Table of Contents
Techniques
- Under age 30 w/ palpable abnormality → start work-up with US rather than mammo
- Breast MR should be done on days 7-17 of cycle
- Regarding biopsy of developing densities → regardless of a needle biopsy result, surgical excision is recommended
Cystic Masses
- Inspissated Cyst
- = Complex Cyst
- has well-defined margin and no internal flow, but may contain debris in a nondependant portion
- Apocrine Cyst
- Multilobulated Appearance, but otherwise simple
- Septated Hypoechoic Cyst
- Suspicious for papillary CA
- Black patients have higher risk of papillary CA
Fat containing masses
- Lipoma
- Fat necrosis
- Galactocele
- Hamartoma
BIRADS 3 Scenarios
- First ever mammo with benign appearing lesion (such as a Focal Asymmetric Density)
- Lesion identified which is also, in retrospect, seen on the old study, stable, and benign appearing
- Status post concordant benign breast biopsy (1 year) or post-lumpectomy f/u (3 years)
Lobular Carcinoma
- very slow growing
- looks like breast tissue
Inflammatory Carcinoma
- DDx is mastitis → need clinical correlation and obtain U/S
- if U/S shows a mass, then it's inflammatory CA
- MR is useful for determining response to neoadjuvant therapy
Breast MRI
MRI Guidelines
- Hormone Replacement Therapy - The patient should be off HRT treatments for at least 3 months or 6 months (optimal). Imaging may be done earlier but it must be known that the results may be compromised
- Post Biopsy - The patient should wait at least two weeks or 30 days (optimal) after biopsy before having a breast MRI.
- Menstrual Cycle - Patients should be scanned 7-10 days after the onset of their menstrual cycle. Otherwise, results may be compromised.
Indications for MRI
- Work-up of extent of disease of a known breast cancer, when the extent is in question on the mammogram or ultrasound, or if the patient is status post lumpectomy with positive margins
- Neoadjuvant chemotherapy
- Axillary metastases with unknown primary and negative mammogram and ultrasound
- Lobular carcinoma
- Recurrence monitoring
- Evaluate for silicone implant rupture
- The indications for MRI are growing, and have been somewhat controversial. Possible other indications for MR:
- Problem-solving when mammogram and/or ultrasound are indeterminate
- Screening for high-risk women
Types of Enhancement on MR
- homogeneous
- heterogeneous
- stippled
- clumped
- reticular-dendritic
Enhancement Curves on MR
- Progressive
- Plateauing
- Early/Rapid Washout
Clumped Enhancement
- multiple foci of enhancement close together
- diffuse clumped enhancement on MR with -MMG should raise suspicion for lobular CA
Fibroadenoma
- well-defined, palpable mass
- changes with cycle
- dark septa on FS T1 CE MR (fatty septa)
Phylloides
- if suspected on MMG, then surgical excision is recommended
- path can be confusing
- can be benign or malignant or have sarcomatous degeneration
- has osseous, chondroid, or adipose matrix
Large Highly Vascular Mass in Young Patient
- Think about other categories of masses
- mesenchymal tumors → fibromatosis (extra-abdominal desmoid)
- systemic → lymphoma
- angiosarcoma
Types of DCIS
- Comedo → high-grade
- dot-dash calcifications
- Non-comedo → cribriform, micropapillary and solid subtypes
- punctate or granular calcifications
Extensive Intraductal Component DCIS
- very aggressive, high nuclear grade
- do not respond to XRT
- need mastectomy
Inflamed Breast Post-Lumpectomy
- need to know tumor type and surgical margins
- MR may be useful
- if there is enhancement in the skin, look at the curves
- if the curves are suspicious, think inflammatory CA
DDx Axillary LAD
- leukemia, lymphoma
- HIV
- scleroderma
- mets (breast, ovary)
- lupus
DDx Calcified Nodes
- treated lymphoma
- gold therapy
- sarcoid
- BCG therapy
- histo
- TB
- mets (adenoCA, osteosarc)
Male Breast
- gynecomastia is fan-like and retroareolar
- real mass on breast U/S in a male → should be considered highly suspicious (BIRAD 5)
- most common cancer type in males →
