Breast Cancer Imaging, A Multidisciplinary, Multimodality Approach

Breast Cancer Imaging

A Multidisciplinary, Multimodality Approach

By Marie Tartar, MD, Director, Body MRI, Scripps Green Hospital; Assistant Clinical Professor, Department of Radiology, University of California at San Diego, La Jolla, CA; Chris E. Comstock, MD, Director of Breast Imaging, Associate Clinical Professor of Radiology, University of Calforina at San Diego, La Jolla, CA; and Michael S. Kipper, MD, Director of PET/CT and Nuclear Services, Pacific Imaging and Treatment Center, Mission Viejo, CA; Associate Professor of Radiology, University of California at San Diego, La Jolla, CA


Chapter 1: Screening for breast cancer in asymptomatic patients
by Chris Comstock, MD and Marie Tartar, MD


Case 1: Breast cancer presenting as a small new mass on mammography
Case 2: Breast cancer presenting as a new mass on mammography
Case 3: Breast cancer presenting as a new spiculated mass on mammography
Case 4: Breast cancer presenting as a small growing mass in the axilla
Case 5: IDC presenting as a small growing mass
Case 6: Small growing breast cancer presenting as a contour change on mammography
Case 7: Breast cancer presenting as a largely obscured mass in dense breast tissue
Case 8: Slowing growing microlobulated colloid carcinoma (benign looking
growing mass)
Case 9: Breast cancer presenting as a new posterior mass on mammography: importance of inclusion of posterior breast tissue on mammography
Case 10: DCIS presenting as a microcalcification cluster
Case 11? DCIS presenting as multiple microcalcification clusters along a ductal ray
Case 12: Breast cancer presenting as architectural distortion in extremely dense breasts
Case 13: ILC presenting as growing amorphous density
Case 14: Small cancer in implant patient, well seen only on implant displaced
views
Case 15: Importance of complete work-up of new mammographic masses
Case 16: MRI high risk screening for occult breast cancer
Case 17: MRI high risk screening for occult breast cancer
Case 18: Breast cancer presenting as a growing small mass on screening MRI
Case 19: CT identification of unknown breast cancer in an asymptomatic patient
Case 20: PET identification of occult breast cancer in an asymptomatic patient



Chapter 2: Evaluation of the symptomatic patient: Diagnostic breast imaging

Cases:
1. Palpable axillary IDC, presenting as a growing mammographic mass simulating a lymph node
2. Palpable lump presenting as malignant microcalcifications on mammography
3. Palpable IDC presenting as mammographic architectural distortion and shadowing sonographic mass
4. Palpable ILC presenting as architectural distortion
5. Palpable lump presenting with masses and pleomorphic microcalcifications
6. Palpable lump presenting as mammographic architectural distortion with microcalcifications
7. Palpable lump presenting as growing amorphous mammographic asymmetry
8. Palpable lump presenting as developing mammographic density
9. Mammographically occult palpable breast cancer
10. Large, palpable, mammographically occult invasive carcinoma
11. Breast cancer involving the nipple-areolar complex, not identified on conventional imaging, demonstrated by MRI
12. Mammographically occult retroaerolar breast cancer presenting as nipple retraction
13. Importance of clear communication and accurate history; Inaccurate history of biopsy ?scar? leads to near-miss of a spiculated cancer
14. Axillary nodal presentation of breast cancer, primary found on MRI
15. Axillary nodal presentation of ILC, occult on conventional imaging, primary found by MRI
16. Axillary nodal presentation with negative mammogram, primary found on PET
17. Axillary nodal presentation with initially negative mammogram, medial primary found on CT
18. Male breast ca
19. Male breast ca
20. Male breast cancer and gynecomastia
21. Male breast cancer with microcalcifications
22. Male breast cancer with skin thickening and nipple enlargement


Chapter 3: Local staging: Imaging options and core biopsy strategies
By Christopher Comstock, MD and Marie Tartar, MD



Cases: 1. Mammography: extent of disease
2. Ultrasound: extent of disease
3. Use of US to find invasive disease within extensive microcalcifications, depiction of disease extent by breast MRI vs. PEM vs. whole body PET
4. Multi-focal breast cancer, first identified on abdominal CT, radiologic ?corner shot?
5. MRI: extent of disease
6. MRI: extent of disease
7. MRI: extent of disease (Tip of the iceberg detected on mammography)
8. MRI: extent of disease (Multi-focal disease, dense breasts)
9. Multi-centric IDC and DCIS: Local staging with MRI
10. Additional disease site identified by PEM
11. Breast cancer presenting with axillary node involvement by mammography and US
12. Subtle axillary nodal involvement
13. Breast MRI problem solving: Deciding among sites for additional sampling
14. Breast MRI problem solving: Assessing depth of involvement of posterior breast cancer
15. Breast MRI problem solving: Chest wall invasion
16. Breast MRI problem solving: positive margins post- lumpectomy, assessment for residual disease
17. Breast MRI problem solving: MRI guidance for tailored lumpectomy
18. Breast MRI problem solving: assessment of completeness of breast cancer excision
19. Contralateral DCIS found by staging breast MRI
20. Contralateral breast carcinoma found on MRI, not seen on second-look ultrasound
21. Contralateral breast carcinoma found on MRI, not seen on second-look ultrasound
22. Evaluation of the other breast with MRI
23. Use of body coil STIR imaging for staging new dx of BC
24. MRI depiction of axillary and internal mammary node involvement
25. Cautionary notes on the use of breast MRI:
26. Cautionary notes on the use of breast MRI:
27. Whole body PET as an adjunct to initial staging of node+ breast cancer: Benign PET pelvic uptake in a corpus luteum cyst
28. Whole body PET as an adjunct to initial staging of node+ breast cancer: Rotter node involvement
29. Bracketing needle localization of microcalcifications
30. Medial breast cancer with internal mammary drainage on lymphoscintigraphy
31. Biopsy quality control: Mammographic lesion, discordance with pathology results
32. Biopsy quality control: Mammographic lesion, wrong US correlate biopsied, rationale for post US biopsy clip placement and mammogram
33. Biopsy quality control: DCIS presenting as disappearing microcalcifications and subsequent development of a mass


Chapter 4: Unusual and Problem Types of Breast Cancers: DCIS, Intracystic papillary carcinoma, Benign-looking breast cancers, ILC, inflammatory breast cancer, and breast cancer in implant patients
By Christopher Comstock, MD and Marie Tartar, MD


Cases:
1. DCIS, calcified and non-calcified
2. Extensive intraductal carcinoma presenting as a palpable, tumor-filled ductal system
3. BRCA-1 patient, abnormal whole body PET leading to diagnosis of DCIS
4. Intracystic papillary carcinoma
5. Intracystic papillary carcinoma
6. Colloid cancer, 2 cases
7. Medullary cancer, question of liver metastases on breast MRI; FDG uptake on PET in a fibroid
8. Bilateral breast carcinomas on 18F-FDG positron emission tomography
9. ILC
10. ILC presenting with orbital metastasis, bilateral shrinking breasts
11. ILC presenting as a mass, post-operative changes on CT and PET
12. ILC presenting as architectural distortion
13. ILC presenting as a palpable, predominantly hyperechoic ultrasound mass
14. Echogenic breast cancer
15. ILC treated with neo-adjuvant chemotherapy
16. Stage IV ILC, presentation with liver metastases
17. US findings of inflammatory cancer
18. Inflammatory breast cancer in a lactating patient
19. Initial identification of breast cancer during breast MRI for implant integrity
20. Multi-focal IDC in a patient with implants and dense breasts
21. Large, locally advanced IDC in implant patient


Chapter 5: Locally Advanced Breast Cancer (LABC) and Neo-adjuvant Chemotherapy by Marie Tartar, MD; Christopher Comstock, MD; and Michael Kipper, MD

Cases:
1. LABC (large tumor size)
2. LABC with axillary and internal mammary involvement, staging with whole body PET and PEM
3. LABC with nipple skin involvement
4. Natural history of untreated inflammatory breast cancer
5. LABC with secondary inflammation (secondary IBC)
6. PABC, treated during pregnancy with neo-adjuvant chemotherapy with complete pathologic response
7. Post-partum LABC, with multiple axillary nodes involved, excellent response to neo-adjuvant chemotherapy
8. IDC treated with neo-adjuvant chemotherapy with incomplete imaging response, but complete pathologic response
9. LABC, responsive to neo-adjuvant chemotherapy; splenic activation with G-CSF therapy
10. Complete imaging response to neo-adjuvant chemotherapy
11. IDC with cystic component, mixed response to neo-adjuvant chemotherapy
12. LABC, unresponsive to neo-adjuvant chemotherapy
13. Rapidly progressive inflammatory breast cancer, unresponsive to chemotherapy
14. LABC, good response by imaging to neo-adjuvant chemotherapy, but significant residual pathologic disease; imaging-guided tailored lumpectomy



Chapter 6: Locally recurrent disease: Imaging surveillance

Cases:
1. Post-operative scar with hematoma on MRI
2. Changes from recent bilateral mastectomy and tissue expander placement
3. Normal CT appearance of bilateral TRAM flap reconstruction and post-TRAM flap abdominal complications
4. Recurrent DCIS presenting as new microcalcifications
5. Recurrent DCIS detected on surveillance MRI
6. ADH/DCIS found on breast MR obtained to evaluate silicone implant integrity in BCT patient
7. New palpable chest wall lump post mastectomy with implant reconstruction, excisional biopsy proven recurrent IDC
8. Axillary recurrence (new soft tissue around axillary lymph node dissection clips), presentation with pain
9. Parasternal recurrence, draining to contralateral axilla (role of lymphoscintigraphy)
10. Multicentric recurrent breast cancer with skin involvement
11. Physical examination change and abnormal enhancement of a 4 yr old lumpectomy scar, pathology proven fat necrosis mimicking tumor bed recurrence
12. Enhancing scar, suspicious for recurrence; contralateral axillary nodal presentation of new occult breast primary
13. Proven multi-centric fat necrosis mimicking multi-centric recurrence
14. TRAM flap recurrence on mammography
15. Residual carcinoma in TRAM flap reconstructed neo-breast
16. TRAM flap reconstruction with fat necrosis and supraclavicular lymphadenopathy, simulating recurrent disease
17. Chest wall recurrence detected on surveillance MRI
18. Recurrent IDC and radiation-induced pleomorphic sarcoma, with chest wall invasion


Chapter 7: Breast cancer mimics
By Christopher Comstock, M.D. and Marie Tartar, M.D.


Case 1. Papilloma presenting with bloody nipple discharge, ductogram and ultrasound
Case 2. Multiple papillomas
Case 3. Small phylloides tumor
Case 4. Large phylloides tumor (ultrasound)
Case 5. Large phylloides tumor
Case 6. Multifocal breast abscesses
Case 7. Granulomatous mastitis
Case 8. Lymphocytic mastitis
Case 9. New fat necrosis mass mimicking recurrence
Case 10. Fibrosis mimicking recurrence in implant reconstructed breast cancer patient
Case 11. Lactational asymmetry on PET




Chapter 8: Bone metastases
By Michael Kipper, M.D. and Marie Tartar, M.D.


Cases:
1. Stage IV presentation of breast cancer with bone metastases
2. Stage IV presentation with bone metastases (breast cancer presenting with back pain)
3. Relapse with bone metastases
4. Progression of bone metastases, epidural extension, radiation therapy effects
5. Recurrence with bone metastases: disease extent discordant between imaging and bone scan, pathologic fractures
6. Diffuse bone metastases, underrepresented on bone scan.
7. Recurrence with mediastinal lymphadenopathy, vocal cord paralysis and sclerotic bone metastases
8. Significance of solitary rib activity on bone scan, chemotherapy-related marrow activation changes on PET
9. Significance of solitary rib activity on bone scan
10. Solitary sclerotic rib metastasis (positive on bone scan, negative on PET)
11. Assessing activity of sclerotic bone metastases
12. Diffuse bone metastases (superscan)
13. Radiation therapy effects on bone
14. Extensive bone metastases, F-18 bone scan



Chapter 9: Liver Metastases
By Marie Tartar, M.D.


Cases:
1. Work-up of indeterminate liver lesion with MRI (hemangioma)
2. Progression liver metastases on CT and PET
3. Pseudocirrhotic appearance of treated breast liver metastases, mislocalization of right liver metastasis into right lung base on PET/CT
4. Progressive liver mets on CT & PET
5. Liver metastases arising in fatty liver, better seen on CT than PET
6. Evolution of liver metastases with treatment to unusual cyst-like residual


Chapter 10: Thoracic metastases, mimics and treatment effects
By Marie Tartar, M.D. and Michael Kipper, M.D.


Cases:
1. Solitary pulmonary nodule in the breast cancer patient: primary lung cancer vs. breast cancer metastasis.
2. Lung metastases, progression to pleural metastases
3. Chest wall, pleural and thoracic nodal recurrence
4. Pleural recurrence-bone scan and CT findings
5. Pleural and chest wall recurrence
6. CT and PET findings of talc pleurodesis for malignant pleural effusion
7. Infraclavicular and mediastinal nodal recurrence presenting with brachial plexopathy symptoms
8. Brachial plexus involvement
9. Atlas case 12 (chest wall and lung recurrence)
10. Atlas case 16 (nodal recurrences to mediastinum and supraclavicular regions)
11. PET+ thoracic nodal recurrence mimic due to silicone implant leak
12. Unusual pattern of chest wall recurrence (intercostal muscle infiltration)
13. Drug reaction (pulmonary toxicity) due to chemotherapy
14. Lymphangitic tumor
15. Lymphangitic tumor


Chapter 11: Breast cancer metastases to the neural axis
By Marie Tartar, M.D. and Steven S. Eilenberg, M.D.


Cases
1. Multilocular thalamic cystic metastasis
2. Brain metastases mimicking multiple sclerosis
3. Brain metastases mimicking multiple sclerosis
4. Brain metastases identified on PET in asymptomatic metastatic breast cancer patient
5. Unusual ?miliary? pattern of brain metastases
6. Dural based sphenoid wing metastasis with orbital extension
7. Plaque-like dural metastases
8. Skull metastases with extra- and intracranial extension
9. Skull metastasis and chemotherapy-induced leukoencephalopathy
10. Recurrent brain metastasis, radiation-induced leukoencephalopathy
11. Spinal leptomeningeal carcinomatosis


Chapter 12: Multi-system and unusual systemic metastases: Imaging assessment of treatment response, By Michael Kipper, M.D. and Marie Tartar, M.D.

Cases:
1. Recurrent PET+ activity in LABC & bone mets with increased tumor markers
2. Gastrointestinal metastases from breast cancer
3. Peritoneal breast carcinomatosis
4. Bone, liver, pericardial and ovarian metastases


Chapter 13: Radiation Therapy
By Eva Lean, Ray Lin, Marie Tartar


Case 1. Utility of Pre-Radiation Mammography
Case 2. Dramatic radiation therapy changes of breast on mammography and MRI
Case 3: 2 Month Old Radiation Therapy Effects on Lung (CT and PET)
Case 4: Breast Cancer Radiation Induced Lung Changes on CT and PET
Case 5: Typical apical change from supraclavicular radiation therapy on CT, MRI, and PET
Case 6: Mass-like apical radiation fibrosis
Case 7: Early post-radiation changes on breast MRI
Case 8: Late post-radiation changes on breast MRI
Case 9: Radiation-induced angiosarcoma