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Non-palpable
Breast
Cancer
Initiallyonly
detected
by
MRI:comprehensiveevaluationandsolutions
TianjinMedicalUniversityCancerInstitute&HospitalPeifang
Liu,MD
MammographyUltrasoundMRI……PET-CTprimaryimagingmodalitiesforscreeningandevaluationofbreastlesion-nothingisabsolutelydiagnostic
Adjunctiveandsupplementalmodalities-尺有所短,寸有所長
!!!Overthepastfewyearsvariousimagingmodalitieshavebeenexploredwithregardtotheirabilitytodetectandcharacterizebreastcancer,including:Mammography:Morphology
(density
difference
between
lesions
and
glandular
tissue)Ultrasound:B-mode(Morphology)
Color
Doppler
Volume
imaging
Elastography
Contrast-enhanced
sonographyMRI:plain
scan
DCE(dynamiccontrast-enhancedMRI)
DWI
MRSPET-CT:combination
anatomical
with
functional
imaging
18F-FDG、estrogenreceptorimagingagent(18F-FES,18F-17β-estrogen)Morphology
+
FunctionFunctionalimagingcan
find
lesions
earlyand
accurately
beforemorphologicalchanges
of
lesions脂肪瘤纖維腺瘤乳腺癌超聲彈性成像技術(shù)乳腺浸潤性導(dǎo)管癌伴多發(fā)淋巴結(jié)轉(zhuǎn)移
“4
key
points”of
imaging
for
surgeon
Diagnostic
principle-尺有所短,寸有所長
!!!Positioning,qualitative,quantitative,staging
BI-RADS5,BI-RADS4C,BI-RADS4B,BI-RADS4A,……Doing
the
4
key
points
should
fully
understand
advantages
and
disadvantages
of
each
imaging
modalities!!!(1)confirm (2)not
sure(3)confirm
partly,and
make
a
suggestion
for
furtherprocessing
AdvantagesofMRIAdvantagesofMRIThe
high
resolution
for
soft
tissue
No
radiationMulti-sequence
imagingMulti-direction
imaging……The
highest
diagnostic
accuracy
of
breast
cancerFor
diagnostic
sensitivity,specificity
and
accuracy
of
breast
lesions,MRI
is
superior
to
mammography
and
ultrasoundThe
suspicious
lesions
detected
only
by
MRI
(prone),not
palpable,
and
negative
on
MG
and
US,
how
to
being
precise
position
in
clinical
biopsy
or
surgery(supine)to
the
next
individualized
intervention,this
is
an
urgent
imaging
problem
challengeImagingtosolvepracticalproblemsforsurgeons:The
suspicious
lesions
detected
only
by
MRI
(prone),not
palpable,
and
negative
on
MG
and
US,
especially
mass
lesions
with
less
than
1
cm
and
atypical
non-mass
lesions,how
to
being
precise
positionand(or)
biopsy(supine)?Imaging-guidedlocalizationorbiopsyofbreastlesionsMammography-guidedUltrasound-guided:firstchoiceMRI-guidedAmong
the
methods
of
localization
and
biopsy,the
ultrasound-guided
with
easy-operation,
low-cost,and
time-saving,hasbeenwidelyand
expertly
usedTheprocessingflowofbreastlesionsdetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular
processing:localization
and
biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization
and
biopsy3rdMRI-guided
localization
and
biopsyMRI-directedUSIndividualized
Treatment
GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLimitations
of
ultrasoundTypes
of
lesions:the
sensitivity
for
micro-calcification
is
lower
than
mammography,iso-echoiclesionsonUS,breastcancerwithnon-massenhancementLackofstandardizationDiagnosticaccuracydepends
ontheindividualexperience,responsibility,mumber
of
patientsandsoon……Reading
images
together
consultation
XMissed
diagnosisTheprocessingflowofbreastlesionsdetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular
processing:localization
and
biopsynegativeIndividualized
Treatment
GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not
palpable,
and
negative
on
MG
and
USCase:a
67-year-old
woman
with
left
axillary
mass,confirmed
a
metastatic
adenocarcinoma
with
histological
grade
2,originatingin
breast
by
immunohistochemistryMammographicfindings:negative1stMRIdirected“second-look”USMRI
showed
non-mass
enhancement
with
ductal
distribution
in
upper
outer
quadrant
of
left
breast,highly
suspicious
breast
cancer,and
lymph
nodes
metastases
in
the
left
axillary3.5mm
size
invasive
ductal
carcinomaSecond-lookUS
showed
two
0.4*0.3cmsize
hapoechoic,
regular,
well-circumscribedmass,with
theabsenceofvascularityHistopathology:3.5mm
size
invasive
ductal
carcinomaofno
specific
type
with
grade
IIUltrasonographicfindings(2011-5-5)
:negative
Case:a33-year-oldwomanwiththe
resection
of
mass
in
upper
outer
quadrant
of
left
breast
15
daysago,the
histopathologywas
atypical
hyperplasia
of
ductal
epitheliumMRI(2011-5-6)“Second-look”Ultrasound(2011-5-6)“Second-look”ultrasonographicfindings:As
the
enhancement
lesions
onMRIin
upper
inner
quadrant
of
left
breastedge,a0.9×0.6×1.0cmsizehepoechoic,regular,circumscribedmass,with
internal
and
peripheralvascularity
(Makeamarkonthebreastskinforlocalization)Macroscopy:atumor
with1.5×1×1cm
sizeshowedgrey-whitecutsurface
Histopathology:
DCIS,
gradeIICase:a
44-year-old
woman
with
mass
of
left
breastfor4years2011-11-25Mammographicfindings:aasymmetryinupperinnerquadrantofleftbreastImpression:highsuspicionformalignancy(BI-RADS:4C)2011-11-25Sonographicfindings:a1.5×1.3×0.8cmsizehepoechoic,irregular,indistinctmasswithinternal
vascularity
inupperinnerquadrantofleftbreastImpression:cancer(BI-RADS:5)2011-11-28“second-look”ultrasound
showed
a1.1x0.6x0.8cm
sizehypoechoic,irregular,indistinctmasswithinternal
vascularity
in
lower
outer
quadrant
of
left
breast(Makeamarkonthebreastskinforlocalization)Impression:cancer(BI-RADS:5)PathologicaldiagnosisAinvasiveductalcarcinomawithnucleargrade
1-2inupperinnerquadrantofleftbreastA
tubular
carcinoma
and
invasiveductalcarcinomawithnucleargrade1-2(10%)inlowerouterquadrantofleftbreast,lobularatypiaandflat
epithelialatypianeartotumor,andregionallymphnodes:axillary1/12Pathologicstaging:pT1cN1aMxCase:a
57-year-old
woman
with
left
massfor2months,skinedemaundertheareola,leftnippleretraction
without
dischargeMammographicimpression:inflammation(BI-RADS:3)2012-6-20First
ultrasonographic
impression(2012-6-20):hyperplasia
with
cysts2012-6-29“Second-look”ultrasound(2012-7-2)
showed
a2.7×1.3×2.6cm
sizehepoechoic,irregular,indistinctmasswithperipheralvascularityin
upper
outer
quadrant
of
left
breastImpression:cancer(BI-RADS:5)Histopathology:invasiveductalcarcinoma,grade
I—II(second-lookUS)The
reasons
of
missed
diagnosis
on
US:individual
dependence---experience,responsibility,onlyfocus
on
the
target
lesion
and
so
onThe
features
of
lesions
itself---microcalcification,iso-echoiclesions,non-massenhancement
Case:a
28-year-old
woman
with
mass
of
rightbreast
for4months,withoutdischargeMammographicimpression:
cancer(BI-RADS:5)2013-8-13ultrasonographical
findings:
a3.1×2.1cm
sizehepoechoic,irregular,indistinctmasswithcalcifications
and
internalandperipheralvascularityin
upper
outer
quadrant
of
right
breastImpression:cancer(BI-RADS:5)2013-8-15
MRI
findings:non-mass
enhancement
in
the
upper
of
right
breast,considering
cancer,
non-mass
enhancement
in
upper
inner
quadrant
of
right
breastImpression:suspicious
cancer
or
atypical
benign
lesion2013-8-15“Second-look”ultrasound
showed
a1.9×1.1cm
sizehepoechoic,ductal
distribution,indistinctlesion
withinternalvascularityin
upper
centralof
left
breastImpression:lowsuspicionformalignancyHistopathology(2013-8-20
)
:invasive
ductal
carcinoma
with
grade
II
of
right
breast,ductal
carcinoma
in
situ
with
microinvasive,grade
II
of
left
breastCase:F,63yRight
breastInvasive
ductal
carcinoma,tumor
emboli
in
the
lymph-vessel
Histopathology:invasive
papillary
carcinoma
of
left
breastLeft
breastlocalization
by
MRI-ditected“Second-lookUS”Case:a
60-year-old
woman
with
lymphadenopathyof
left
neck
2012-4-12
Surgicalexcisionconfirmeda
metastatic
adenocarcinoma
2012-4-23
Mammographicfindings:focal
asymmetry
in
upper
outer
quadrant
of
left
breastPET-CT
findings(2012-4-20)①Lymphadenopathyunderthechin,jaws,bilateralneck,theleftclavicleandbilateralaxillary,thelymphnodesoftheleftneck,theleftclavicleareasandtheleftaxillaryhave
metabolism
actively,consideringforlymphnodemetastasis,followingupforothers②The
increasing
metabolism
of
right
behind
8th
rib,left
front
5th
rib
and
the
1st
lumbar
vertebrae,no
bone
structure
destruction,considering
possibility
of
metastases,no
suspicious
findings
in
residual
PETandCTimagingarea2012-4-23
the
first
ultrasonographic
findings:
negativeLeft
supraclavicular
lymph
nodes
metastases
No
lymphadenopathy
of
axillary2012-5-7
MRI2012-5-7(at
the
same
time
as
MRI)“second-look”ultrasound
showed
a0.7×0.5cm
sizehepoechoic,architecturaldistortion
in
upper
centralof
left
breastImpression:lowsuspicionformalignancy,lymphadenopathyofleftaxillary2012-6-19
Ultrasound-guided
biopsy:invasive
ductal
carcinomaTheprocessingflowofbreastlesionsdetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular
processing:localization
and
biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRIpositiveUS-guidedlocalization
and
biopsyIndividualized
Treatment
GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not
palpable,
and
negative
on
MG
and
UScombiningreal-timeultrasoundandcontrast-enhancedMRI2.thevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRITheprocessingflowofbreastlesionsdetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular
processing:localization
and
biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization
and
biopsy3rdMRI-guided
localization
and
biopsyIndividualized
Treatment
GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not
palpable,
and
negative
on
MG
and
USMRI-guidedneedlelocalizationA
womanof25-year-oldwithhistoryofIDCintheleftbreast,leftbreastconservationfor4years,rightbreastmassseenfor6monthsMammographicimpression:rightbreastcancer,negativeofleftbreastUltrasound:nolesionsMRI:right
breast
cancer(multiplecarcinomas),
focal
enhancement
(1×1.5cm)in
upper
inner
quadrant
of
left
breast,thatis
lowsuspicionformalignancy3.MRI-guided
localization
and
biopsyCaseHistopathology:ductalcarcinomainsituTheprocessingflowofbreastlesionsdetectedbyMRI,not
palpable,
and
negative
on
MG
and
USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular
processing:localization
and
biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization
and
biopsy3rdMRI-guided
localization
and
biopsyIndividualized
Treatment
GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not
palpable,
and
negative
on
MG
and
USStandardizationforultrasoundABUSEmphasizing“Second-lookUS”ABUS:自動(dòng)化全乳腺超聲檢查系統(tǒng)集體讀片、會(huì)診√Second-lookUS(MR-directedSonography,TargetedSonography)Carbognin1G,Girardi1V,Calciolari1C,etal.Utilityofsecond-lookultrasoundinthemanagementofincidentalenhancinglesionsdetectedbybreastMRimaging,Radiolmed,2010,115:1234–1245CandelariaR,.Fornage,B,Second-lookUSexaminationofMR-detectedbreastlesions,JournalofClinicalUltrasound,2010,29:115-121ParkVY,KimMJ,KimEK,etal.Second-lookUS:howtofindbreastlesionswithasuspiciousMRimagingappearance.Radiographics.2013,33(5):1361-1375*Conclusions:Second-lookU
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