View
213
Download
0
Category
Preview:
Citation preview
8/10/2019 Apresentao de Casos
1/8
9/24/20
UnknownCases
ARRSBreastImagingSymposium
,
Case1
Case1:RoutineScreening
History:60yearoldwomanwhopresentedforscreeningmammography
ImageFindings:Fig.1Leftcraniocaudal (A)andleftmediolateral oblique(B)images
demonstrate tworoundmassesintheleftupperouterbreastcontainingclustereddense
particles.Anaccompanyingrightmediolateral obliqueimage(C)showsradiodense deposits
withinrightaxillarylymphnodes.
DifferentialDiagnosis:
Granulomatous disease
Metastatic breastcarcinoma
Extramammary metastases
Golddeposits
Fat necrosisTeachingPoints:
Case1
FinalDiagnosis:Golddepositsinaxillary lymphnodes
malignantprocesses.
Obtainingacarefulhistorycanhelpdistinguishbetweentheseentities.
Malignantaxillarynodalcalcificationsareofthesametypeastheprimary
tumor,appearingpleomorphicandmalignantappearingwhereasbenign
nodalcalcificationstendtobemorecoarse.
50%ofgoldinjectedfortreatmentofrheumatoidarthritisremainsinthe
body,andthehighestconcentrationoftheremaininginjectedgoldcanbe
seeninthelymphnodesandcanresemblestippledcalcificationon
mammography.
Case2
Case2:Subareolar Tenderness
History:43yearoldmanwithcardiomyopathy developsanacutepainful,erythematous,
swollen,andfirmrightbreast
ImageFindings:Fig.2Rightcraniocaudal (A)andmediallateraloblique(B)viewsshow
incidentalgynecomastia andincreasedsubareolar densityincomparisonwithamammogram
performedfiveyearsearlier(notshown)withnewmarkedthickeningoftheperiareolar skin.
Rightbreastultrasound(C)showsahypoechoic complexirregularfluidcollectionandconfirms
overlyingskinthickening.Therewasmarkedadjacent increaseinvascularity(notshown).
DifferentialDiagnosis:
Abscess
Gynecomastia
Mastitis
Hematoma
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
2/8
9/24/20
TeachingPoints:
Breastabscesscanhaveavariablemammographicappearanceinmenand
women,rangingfromanilldefined,noncalcifiedmasstoanirregularor
Case2
FinalDiagnosis:Abscess
sp cu ate mass. tcana so em sta en orgynecomast a nmen. reast
abscessesaremorecommoninwomenthaninmen.
Skinthickeningmammographically shouldsuggestthediagnosisofan
inflammatoryprocessand/orabscess.Ultrasoundisveryhelpfulinthiscase
toidentifytheabscessfluidcollection.
Abscessformationcanbesecondarytoarupturedepidermalinclusioncyst.
Subareolar abscessisassociatedwithductectasia.Itisachroniclesionwhich
tendstorecurifnottreatedwithexcisionoftheabscessandinvolvedduct.
StaphylococcusandStreptococcusarethemostcommonpathologicagents.
Case3
Case3:Palpable,NonTenderLump
History:45yearoldmanwithprogressivelyenlargingnonpainfulleftbreastmass
ImageFindings:Fig.3Leftcraniocaudal (A)andmediallateraloblique(B)viewsshowawell
circumscribedhighdensity massthatcorrespondstothepalpablefindingmarkedwithaBB.
Incidentalgynecomastia ispresentinthesubareolar regionseparatefromthemass.Leftbreast
ultrasound(C)showsanovalcircumscribedhypoechoic masswithmildincreasedvascularity
(notshown).
DifferentialDiagnosis:
Mesenchymal neoplasm(fibrohistiocytic neoplasm)
Metastaticlesion
Breastcarcinoma
TeachingPoints:
Allconditionsthatoccurinthefemalebreasthavethepotentialtobeseeninthe
malebreast,withtheexceptionthatbiphasictumors(thosecomposedof
epithelialandmesenchymal elements)arerare(i.e.,fibroadenomas and
phyllodes tumors).
Themalebreastiscomposedofsubcutaneousfatandaremnantofsubareolar
Case3
FinalDiagnosis:Mesenchymal neoplasm(fibrohistiocytic neoplasm)
. .
Cooperligamentsarenotseeninthemalebreast.
Conditionsthatarisefromtheskin,subcutaneousfat,bloodvessels,lymphatics,
andnervescandevelopinthemalebreastandmanifestasmasses.
Adiscretemassatmammography orultrasoundinthemalebreastisconsidered
suspiciousformalignancyandpathologiccorrelationmustbeperformed.
Fibrohistiocytic tumorsaremorecommoninwomen.Thistumorinvolvesthe
subcutaneousadiposetissue.Itisararemesenchymal tumorwithalowgrade
malignantbehaviorandispronetorecurlocallyandoccasionallymetastasize
regionallyandsystemically.Itmanifestsasapainlesssofttissuemassandmostoftenaffectstheupperextremities.
Case4
Case4:Palpablelump
History:42yearoldwomanpresentswithapalpablemassintheuppermidportionofthe
leftbreast
ImageFindings:Fig.4Ultrasound(A)showswellcircumscribedhypoechoic solidmass.Left
mammogram(BandC)showsawellcircumscribedovalmass.
Differential Diagnosis:
Pseudoangiomatous stromalhyperplasia(PASH)
Fibroadenoma
Focalfibrosis
Hamartoma
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
3/8
9/24/20
TeachingPoints:
TheclinicalpathologicspectrumofPASHcanrangefromafocalmicroscopic
findingtoadominantpalpablebreastmass.PASHhasbeenreportedasan
Case4
FinalDiagnosis:Pseudoangiomatous stromalhyperplasia(PASH)
incidentalmicroscopicfindingofbreastbiopsiesperformedforeitherbenignor
malignantdisease(23%of200consecutivebreastbiopsies).PASHissimilartoa
fibroadenoma inclinicalandimagingfeatures.Toconfirmthediagnosis,biopsy
isrequired.ItisimportanttodistinguishPASHfromalowgradeangiosarcoma
onhistology.HormonalfactorsarelikelytocontributetoPASH.Animpressive
responsetotamoxifen inapatientwithPASHhasbeenreported.
Case5
Case5:PalpableLump
History:81yearoldwomantakingwarfarinwhohasapalpableabnormalityinthe12oclock
positionoftherightbreast
ImagingFindings:Fig.5Rightcraniocaudal mammogram(A)showsacircumscribedround
11mmmassinthemidposterior portionofthebreastcorrespondingtoapalpable
abnormality. Rightmediolateral obliquemammogram(B)showsthemassintheupperpartof
thebreastwasnotpresentatpreviousexaminations.Radialultrasound image(C)ofright
breastshowsapredominantlyechogenicroundmasswithasmallcysticcomponent
correspondingtotheareaofclinicalconcernatthe12oclockposition.
DifferentialDiagnosis:
Angiolipoma
Focalatrophicbreasttissue
Hamartoma,fibroadenolipoma
Hemangioma
Hematoma
Case5
TeachingPoints:
Sevenpercentofbenignmassesarehyperechoic,definedasincreased
echogenicityrelativetoadjacentfat.
FinalDiagnosis:Hematoma
Alesionthatishomogeneouslyhyperechoic andcircumscribedis
nearly100%likelytobebenign.
Anechogenicrimaroundamassisconsideredsuspicious;the
likelihoodofmalignancyis2.6timesashighasthatofamasswithout
anechogenicrim
Case6
Case6:TwoPalpableLumps
History:27yearoldwomanwithtwopalpablelumpsintherightbreast
ImagingFindings:Fig.6Ultrasoundimage(A)showsacircumscribedhypoechoic palpable
masswithtinyinternal echogenicandanechoicareas.Increasedinternalandadjacent blood
flowwaspresentoncolorflowimage(notshown).Ultrasoundimage(B)showssecond
palpableregioncorrespondstodensefibroglandular tissue.Nomassorcystispresent.
DifferentialDiagnosis:
Bothlesionsbenign,nofurtherevaluationneeded
Biopsyofsolidmasswithoutfurtherevaluationofotherarea
Biopsyofsolidmass,clinicalfollowupandmanagement ofareaofclinicalinterestwithout
imagingfinding
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
4/8
9/24/20
Case6
TeachingPoints:
Patientsyoungerthan30yearswithapalpablemassneedaninitial
evaluationwithultrasound.
FinalDiagnosis:Biopsyofsolidmass,clinicalfollowupandmanagement of
areaofclinicalinterestwithoutimagingfinding
, .
findingissuspiciousformalignancy,mammography ofbothbreastsshouldbe
performed.
Iftherearenoimagingfindingsonthepalpablelesion,clinicalfollowupis
recommended.Clinically suspiciousareasshouldbefollowedfor12yearsof
stability.Ifthearearemainsclinically suspicious,biopsyshouldbeperformed
byfineneedleaspiration,corebiopsy,orsurgicalexcision.
Case7
Case7:RoutineMammogram,historyofbreastconservingtreatment(BCT)
History:67yearoldwomanwithcentralcalcificationsonherannualdiagnosticmammogram
andhistoryofrightupperquadrantlumpectomy1yearago
ImagingFindings:Fig.7Rightcraniocaudal (A)andmediolateral oblique(B)mammograms
showlumpectomychangessurroundedbysurgicalclipsintheupperouterquadrant.Central
inrelationtothenippleisanewclusterofcalcifications.Lateralspotmagnificationview(C)
furthershowsthepleomorphicclusteredcalcificationswithoutlayering.Findingatinitial
imagingguidedbiopsywasbenignfibrocysticchangeswithstromalcalcifications.
DifferentialDiagnosis:
Acceptthepathologicdiagnosisandrecommend6monthfollowupmammography
Acceptfindingsasconcordant andhavepatientresumeannualscreeningexaminations
Re ect the atholo ic dia nosis as discordant with ima in findin s and recommend
additionaltissuesampling
Case7
TeachingPoints:
Coreneedlebiopsyhasareportedsensitivityof8599%.Technicalissuesof
biopsyandpathologicassessmentresultinthisrange.
FinalDiagnosis:Rejectthepathologicdiagnosisasdiscordantwithimaging
findingsandrecommendadditionaltissuesampling
Ifthepatienthasmorethanonegroupofcalcifications,theradiologistmust
ensurethatthebiopsyisofthecorrectgroupandthatthemarkerisatthe
locationofthelesionofinterestonthepostprocedure mammogram.
Effectivecommunicationwiththepathologistabouttheimagingfindingson
thebiopsiedlesion(massorcalcifications)andtheoverallsuspicionofthe
lesionisimportant.Iftheimagingandpathologicfindingsonlesionare
discordant,furthertissuesamplingisneededwitheitherasecondneedle
biopsyor,preferably,surgicalbiopsy.
Case8 Case8:BloodyNippleDischarge,right
History:50yearoldwomanwithbloodyandcleardischargefromrightnipple,normal
mammographicfindings,andanunsuccessfulductogram
ImagingFindings:Fig.8Axial(A)contrastenhancedsubtractionMRimageshowslinear
branchingnonmasslike enhancementinthemedialsubareolar regionoftherightbreast.
Axialcomputeraideddetectionimage(B)depictsabnormalenhancement. SagittalMR
image(C)showslocationofenhancement ininferioraspectofthebreast.
DifferentialDiagnosis:
Ductalcarcinomainsitu
Ductalectasia
Papilloma
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
5/8
9/24/20
Case8
TeachingPoints:
Bloodynippledischargeismostcommonlyassociatedwithbenign
FinalDiagnosis:Papilloma
, , .
areassociatedwithcancer,intraductal,invasive,orPagetdisease.
MRIcanhelpindetectionofanintraductal lesioninwomenwithnipple
dischargeandnormalconventionalimagingfindings.
Differentiatingpapillomaandsmallinvasivecancerorductalcarcinomain
situusuallyisnotpossiblewithbreastMRI.
Case9
Case9:ScreeningMRI,highriskpatient
History:51yearoldwomanwithstrongfamilyhistoryofbreastcancerandnormalfindingsonscreening
mammograms
ImagingFindings:Fig.9MRimagesshowbilateralabnormalities.Contrastenhancedaxial(A)andT1
weightedaxial(B)MRimagesshowanenhancingroundmassinthelateralaspectoftheleftbreast.A
hypoechoic masswithanirregularmarginwasfoundatultrasoundexaminationofthisregion(not
shown).ContrastenhancedaxialMRimage(C)showsnonmasslike regionalenhancementofthelateral
aspectoftherightbreast.
Differential Diagnosis:
Leftbreast:
Fibroadenoma
Invasivecarcinoma
Metastaticlesion
Rightbreast:
Ductalcarcinomainsitu(DCIS)
Fibrocysticchange
Invasivelobularcarcinoma
Lobularcarcinomainsitu
Case9
TeachingPoints:
IndicationsforscreeningMRIaretheBRCA1,BRCA2,geneticsyndromes
(e.g.,Cowden,LiFraumeni),mantleradiation,andastrongfamilyhistory
(greaterthan20%lifetimerisk).
FinalDiagnosis:Left:Invasivecarcinoma,Right:DCIS
,
thatis,ductal,segmental,linear,focal,regionalormultiregional,and
diffuse.
Theenhancementkineticsofnonmasslike lesionscanbemisleading
Nonmasslike cancerouslesionsaremorelikelytobeDCISandlobular
cancer.
Bilateralsymmetricnonmasslike enhancementinanydistributionismore
oftenbenign.
Case10
Case10:SurveillanceMRIpostmastectomy andTRAMflapreconstruction
History:48yearoldwomanwithafamilyhistoryofbreastcancer,previouslefttransverse
rectusabdominis myocutaneous (TRAM)flapreconstructionforductalcarcinomainsitu(DCIS)
andlobularcarcinomainsitu(LCIS)ofleftbreast,normalfindingsatscreeningmammography
ImagingFindings:Fig.10Axialcomputeraideddetection(A),subtraction(B),andT1
weighted(C)screeningMRimagesshowanirregular2cmmasswithabnormalenhancement
inthemedialaspectoftheleftTRAMflap.Secondlookultrasoundimages(notshown)
depictedasuspiciousirregularhypoechoic solidmass.
DifferentialDiagnosis:
Fatnecrosis
Invasive
cancer
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
6/8
9/24/20
Case10
Teaching
Points:
FatnecrosiscanmimicmalignantgrowthwithvaryingappearancesatMRI.
Suspiciousmorphologicandkineticfeaturesmaybepresent,necessitating
biopsytoexcludeneworrecurrentbreastcancer.
FinalDiagnosis:Invasivecancer
RecurrentbreastcancerinTRAMflapreconstructionsforDCISmaybean
invasivemalignanttumor.
AlthoughTRAMflapreconstructionsareofpredominantfatdensity,
recurrencecanbemissedatmammographicscreeningifthelesionisina
medialandposteriorlocation.
A BCase11
C D
Case11:PalpableLump
BIRADSCode:2
History:42yearoldwomanwithnewpalpableabnormalityoftheleftbreast
ImagingFindings:Fig.11Leftcraniocaudal (A)andmediolateral oblique(B)mammograms
showacircumscribed6.7cmmixeddensityfatcontainingmassintheupperouterquadrant.
Themasscorrespondstothepalpableabnormality.Ultrasoundimages(CandD)showa
circumscribedpredominantlyechogenicmasscorrespondingtothepalpableabnormalityand
mammographicmass.
DifferentialDiagnosis:
Fibroadenoma
Galactocele
Hamartoma fibroadenoli oma
A B
Oilcyst,fatnecrosis
C D
Case11
TeachingPoints:
Breasthamartoma,alsoknownasfibroadenolipoma,isarelatively
uncommonbenignlesion.Thelesionscanpresentaspalpableabnormalities
orasincidentalmammographicfindings.
FinalDiagnosis:Hamartoma (fibroadenolipoma)
Hamartomas containthemajorconstituentsofthebreastinanencapsulated
lesion.Mammograms showcircumscribedfatcontaininglesionswitha
capsuleandfibroglandular elements.
Theclassicmammographicappearanceisdiagnosticandobviatesbiopsy.
Ultrasoundshowshamartomas assharplydefinedmasseswithsonolucent
areasandechoproducingstructures.Theyaretypicallyheterogeneous.A
hamartoma withaclosertouniformsonographic appearance,however,is
difficulttodifferentiatefromfibroadenoma.
Case12A B
C
Case12:PalpableLump
BIRADSCode:4A
History:39yearoldwomanwithpossibleincreaseinsizeofpalpableabnormalityinleft
breast
ImagingFindings:Fig.12Leftcraniocaudal (A)andmediolateral oblique(B)mammograms
showacircumscribedhighdensitymassintheposteriorupperinnerquadrant.Ultrasound
image(C)showsacorrespondingcircumscribedovalpredominantlyhypoechoic 2.9cmmass
withassociatedposterioracousticenhancement.
DifferentialDiagnosis:
Epidermoid inclusioncyst
Fibroadenoma
A B
Pseudoangiomatous stromalhyperplasia
C
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
7/8
9/24/20
Case12
TeachingPoints:
Skin
lesions
visible
on
mammograms
can
be
mistaken
for
intramammarylesions.
Skinlesions,whichareraised,firm,andnotcompressibleanddonothavean
airsofttissueinterfacecanprojectasanintramammary masson
FinalDiagnosis:Epidermoid inclusioncyst
mammograms.
Epidermalinclusioncystsarebenignlesions.Theyareoftenpalpablejust
beneaththeskinsurface.
Coreneedlebiopsyofepidermoid inclusioncystsshouldbeavoidedbecause
theneedlecandisplacethelesioncontentsintoadjacentbreasttissue,andan
inflammatoryreactioncanresult.
BA
Case13
DC
Case13:ScreeningMRI,highriskpatient
BIRADSCode:2
History: 37yearoldwomanwithBRCA2mutationundergoinghighriskscreeningbreastMRIafterrecent
negativemammogram
ImagingFindings:Fig.13T1weightedfatsuppressedsubtractionmaximumintensityprojection(MIP)
(A)andaxial(B)MRimagesshowsegmentalreticulardendriticnonmasslike enhancementintheupper
outerquadrantsofbothbreasts.FollowupT1weightedfatsuppressedsubtractionMIP(C)andaxial(D)
MRimages1yearafterAandBshowresolutionofthebilateralenhancement.
Differential Diagnosis:
Bilateralductalcarcinomainsitu
Bilateralfibrocysticchange
Bilateralnormalbackgroundenhancement
Bilateralsclerosing adenosis
DC
BA
Case13
TeachingPoints:
Backgroundenhancementcanbeminimal,mild,moderate,or
markedandshouldbedescribedintheMRIreport.
FinalDiagnosis:Bilateralnormalbackgroundenhancement
.
Comparedwiththeuntreatedside,itcanbeincreasedintheshort
termanddecreasedinthelongterm.
Backgroundenhancementissensitivetohormonalvariations.
Screeningondays710ofthemenstrualcycleisrecommendedto
decreasebackgroundenhancement.
A B C
Case14
E FD
Case14:RoutineScreening
History:44yearoldwomanundergoingbaselinescreeningmammographywithfamilyhistoryofbreast
cancer(maternalaunt)andcoreneedlebiopsypathologicdiagnosisofradialscar;theradiologicpathologic
correlationandarecommendationmustbemade
ImagingFindings:Fig.14Craniocaudal (A)andmediolateral oblique(B)mammogramsoftherightbreast
showarchitecturaldistortion(arrow)intheupperouterquadrantthatpersistsoncraniocaudal (C)and
mediolateral oblique(D)spotcompressionimages.Targeted ultrasoundimage(E)atthesiteofthe
mammographicabnormalityshowsnormalfindings.Stereotacticbiopsywasperformed.Postprocedure
craniocaudal mammogram(F)showsthebiopsyclipatthesiteofmammographicabnormality.
Differential Diagnosis:
Concordant;recommend6monthfollowuppostbiopsy mammogram
Concordant;recommendsurgicalconsultationforexcision
Discordant;recommendbreastMRIforfurtherevaluationandmanagement
Discordant;
recommend
surgical
consultation
for
excision
A B C
E FD
ght American Roentgen Ray Society 2012
8/10/2019 Apresentao de Casos
8/8
9/24/20
TeachingPoints:
Architecturaldistortionisdescribedasdistortionofthenormalarchitectureofthebreast
withoutadefinite
mass.
This
finding
often
appears
as
thin
lines
or
spiculation radiating
fromapointandfocalretractionordistortionoftheedgeoftheparenchyma.
Truearchitecturaldistortion,confirmedwithdiagnosticmammography,isasuspicious
findin If not definitivel secondar to sur er or trauma architectural distortion re uires
Case14
FinalDiagnosis:Concordant;recommendsurgicalconsultationforexcision
. ,
additionalevaluationwithbiopsyfortissuediagnosis,whetherornotacorrelative
sonographic findingismade.
Percutaneousbiopsyisoftenperformedforevaluationofarchitecturaldistortion.Radial
scarisaconcordant explanationformammographicarchitecturaldistortion;however,
surgicalexcisionoftenisperformedbecauseofunderestimationofmalignancyat
percutaneous coreneedlebiopsy.
Radialscardiagnosedatcoreneedlebiopsyismorelikelytobeupgradedtomalignancyat
surgicalexcisionifthereisassociatedatypia.However,studieshaveshowntheupgrade
rateofradialscarwithoutatypia isgreaterthan2%.Therefore,surgicalexcisionisoften
undertaken.
Case15
A B
DC
Case15:SurveillanceMRI,1yearpostBCT
History:68yearoldwomanundergoingscreeningMRI1yearafterlumpectomy
ImagingFindings:Fig.15Axial(A)andsagittal(B)contrastenhancedT1weightedfat
suppressedbreastMRimagesshowalobulatedmasswithirregularmarginsandrim
enhancement inthelowerouterrightbreast.T1weightedimageobtainedwithoutfat
suppression(C)showthatthecenterofthemasshashighsignalintensitylikethatofthe
surroundingbreastfat.Rightcraniocaudal mammogram(D)showsdystrophic andrim
calcificationssurroundingaradiolucentmassinthelateralbreast.
DifferentialDiagnosis:
Fatnecrosis
Mucinouscarcinoma
RimenhancinginflamedcystA
D
B
C
TeachingPoints:
Imagingfindingsofcentraltissuethathasthesamesignal
characteristicsasfatinallsequencessupportthediagnosisoffat
Case15
FinalDiagnosis:FatNecrosis
necros s.
Ahistoryofsurgeryortraumacanbeakeyfactorinmakingthe
diagnosisoffatnecrosis.
Mammographyisacosteffectivemethodofevaluatingforthe
lucency ordystrophiccalcificationsassociatedwithfatnecrosis
suspectedonMRI.
Congratulationstothewinners!
Abike Durojaye
ToddEverett
Luciana
Tajara PhilipMurphy
Sridevi Ratakonda
Thankyou
En o
thelast
session
of
the
course!
Recommended