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  • 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

  1. 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
  2. Neoadjuvant chemotherapy
  3. Axillary metastases with unknown primary and negative mammogram and ultrasound
  4. Lobular carcinoma
  5. Recurrence monitoring
  6. Evaluate for silicone implant rupture
  7. 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


  • well-defined, palpable mass
  • changes with cycle
  • dark septa on FS T1 CE MR (fatty septa)


  • 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 → :?: