University of Washington Radiology Review Course: Strange and Specific Diagnoses Katherine E. Dee, MD Seattle Breast Center Via Radiology 2014 Case #1 37 year old presents with bilateral palpable lumps. Work-up 6 months ago for same lump on the left was negative. 1
Left 4:00 2
Right 6:00 What is your BI-RADS assessment? a. BI-RADS 1, Negative b. BI-RADS 2, Benign c. BI-RADS 3, Probably Benign d. BI-RADS 4, Suspicious e. BI-RADS 5, Highly Suggestive of malignancy 3
The patient tells you during the biopsy that she was diagnosed with Type I Diabetes at age 9. The most likely diagnosis is: A. Bilateral infiltrating ductal carcinoma B. Diabetic mastopathy C. Mastitis D. Lymphoma The patient tells you during the biopsy that she was diagnosed with Type I Diabetes at age 9. The most likely diagnosis is: A. Bilateral infiltrating ductal carcinoma B. Diabetic mastopathy C. Mastitis D. Lymphoma 4
Diabetic Mastopathy Long standing Type I diabetes Palpable lumps, may be bilateral Dense fibrous tissue forms poorly defined hypoechoic masses that can mimic cancer A biopsy must be performed to prove it is not cancer Case #2 Bilateral palpable lumps 5
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What is your assessment? A. BI-RADS 1 Negative B. BI-RADS 2 Benign C. BI-RADS 3 Probably Benign D. BI-RADS 4 Suspicious E. BI-RADS 5 Highly suggestive of malignancy What is the diagnosis? A. Multiple lipomas B. Multiple papillomas C. Multiple fibroadenomas D. Steatocystoma Multiplex 7
What is the diagnosis? A. Multiple lipomas B. Multiple papillomas C. Multiple fibroadenomas D. Steatocystoma Multiplex Asymptomatic Another Aunt Minnie Case #3 8
What is the Diagnosis? A. Neurofibromatosis B. Silicone injections C. Fibrocystic disease D. Lymphoma 9
Neurofibromatosis Autosomal dominant Type I, Von Recklinghausen s >90% of all NF Café au lait spots, neurofibromas, meurilemomas Other causes of multiple cutaneous lesions much more rare: cutaneous metastases, Gardner s syndrome, etc. Case #4 64 year old male with bilateral painful lumps. 10
What is your assessment? A. BI-RADS 1 Negative B. BI-RADS 2 Benign C. BI-RADS 3 Probably Benign D. BI-RADS 4 Suspicious E. BI-RADS 5 Highly suggestive of malignancy 11
A. Yes B. No Is ultrasound indicated? Gynecomastia Benign glandular tissue in men, often tender Bilateral or unilateral, often asymmetric Can be related to medications, pot, liver disease anything that increases estrogens Ultrasound not necessary to establish the diagnosis and can occasionally be confusing Ultrasound indicated only if a mass is present 12
Case #5 80 year old male with palpable lump in the right breast. 13
Is ultrasound indicated? A. Yes B. No. The lesion is benign C. No. The lesion is malignant 14
What is the most likely diagnosis? A. Fibroadenoma B. Papilloma C. Metastasis D. Myofibroblastoma Myofibroblastoma Rare benign stromal tumor usually found in older men Circumscribed mass with benign features Excision often recommended, but lesion is slow growing and benign malignant transformation has not been reported Men do not typically develop the common benign tumors found in women 15
Case #6 74 year old, asymptomatic 16
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What is your assessment? A. BI-RADS 1 Negative B. BI-RADS 2 Benign C. BI-RADS 3 Probably Benign D. BI-RADS 4 Suspicious E. BI-RADS 5 Highly suggestive of malignancy 18
Post-contrast T2 What is the most likely diagnosis? A. Tubular carcinoma B. Mucinous carcinoma C. Lobular carcinoma D. Medullary carcinoma 19
Mucinous Carcinoma AKA Colloid carcinoma 2% of all breast cancers Produces mucin Bright on T2-weighted images May show posterior acoustic enhancement on US Slow growth rate, good prognosis Case #7 72 year old with palpable cord in the right breast 20
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What is the diagnosis? A. DCIS B. Invasive ductal carcinoma C. Papillomas D. Mondor s Disease What is the treatment? A. No treatment necessary B. Surgical excision C. Percutaneous aspiration D. Antibiotics 22
Mondor s Disease Thrombophlebitis of a superficial vein of the breast Tender cord-like lump, erythema, skin dimpling Resolves spontaneously, veins recannulate No treatment indicated Benign Same Patient 1 year later 23
Case #8 Screening 24
What is your next step? A. Compare to Priors B. Recall for spot compression magnification views and ultrasound C. MRI D. Negative mammogram, return in one year Sternalis Muscle Small slip of muscle seen in the medial posterior breast on the CC view only No abnormality on US or MRI Can occasionally pose a challenge to prove there is nothing there Compare to priors: often seen on a prior mammogram avoid a work-up! No treatment or follow-up necessary 25
Case #9 41 year old with palpable lump 26
What is your assessment? A. BI-RADS 1 Negative B. BI-RADS 2 Benign C. BI-RADS 3 Probably Benign D. BI-RADS 4 Suspicious E. BI-RADS 5 Highly suggestive of malignancy 27
Biopsy yields desmoid tumor. Is surgical excision necessary? A. Yes B. No Extra-abdominal Desmoid aka Fibromatosis Aggressive appearance: spiculated, irregular, shadowing Benign but locally aggressive, requires wide excision 20% recurrence Associated with Gardner s syndrome One of MANY rare tumors that can occur in the breast 28
Chondrocytic Sarcoma Case #10 74 year old with large fungating mass 29
Case # 10 What is more likely? A. Metaplastic Carcinoma B. Infiltrating Ductal Carcinoma C. Lymphoma D. Angiosarcoma 30
Rare breast tumors No specific appearance BI-RADS 4 or 5: biopsy necessary The vast majority of these suspicious masses will be breast cancer. Treatment depends on tumor type Rare breast tumors Lymphoma/leukemia Angiosarcoma Adenoid cystic carcinoma Squamous cell carcinoma Metaplastic carcinoma Other sarcomas Metastases 31
Case #11 47 year old, asymptomatic 32
What is your assessment? A. BI-RADS 1 Negative B. BI-RADS 2 Benign C. BI-RADS 3 Probably Benign D. BI-RADS 4 Suspicious E. BI-RADS 5 Highly suggestive of malignancy 33
Biopsy yields Pseudoangiomatous Stromal Hyperplasia (PASH). What do you recommend? Return to screening 6 month follow-up Surgical excision MRI Mastectomy Biopsy yields Pseudoangiomatous Stromal Hyperplasia (PASH). What do you recommend? Return to screening 6 month follow-up Surgical excision MRI Mastectomy 34
PASH Mammographic appearance: mass or asymmetry Ultrasound: mass or no abnormality Benign, hormonally sensitive No treatment necessary, but may grow triggering surgical excision May recur 35