Breast Magnetic Resonance Imaging of Multicentric, Multifocal and Bilateral Cancer – A Case-based Review

European Oncology & Haematology, 2011;7(1):24-30

Abstract:

Multifocal or multicentric breast cancer can be difficult to detect on mammography or ultrasound, particularly in patients with dense breast tissue. A multimodality approach that includes breast magnetic resonance imaging (MRI) is indicated, particularly when conservative surgery is being considered as it is the most sensitive technique for identifying additional sites of disease. However, its influence on recurrence and survival rates has yet not been clearly established, and false-positive cases may lead to more aggressive management and treatment. Radiologists should therefore be aware of relevant breast MRI findings. Infiltrating carcinomas, contralateral unsuspected carcinomas, occult carcinomas, false-positive cases and post-chemotherapy changes. Several cases of multiple-site breast carcinomas and their corresponding mammographic, ultrasound and MRI features have been reviewed for this article, in which the definition and differences between multifocal, multicentric and contralateral breast carcinoma are explained and the most relevant imaging findings on MRI are illustrated and correlated with mammogram and ultrasound findings. Finally, the role of breast MRI in the pre-operative assessment of breast cancer is discussed.
Keywords: Breast neoplasm, invasive lobular/ductal carcinoma, multifocal/multicentric extent, magnetic resonance imaging, pre-operative staging, false-positive, local recurrence rate, survival rate
Disclosure: The authors have no conflicts of interest to declare.
Received: July 03, 2010 Accepted January 23, 2011 Citation European Oncology & Haematology, 2011;7(1):24-30
Correspondence: Virginia Pérez Dueñas, Department of Radiology, Hospital Universitario Madrid Sanchinarro, C/ Oña 13, 28050 Madrid, Spain. E: virpedue@gmail.com

Breast cancer is an important public health problem, as it is the leading cause of death from cancer in women and the leading cause of death in 35–55-year-old women in the EU. Well-known risk factors are a previous breast carcinoma, atypical ductal hyperplasia, atypical columnar hyperplasia, lobular lesion in situ, papillomatosis or atypical papillary lesion, mediastinal radiotherapy and family history of breast cancer, especially the positive genes BRCA 1 and 2.1 Invasive breast carcinoma includes a wide range of tumours. The most frequent is invasive ductal carcinoma not otherwise specified ([NOS] 60–80%), followed by invasive lobular carcinoma (about 15%), which is often multicentric or bilateral. The remaining most frequent subtypes are medullary, mucinous, papillary and tubular carcinomas, each of which occurs with a frequency of approximately 2–4%.1 It is important to establish the classification of breast cancer according to its local extent. Multifocal carcinoma refers to two or more tumour areas in a unique quadrant or a distance of <4–5cm (although in breasts of small volume it can involve several quadrants, see Figure 1). Multicentric carcinoma refers to two or more tumour areas in different quadrants of the same breast/to a distance >4–5cm (see Figures 2–3). Contralateral cancer can be synchronous, when the detection of a contralateral tumour occurs in the first six months following diagnosis of the primary tumour, or metachronous, when the recurrence is later.1 Multifocal or multicentric carcinomas are more frequent in young patients or peri-menopausal women with large tumours (>5cm) and high-density fibroglandular parenchyma, women with a family history of breast cancer and in cases of invasive lobular carcinoma.1

Imaging Techniques in Breast Cancer
Breast cancer detection requires a multimodality approach and several imaging modalities must be adequately employed by the radiologist. For this reason we will include a short review of mammography and breast ultrasounds findings and indications before explaining the role of breast magnetic resonance imaging (MRI).

Mammography
Mammography is the primary diagnostic imaging modality in the evaluation of any mammary pathology because it is accessible, rapid, reproducible, relatively cheap and useful. The sensitivity and specificity for screening of breast cancer depend on the quality of the images, the experience of the radiologist and the reason for the imaging: screening versus diagnostic mammogram in symptomatic patients. It has been demonstrated that the likelihood of death from breast cancer is 50% lower in women who regularly participate in screening mammography programmes than in women who do not, with a similar death rate in the latter group to those obtained prior to the introduction of screening mammograms.2 The sensitivity of mammography is higher in fatty breasts and decreases in dense breasts, especially in young women. Sensitivity for the detection of multifocal–multicentric carcinoma is 66%.3 The classic signs of malignancy in mammography are spiculated nodule, irregular shape, microlobulated or blurred margins and a group of amorphous, heterogeneous or pleomorphic microcalcifications.4
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Keywords: Breast neoplasm, invasive lobular/ductal carcinoma, multifocal/multicentric extent, magnetic resonance imaging, pre-operative staging, false-positive, local recurrence rate, survival rate