This document contains a panel of unknown cases presented by Dr. Tejas Mehta at NERRS: Women's Imaging on April 5, 2013. The first case involves a 61-year-old woman with a family history of breast and ovarian cancer who presented for routine screening mammography. The second case discusses the imaging and biopsy findings of a 54-year-old woman with bilateral lymph node calcifications found on screening mammography. The third case presents a 65-year-old woman with a left breast mass and nipple change, whose mammogram and ultrasound revealed a grade 2 invasive lobular carcinoma.

1. NERRS: Women‟s Imaging
April 5, 2013
Panel of Unknown Cases
Tejas S. Mehta MD MPH
Assistant Professor of Radiology
Chief, Breast Imaging

2. Dr. Yiming Gao

3. HISTORY
• 61 yo female
• Strong family history of breast and ovarian
cancer
• Presents for routine screening
mammography

7. • What would you do next?

8. FNA Cytology
• NEGATIVE FOR
CARCINOMA.
Polymorphic
population of
lymphocytes,
consistent with
lymph node sampling.
• Concordant?
• Recommend surgical
excision

9. Lymph nodes with scattered small
aggregates of macrophages (micro-
granulomas) and calcification (including
psammoma-body type calcifications)
associated with multinucleated giant cells.

10. LN “Calcifications”
Benign Malignant
• Infectious/inflammatory • Primary breast
• Granulomatous Dz • Metastases
• Tattoo pigment – Ovarian
– Thyroid
• Gold therapy – RA
• Fat necrosis

11. COMPANION CASE
• 54 yo female – screening MG showing
bilateral LN calcifications; additional imaging
recommended

12. Gold Therapy for RA

13. Dr. Vandana Dialani

14. HISTORY
• 65 yo female
• Presents from OSH with worsening „left
breast swelling‟ for 8-9 months
• New 1 month history of „change in left
nipple‟

15. Current Bilateral Mammogram
RCC LCC RMLO LMLO

16. Current and Comparison Left Breast MGs
4 YRS PRIOR CURRENT 4 YRS PRIOR

17. US retroareolar region
US Left upper outer breast

18. • What would you do next?

19. What next?

21. Grade 2 Invasive Lobular Carcinoma
with LN positive for Metastatic Adenocarcinoma
SURGERY – Mastectomy with LN dissection

22. Invasive Lobular Carcinoma
• 10-15% of all invasive breast ca
• Sensitivity of MG 57-81%
– Mass most common – usually spiculated (44-
65%)
– Distortion 10-34%
– Asymmetry 1-14%
• Much less freq assoc with calcs than IDC
• Sensitivity of US 68-98%
– Spiculated mass
– Shadowing
Lopez et al. Radiographics 2009; 29:165.

23. Invasive Lobular Carcinoma
• Sensitivity of MRI up to 95%
– Changes in clinical management up to 50%
– Changes in surgical management up to 28%
• Kinetics – progressive more typical than
washout
Lopez et al. Radiographics 2009; 29:165.

24. Companion Case
64 yo female
6 months hx of “right breast is swollen; it‟s not the same”.
MG – dense tissues, negative.
Clinical breast exam – negative.
Sent for US by PCP – negative.
Biopsy – DCIS. Surgery – mastectomy.

25. Always Listen to your Patients

26. Dr. Ana Lourenco

27. HISTORY
• 36 yo female 30.5 weeks pregnant
• Referred with „multiple fetal anomalies‟ for
fetal ultrasound

28. LUS – Cephalic

32. POSTNATAL BABYGRAM

34. -Cephalic
-Heart - right side
-Stomach – right side
-Liver – left side
-Des colon – right side

35. Esophageal Pouch

36. Situs Inversus Totalis
• 3-5% with cardiac abnormalities
• 25% with primary ciliary dyskinesia (PCD)
– Kartagener‟s Syndrome
– Chronic sinus infections; respiratory infections;
infertility

37. Terminology
• Situs solitus – normal anatomy
• Situs inversus – mirror image of normal
• Situs ambiguous – heterotaxy
– Disordered arrangement of organs in chest and
abdomen
– Asplenia – right atrial isomerism
– Polyslenia – left atrial isomerism

38. Esophageal Atresia
• Polyhydramnios
• small / absent stomach if no
fistula
• Often other assoc anomalies
– Imperforate anus
– Duodenal atresia/stenosis
– Vertebral/rib anomalies
– VACTERL spectrum

39. Dr. Anne Silas

40. HISTORY
• 40 yo female 8.5 weeks pregant
• S/P D&C for pregnancy implanted at site of
c-section scar

42. • 6 weeks post D&C patient presents with
heavy persistent bleeding
• For Pelvic US
• HCG = 451 mIU/mL

50. D&C complicated by Perforation,
AVM w RPOC at Site of Perforation
• AVM – Acquired or Congenital
• Acquired
– Traumatic – D&C, TAB, uterine surgery
– Less common: Endometrial / Cervical CA, GTD
– Clue on US: numerous tortuous vessels, high velocities
• Tx:
– transcatheter arterial embolization
• Potential to preserve fertility
– UA ligation, hysterectomy

51. Angio after MRI

52. POST PROCEDURE
S/P embolization of right UA and left UA due to
cross collateralization

53. 1 month follow up
HCG < 5 mIU/mL
No flow in area – smaller in size
Felt residual hematoma
Will continue US follow up

54. Dr. Hedvig Hricak

55. HISTORY
• 42 yo female
• Recent immigrant from China
• C/O postcoital and intermenstrual bleeding
• Abnormal GYN exam
• Abnormal biopsy
• Further imaging performed

63. MRI findings - Stage IIB
with PET/CT - Stage IIIB
Cervical Cancer

64. Stage I – Carcinoma Confined to Cervix
<= 4 cm greatest dimension > 4 cm greatest dimension
<= 7 mm wide
A1 < =3mm deep
A2 >3 but < 5mm deep

65. Stage II – Carcinoma Invades Beyond Uterus
But not to Pelvic Wall or Lower 1/3 Vagina
With(A) or without (B)
parametrial invasion

66. Stage III – Carcinoma to Pelvic Wall and/or Lower 1/3 of
Vagina and/or Causes Hydronephrosis or Nonfxing Kidneys
Lower 1/3 Vagina
No pelvic wall
Extends to pelvic wall
and/or renal issues

67. Stage IV – Carcinoma beyond True Pelvis or Involvement
Of Mucosa of Bladder or Rectum (bx proven)
Distant Mets
Spread to adj organs

68. Role of MR Imaging in Tx Stratification
of GYN (Cervical) Cancer
• Cervical Cancer – 2nd most common ca in women
worldwide
– Developing countries; pk 30-40 yrs
• FIGO classification – revised in 2009 from just clinical to
incorporate cross-sectional imaging (CT, MR)
• Staging accuracy of MR 85-96%
– Best test to assess tumor size and location; invasion into
parametria, pelvic side wall, adjacent organs; local nodal enlgment
• PET/CT helpful in staging advanced disease
– Demonstrates unexpected sites beyond pelvis
• Treatment options
– Radical surgery - early stage (IA, IB1, IIA1)
– Primary Chemo and Radiation – bulky IB2 or IIA2, or local
advanced (IIB or greater)
Sala et al. Radiology 2013; 266: 717.

69. Thank you!