First AD

Second AD

A 72 year-old woman presents for routine screening mammogram with no complaints.

Conventional mammographic craniocaudal (CC) and mediolateral oblique (MLO) views demonstrate a developing focal asymmetry in the right breast, which has gradually increased over multiple prior examinations. The margins are spiculated and there is associated architectural distortion, resulting in tethering and indentation of nearby fibroglandular breast parenchyma. Targeted sonography reveals a heterogeneous hypoechoic 1.6 cm mass at 11:00 radian with indistinct, irregular angular margins, mild posterior shadowing and mild surrounding echogenic rim. MRI reveals an irregular enhancing mass with spiculated margins and rapid enhancement with washout kinetics. No other suspicious lesions were seen on MRI, including detailed review of the contralateral breast. Diagnosis was confirmed with ultrasound-guided core needle biopsy.

Invasive lobular carcinoma (ILC) comprises 10-15 percent of all invasive breast cancers and is the second most common invasive breast carcinoma after invasive ductal carcinoma NOS (not otherwise specified). ILC can be a subtle diagnosis, often resulting in misdiagnosis or delayed diagnosis. ILC typically presents as a vague developing asymmetry. A detailed review of multiple prior examinations is often required to demonstrate gradual changes of developing asymmetry, which may not be apparent on a single year-to-year basis.

ILC is an insidious process characterized by a loss of normal cellular adhesion, insinuating through the breast in a sheet-like manner, usually without inducing the intense desmoplastic reaction that typically accompanies invasive ductal carcinoma. The histopathologic hallmark is a loss of E-cadherin, resulting in cellular infiltration in "single-file" or column-like fashion.

Ultrasound and breast MR offer higher sensitivity for detection than mammography alone, with MRI providing the best characterization for overall extent of disease. MR offers high sensitivity for the detection of additional malignant lesions in ILC, which may be bilateral, multicentric, or multifocal. ILC may also co-exist with lobular carcinoma in-situ or atypical lobular hyperplasia.

Berg, WA, Yang WT. Diagnostic Imaging: Breast, 2nd Ed. Amirsys. 2013.

Ikeda, DM. Breast Imaging: The Requisites. Elsevier, Inc. 2004.

Albayrak ZK, et al. Invasive lobular carcinoma of the breast: Mammographic and sonographic evaluation. 

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Ultrasound

A 72 year-old woman presents for routine screening mammogram with no complaints. 

Image IQ: 72 year-old Female, Focal Asymmetry in Breast

Arash R. Zandieh, MD

Erini Makariou, MD