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Breast Magnetic Resonance Imaging of Multicentric, Multifocal and Bilateral Cancer


Figure 1: Multifocal Carcinoma in a 37-year-old Woman with Three Palpable Nodules in the Right Breast


AB


Figure 2: Multicentric Carcinoma in a 51-year-old Woman with Two Palpable Masses in the Left Breast


A


CD


E


BC


FG


D


E


A and B: Radial ultrasound image shows three hypoechoic masses with internal echoes, craniocaudal diameter greater than the mediolateral diameter and microlobulated contours – features suggestive of malignancy. Fine-needle aspiration cytology (FNAC) was performed and all of the masses were positive for malignancy: poorly differentiated (G3) infiltrative ductal carcinoma with necrosis and intraductal component, all in the same quadrant. C–G: Magnetic resonance imaging (MRI) of both breasts was performed for detecting additional foci and pre-surgical staging. Unenhanced (C) and enhanced MRI (D) show a hypointense mass with peripheral enhancement that presents a type III enhancement curve (E). Axial (F) and coronal (G) maximum-intensity projection (MIP) reconstructions show the enhancing mass (arrowhead) in the upper lateral quadrant of the right breast, with irregular shape, lobulated margins and several satellite lesions (arrows). A round and enhancing right axillary lymphadenopathy is also seen (thick arrow). The treatment decided on was right mastectomy.


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


Figure 3: Occult Multicentric Carcinoma Detected by Magnetic Resonance Imaging


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


Breast Ultrasound


Sonography is the second most important imaging modality for the detection of mammary pathology. It is indicated in young women who have a very dense parenchyma during pregnancy and breastfeeding, because the fibroglandular component of the parenchyma grows; in inflammatory pathology, because it is better tolerated and identifies abscesses better than mammography; and in mastectomised women. It is also indicated as a complementary technique after mammography for the study of the breast with prosthesis, unspecific findings in mammogram or characterisation of injuries that cannot be completely purified by means of mammography, nipple secretion, negative mammography and palpable tumour, probable breast metastatic disease or women with high-risk factors and dense breasts.5


Breast


Magnetic resonance imaging (MRI) of a 69-year-old woman with a left palpable axillary lymph node and negative mammogram and sonogram (not shown). A: Pre-gadolinium T1-weighted sequence shows enlarged left axillary lymph nodes (arrow). B and C: Post-gadolinium MRI (B) and maximum-intensity projection (MIP) reconstruction (C) show enhancing retroareolar masses (arrows) in the left breast with micronodular and linear parenchymatous enhancement. The histology demonstrated poor differentiated (G3) infiltrative ductal carcinoma with extensive intraductal component and axillary metastases in seven of 17 lymphatic nodules. The treatment decided on was tumourectomy and lymphadenectomy.


only glandular asymmetry, and is more sensitive than mammography for invasive cancer in non-fatty breasts.7


Finally, ultrasound is an excellent guide for interventional procedures; it is diagnostic for cysts and allows suitable definition of benign nodules that do not need biopsies.6


ultrasound is not recommended as a screening technique mainly because of three reasons: microcalcifications are very difficult to identify, it depends very much on the sonographer experience and the procedure takes a long time. Nevertheless, ultrasound can detect lesions in cases where the mammogram is absolutely normal or shows


EUROPEAN ONCOLOGY & HAEMATOLOGY AB C


A: Mammography, mediolateral oblique and craniocaudal projections of both breasts show fibroglandular tissue located fundamentally in the upper external quadrants, an area of tissue asymmetry (white arrows) and a calcification of benign aspect (pink arrow) in the left external quadrant. B: Ultrasound scan centred on the region in which the patient noticed the increase of density shows a mass with suspicious characteristics: polylobulated, with irregular margins and acoustic posterior shadow. C–E: Enhanced magnetic resonance imaging (MRI), maximum-intensity projection (MIP) reconstruction (C): several dominant lesions in left external quadrants not detected at ultrasound are shown. Linear/micronodular enhancement (arrowhead) of the surrounding parenchyma and a growth of vascularity are associated (arrows). A subtraction image of the larger posterior lesions (D) shows a type III enhancement curve (E). Biopsy showed multifocal infiltrative ductal carcinoma (G3) with foci of micropapillar and colloid infiltration, an intramammary metastatic lymphatic nodule and extent component of intraductal carcinoma (high nuclear grade). Metastasis in seven of 10 axillary lymphatic nodules. The treatment decided on mastectomy with lymphadenectomy, posterior reconstruction and right breast reduction.


For this reason, ultrasound


with mammogram and medical examination is indispensable for the diagnosis of benign and malignant breast lesions.6


The signs of malignancy in sonography are spiculated nodule, angular margins, marked hypoechogenicity, posterior shadow, greater height than width of the nodule, dotted calcifications, ductal extension, ramified aspect and microlobulated contours. The classic echographic appearance of the invasive carcinoma is a hypoechoic mass with internal echoes, heterogeneous, with irregular margins and acoustic shadow.8


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