Invasive lobular carcinoma of the breast; spectrum of imaging findings.

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1 Invasive lobular carcinoma of the breast; spectrum of imaging findings. Poster No.: C-0847 Congress: ECR 2014 Type: Educational Exhibit Authors: D. Mandich, T. Diaz de Bustamante, L. Koren, M. Arroyo, G. Ayala, A. L. VEITIA, B. Sancho Perez ; Madrid, Ma/ES, 2 3 Madrid/ES, MADRID, SP/ES Keywords: Cancer, Diagnostic procedure, MR, Mammography, Breast DOI: /ecr2014/C-0847 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 41

2 Learning objectives To review imaging findings of invasive lobular carcinoma of the breast (ILC) by mammography, ultrasound and magnetic resonance during years 2012 and 2013, based in 27 patients with ILC histologically confirmed by surgical specimen. To identify the diverse radiologic appearance and describe the role of different imaging tests. Page 2 of 41

3 Background Invasive lobular carcinoma of the breast (ILC) is the second most common histological type of breast cancer and it represents 10-15% about all breast carcinoma. It is associated with a higher rate of multiplicity and bilaterality than invasive ductal carcinoma, however the overall survival rate is slightly higher in patients with ILC. It has a characteristic histopathologic appearance which consists of small tumor cells with round nuclei arranged in a single-file pattern along Cooper's ligaments. It has a tendency to spread diffusely between the collagen fibbers invading breast tissue without producing architecture distortion. In consequence with this little desmoplastic response, clinical presentation and imaging findings are often subtle. ILC is often difficult to diagnose mammographically with a higher false-negative rates than for other invasive cancers. The radiographic findings can be atypical which makes the diagnosis challenging for radiologists. In comparison with invasive ductal carcinoma, there are a lower percentage of microcalcifications, more architectural distortion and lower density lesions which are similar to normal breast tissue. Mammographic findings Mammography is always the first step in breast cancer diagnosis. Craniocaudal view is the best projection to identify lesions because of the lower thickness of mammary gland. ILC most commonly manifests as a mass (up to 65% of cases) with irregular margins mostly speculated (Fig. 1 and 2), even if sometimes they can also be circumscribed (Fig. 3). Other mammographic findings are architectural distortion and focal asymmetric density (Fig. 4 and 5). Architectural distortion is the second most common manifestation and it is defined as lines that converge to a point without a clear - cut nodule. Focal asymmetric density is an opacity with indistinct margins but that it is identified in both projections. Page 3 of 41

4 Even if microcalcifications are far less frequently associated with ILC than with invasive ductal carcinoma, they have been described with a reported prevalence that ranges from 0% to 24%. Normal or benign mammographic findings in ILC are reported in 8%-16% of cases with a sensitivity of mammography for the detection of ILC between 57% and 81%. The sensitivity decreases in high dense breasts making necessary US and MR for the detection of mammographic occult lesions (Fig 6). US and MRI increase diagnostic sensibility and, consequently, in recent years they have become widely used tools in detection of ILC. They also have a main role in management of ILC as they allow knowing volume and tumoral extension, multifocality and multicentricity and response to chemotherapy. Ultrasound findings Its role as a complementary diagnostic test in patients with a negative mammography or with suspected lesions just identified in one mammographic view. It is also a useful tool to execute interventional procedures as biopsy due to its accessibility, reproducibility and image control in real time. The most common US manifestation is an irregular heterogeneous mass not parallel to the skin surface, predominately hypoechoic, with ill-defined or spiculated margins and posterior acoustic shadowing (Fig 7 and 8). Additional manifestations include circumscribed nodules without shadowing and architectural distortion without a nodule but with focal shadowing (Fig 9). There may also be sonographically invisible lesions. MR findings At MR imaging the most common manifestation is an enhancing solitary nodule with spiculated or ill-defined margins (Fig. 10 and 11). Additional manifestations include a dominant lesion surrounded by multiple small enhancing foci, multiple clumped enhancing foci interconnected by Page 4 of 41

5 enhancing strands, architectural distortions, focal heterogeneous enhancement and enhancing septa (fig. 12). MR also allows obtaining kinetic curves which value breast tissue intensity over time after contrast injection. The kinetic curve assessment includes a description of the initial peak and the delayed phase of contrast enhancement. The most suspicious enhancement pattern is number 3, with an initial increase and subsequent washout. Type 2 is a plateau pattern, in which there is a rapid initial rise followed by a flattening in the delayed phase. Both type 2 and type 3 curves should be considered suggestive of malignancy. MR is an essential tool in ILC diagnosis and management as it has been shown to be superior to mammography and US in estimating tumor size and detecting multifocality and multicentricity, leading to changes in surgical management in 28% of cases. It plays also an important role in evaluating response to chemotherapy. Page 5 of 41

Images for this section: Fig. 1: Fig 1. (a) Craniocaudal and (b) mediolateral oblique mammograms of the right breast showed an irregular nodule with spiculated margins at upper outer quadrant.

6 Images for this section: Fig. 1: Fig 1. (a) Craniocaudal and (b) mediolateral oblique mammograms of the right breast showed an irregular nodule with spiculated margins at upper outer quadrant. In this case, the ILC appeared similar to the typical manifestation of the usual type invasive ductal carcinoma. Patient was asymptomatic and it was suspected in screening test. Page 6 of 41

Fig. 2: Fig. 2. 81-year -old woman with a palpable lump (a) Left craniocaudal mammogram showed an irregular nodule with spiculated margins at lower inner quadrant.

7 Fig. 2: Fig year -old woman with a palpable lump (a) Left craniocaudal mammogram showed an irregular nodule with spiculated margins at lower inner quadrant. (b) US image showed an hypoechoic irregular nodule not parallel to the surface skin, with indistinct margins and posterior acoustic shadowing. Histopathologic evaluation of a lumpectomy specimen revealed ILC. Page 7 of 41

8 Fig. 3: Fig 3. (a) Left craniocaudal and (b) mediolateral oblique mammograms showed a circumscribed mass. Pathologic analysis revealed a ILC. Page 8 of 41

Fig. 4: Fig. 4. 66-year-old patient asymptomatic.

9 Fig. 4: Fig year-old patient asymptomatic. Screening (a) mediolateral oblique and (b) craniocaudal mammograms identified focal asymmetric density in the upper quadrants transition of left breast. Page 9 of 41

10 Fig. 5: Fig. 5. Subtle mammographic asymmetry in a 57-year-old woman who presented with distinct palpable nodule in the superior left breast. (a) Bilateral craniocaudal mammograms showed an ill-defined asymmetry in left outer quadrant. (b) On left mediolateral oblique mammogram there is a matching focal opacity. (c) US showed an hypoechoic, irregular nodule with indistinct margins and posterior acoustic shadowing. Page 10 of 41

Fig. 6: Fig. 6. 52-year-old patient with palpable lump in the right breast.

11 Fig. 6: Fig year-old patient with palpable lump in the right breast. (a) Bilateral mediolateral oblique mammograms showed a heterogeneously dense breast with no discernible abnormality. (b) Directed US in the area of the palpable lump was performed and revealed several hypoechoic nodules with indistint margins and complex echo pattern. Page 11 of 41

Fig. 7: Fig 7. 41-year-old patient. Mammograms showed dense breasts with no discernible alterations.

12 Fig. 7: Fig year-old patient. Mammograms showed dense breasts with no discernible alterations. US image illustrated an irregular mass, not parallel to skin surface, with hypoechoic and heterogeneous internal echoes and posterior acoustic shadowing in retroareolar of left breast Page 12 of 41

13 Fig. 8: Fig 8. Asymptomatic patient with spiculated nodule in upper outer quadrant of right breast identified in screening mammogram. US image showed an hypoechoic mass with pronounced posterior acoustic shadowing. Page 13 of 41

Fig. 9: Fig 9. 84-year-old woman with palpable lump in left breast.

14 Fig. 9: Fig year-old woman with palpable lump in left breast. (a) Directed US image obtained in the area of the palpable abnormality showed a region of ill-defined shadowing without a clear mass. (b) Left craniocaudal mammogram performed after ultrasound guided biopsy and placement of BB marker (orange circle) showed an heterogeneous dense breast without a discrete mass. Page 14 of 41

Fig. 10: Fig. 10. 55-year-old woman with suspicious nodule in upper outer quadrant of right breast identified in screening mammograms.

15 Fig. 10: Fig year-old woman with suspicious nodule in upper outer quadrant of right breast identified in screening mammograms. (a) Axial and (b) sagittal post-contrast maximum intensity projection MR image showed an isolated, irregular and spiculated enhancing mass, less than 2 cm. Notice also the enhacenment of the blood vessels directed to the lesion. Page 15 of 41

Fig. 11: Fig.11. (a) Axial Contrast-enhanced T1-weighted fat-saturated image from a 62year-old woman with palpable lump showed an enhancing, irregular, spiculated mass.

16 Fig. 11: Fig.11. (a) Axial Contrast-enhanced T1-weighted fat-saturated image from a 62year-old woman with palpable lump showed an enhancing, irregular, spiculated mass. (b) Contrast-enhanced T1-weighted subtraction image with a ROI selected in area of rapid peak enhancement within the lesion. (c) The enhancement curve is type III, with an early peak and delayed phase washout. The vertical axis indicates the percentage of enhancement and the horizontal axis indicates the time in second. Page 16 of 41

17 Fig. 12: Fig year-old patient with not abnormality on mammograms (a) Sagittal and (b) coronal contrast-enhanced T1-weighted showed a non-mass like enhancement area with ductal / segmentary distribution. Pathologic analysis revealed a ILC Page 17 of 41

18 Findings and procedure details We performed a retrospective study of 27 cases with surgically and histopathologically confirmed invasive lobular cancer diagnosed during years 2012 and Their age ranged from 30 to 84 years old (average of 57,6). 2 cases did not have mammographic tests and were diagnosed exclusively with MRI so we did not include them in percentages. Of these 25 patients, mammograms suggested the diagnosis in 19 (76%) with five false negative that were diagnosed by ultrasound and only one case by MR. Those six false negatives (24%) corresponded mostly to dense breasts with occult lesions. Fig. 13 References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España The most common mammographic finding was a nodule or mass (12/19 cases, 63%) followed by focal asymmetric density 26%. Microcalcifications were infrequently, only in 2 cases, and architectural distortion was no found despite being described as one of the most probably appearance. 32% of cases (8/25 cases) were asymptomatic and hence suspected in screening tests. Patterns of presentation in our review: Page 18 of 41

19 Dense breast tissue 6 / 25 without discernible tumor 24% Positive mammographic findings 19 / 25 Focal asymmetric 5 / 19 26% density 76% Spiculated mass 12/ 19 63% Microcalcifications 2 / 19 10% Architectural distortion 0 Fig. 14 References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España US was a valuable adjunct to mammography mainly in patients with dense breast with benign and negative findings. Suspicious lesions where depicted as solid irregular nodular lesions, with blurred margins and posterior acoustic shadowing. There was only one case without a discrete mass but just a focal shadowing. Page 19 of 41

20 Almost all of patients had a MRI and most showed nodular enhancement with just three cases of non-nodular enhancement. MRI also revealed 4 cases of multicentric carcinoma and 1 with multifocal carcinoma. CASES CASE 1 Fig. 15: Fig 15 and Fig 16. CASE year-old patient with skin retraction without palpable distinct mass. Fig. 15 (a) Craniocaudal and (b) mediolateral oblique mammograms of the left breast showed an irregular nodule with spiculated margins located in the upper outer quadrant. (b) Directed US image identified hypoechoic, irregular, not parallel mass. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España Page 20 of 41

21 Fig. 16: Fig 15 and Fig 16. CASE year-old patient with skin retraction without palpable distinct mass. Fig 16. (a) Axial contrast-enhanced maximum intensity projection MR image showed an irregular mass with marked enhancement. b) Axial contrast-enhanced subtraction image with a ROI selected in area of rapid peak enhancement. (c) Enhancement curve for the ROI in b shows a type III pattern References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España CASE 2 Page 21 of 41

22 Fig. 17: Fig. 17 and Fig. 18. CASE year-old woman with palpable lump in left breast. Fig 17. (a) Mediolateral oblique and (b) craniocaudal mammograms identified a focal asymmetric density located in upper quedrants transition of left breast. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España Page 22 of 41

23 Fig. 18: Fig. 17 and Fig. 18. CASE year-old woman with palpable lump in left breast. Fig.18 (a) Ultrasound showed a not parallel, ill-circumscribed, indistinct mass, with complex echo pattern and posterior acoustic shadowing. (b) Axial contrastenhanced fat-saturated subtraction MR showed a large area of heterogeneous regional enhancement in the left breast with focis of nodular enhacement inside (three ROIs selected in areas of rapid peak enhancement). MRI confirmed a multicentric carcinoma. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España CASE 3 Page 23 of 41

24 Fig. 19: Fig. 19 and Fig. 20. CASE year-old patient with a palpable lump in right breast. Fig. 19 (a) Right and (b) left craniocaudal mammograms showed a subtle asymmetry with higher density in outer quadrants of right breast. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España Page 24 of 41

25 Fig. 20: Fig. 19 and Fig. 20. CASE year-old patient with a palpable lump in right breast. Fig 20. (a) Spot compression craniocaudal mammogram image do not revealed any mammographic abnormality. (b) Ultrasound showed a large, irregular, hypoechoic, indistinct mass with marked posterior acoustic shadowing. (c) Axial and (d) sagital contrast-enhanced maximum intensity projection MR image showed multicentric irregular, spiculated enhancing masses. Pathologic analysis revealed a large ILC pleomorfic variant. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España CASE 4 Page 25 of 41

26 Fig. 21: Fig. 21 and Fig. 22. CASE year-old patient, asymptomatic. Fig 21. (a) Pleomorfic microcalcifications identified in a screening test in upper outer quadrant of right breast. (b) Detail from image a showed clustered pleomorphic calcifications with no other abnormalities. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España Page 26 of 41

27 Fig. 22: Fig. 21 and Fig. 22. CASE year-old patient, asymptomatic. Fig 22. (ac) Axial contrast-enhanced subtraction image showed an nonmasslike enhancement. ROI was placed in the center of the lesion. (b) Enhancement curve for the ROI showed a early peak. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España CASE 5 Page 27 of 41

28 Fig. 23: Fig.23. CASE 5. Spiculated mass with focal asymmetric density in a 45-yearold woman who complained of a palpable lump in the left breast. (a) Left Mediolateral oblique and (b) craniocaudal mammograms shows ill-defined asymmetry and a cluster of irregular and spiculated nodules in upper outer quadrant. (c) US image identified an irregular, not parallel mass with indistinct margin and complex echo pattern. (d) Axial contrast enhacenced fat-saturated substraction MR image showed an enhancing, irregular mass in the left breast. References: Department of Radiology, Hospital Universitario 12 de Octubre, Madrid/ España Page 28 of 41

29 Images for this section: Fig. 13 Fig. 14 Page 29 of 41

30 Fig. 15: Fig 15 and Fig 16. CASE year-old patient with skin retraction without palpable distinct mass. Fig. 15 (a) Craniocaudal and (b) mediolateral oblique mammograms of the left breast showed an irregular nodule with spiculated margins located in the upper outer quadrant. (b) Directed US image identified hypoechoic, irregular, not parallel mass. Page 30 of 41

31 Fig. 16: Fig 15 and Fig 16. CASE year-old patient with skin retraction without palpable distinct mass. Fig 16. (a) Axial contrast-enhanced maximum intensity projection MR image showed an irregular mass with marked enhancement. b) Axial contrastenhanced subtraction image with a ROI selected in area of rapid peak enhancement. (c) Enhancement curve for the ROI in b shows a type III pattern Page 31 of 41

32 Fig. 17: Fig. 17 and Fig. 18. CASE year-old woman with palpable lump in left breast. Fig 17. (a) Mediolateral oblique and (b) craniocaudal mammograms identified a focal asymmetric density located in upper quedrants transition of left breast. Page 32 of 41

33 Fig. 18: Fig. 17 and Fig. 18. CASE year-old woman with palpable lump in left breast. Fig.18 (a) Ultrasound showed a not parallel, ill-circumscribed, indistinct mass, with complex echo pattern and posterior acoustic shadowing. (b) Axial contrast-enhanced fatsaturated subtraction MR showed a large area of heterogeneous regional enhancement in the left breast with focis of nodular enhacement inside (three ROIs selected in areas of rapid peak enhancement). MRI confirmed a multicentric carcinoma. Page 33 of 41

34 Fig. 19: Fig. 19 and Fig. 20. CASE year-old patient with a palpable lump in right breast. Fig. 19 (a) Right and (b) left craniocaudal mammograms showed a subtle asymmetry with higher density in outer quadrants of right breast. Page 34 of 41

35 Fig. 20: Fig. 19 and Fig. 20. CASE year-old patient with a palpable lump in right breast. Fig 20. (a) Spot compression craniocaudal mammogram image do not revealed any mammographic abnormality. (b) Ultrasound showed a large, irregular, hypoechoic, indistinct mass with marked posterior acoustic shadowing. (c) Axial and (d) sagital contrast-enhanced maximum intensity projection MR image showed multicentric irregular, spiculated enhancing masses. Pathologic analysis revealed a large ILC pleomorfic variant. Page 35 of 41

36 Fig. 21: Fig. 21 and Fig. 22. CASE year-old patient, asymptomatic. Fig 21. (a) Pleomorfic microcalcifications identified in a screening test in upper outer quadrant of right breast. (b) Detail from image a showed clustered pleomorphic calcifications with no other abnormalities. Page 36 of 41

37 Fig. 22: Fig. 21 and Fig. 22. CASE year-old patient, asymptomatic. Fig 22. (a-c) Axial contrast-enhanced subtraction image showed an nonmasslike enhancement. ROI was placed in the center of the lesion. (b) Enhancement curve for the ROI showed a early peak. Page 37 of 41

38 Fig. 23: Fig.23. CASE 5. Spiculated mass with focal asymmetric density in a 45-year-old woman who complained of a palpable lump in the left breast. (a) Left Mediolateral oblique and (b) craniocaudal mammograms shows ill-defined asymmetry and a cluster of irregular and spiculated nodules in upper outer quadrant. (c) US image identified an irregular, not parallel mass with indistinct margin and complex echo pattern. (d) Axial contrast enhacenced fat-saturated substraction MR image showed an enhancing, irregular mass in the left breast. Page 38 of 41

39 Conclusion The detection of suspicious radiological signs in screening tests and the acknowledgment of subtle findings allow the diagnosis of ILC. The combined use of mammography, ultrasound and MRI decreases the amount of false negatives and increases the sensitivity in the diagnosis, improving hence the therapeutic approach. MRI has an expanding role in the management of ILC as it is the best imaging test in detecting multifocality, multicentricity and in estimating tumor size and, in addition, it permits to evaluate response to chemotherapy. Page 39 of 41

40 Personal information Author: Danitza Mandich Crovetto Hospital Universitario 12 de Octubre, Madrid SPAIN Page 40 of 41

41 References Lopez JK, Basset LW. Invasive lobular carcinoma of the breast: Spectrum of mammographic, US, and MR imaging findings. Radiographics 2009;29: K. J. Macura, R. Ouwerkerk, M. A. Jacobs, and D. A. Bluemke. Patterns of Enhancement on Breast MR Images: Interpretation and Imaging. RadioGraphics, November 1, 2006; 26(6): Qayyum A, Birdwell RL, Daniel BL, et al: MR imaging features of infiltrating lobular carcinoma of the breast: Histopathologic correlation. AJR Am J Roentgenol 2002;178: Albayrak ZK, Onay HK, Karatag GY, Karatag O. Invasive lobular carcinoma of the breast: mammographic and sonographic evaluation. Diagn Interv Radiol Sep;17(3): Michael M, Garzoli E, Reiner CS. Mammography, sonography and MRI for detection and characterization of invasive lobular carcinoma of the breast. Breast Disease (2009);30: Page 41 of 41

Evaluation of surgical margins by specimen in impalpable breast carcinoma: a radiopathological correlation

Evaluation of surgical margins by specimen in impalpable breast carcinoma: a radiopathological correlation Poster No.: C-1146 Congress: ECR 2014 Type: Scientific Exhibit Authors: D. Mandich, L. Koren,