicsCharacteristics
• Ellipsoid shape
• Thin definable
capsule
• Two or three
lobulations
• Hyperechogenicity.

25. MalignantMalignant
CharacteristicsCharacteristics
• Solid
• Irregular shape
• Irregular borders
• Almost anechoic

26. •Angular margin
•Taller than wide
•Thick echogenic rim
•Posterior shadowing

27. 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

28. 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

29. Fibroadenoma
Homogeneous internal echoes with an ovoid
shape and circumscribed margins – benign
There is posterior acoustic enhancement..

30. A typical 'tall' irregular spiculated hypoechoic
attenuating mass in keeping with a
malignant breast tumour.

31. Invasive lobular carcinoma presenting as
areas of scattered indeterminate attenuation.

32. 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.

33. A power Doppler image of invasive grade 3
breast cancer.
irregular tortuous vessels penetrating into
the centre of the lesion.

34. MammographyMammography
INDICATIONS
• Screening asymptomatic >50yrs
• Screening high risk asymptomatic >35yrs
• Symptomatic >35yrs with lump/ cancer

35. • Surveillance after excision of cancer
• Evaluation after augmentation
mammoplasty
• Suspicious breast lump in man

36. CHARACTERISTICS
• SPICULATE MASS
– Commonest appearance of invasive Ca
– Central soft tissue tumor
– Spicules extending to surrounding

37. Spiculate mass due to invasive carcinoma
Lateral view
Localized compression
magnification view

38. • ARCHITECTURAL DISTORTION
– Numerous straight lines
– 1 to 4 cm long
– Radiating towards centre

39. Stellate lesion due to invasive tubular carcinoma

40. ASYMMETRICAL SOFT TISSUE
DENSITY
Areas of
• Low soft tissue density
• Lucency
• Curvilinear margins

41. Soft tissue density with irregular margins

42. CIRCUMSCRIBED MASS
• DENSITY
– Radiopaque
• CONTOUR
– Ill defined
• NUMBER
– Solitary

43. Circumscribed soft tissue mass
showing intracystic carcinoma

44. Phyllodes tumor. Circumscribed mass with
lobulated outline

45. 1. Poorly defined spiculate mass.. Invasive ductal Ca
2. Circumscribed soft tissue mass..mucinous Ca

46. Circumscribed retroareolar mass,
poorly defined posterior margin
Invasive ductal Ca

47. MICROCALCIFICATIONS
• Ductal
– Variable in density.
– Variable in shape like linear, casting,
branching, irregular
– Distribution With in one lobe/segment

48. Ductal Carcinoma in situ ,irregular linear branching calcifications

49. Ductal Carcinoma in situ
Irregular pleomorphic calcification

50. EDEMATOUS BREAST
• Thickened skin
• Increased density
• Coarse trabecular pattern
• Enlargement of breast

51. 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

52. • 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

53. • 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

54. • Needle localization and guided biopsy
• Known or suspected rupture of breast
implants
• Screening patients with certain well-
defined risk factors for breast cancer.

55. Dense breast tissue Two lesions on contrast
enchanced MRI
Biopsy proven case of breast carcinoma

56. 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

57. 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

58. BI-RADS assessmentBI-RADS assessment
categoriescategories
• Category 0
• Category 1
• Category 2
• Category 3
• Category 4
• Category 5
• Category 6

59. Category 0Category 0
• Assessment incomplete
• Further workup needed
• e.g Screening mammogram shows a
nodule…..
• Till further workup its labelled as category
0

60. 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

61. 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

62. – Oval opacities with a radiolucent center
– Fatty densities or partially fatty images
(lipoma, galactocele, oil cyst,
hamartoma )
– Vascular calcifications

63. – Scattered macrocalcifications
(fibroadenoma, cyst, cytosteatonecrosis,
secretory ductal ectasia);
– Breast implants,silicone granuloma.
– Surgical scar

65. Category 3Category 3
• Probably Benign
• Positive predictive value less than 1%
• a follow-up of 6 months is usually
recommended.

66. Findings include:
• Clusters of tiny calcifications if round or
oval
• Non-calcified solid nodules (no size
limitation but non palpable), round, ovoid,
well-defined,

67. • 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

68. • 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

69. indeterminate BI-RADS 3 and
not BI-RADS 2, because of the
poorly defined, fuzzy edge.

70. 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.

71. It is often subdivided into three smaller
sub-categories:
– "A" for low suspicion of malignancy,
– "B" for moderate suspicion,
– "C" for high suspicion.

72. 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

74. 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;

75. • 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.

77. Category 6Category 6
• Known Cancer
• Proven by biopsy.
• Used when patients undergoing breast
cancer treatment have follow-up
mammograms.

78. THANKS