Transcript 110_eposter - Stanley Radiology

Abstract ID - 1091
Two uncommon breast lesions
Medullary carcinoma of breast
Male breast abscess
Case 1: Medullary Carcinoma of Breast
History
A 40 year old female presented with a lump in the left breast, clinically
diagnosed as fibroadenoma
Mammography
Craniocaudal View
Mediolateral Oblique View
 Large lobulated dense lesion with well defined superior and anterior margins and obscured posterior and
inferomedial margins (orange arrows).
 No calcifications were seen. No architectural distortion was seen.
 An enlarged right axillary lymph node was also seen (curved arrow).
Ultrasound
 Well-defined hypoechoeic lesion showing relatively smooth margins with microlobulations along its
anteromedial and posterior aspects (orange arrows).
 Internal vascularity was seen within lesion (curved white arrow) on color doppler ultrasound image.
Histological features of Medullary Carcinoma
Syncytial arrangement of the tumor cells (T)
with
markedly
hyperchromatic
and
pleomorphic nuclei with lymphoplasmacytic
cell infiltration (L)
Tumor infiltrating into the adipose tissue
Markedly
pleomorphic
and
hyperchromatic nuclei of the tumor cells
with increased mitotic figures
Cut surface showing a well circumscribed
grey white tumour measuring 4x4x4 cm
(encircled) with pushing borders.
Medullary Carcinoma of Breast
 Medullary carcinoma of the breast is a rare subtype of invasive ductal carcinoma
accounting for fewer than 2 % of all cases of breast cancer1 and more frequently in
younger
woman2.
 It is also called medullary carcinoma, because the tumor is a soft, fleshy mass that
resembles
the
part
of
the
brain
called
the
medulla.
 Medullary carcinoma can occur at any age but it usually affects women in their late
40’s and early 50’s.
 Medullary
carcinoma
–
common
–
BRCA
1
gene
mutation.
 Due to its increased prevalence in younger population, it is often mistaken for
fibroadenoma.
Cardenosa G. Malignant lesions. In: Breast imaging. Philadelphia, Pa: Lippincott Williams & Wilkins, 2004; 239–280
Rosen PP. Medullary carcinoma. In: Rosen’s breast pathology. Philadelphia, Pa: Lippin- cott-Raven, 1997; 355–374
Mammography
 Noncalcifed mass, frequently of high density with circumscribed, indistinct or
obscrued margin.
 Absence of calcification in medullary carcinomas, may be attributed to absence
of intraductal components
Ultrasound
 Hypoechoic masses associated with acoustic enhancement, shadowing or no
posterior acoustic features.
 Margins may be lobular, circumscribed or indistinct but tend not to be
spicualted.
 Microlobulations strongly favour neoplastic nature of the lesion.
 Lesions can show cystic component with focally thick walls, a feature that helps
in differentiating it from a fibroadenoma.
Liberman L, La Trenta LR, Samli B, et al. Over- diagnosis of medullary carcinoma: a mammo- graphic-pathologic correlative study. Radiology 1996;201:443–6
Meyer JE, Amin E, Lindfors KK, et al. Medullary carcinoma of the breast: mammographic and US appearance. Radiology 1989;170:79–82
MR features of fibroadenoma VS medullary carcinoma
Fibroadenoama
Contrast enhanced T1-weighted GRE(left) – oval mass
with smooth and lobular margins with enhancement of
dark internal septa.
T2-weighted(right) increased signal intensity in the
lesion.
Medullary Carcinoma
Isotense on T2W STIR
Homogenous enhancement during the early dynanic post-gadolinium at 1 minute
Delayed peripheral enhancement during the dynamic post-gadolinium at 6 minutes
Dynamic Contrast enhanced MR kinetic study
FibroadenoamaVs Medullary Carcinoma
Early wash-in and and early washout Type III pattern
Gradual enhancement pattern
throughout the dynamic phase
Type I pattern
Medullary Carcinoma
Fibroadenoma
Summary
 Medullary carcinoma of the breast is an uncommon tumor, which
may mimic a benign mass both in mammography and
ultrasonography features.
 Mammography, ultrasonography and dynamic contrast enhanced
MR with kinetic study aids in differentiating it from fibroadenoma.
Tominaga J, Hama H, Kimura N, Takahashi S. MR imaging of medullary carcinoma of the breast. Eur J Radiol 2009; 70:525–529
Case 2: Male Breast Abscess
History
 27 year old male complaints of painful left breast
swelling for a period of 7 days, progressively
increasing in size with intermittent fever
 No nipple discharge
 Examination  Tender with erythematous areola
 Multiple, enlarged left axillary
lymphnode
 Clinical Diagnosis – Breast Abscess
 Ultrasound
 Thick walled collection measuring 8 x 10 cm in subareolar location of left breast
suggestive of abscess (Figure A).
 Computed tomography
 Hypodense lesion seen in the subcutaneous plane of left anterior chest wall. No invasion of
adjacent structures noted.
 Pectoralis muscles appears normal (Figure B) .
 Incision & Drainage




800 ml of pus drained.
Culture showed growth of staphylococcus aureus.
No evidence of malignant cells noted in cytology.
Patient improved very well symptomatically.
Male Breast Abscess
 Gynaecomastia – most common male breast abnormality.
 Non-neoplastic benign breast conditions








Subareolar abscess
Intramammary lymph node
Sebaceous cyst
Diabetic mastopathy
Posttraumatic Hematoma & Fat necrosis
Venous malformation
Secondary syphilis
Nodular Fascitis
Nguyen C, Kettler MD, Swirsky ME et al. Male breast disease: pictorial review with radiologic-pathologic correlation. Radiographics. 2013 May;33(3):763-79
Subareolar abscess
 Localized infection secondary to ductal ectasia, chronic obstruction
and inflammation
 Staphylococcus aureus and epidermidis – most common causative
organism.
Mimics of Breast Abscess
VENOUS MALFORMATION
Mammogram shows multiple tubular densities [
arrows]
SUBACUTE HEMATOMA
Mammogram shows a mass with fluid
level(arrow)
Ultrasonography shows multiple anechoic ,
tubular cystic spaces showing internal vascularity on Ultrasonography shows a solid-cystic mass
colour doppler.
(arrowheads) with internal echoes and fluid debris
level(arrow)
Summary
Breast abscess has predilection for subareolar location, and
can mimic gynaecomastia, but corollary findings such as skin
thickening, regional erythema and sonographic appearance
will enable correct diagnosis.
Treatment includes antibiotic therapy and percutaneous US
guided drainage. Recurrent abscess are treated with surgical
excision of abscess and regional lactiferous ducts to prevent
recurrence
Radiologist are pivotal in treatment team and
multidisciplinary management of breast abscess with
physicians and surgeons will lead to optimal care.