Transcript שקופית 1

The Role of Preoperative MRI
in Patients With Invasive
Lobular Carcinoma
Golan.O, Sperber.F, Shalmon.A, Weinstein.I, Gat.A
Breast Imaging Department
Tel-Aviv Medical Center
Invasive lobular carcinoma (ILC) was first
described in 1946 by Foote and Stewart.
ILC accounts for 5-14% of breast
malignancies.
Diagnostically ILC is challenging because of
its veiled presentation on clinical
examination and on imaging.
Histology
ILC spreads through the breast parenchyma by
means of diffuse infiltration of single rows of
malignant cells in a linear fashion (Indian-file
pattern) around nonneopolastic ducts.
Little disruption of the underlying anatomic structures,
Little surrounding connective tissue reaction
Invasive lobular carcinoma (ILC) of the breast is
known to be substantially underestimated by
mammography
Because ILC frequently does not form a demonstrable
mass or distort the architecture or commonly produce
calcifications, and is frequently isodense with normal
tissue, it is not unusual for ILC to go undetected on
sequential mammograms until it becomes clinically
evident.
False negative 3-16%
Mammographic Characteristics of ILC
(Ellen B.Mendelson et al AJR)
Asymmetric density without definable margins.
A Mass with spiculated margins.
No tumor discernible by mammography especially
in dense breast tissue .
Microcalcifications (rare)
Ultrasound Appearance
ILC cannot be distinguished from ductal carcinoma by
ultrasound.
Hypoechoic tissue is seen with varying degrees of
posterior enhancement.
In their retrospective review, Selinko et al found
that ILC lesions were more easily seen on ultrasound
than mammography.
Measurement of tumor size plays a pivotal
role in treatment planning of breast cancer
Breast conserving surgery VS Mastectomy
Neoadjuvant chemotherapy ?
Objective
To evaluate MRI ability to determine the extent of
ILC compared to mammography and ultrasound, and
to determine if ILC, as depicted on MRI, correlated
with histopathological findings.
Materials and methods
Retrospective study of 22 patients with biopsy
proven ILC who underwent MRI (7/20059/2007)
Age: 32-67 years (median 50 )
MRI technique
MRI was performed using 1.5T magnet (signa
GE) using 4 channels breast coil
Imaging protocol:
Bilateral parallel imaging
T2 weighted sagittal fat suppressed
T1 weighted dynamic sagittal fat suppressed 3D
FSPGR before and following contrast
Subtraction, curves of enhancement and MIP.
Typical section thickness: 2-2.5 mm
Results
Mammographic findings
Mass 55%
Asymmetrical density 27%
Calcifications 9%
No mammographic findings 9%
Mammographic /ultrasound correlation
• No mammographic finding-multifocal
irregular solid masses bilateral.
• Masses on mammography- irregular solid
masses on US on 33% multifocal (versus
17% on mammography).
• Asymmetrical density on mammographyirregular solid masses on US.
• Calcifications on mammographymultifocal irregular solid masses on US .
MRI findings
Pattern of enhancement:
Masses 91%
73% irregular spiculated
18% mass with irregular thick ring enhancement
Focal irregular enhancement with no
dominant mass 9% .
In 27% irregular ductal enhancement was also
present.
Size:
The median diameter of the dominant mass
on MRI was 5.6cm (2.2-9cm) versus 2.7 cm
(1.7-5.3cm) on US and 2.5 cm (2-5cm)
on mammography.
Extension of the disease: In 64% more than
one mass versus 54% on US and 17% on mammography
3 multifocal
4 multifocal multicentric
MRI findings
Curves of enhancement
A strong and fast enhancement with washout 45%
A more benign curve 55% (speed, intensity,
washout)
Pathologic correlation
27% had a mastectomy – the tumor size and the extent
of the disease was much bigger than those we saw on
mammography and US and had a good correlation with
MRI findings.
73% were operated after neoadjuvant chemotherapy (3
mastectomy) – better correlation to the MRI than
mammography and us.
54 years old who presented with a palpable mass on the right (UOQ) breast
RT
LT
RT
RT
LT
LT
42 years old who presented with a palpable mass on the right (uoq) breast
45 years old who
presented with a
palpable mass on
the right (uoq)
breast. BRCA
carrier.
MIP
43 years old who presented with a palpable mass on the right (uoq) breast
MIP
Conclusions
Invasive lobular carcinoma is the second most frequent invasive
breast cancer.
It is unusually discovered on screening mammography and the
presenting symptom is commonly a palpable mass.
Mammography is disappointing with a high rate of false negative.
US improves the imaging of ILC but still does not show the full
extent of the disease.
MRI provides the most accurate estimation of tumor size and the
extent of the disease, commonly showing us a multifocal disease
which is underestimated by the conventional methods.
MRI often modify the therapeutic strategy ruling out conservative
procedures.
MRI of the breast should be
considered as a preoperative
routine patients diagnosed with
Invasive lobular carcinoma.