Stamatia Destounis, MD

47- year old patient presented for a bilateral screening mammogram. At the time of her appointment she was offered a screening ultrasound due to dense breast tissue. Mammography was performed with digital breast tomosynthesis and C-view which noted dense breast tissue; no suspicious masses or calcification were seen in either breast.


Screening ultrasound was performed and demonstrated a 3cm irregular, hypoechoic mass in the 12:00 position of the right breast. An ultrasound guided needle core biopsy of the mass was performed. Needle core biopsy of the right breast lesion was performed under ultrasound guidance revealing invasive mammary carcinoma. Two abnormal-appearing enlarged lymph nodes were also noted in the axilla on ultrasound and one was biopsied revealing metastatic mammary carcinoma.  Both lesions biopsied were mammographically occult in this patient with dense breast tissue.


Mammography is the gold standard for detecting breast cancers. Digital Breast Tomosynthesis can increase breast cancer detection at a range of 1.2 to 2.7 per 1,000 screenings. Ultrasound, when used as a screening tool, can detect breast cancers that are not visualized on mammography. In one ongoing study, participants that had normal 2D mammography and had dense breast tissue underwent a tomosynthesis mammogram and an ultrasound. Tomosynthesis was shown to yield 4.0 cancers per 1,000 screenings while ultrasound was shown to yield 7.1 cancers per 1,000 screenings in women with dense breast tissue and normal mammograms.


Tagliafico AS, Calabrese M, Mariscotti G, et al. Adjunct Screening With Tomosyntheses or Ultrasound in Women With Mammographically-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial. 

Poll

47-year-old patient offered screening ultrasound due to dense breast tissue.

Image IQ: Screening Ultrasound for Dense Breasts

A 74-year-old patient presents with a palpable lump in the left breast. She is status post left lumpectomy for infiltrating ductal carcinoma with sequential radiation 16 years ago. A new 2 cm mass is seen within the left breast on mammography as well as on ultrasound. The patient proceeds to have a biopsy of the area. The patient also has a breast magnetic resonance imaging (MRI) to evaluate extent of disease. 


When an angiosarcoma presents in the breast in a patient with prior breast cancer and treatment with surgery and radiation, it is thought that the angiosarcoma may be arising from the breast cancer treatment itself.


Angiosarcomas are a rare type of sarcoma that accounts for <1 percent of all sarcomas. Usually they are found in older patients occurring in the skin of the scalp. Approximately 25 percent of the time they are found in soft tissue of the body, however it is very rare to see them in the breast. They can present in either a primary malignancy or a secondary malignancy. When it is a primary carcinoma, it is typically found in younger patients and involves the breast parenchyma, such as milk ducts and glands that produce milk. When it presents as a secondary carcinoma, it is usually in older women who have a history of breast cancer with radiation to the breast and is cutaneous and multifocal. The occurrence rate of the secondary malignancy is between 0.04– 0.15 percent. 


Biswas T, Tang P, Muhs A, Ling M. Angiosarcoma of the breast: a rare clinicopathological entity.  

74-year-old presents with palpable lump in left breast, status post left lumpectomy for infiltrating ductal carcinoma with sequential radiation 16 years ago.

Author | Stamatia Destounis, MD

Articles

Image IQ: Screening Ultrasound for Dense Breasts

Image IQ: Palpable Lesion in a Prior Cancer Patient