Inflammatory Breast Carcinoma: Mammographic, Ultrasonographic, MRI and Pathologic Findings

Inflammatory Breast Carcinoma: Mammographic, Ultrasonographic, MRI and Pathologic Findings Poster No.: C-2248 Congress: ECR 2013 Type: Educational Exhibit Authors: L. Fernandes, J. Lopes Dias, H. A. M. R. Tinto, P. L. Pegado, 1 2 1 1 1 1 2 2 J. Raposo, P. Santos ; Lisbon/PT, Lisboa/PT Keywords: Breast, MR, Ultrasound, Mammography, Biopsy, Cancer DOI: 10.1594/ecr2013/C-2248 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 19

Learning objectives To determine radiologic characteristics of inflammatory breast carcinoma and to report clinical and pathologic findings. To ascertain Magnetic resonance imaging importance in the therapeutic approach in women with this type of breast cancer. Background Inflammatory carcinoma (IC) of the breast is a relatively uncommon but aggressive form of invasive breast carcinoma with no characteristic clinical presentation or unique radiographic appearances. Pathologically, any subtype of primary breast carcinoma may be present, but dermal lymphatic vessels must be involved. Clinically, inflammatory breast cancer mimics mastitis. The breast is enlarged (often of relatively short onset), indurated, erythematous, warm, tender and painful. The skin is thickened and edematous, with a "peau d'orange" appearance. There may or may not be an underlying palpable mass. The condition may also present with flattening, erythema, crusting, blistering or retraction of the nipple. Fixed palpable ipsilateral axillary lymph nodes with metastatic disease, are frequently observed. The occurrence of inflammatory breast carcinoma, although uncommon when compared with that of other malignancies, remains a very aggressive malignancy, with atendency to metastasize at an early stage. Therefore, information about this carcinoma is considered of value and interest to both radiologists and clinicians. Imaging findings OR Procedure details Imaging Findings or Procedure Details Analysis included history; findings at physical examination, ultrasonography, MRI and histologic type of inflammatory carcinoma. mammography, Page 2 of 19

Mammography Findings Mammography in two standard planes of imaging (craniocaudal and mediolateral oblique) was performed, sometimes with additional views. The most common mammographic findings are diffuse or focal skin thickening (skin of the involved breast is thicker than that of the contralateral breast), trabecular prominence and diffusely increased breast density compatible with edema. Other findings can be presente, such as nipple retraction, presence of a mass, asymmetric focal density (asymmetry of tissue density with a similar shape seen on two views but completely lacking borders and the conspicuity of a true mass), microcalcifications, and axillary lymphadenopathy. Most commonly the microcalcifications are pleomorphic or linear and branching, suggestive of malignancy. But they can be diffuse, scattered,round, or punctate meant that they are considered benign or probably benign. Page 3 of 19

Fig. 1: Mammograms are of a 45 -year-old woman with clinically evident IC. A,B Craniocaudal and C,D mediolateral oblique views of both breasts are shown. A central mass is present. Left breast was enlarged, the right breast is normal. Diffusely Page 4 of 19

increased opacity, stromal coarsening, and skin thickening are seen on the left when compared with the contralateral breast. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT US Findings All patients underwent both axillary and breast US, which was performed either to detect or to evaluate solid masses or axillary lymphadenopathy. When a mass was present, the location, size, contour, and acoustic features were evaluated. US findings : skin thickening ( skin of the involved breast was thicker than that of the contralateral breast), skin invasion (interruption deep echogenic line of the skin, the dermis, or the subcutaneous fat interface), dilated lymphatic channels (branching anechoic tubular structures in the subcutaneous fatty tissues), pectoral muscle invasion (the mass was in contact with the pectoral muscle, and the tissue planes in between were obliterated), multifocality (the mass are within the same quadrant), multicentricity (the mass are in different quadrants), increased vascularity on color Doppler. Fig. 2: Images obtained in a 43-year-old woman with a mass measuring 3cm in longest diameter in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. A,B Transverse US scans show marked skin thickening. Hypoechoic masses are also seen with posterior acoustic shadowing. The mass limits was hard to demonstrate because the breast was thick owing to parenchymal edema. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Page 5 of 19

Axillary lymphadenopathy are identified on the basis of the following criteria: nodular cortical appearance and cortical thickness larger than 3mm, replacement of fatty hilum and round shape. Fig. 3: Image obtained in a 45-year-old woman with a palpable mass in the upper quadrant of the left breast and breast erythema. Round axillary, supra-clavicular and cervical nodes with increased density and loss of lucent fatty hilum are consistent with lymphadenopathy with metastatic disease. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Page 6 of 19

Fig. 4: Ultrasound-guided core needle biopsy obtained in a 45-year-old woman with a mass 3cm in longest diameter in the upper outer quadrant of the left breast. Histologic subtype: invasive ductal carcinoma. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT MR Findings The breast should be imaged at axial, coronal or sagittal planes. Core pulse sequences when evaluating the breast for cancer include a three-plane localizer, T1WIs, T2WIs, and two- or three-dimensional fat-suppressed gradient echo series performed before contrast administration, immediately after, and delayed. The number of postcontrast series can vary, but at least three are needed to perform kinetic enhancement curves. The T1WIs allow clear differentiation of adipose tissue from glandular tissue. T2W fat-suppressed images allow identification of fluid-filled structures such as cysts. Dynamic images obtained prior to and after IV gadolinium enhancement help to identify potential malignancies based on morphology and enhancement kinetics. The intravenous gadolinium DTPA dose ranges from 0.1 to 0.2 mmol/kg body weight. In posterior breast masses, MRI can identify muscle invasion (muscle enhancement on MR images) with accuracy. Page 7 of 19

Fat suppression can be accomplished before gadolinium administration using chemical selective fat saturation or water-only excitation techniques. After IV contrast administration, passive fat suppression can be accomplished with post processing image subtraction, but patient movement between precontrast and postcontrast enhanced images can degrade the images because of misregistration. Kinetic curves can be performed on enhancing lesions. Fig. 5: Axial MR images obtained in a 43-year-old woman with a mass in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. (A) T2WIs (B) T1WIs Precontrast (C;D), early postcontrast, and late postcontrast (E,F) enhanced fat-suppressed T1W fast spoiled gradient-echo MR images of the left breast show multifocal spiculated enhancing mass at left breast. The mass demonstrates rapid initial mass enhancement without pectoral muscle involvement. Note the skin enhancement, pointing to edema and nflammatory alterations. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Page 8 of 19

Fig. 6: Axial (A) sagittal (B) and coronal (C) MIP reformated images obtained in a 43-year-old woman with a mass in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Kinetic curves improve the specificity of breast MR. These curves can be evaluated qualitatively according to the curve shape and classified as a persistent pattern of enhancement, a plateau of enhancement, or washout of signal intensity. Most invasive carcinomas demonstrate rapid initial enhancement with a plateau or washout. Page 9 of 19

Fig. 7: Axial MR images obtained in a 43-year-old woman with a mass at upper outer quadrant of the left breast, which was enlarged with peau d'orange, and nipple retraction. (A,B,C,D) Kinetic curves demonstrates rapid initial enhancement of multifocal mass with a plateau and washout pointing to carcinoma. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Page 10 of 19

Fig. 8: Axial MR images obtained in a 45-year-old woman with a mass in the upper outer quadrant of the left breast, which was enlarged with peau d'orange, and nipple retraction. (A,B,C,D) washout maps demonstrate multifocal mass with a plateau or washout pointing to carcinoma. References: radiology, Centro Hospitalar de Lisboa Central - Lisbon/PT Images for this section: Page 11 of 19

opacity, stromal coarsening, and skin thickening are seen on the left when compared with the contralateral breast. Fig. 2: Images obtained in a 43-year-old woman with a mass measuring 3cm in longest diameter in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. A,B Transverse US scans show marked skin thickening. Hypoechoic masses are also seen with posterior acoustic shadowing. The mass limits was hard to demonstrate because the breast was thick owing to parenchymal edema. Page 13 of 19

Fig. 3: Image obtained in a 45-year-old woman with a palpable mass in the upper quadrant of the left breast and breast erythema. Round axillary, supra-clavicular and cervical nodes with increased density and loss of lucent fatty hilum are consistent with lymphadenopathy with metastatic disease. Page 14 of 19

Fig. 6: Axial (A) sagittal (B) and coronal (C) MIP reformated images obtained in a 43year-old woman with a mass in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. Fig. 7: Axial MR images obtained in a 43-year-old woman with a mass at upper outer quadrant of the left breast, which was enlarged with peau d'orange, and nipple retraction. (A,B,C,D) Kinetic curves demonstrates rapid initial enhancement of multifocal mass with a plateau and washout pointing to carcinoma. Page 16 of 19

Fig. 5: Axial MR images obtained in a 43-year-old woman with a mass in the upper outer quadrant of the left breast, peau d'orange, and nipple retraction. (A) T2WIs (B) T1WIs Precontrast (C;D), early postcontrast, and late postcontrast (E,F) enhanced fatsuppressed T1W fast spoiled gradient-echo MR images of the left breast show multifocal spiculated enhancing mass at left breast. The mass demonstrates rapid initial mass enhancement without pectoral muscle involvement. Note the skin enhancement, pointing to edema and nflammatory alterations. Page 18 of 19

Conclusion Unlike another types of breast cancer in which surgery is the first modality of treatment, chemotherapy before surgery or radiation therapy is the current standard treatment of Inflammatory carcinoma. The presence of isolated inflammatory signs is sufficient to suspect inflammatory breast carcinoma clinically. Radiologically, this carcinoma has a mammographic pattern of inflammatory changes, such as skin thickening and stromal coarsening and/or diffusely increased breast density. Associated mass and/or malignant-type microcalcifications are usually evident but may be absent. The assessment of the mass may not be made precisely because of the diffusely increased density on mammograms. US evaluation is helpful not only in depiction of masses but also in depiction of skin and pectoral muscle invasion and axillary involvement in inflammatory carcinoma. Because dynamic MR imaging kinetics correspond to a tumor's vascular parameters, quantification of these signals may be used to better evaluate tumor extension and has been used to monitor response to chemotherapy. MR imaging can be used to differentiate post chemotherapy residual tumor from post chemotherapy fibrosis and glandular tissue. References I. Gunhan-Bilgen, E. E. Ustun, A. Memis, Inflammatory Breast Carcinoma: Mammographic, Ultrasonographic, Clinical, and Pathologic Findings in 142 Cases, Radiology 2002; 223:829-838 A. Thukral, D. Thomasson, C. K. Chow, R. Eulate, S. B. Wedam, S.N. Gupta, B. J. Wise, S. M. Steinberg, D. J. Liewehr, P.L. Choyke, S. M.Swain, Inflammatory Breast Cancer: Dynamic Contrast-enhanced MR in Patients Receiving Bevacizumab- Initial Experience, Radiology : Volume 244: Number 3-September 2007 Personal Information Page 19 of 19