Radiologic and pathologic correlation of non-mass like breast lesions on US and MRI: Benign, high risk, versus malignant

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1 Radiologic and pathologic correlation of non-mass like breast lesions on US and MRI: Benign, high risk, versus malignant Poster No.: C-1161 Congress: ECR 2013 Type: Educational Exhibit Authors: J. Kwak, B. K. Seo, S. E. Song, K. R. Cho, O. H. Woo, S. H Cha ; Ansan/KR, Seoul/KR, Ansan-si, Gyeonggi-do/KR Keywords: Breast, MR, Biopsy, Pathology DOI: /ecr2013/C-1161 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Learning objectives Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) High risk screening, Pre-operative staging, Post-treatment follow-up > Radiologists assesses the morphology as well as kinetics of the lesion following the breast imaging reporting and data system (BI-RADS) lexicon Non-mass like enhancement is the predominant morphology of ductal carcinoma in situ (DCIS) which exhibits a variety of kinetic curve shapes 1.To provide descriptions of non-mass-like lesion on MRI and US 2.To show correlations of radiologic findings of non-mass like lesions on breast US and MRI with pathologic features 3.To classify non-mass like lesions into three types, benign, high-risk, and malignant lesions and demonstrate radiologic characteristics among pathologic diagnosis. 4.To provide guidelines for interpretation of non-mass like breast lesions on US and MRI Page 2 of 24

3 Background Non-mass-like lesions does not exist in standardized terminology of BI-RADS-US lexicon. DCIS and invasive lobular carcinoma that usually manifest as a non-mass-like lesion on US. Common benign pathologic disease such as fibrocystic change and fibroadenoma occasionally manifest as non-mass like lesions on US and MRI. However, image interpretations of non-mass like lesions are not familiar to radiologists and needs more experiences! <Distribution of NMLE>(Fig.1~3) Distribution Positive predictive malignancy Focal Not known Linear or branching ductal 24%- 85% Regional 21% Marked regional 59% Segmental 78% value (PPV) for value (PPV) for Linear or branching ductal Benign lesions : linear-ductal pattern Malignant lesion: branching-ductal pattern Differential diagnosis of ductal enhancement ;Atypical ductal hyperplasia, lobular carcinoma in situ and DCIS Fibrocystic change, ductal epithelial hyperplasia, and fibrosis Internal enhancement of NMLE (Fig4~6) Internal Enhancement Positive predictive malignancy Reticular Not known Stippled 25% Page 3 of 24

4 Heterogeneous 53% Clumped 60% Homogeneous 67% *Classification by Uematsu et al. Milk duct system: ''single ductal'' hypoechoic ''multiple ductal'' hypoechoic areas Intraductal lesions growing in the milk duct Glandular tissue ''non-ductal'' hypoechoic areas: Focal/ Segmental Lesion that differs from the surrounding glandular tissue or the same area in the contralateral breast Con#ned asymmetry with an indistinct shape on two different projections *Classification by Sotome et al. Duct dilatation DCIS, IDC with a predominant intraductal component, intraductal papilloma, ductal epithelial hyperplasia Multi-vesicular pattern DCIS, Matopathy Low echo area in the mammary gland DCIS, IDC with a predominant intraductal component, ILC, mastopathy Various pathology presented as NMLE Benign High risk Malignant Fibrocystic change Atypical ductal hyperplasia Ductal Carcinoma in situ Page 4 of 24

5 Ductal hyperplasia epithelial Intraductal papilloma Invasive ductal carcinoma Matopathy (focal adenosis) Lobular carcinoma in situ Invasive tubular carcinoma Hormonal Stimulation Invasive lobular carcinoma Inflammatory change Page 5 of 24

6 Images for this section: Fig. 1: Distribution of NMLE Page 6 of 24

7 Fig. 2: Distribution of NMLE Page 7 of 24

8 Fig. 3: Distribution of NMLE Fig. 4: Internal Enhancement Pattern of NMLE Page 8 of 24

9 Fig. 5: Internal Enhancement Pattern of NMLE Page 9 of 24

10 Fig. 6: Internal Enhancement Pattern of NMLE Page 10 of 24

11 Imaging findings OR Procedure details Fig.7 A-54-year-old-woman with invasive ductal carcinoma in right breast A. On US, non-mass-like-lesion is seen in 12 O'clock direction of left breast and the lesion is confirmed as fibrocystic change by core biopsy. B. On axial contrast enhanced T1WI, non-mass-like enhancement with focal distribution and internal stippled enhancement is seen in upper mid portion of left breast. Fig.8 A-48-year-old-woman with invasive ductal carcinoma in right breast A. On US, non-mass-like-lesion is seen in 10 O'clock direction of left breast and the lesion is confirmed as fibrocystic change by core biopsy. B. On sagittal contrast enhanced T1WI, non-mass-like enhancement with segmental distribution and internal clumped enhancement is seen in upper inner portion of left breast. Fig.9 A-52-year-old-woman with previous history of paraffin injection in her breasts A. On US, a single ductal non-mass-like-lesion is seen in 10 O'clock direction of right breast and the lesion is confirmed as moderate ductal epithelial hyperplasia by core biopsy. B. On axial contrast enhanced T1WI, non-mass-like enhancement with ductal distribution and internal homogeneous enhancement is seen in upper outer portion of right breast. Fig.10 A-60-year-old-woman with invasive ductal carcinoma in left breast A. On US, non-mass-like-lesion is seen in 6 O'clock direction of right breast and the lesion is confirmed as chronic granulomatous inflammation with necrosis by core biopsy. Page 11 of 24

12 B. On axial contrast enhanced T1WI, non-mass-like enhancement with regional distribution and internal heterogeneous enhancement is seen in upper outer portion of right breast. Fig.11 A-55-year-old-woman with hormone replacement therapy On axial contrast enhanced T1WI, bilateral, symmetric non-mass-like enhancements with regional distribution and internal stippled enhancement are seen in upper outer portion of both breasts. Fig.12 A-33-year-old-woman with no clinical symptom On US, dilated duct with intraductal echogenic material is seen in subareolar area of right breast. The lesion is confirmed as atypical ductal hyperplasia with fibrocystic change by surgical excision with US-guided needled localization. Fig.13 A-44-year-old-woman with no clinical symptom A. On left mammography, indistinct and round microcalcifications are regionally distributed in subareolar area of left breast. B. On US, duct ectasia with internal microcalcifications and intraductal echogenic material is seen in left subareolar area. C. On axial contrast enhanced T1WI, non-mass-like enhancement with segmental distribution and internal heterogeneous enhancement is seen in upper outer portion of right breast. The lesion is confirmed as ductal carcinoma in situ, low grade by breast conserving therapy. Fig.14 A-53-year-old-woman with ductalcarcinoma insitu in left breast A.On MMG, a focal asymmetric density with clustered microcalcifications is seen.b.on US, ductal change is seen. C,D. On MRI and a CAD system, a non-mass-like enhancement shows linear distribution and internal clumped enhancement. Page 12 of 24

13 E. MR-guided mammotome is done and the lesion is confirmed as DCIS. Fig.15 A-47-year-old-woman with invasive ductal carcinoma in left breast A.On MMG, a focal asymmetric density with clustered microcalcifications is seen.b.on US, ductal change is seen. C. On CT, non-mass like enhancement is seen. D,E. On MRI and CAD system, non-mass like enhancement shows segmetal distriburion and internal heterogeneous enhancement. F. On gross specimen, the lesion is confirmed as invasive ductal carcinoma. Fig.16 A-56-year-old-woman with invasive ductal carcinoma in left breast A.On MMG, segmentally distributed microcalcifications are regionally distrubuted in LUIQ.B.On US, indistinct irregular shaped hypoechoic mass is seen in left breast. C,D. On CT and MRI, non-mass like enhancement shows regional distribution and heterogeneous enhancement. Fig.17 A-44-year-old-woman with no clinical symptom A. On US, a non-ductal hypoechoic area is seen in subareolar area of left breast. B. On axial contrast enhanced T1WI, non-mass-like enhancement with regional distribution and internal clumped enhancement is seen in her left breast. The lesion is confirmed as invasive lobular carcinoma by breast conserving therapy. Page 13 of 24

14 Images for this section: Fig. 7: Fibrocystic Change Fig. 8: Fibrocystic Change Page 14 of 24

15 Fig. 9: Ductal epithelial hyperplasia Fig. 10: Granulomatous Mastitis Page 15 of 24

16 Fig. 11: Hormonal Replacement Treatment Page 16 of 24

17 Fig. 16: Invasive Ductal Carcinoma Fig. 15: Invasive Ductal Carcinoma Page 17 of 24

18 Fig. 14: DCIS Page 18 of 24

19 Fig. 13: DCIS Page 19 of 24

20 Fig. 17: Invasive lobular carcinoma Page 20 of 24

21 Fig. 12: Atypical Ducal Hyperplasia Page 21 of 24

22 Conclusion Non-mass like lesions on breast US and MRI have various pathologic diagnoses from benign to malignant lesions. On US, non-mass like lesions associated with segmental or linear distributed suspicious microcalcifications or intraductal nodules prefer malignancy. On dynamic MRI, non-mass like lesions with ductal or segmental distribution and heterogeneous or clumped enhancements prefer malignancy. On the other hand, kinetic assessment on MRI is not helpful to distinguish benign from malignant non-mass like lesions. Page 22 of 24

23 Images for this section: Fig. 18: Guidelines for interpretation of non-mass like breast lesions on US and MRI Page 23 of 24

24 References Breast Cancer 2007, 14(4): Breast Cancer 2012, 19(4): Radiology 2006, 238(1):42-53 Radiology 2001, 219(2): AJR 2003, 181(2): Radiologic clinics of North America 2004, 42(5): , vii. AJR 2006, 187(2): Medical physics 2008, 35(7): Page 24 of 24