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. 

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

A 57-year-old female presents for a screening mammogram. The patient has heterogeneously dense breasts. The patient also has a digital breast tomosynthesis study. In the left upper inner quadrant a spiculated mass is seen.

Pseudoangiomatous stomal hyperplasia (PASH)

Utilizing the DBT alongside the conventional screening FFDM can give a better understanding of a lesion in dense breasts. The combination study showed a spiculated mass within the parenchymal dense breast tissue.

The use of digital breast tomosynthesis in breast cancer screening can improve the detection of invasive carcinomas. With digital breast tomosynthesis multiple slices are obtained of each breast which are reconstructed to produce a 3-dimentional image.

Skaane, P., Bandos, AI., Gullien, R., Eben, U., Haakenaasen, U., Izadi, M., Jebsen, IN., Jahr, G., Krager, M., Niklason, LT., Hofvind, S., Gur, D. Comparison of Digital Mammography Alone and Digital Mammography Plus Tomosynthesis in a Population-based Screening Program. 

Image IQ: 57-year-old with Dense Breasts, Spiculated Mass

A 42- year-old female with recent diagnosis of stage III malignant melanoma in her leg presents for evaluation of a palpable right breast lump.

On mammography, in the patient’s area of concern in the right 8:00 position, a well-circumscribed, round mass is seen measuring 5 mm. Just adjacent to this is an additional 10 mm round, well-circumscribed mass. On physical examination, there is a palpable superficial mobile lump in the right 8:00 area of concern.  Ultrasound demonstrates a cyst measuring 4 mm, corresponding to the area of concern at 8:00. At the 8:30 position, there is a heterogeneous round mass noted measuring 12 x 9 x 6 mm.

Needle core biopsy under ultrasound guidance was performed of the largest mass at 8:30, with pathology revealing metastatic malignant melanoma.

Metastases to the breast are rare, with melanoma and lymphoma being the two most commonly seen. Metastasis to the breast usually presents as an asymptomatic lesion in the upper outer quadrant of the breast. Clinically they are seen as well circumscribed lesions. Malignant melanoma accounts for only 1.3-6.6% of all malignant mammary tumors and are often seen in younger patients due to the larger amount of vascularity in the breasts.  The average age of patients ranges from 38-40 years.

Bassi, F., Gatti, G., Mauri, E., Ballardini, B., DePas, T., Luini, A. Breast metastases from cutaneous malignant melanoma. 

Majeski, J. Bilateral breast masses as initial presentation of widely metastatic melanoma. 

Arora, R., Robinson, WA. Breast metastases from malignant melanoma. 

Toombs, BD., Kalisher, L. Metastatic disease to the breast: clinical, pathologic and radiographic features. 

DiBonito, L., Luchi, M., Giarelli, L., Falconieri, G., Viehl, P. Metastatic tumors to the female breast. An autopsy study on 12 cases. 

Image IQ: 42-year-old Woman with Recent Stage III Malignant Melanoma Diagnosis

A 52-year-old woman presents for diagnostic evaluation of spontaneous left bloody discharge. On full field digital mammography, no suspicious masses or calcifications are seen.

On digital Galactography, a filling defect is noted in the left subareolar region.

The area identified on galactography underwent a core needle biopsy.

Galactography may provide additional information when nipple discharge is present. A finding identified with Galactography is important for surgical and follow-up recommendations.  

Kim SH, Cha ES, Kim HS, Kang BJ, Choi JJ. Galactography acquired with digital mammography in patients with nipple discharge: a retrospective analysis. 

 August 2009, Volume 280, Issue 2 pp 217-222

Image IQ: 52-year-old with Spontaneous Bloody Left Breast Discharge

A 47-year-old woman presents for screening mammography and requests a screening breast ultrasound. On mammography, no suspicious masses or areas of calcifications are identified. The breast tissue is extremely dense.

On ultrasound, there is a newly identified irregular hypoechoic mass in the left 2:00 area. 

The mass identified on ultrasound underwent an ultrasound guided core needle biopsy.

Mammographic sensitivity has been shown to be reduced signiï¬cantly with increasing breast density. Screening breast ultrasound has a role in imaging dense breast tissue as it has been shown to signiï¬cantly increase the detection of small cancers and depict signiï¬cantly more cancers of small size and low stage.

References:Kolb TM, Lichy J, Newhouse JH. Comparison of the Performance of Screening Mammography, Physical Examination, and Breast US and Evaluation of Factors that Inï¬uence Them: An Analysis of 27,825 Patient Evaluations. Radiology 2002; 225:165–175.

Image IQ: 47-year-old with Irregular Mass in Dense Breast Tissue

A 42-year-old woman presents for baseline screening mammography and a combination digital breast tomosynthesis study is performed. She has a positive family history for breast cancer. 

Dense glandular tissue is noted on mammography, as well as an area of architectural distortion in the left breast. This is best demonstrated on digital breast tomosynthesis (arrows).

The architectural distortion on digital breast tomosynthesis was imaged with ultrasound and a 1.0 cm hypoechoic mass was identified.  

A 12-gauge vacuum assisted ultrasound guided breast biopsy was recommended.

Results: Invasive carcinoma with ductal and lobular features

: This case demonstrates the value added by digital breast tomosynthesis (DBT) to breast cancer screening. Due to the technology’s capability of allowing cross-sectional visualization of breast tissue, the difficulty caused by overlapping tissue can be reduced. Because of this, DBT’s ability to render lesions more visible is most evident for masses, asymmetries, and areas of architectural distortion.

Gur D, Abrams GS, Chough DM, et al. Digital Breast Tomosynthesis: Observer Performance Study. AJR 2009; 193:586–591.

Rafferty EA, Park JM, Philpotts LE, et al. Assessing Radiologist Performance Using Combined Digital Mammography and Breast Tomosynthesis Compared with Digital Mammography Alone: Results of a Multicenter, Multireader Trial. Radiology 2013; 266: 104-113.

Image IQ: 42-year-old with Architectural Distortion on Breast Tomo

An 81-year-old woman presents for a routine screening mammogram (Figure A). The patient is recalled due to a mass seen in the lateral right breast. On the right magnification craniocaudal view (Figure B) an irregular mass measuring 0.9 cm is noted. This is also seen on the right medial lateral view as well (Figure C). On ultrasound (Figure D) the mass is seen 4 cm from the nipple measuring 0.9 cm.  A biopsy is performed showing Invasive Ductal Carcinoma. 

Magnetic resonance imaging (MRI) (Figure E, below)

: The patient returned for an extent of disease MRI (Figure E, above). At the time of the exam, the mass was identified on MRI measuring 2.9 x 1.6 x 1.2cm. The MRI is important in this case as it demonstrates that the lesion is much larger than identified on mammography and ultrasound.

Breast conservation surgery occurs frequently in women who are diagnosed with breast cancer. MRI provides more accurate information to both the patient and the physician. MRI gives more detail about tumor size and its distribution when compared to mammography and ultrasound.

Ref. Kim, DY., Moon, WK., Cho, N., Ko, ES., Yang, SK., Park, JS., Kim, SM., Park, IA., Cha, JH., Lee, EH. 