Triple-negative breast cancer: which typical features can we identify on conventional and MRI imaging? Poster No.: C-1862 Congress: ECR 2013 Type: Educational Exhibit Authors: V. Bertani 1, A. Gualano 2, V. Londero 2, A. Linda 2, C. Molinari 2, E. Keywords: DOI: Di Gaetano 2, C. Zuiani 2, M. Bazzocchi 2 ; 1 San Vito al Tagliamento/ IT, 2 Udine/IT Breast, MR, Mammography, Ultrasound, Education, Cancer 10.1594/ecr2013/C-1862 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. www.myesr.org Page 1 of 18
Learning objectives To illustrate mammographic, sonographic and Magnetic Resonance Imaging (MRI) features of Triple Negative Breast Cancers (TNBCs). Background TNBCs are a subgroup of breast tumors which do not express Estrogen Receptor (ER-), Progesteron Receptor (PR-), and Human Epidermal Growth Factor Receptor 2 (HER2-). TNBCs represent 10-20% of all breast cancers but they are responsible for relatively large proportion of breast cancer death. TNBCs occur most frequently in premenopausal age and women with familiar history of breast cancer [1; 2]. This subtype of carcinoma is characterized by high malignancy potential and poor prognosis. Indeed, TNBCs are often associated with aggressive features, such high histological grade and a high degree of correlation with BRCA1 mutation [3]. About histological type, most frequently TNBCs occur as Invasive Ductal Carcinomas (IDCs) [4]. They can appear like no-suspicious lesions and so their diagnosis often is delayed. Moreover, TNBCs have a higher rate of regional lymph node positivity at diagnosis than non-tnbcs [5]. These cancers show specific patterns of distant metastases, with a high predilection for visceral sites, such as lung and brain, and a lower predilection for bone and liver. Also TNBCs have a higher rate of distant metastatic disease and a shorter mean time to distant metastatic disease than non-tnbcs [5;6]. Furthermore, TNBCs are unresponsive to the usual endocrine therapies; therefore, the primary adjuvant therapy for these cancers is chemotherapy [1]. All these conditions contribute to a poor survival rate [5]. Imaging findings OR Procedure details On mammography TNBCs are most commonly visible as masses, with or without calcifications (Fig. 1 and 2) [3; 4; 5; 7]. Mass with no associated calcifications is the most frequent mammographic feature; that reflects an aggressive, rapidly proliferating tumor with a low association with ductal in situ carcinoma at the time of diagnosis [7]. Less frequently they can also occur as focal asymmetry of density, calcifications only or distorsion. On mammography about 10% (9-11%) of TNBCs remain occult [3; 5]. As masses, TNBCs occur both as irregular shape and ill-defined margins that regular shape and circumscribed margins (Fig. 3 and 4); spiculated margins are rare [7;8]. This subtype of breast cancers presents higher rate of no-suspicious mammographic features compared to no-tnbcs lesions. [7; 8] Page 2 of 18
On ultrasound (US) they appear usually like masses (Fig. 5), less commonly as architectural distortion (Fig. 6) [3]. Echo pattern of mass lesions is oftenhypoechoic or markedly hypoechoic (Fig. 7) and shape more commonly is irregular or lobulated [4; 5; 8].On US, TNBCs often present circumscribed margins (Fig. 8 and 9) and abrupt interface [3; 4; 5 ]. In many cases they show also other characteristics which usually occur in low suspicious lesions as parallel orientation to the skin and posterior acoustic enhancement or no posterior features (Fig. 5, 8 and 9) [3;4;5]. On MRI TNBCs are almost always mass-like (ML) lesions (Fig. 10). Instead non masslike (NML) lesions occur in few cases and show usually segmental or regional pattern. [2; 9] In ML cases more frequently TNBCs present morphological features like ovalar or lobulated shape and spiculated or smooth margins [2;3;9;10;]. In these lesions internal enhancement pattern is most commonly characterized by rim enhancement [2;3;9;10;] (Fig. 11 and 12). This is defined as greater enhancement in the periphery relative to the centre of the lesion, in which central area can represent fibrosis or necrosis [11]. Rim enhancement may be the most useful MRI finding for identifying TNBCs and some authors have identified it as an accurate prognostic enhancement criterion for Estrogen Receptor negative status [12]. This subtype of breast cancer also present kinetic pattern more suggestive for malignancy like curves that show wash-out (type III) [2;3;9]. On T2- weighted images they are most commonly hyperintense lesions because of high necrotic content of these lesions (Fig. 13). [2; 11]. Necrosis is a prognostic factor in invasive breast cancer because is correlated to increased mortality and decreased relapsed-free survival [9]. Images for this section: Page 3 of 18
Fig. 1: Triple negative breast cancer in a 74 year-old woman with palpable nodule in right breast (IDC, high grade). Mammogram (magnified craniocaudal, A, and oblique, B, view) shows a round mass with ill-defined margins (arrows). Page 4 of 18
Fig. 2: Triple negative breast cancer in a 54 year-old woman in the left breast (IDC, high grade). Mammogram (magnified oblique view, A, and detail, B) shows an irregular mass with ill-defined margins and associated calcifications (arrows). Page 5 of 18
Fig. 3: Triple negative breast cancer in a 77 year-old woman with palpable nodule in the left breast (IDC, high grade). Mammogram (magnified craniocaudal, A, and oblique, B, view) shows a round mass with circumscribed margins (arrowheads). Page 6 of 18
Fig. 4: Triple negative breast cancer in a 50 year-old woman in the right breast (medullary carcinoma, high grade). Mammogram (magnified craniocaudal, A, and oblique, B, view) shows a oval mass with circumscribed margins in right breast (arrows). Page 7 of 18
Fig. 5: Ultrasound features of the triple negative breast cancer shown in Fig.1 (IDC, high grade): images show a solid hypoechoic round mass (A) with ill-defined margins (arrow), central posterior enhancement (arrowheads) and low vascularization at colordoppler examination (B). Page 8 of 18
Fig. 6: Ultrasound features of a triple negative breast cancer in a 64 year-old woman in the left breast (invasive lobular carcinoma, moderate grade): US images show an heterogeneous area with irregular shape (architectural distorsion) in the left breast (A) and abundant peripheral vascularization at color Doppler examination(b). Page 9 of 18
Fig. 7: Ultrasound features of the triple negative breast cancer in a 57 year-old woman in the right breast (IDC, high grade): US images show a markedly hypoechoic mass (A) with lobulated shape, ill-defined margins (arrows) and moderate vascularization at color Doppler examination (B). The lesion doesn' t show posterior features (arrowheads). Page 10 of 18
Fig. 8: Ultrasound features of the triple negative breast cancer shown in Fig. 4 (medullary carcinoma, high grade): an hypoechoic oval mass with smooth margins and posterior enhancement in the right breast (A). Metastatic lymphonode associated with cortical thickening in the right anxilla (B). Page 11 of 18
Fig. 9: Ultrasound features of the triple negative breast cancer in a 41 year-old woman in the right breast (medullary carcinoma, high grade): US images show a heterogeneous hypoechoic mass with oval shape, smooth margins and posterior enhancement in the right breast (arrowheads). Page 12 of 18
Fig. 10: MRI appearance of the triple negative breast cancer in a 58 year-old woman in the right breast (IDC, moderate grade): axial pre-contrast (A) and early enhanced 3D T1-weighted images (B) with early subtraction (C) showing a mass-like lesion with heterogeneous, rapid (type III of kinetic curve) and strong (142%) enhancement rate; this lesion presents ill-defined margins and oval shape (arrow). Page 13 of 18
Fig. 11: MRI appearance of the triple negative breast cancer in a 68 year-old woman in the left breast (IDC, high grade): axial pre-contrast (A) and early enhanced 3D T1- weighted images (B) with early subtraction (C) showing a mass-like lesion with ill-defined margins and oval shape (arrow); the kinetic curve of the lesion shows plateau (II) and strong (150%) enhancement rate. Page 14 of 18
Fig. 12: MRI appearance of the triple negative breast cancer in a 72 year-old woman in the right breast (medullary carcinoma, high grade): axial pre-contrast (A) and early enhanced 3D T1-weighted images (B) with early subtraction (C) showing a mass-like lesion with rim enhancement; the kinetic curve of the lesion shows plateau (II) and moderate (74%) enhancement rate. The morphological features are smooth margins and oval shape (arrow). Page 15 of 18
Fig. 13: MRI appearance of the triple negative breast cancer shown in Fig.12: the lesion has central hyperintense signal in axial STIR T2-weighted image (arrow). Page 16 of 18
Conclusion TNBCs are a subgroup of breast cancers with high malignancy potential and poor prognosis. On conventional imaging (mammography and US) they may not present features suggestive for malignancy. Otherwise, MRI show enhancement and kinetic patterns that are suspicious for malignant lesions. References 1. Irvin et al. What is triple negative breast cancer? European Journal of Cancer (2008) 44: 2799-2805 2. Youk et al. Triple negative invasive breast cancer on dynamic contrastenhanced and diffusion-weighted MR imaging: comparison with other breast cancer subtypes. European Radiology (2012) 22: 1724-1734 3. Dogan et al. Multimodality imaging of triple receptor-negative tumors with mammography, ultrasound and MRI. American Journal of Roentgenology (2010) 194: 1160-1166 4. Ko et al. Triple-negative breast cancer: correlation between imaging and pathological findings. European Radiology (2010) 20: 1111-1117 5. Krizmanich-Conniff et al. Triple receptor-negative breast cancer: imaging and clinical characteristics. American Journal of Roentgenology (2012) 198: 458-464 6. Whitman et al. Triple-negative breast cancer: what the radiologist needs to know. Seminars in Roentgenology (2011) 46: 26-39 7. Yang et al. Mammographic features of triple receptor-negative primary breast cancers in young premenopausal women. Breast Cancer Research and Treatment (2008) 111: 405-410 8. Kojima et al. Mammography and ultrasound features of TNBC. Breast Cancer (2011) 18: 146-151 9. Uematsu et al. Triple-negative breast cancer: correlation between MR imaging and pathologic findings. Radiology (2009) 250: 638-47 10. Uematsu. MR imaging of triple-negative breast cancer. Breast Cancer (2011) 18: 161-164 11. Kobayashi et al. Two different types of ring-like enhancement on dynamic MR imaging in breast cancer: correlation with the histopathologic findings. Journal of Magnetic Resonance Imaging (2008) 28: 1435-1443 12. Teifke et al. Dynamic MR imaging of breast lesions: correlation with microvessel distribution pattern and histologic characteristics of prognosis. Radiology (2006) 239: 351-60 Page 17 of 18
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