Stamatia Destounis, MD, FACR

 positive patient presented for a bilateral screening breast MRI. On MRI, two irregular enhancing masses were detected in the right breast, measuring 12 mm and 4 mm (Figure 1).

Targeted ultrasound was performed and demonstrated two ill-defined, hypoechoic masses in the 3 o’clock area corresponding to the MRI findings (Figures 2, 3). An ultrasound guided needle core biopsy of the larger mass was performed.


Core needle biopsy of the larger right breast mass was performed under ultrasound guidance revealing invasive ductal carcinoma. At surgical excision there were two foci of cancer in the right breast.

 gene mutation have an increased risk of developing breast cancer. The American Cancer Society (ACS), Society of Breast Imaging (SBI), and American College of Radiology (ACR) recommend breast MRI screening for 

positive patients, as well as an annual mammography. Although mammography is the gold standard for detecting breast cancer, the sensitivity of MRI has shown to be greater than that of mammography. Studies have demonstrated that the increased sensitivity is due to the ability of MRI to detect very small cancerous lesions that are more difficult to distinguish on mammography.

1. Warner E, Hill K, Causer P, et al. Prospective Study of Breast Cancer Incidence in Women With a BRCA1 or BRCA2 Mutation Under Surveillance With and Without Magnetic Resonance Imaging. 

2. Passaperuma K, Warner E, Causer PA, et al. Long-term results of screening with magnetic resonance imaging in women with BRCA mutations. 

Poll

53-year-old BRCA2 positive patient presented for bilateral screening breast MRI.

Image IQ: 53-year-old, BRCA2 Positive, Screening Mammo

49-year-old patient presented for a bilateral screening mammogram as well as a bilateral screening ultrasound due to dense breast tissue. On mammography, dense breast tissue was noted and no suspicious masses or calcification were seen in either breast.

Screening ultrasound demonstrated a 10 mm irregular, hypoechoic mass in the 2:00 position of the left breast.  An ultrasound guided needle core biopsy of the mass was performed.

Needle core biopsy of the left breast lesion was performed under ultrasound guidance revealing invasive lobular carcinoma. An MRI for extent of disease evaluation was performed which demonstrated an enhancing mass in the right breast, which was not previously detected. An MRI guided needle core biopsy was performed of the contralateral breast MRI finding revealing a complex sclerosing lesion. Both lesions biopsied were mammographically occult in this patient with dense breast tissue.

Mammography is still the gold standard for detecting breast cancers. It can detect up to 98% of breast cancers in fatty replaced and scattered tissue, however only 48% of cancers are detected in dense breast tissue utilizing mammography only. Ultrasound, when used as a screening tool, can detect breast cancers that are not visualized on mammography. In one study, ultrasound was shown to yield 3.25 per 1,000 cancers in women with dense breast tissue and normal mammograms.

Weigert J, Steenbergen S. The Connecticut Experiment: The role of ultrasound in the Screening of Women With Dense Breasts. 

49-year-old patient presented for bilateral screening mammogram as well as bilateral screening ultrasound due to dense breast tissue.

Image IQ: Ultrasound Screening of Dense Breasts

A 50-year-old patient presented for screening mammogram. Extremely dense breast tissue was noted.

), a 1-cm spiculated mass (arrow) was identified within the left breast, best demonstrated on the lateral view (

) demonstrated an 8-mm hypoechoic mass in the 10:00 position of the left breast and, in addition, ultrasound identified a 1.1-cm hypoechoic mass at the 1:00 position (

). A needle core biopsy of the 10:00 mass was performed resulting in a diagnosis of invasive ductal carcinoma. The patient was referred for breast magnetic resonance imaging (MRI) for extent of disease evaluation. Breast MRI (

) demonstrated a new enhancing mass in the contralateral breast. MRI of the ipsilateral breast (

) demonstrated two enhancing masses consistent with the two lesions identified on ultrasound. Biopsy of new lesion in the contralateral breast was recommended.


Needle core biopsy of the contralateral breast lesion was performed under MRI guidance revealing invasive ductal carcinoma. 


Despite the normal findings on the mammogram and physical exam of the contralateral breast, cancer in the contralateral breast can subsequently be detected in up to 10% of women. On average, MRI can detect 5% of occult breast carcinomas found in the contralateral breast in women with a newly diagnosed cancer.  


Lehman, CD, Gastsonis, C, Kuhl, CK et al. MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer.  

50-year-old patient presented for screening mammogram. Extremely dense breast tissue was noted. 

Image IQ: Contralateral Breast after Cancer Diagnosis

A 30-year-old presents for evaluation of a right breast lump that is nontender and has been present for two weeks. She has been breastfeeding for three months. The patient undergoes standard mammography with a tangential magnified superior inferior oblique (SIO) as well as an ultrasound of both breasts. Upon a physical examination, the lesion is palpated and is mobile.


Lactating women tend to have increased parenchymal density due to the prominent ductal system and increased vascularity in the breast that is associated with breast feeding. Young women usually have heterogeneously to extremely dense breast tissue that is visualized on mammography. With the combination of these factors, mammography sensitivity may decrease. Ultrasound is frequently the mode of detection and diagnosis of a palpable lesion in this subset of patients. A fine needle aspiration under ultrasound guidance of this lesion shows cells that are consistent with a lactating adenoma. 

Lactating adenomas are primarily seen during the third trimester of pregnancy and during lactation. This type of lesion can be a mobile mass with no associated pain. On ultrasound this lesion appears to be oval and appear benign. 


Vashi R, Hooley R, Butler R, Geisel J, Philpotts L. Breast Imaging of the Pregnant and Lactating Patient: Physiologic Ganges and Common Benign Entities. 

Sabate JM, Clotet M, Torrubia S, Gomez A, Guerreo R, Las Heras P, Lerma E. Radiologic Evaluation of Breast Disorders Related to Pregancy and Lactation. 

A 30-year-old who has been breastfeeding for three months presents for evaluation of a right breast lump that is nontender and has been present for two weeks. 

Stamatia Destounis, MD, FACR

Articles

Image IQ: 53-year-old, BRCA2 Positive, Screening Mammo

Image IQ: Ultrasound Screening of Dense Breasts

Image IQ: Contralateral Breast after Cancer Diagnosis

Image IQ: 30-year-old, Breastfeeding, with Nontender Breast Lump