apresentação de casos

8/10/2019 Apresentao de Casos

1/8

9/24/20

UnknownCases

ARRSBreastImagingSymposium

,

Case1

Case1:RoutineScreening

History:60yearoldwomanwhopresentedforscreeningmammography

ImageFindings:Fig.1Leftcraniocaudal (A)andleftmediolateral oblique(B)images

demonstrate tworoundmassesintheleftupperouterbreastcontainingclustereddense

particles.Anaccompanyingrightmediolateral obliqueimage(C)showsradiodense deposits

withinrightaxillarylymphnodes.

DifferentialDiagnosis:

Granulomatous disease

Metastatic breastcarcinoma

Extramammary metastases

Golddeposits

Fat necrosisTeachingPoints:

Case1

FinalDiagnosis:Golddepositsinaxillary lymphnodes

malignantprocesses.

Obtainingacarefulhistorycanhelpdistinguishbetweentheseentities.

Malignantaxillarynodalcalcificationsareofthesametypeastheprimary

tumor,appearingpleomorphicandmalignantappearingwhereasbenign

nodalcalcificationstendtobemorecoarse.

50%ofgoldinjectedfortreatmentofrheumatoidarthritisremainsinthe

body,andthehighestconcentrationoftheremaininginjectedgoldcanbe

seeninthelymphnodesandcanresemblestippledcalcificationon

mammography.

Case2

Case2:Subareolar Tenderness

History:43yearoldmanwithcardiomyopathy developsanacutepainful,erythematous,

swollen,andfirmrightbreast

ImageFindings:Fig.2Rightcraniocaudal (A)andmediallateraloblique(B)viewsshow

incidentalgynecomastia andincreasedsubareolar densityincomparisonwithamammogram

performedfiveyearsearlier(notshown)withnewmarkedthickeningoftheperiareolar skin.

Rightbreastultrasound(C)showsahypoechoic complexirregularfluidcollectionandconfirms

overlyingskinthickening.Therewasmarkedadjacent increaseinvascularity(notshown).


Abscess

Gynecomastia

Mastitis

Hematoma

ght American Roentgen Ray Society 2012


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TeachingPoints:

Breastabscesscanhaveavariablemammographicappearanceinmenand

women,rangingfromanilldefined,noncalcifiedmasstoanirregularor

Case2

FinalDiagnosis:Abscess

sp cu ate mass. tcana so em sta en orgynecomast a nmen. reast

abscessesaremorecommoninwomenthaninmen.

Skinthickeningmammographically shouldsuggestthediagnosisofan

inflammatoryprocessand/orabscess.Ultrasoundisveryhelpfulinthiscase

toidentifytheabscessfluidcollection.

Abscessformationcanbesecondarytoarupturedepidermalinclusioncyst.

Subareolar abscessisassociatedwithductectasia.Itisachroniclesionwhich

tendstorecurifnottreatedwithexcisionoftheabscessandinvolvedduct.

StaphylococcusandStreptococcusarethemostcommonpathologicagents.

Case3

Case3:Palpable,NonTenderLump

History:45yearoldmanwithprogressivelyenlargingnonpainfulleftbreastmass

ImageFindings:Fig.3Leftcraniocaudal (A)andmediallateraloblique(B)viewsshowawell

circumscribedhighdensity massthatcorrespondstothepalpablefindingmarkedwithaBB.

Incidentalgynecomastia ispresentinthesubareolar regionseparatefromthemass.Leftbreast

ultrasound(C)showsanovalcircumscribedhypoechoic masswithmildincreasedvascularity

(notshown).


Mesenchymal neoplasm(fibrohistiocytic neoplasm)

Metastaticlesion

Breastcarcinoma

TeachingPoints:

Allconditionsthatoccurinthefemalebreasthavethepotentialtobeseeninthe

malebreast,withtheexceptionthatbiphasictumors(thosecomposedof

epithelialandmesenchymal elements)arerare(i.e.,fibroadenomas and

phyllodes tumors).

Themalebreastiscomposedofsubcutaneousfatandaremnantofsubareolar

Case3

FinalDiagnosis:Mesenchymal neoplasm(fibrohistiocytic neoplasm)

. .

Cooperligamentsarenotseeninthemalebreast.

Conditionsthatarisefromtheskin,subcutaneousfat,bloodvessels,lymphatics,

andnervescandevelopinthemalebreastandmanifestasmasses.

Adiscretemassatmammography orultrasoundinthemalebreastisconsidered

suspiciousformalignancyandpathologiccorrelationmustbeperformed.

Fibrohistiocytic tumorsaremorecommoninwomen.Thistumorinvolvesthe

subcutaneousadiposetissue.Itisararemesenchymal tumorwithalowgrade

malignantbehaviorandispronetorecurlocallyandoccasionallymetastasize

regionallyandsystemically.Itmanifestsasapainlesssofttissuemassandmostoftenaffectstheupperextremities.

Case4

Case4:Palpablelump

History:42yearoldwomanpresentswithapalpablemassintheuppermidportionofthe

leftbreast

ImageFindings:Fig.4Ultrasound(A)showswellcircumscribedhypoechoic solidmass.Left

mammogram(BandC)showsawellcircumscribedovalmass.

Differential Diagnosis:

Pseudoangiomatous stromalhyperplasia(PASH)

Fibroadenoma

Focalfibrosis

Hamartoma



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TeachingPoints:

TheclinicalpathologicspectrumofPASHcanrangefromafocalmicroscopic

findingtoadominantpalpablebreastmass.PASHhasbeenreportedasan

Case4

FinalDiagnosis:Pseudoangiomatous stromalhyperplasia(PASH)

incidentalmicroscopicfindingofbreastbiopsiesperformedforeitherbenignor

malignantdisease(23%of200consecutivebreastbiopsies).PASHissimilartoa

fibroadenoma inclinicalandimagingfeatures.Toconfirmthediagnosis,biopsy

isrequired.ItisimportanttodistinguishPASHfromalowgradeangiosarcoma

onhistology.HormonalfactorsarelikelytocontributetoPASH.Animpressive

responsetotamoxifen inapatientwithPASHhasbeenreported.

Case5

Case5:PalpableLump

History:81yearoldwomantakingwarfarinwhohasapalpableabnormalityinthe12oclock

positionoftherightbreast

ImagingFindings:Fig.5Rightcraniocaudal mammogram(A)showsacircumscribedround

11mmmassinthemidposterior portionofthebreastcorrespondingtoapalpable

abnormality. Rightmediolateral obliquemammogram(B)showsthemassintheupperpartof

thebreastwasnotpresentatpreviousexaminations.Radialultrasound image(C)ofright

breastshowsapredominantlyechogenicroundmasswithasmallcysticcomponent

correspondingtotheareaofclinicalconcernatthe12oclockposition.


Angiolipoma

Focalatrophicbreasttissue

Hamartoma,fibroadenolipoma

Hemangioma

Hematoma

Case5

TeachingPoints:

Sevenpercentofbenignmassesarehyperechoic,definedasincreased

echogenicityrelativetoadjacentfat.

FinalDiagnosis:Hematoma

Alesionthatishomogeneouslyhyperechoic andcircumscribedis

nearly100%likelytobebenign.

Anechogenicrimaroundamassisconsideredsuspicious;the

likelihoodofmalignancyis2.6timesashighasthatofamasswithout

anechogenicrim

Case6

Case6:TwoPalpableLumps

History:27yearoldwomanwithtwopalpablelumpsintherightbreast

ImagingFindings:Fig.6Ultrasoundimage(A)showsacircumscribedhypoechoic palpable

masswithtinyinternal echogenicandanechoicareas.Increasedinternalandadjacent blood

flowwaspresentoncolorflowimage(notshown).Ultrasoundimage(B)showssecond

palpableregioncorrespondstodensefibroglandular tissue.Nomassorcystispresent.


Bothlesionsbenign,nofurtherevaluationneeded

Biopsyofsolidmasswithoutfurtherevaluationofotherarea

Biopsyofsolidmass,clinicalfollowupandmanagement ofareaofclinicalinterestwithout

imagingfinding



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Case6

TeachingPoints:

Patientsyoungerthan30yearswithapalpablemassneedaninitial

evaluationwithultrasound.

FinalDiagnosis:Biopsyofsolidmass,clinicalfollowupandmanagement of

areaofclinicalinterestwithoutimagingfinding

, .

findingissuspiciousformalignancy,mammography ofbothbreastsshouldbe

performed.

Iftherearenoimagingfindingsonthepalpablelesion,clinicalfollowupis

recommended.Clinically suspiciousareasshouldbefollowedfor12yearsof

stability.Ifthearearemainsclinically suspicious,biopsyshouldbeperformed

byfineneedleaspiration,corebiopsy,orsurgicalexcision.

Case7

Case7:RoutineMammogram,historyofbreastconservingtreatment(BCT)

History:67yearoldwomanwithcentralcalcificationsonherannualdiagnosticmammogram

andhistoryofrightupperquadrantlumpectomy1yearago

ImagingFindings:Fig.7Rightcraniocaudal (A)andmediolateral oblique(B)mammograms

showlumpectomychangessurroundedbysurgicalclipsintheupperouterquadrant.Central

inrelationtothenippleisanewclusterofcalcifications.Lateralspotmagnificationview(C)

furthershowsthepleomorphicclusteredcalcificationswithoutlayering.Findingatinitial

imagingguidedbiopsywasbenignfibrocysticchangeswithstromalcalcifications.


Acceptthepathologicdiagnosisandrecommend6monthfollowupmammography

Acceptfindingsasconcordant andhavepatientresumeannualscreeningexaminations

Re ect the atholo ic dia nosis as discordant with ima in findin s and recommend

additionaltissuesampling

Case7

TeachingPoints:

Coreneedlebiopsyhasareportedsensitivityof8599%.Technicalissuesof

biopsyandpathologicassessmentresultinthisrange.

FinalDiagnosis:Rejectthepathologicdiagnosisasdiscordantwithimaging

findingsandrecommendadditionaltissuesampling

Ifthepatienthasmorethanonegroupofcalcifications,theradiologistmust

ensurethatthebiopsyisofthecorrectgroupandthatthemarkerisatthe

locationofthelesionofinterestonthepostprocedure mammogram.

Effectivecommunicationwiththepathologistabouttheimagingfindingson

thebiopsiedlesion(massorcalcifications)andtheoverallsuspicionofthe

lesionisimportant.Iftheimagingandpathologicfindingsonlesionare

discordant,furthertissuesamplingisneededwitheitherasecondneedle

biopsyor,preferably,surgicalbiopsy.

Case8 Case8:BloodyNippleDischarge,right

History:50yearoldwomanwithbloodyandcleardischargefromrightnipple,normal

mammographicfindings,andanunsuccessfulductogram

ImagingFindings:Fig.8Axial(A)contrastenhancedsubtractionMRimageshowslinear

branchingnonmasslike enhancementinthemedialsubareolar regionoftherightbreast.

Axialcomputeraideddetectionimage(B)depictsabnormalenhancement. SagittalMR

image(C)showslocationofenhancement ininferioraspectofthebreast.


Ductalcarcinomainsitu

Ductalectasia

Papilloma



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Case8

TeachingPoints:

Bloodynippledischargeismostcommonlyassociatedwithbenign

FinalDiagnosis:Papilloma

, , .

areassociatedwithcancer,intraductal,invasive,orPagetdisease.

MRIcanhelpindetectionofanintraductal lesioninwomenwithnipple

dischargeandnormalconventionalimagingfindings.

Differentiatingpapillomaandsmallinvasivecancerorductalcarcinomain

situusuallyisnotpossiblewithbreastMRI.

Case9

Case9:ScreeningMRI,highriskpatient

History:51yearoldwomanwithstrongfamilyhistoryofbreastcancerandnormalfindingsonscreening

mammograms

ImagingFindings:Fig.9MRimagesshowbilateralabnormalities.Contrastenhancedaxial(A)andT1

weightedaxial(B)MRimagesshowanenhancingroundmassinthelateralaspectoftheleftbreast.A

hypoechoic masswithanirregularmarginwasfoundatultrasoundexaminationofthisregion(not

shown).ContrastenhancedaxialMRimage(C)showsnonmasslike regionalenhancementofthelateral

aspectoftherightbreast.


Leftbreast:

Fibroadenoma

Invasivecarcinoma

Metastaticlesion

Rightbreast:

Ductalcarcinomainsitu(DCIS)

Fibrocysticchange

Invasivelobularcarcinoma

Lobularcarcinomainsitu

Case9

TeachingPoints:

IndicationsforscreeningMRIaretheBRCA1,BRCA2,geneticsyndromes

(e.g.,Cowden,LiFraumeni),mantleradiation,andastrongfamilyhistory

(greaterthan20%lifetimerisk).

FinalDiagnosis:Left:Invasivecarcinoma,Right:DCIS

,

thatis,ductal,segmental,linear,focal,regionalormultiregional,and

diffuse.

Theenhancementkineticsofnonmasslike lesionscanbemisleading

Nonmasslike cancerouslesionsaremorelikelytobeDCISandlobular

cancer.

Bilateralsymmetricnonmasslike enhancementinanydistributionismore

oftenbenign.

Case10

Case10:SurveillanceMRIpostmastectomy andTRAMflapreconstruction

History:48yearoldwomanwithafamilyhistoryofbreastcancer,previouslefttransverse

rectusabdominis myocutaneous (TRAM)flapreconstructionforductalcarcinomainsitu(DCIS)

andlobularcarcinomainsitu(LCIS)ofleftbreast,normalfindingsatscreeningmammography

ImagingFindings:Fig.10Axialcomputeraideddetection(A),subtraction(B),andT1

weighted(C)screeningMRimagesshowanirregular2cmmasswithabnormalenhancement

inthemedialaspectoftheleftTRAMflap.Secondlookultrasoundimages(notshown)

depictedasuspiciousirregularhypoechoic solidmass.


Fatnecrosis

Invasive

cancer



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Case10

Teaching

Points:

FatnecrosiscanmimicmalignantgrowthwithvaryingappearancesatMRI.

Suspiciousmorphologicandkineticfeaturesmaybepresent,necessitating

biopsytoexcludeneworrecurrentbreastcancer.

FinalDiagnosis:Invasivecancer

RecurrentbreastcancerinTRAMflapreconstructionsforDCISmaybean

invasivemalignanttumor.

AlthoughTRAMflapreconstructionsareofpredominantfatdensity,

recurrencecanbemissedatmammographicscreeningifthelesionisina

medialandposteriorlocation.

A BCase11

C D

Case11:PalpableLump

BIRADSCode:2

History:42yearoldwomanwithnewpalpableabnormalityoftheleftbreast

ImagingFindings:Fig.11Leftcraniocaudal (A)andmediolateral oblique(B)mammograms

showacircumscribed6.7cmmixeddensityfatcontainingmassintheupperouterquadrant.

Themasscorrespondstothepalpableabnormality.Ultrasoundimages(CandD)showa

circumscribedpredominantlyechogenicmasscorrespondingtothepalpableabnormalityand

mammographicmass.


Fibroadenoma

Galactocele

Hamartoma fibroadenoli oma

A B

Oilcyst,fatnecrosis

C D

Case11

TeachingPoints:

Breasthamartoma,alsoknownasfibroadenolipoma,isarelatively

uncommonbenignlesion.Thelesionscanpresentaspalpableabnormalities

orasincidentalmammographicfindings.

FinalDiagnosis:Hamartoma (fibroadenolipoma)

Hamartomas containthemajorconstituentsofthebreastinanencapsulated

lesion.Mammograms showcircumscribedfatcontaininglesionswitha

capsuleandfibroglandular elements.

Theclassicmammographicappearanceisdiagnosticandobviatesbiopsy.

Ultrasoundshowshamartomas assharplydefinedmasseswithsonolucent

areasandechoproducingstructures.Theyaretypicallyheterogeneous.A

hamartoma withaclosertouniformsonographic appearance,however,is

difficulttodifferentiatefromfibroadenoma.

Case12A B

C

Case12:PalpableLump

BIRADSCode:4A

History:39yearoldwomanwithpossibleincreaseinsizeofpalpableabnormalityinleft

breast

ImagingFindings:Fig.12Leftcraniocaudal (A)andmediolateral oblique(B)mammograms

showacircumscribedhighdensitymassintheposteriorupperinnerquadrant.Ultrasound

image(C)showsacorrespondingcircumscribedovalpredominantlyhypoechoic 2.9cmmass

withassociatedposterioracousticenhancement.


Epidermoid inclusioncyst

Fibroadenoma

A B

Pseudoangiomatous stromalhyperplasia

C



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Case12

TeachingPoints:

Skin

lesions

visible

on

mammograms

can

be

mistaken

for

intramammarylesions.

Skinlesions,whichareraised,firm,andnotcompressibleanddonothavean

airsofttissueinterfacecanprojectasanintramammary masson

FinalDiagnosis:Epidermoid inclusioncyst

mammograms.

Epidermalinclusioncystsarebenignlesions.Theyareoftenpalpablejust

beneaththeskinsurface.

Coreneedlebiopsyofepidermoid inclusioncystsshouldbeavoidedbecause

theneedlecandisplacethelesioncontentsintoadjacentbreasttissue,andan

inflammatoryreactioncanresult.

BA

Case13

DC

Case13:ScreeningMRI,highriskpatient

BIRADSCode:2

History: 37yearoldwomanwithBRCA2mutationundergoinghighriskscreeningbreastMRIafterrecent

negativemammogram

ImagingFindings:Fig.13T1weightedfatsuppressedsubtractionmaximumintensityprojection(MIP)

(A)andaxial(B)MRimagesshowsegmentalreticulardendriticnonmasslike enhancementintheupper

outerquadrantsofbothbreasts.FollowupT1weightedfatsuppressedsubtractionMIP(C)andaxial(D)

MRimages1yearafterAandBshowresolutionofthebilateralenhancement.


Bilateralductalcarcinomainsitu

Bilateralfibrocysticchange

Bilateralnormalbackgroundenhancement

Bilateralsclerosing adenosis

DC

BA

Case13

TeachingPoints:

Backgroundenhancementcanbeminimal,mild,moderate,or

markedandshouldbedescribedintheMRIreport.

FinalDiagnosis:Bilateralnormalbackgroundenhancement

.

Comparedwiththeuntreatedside,itcanbeincreasedintheshort

termanddecreasedinthelongterm.

Backgroundenhancementissensitivetohormonalvariations.

Screeningondays710ofthemenstrualcycleisrecommendedto

decreasebackgroundenhancement.

A B C

Case14

E FD

Case14:RoutineScreening

History:44yearoldwomanundergoingbaselinescreeningmammographywithfamilyhistoryofbreast

cancer(maternalaunt)andcoreneedlebiopsypathologicdiagnosisofradialscar;theradiologicpathologic

correlationandarecommendationmustbemade

ImagingFindings:Fig.14Craniocaudal (A)andmediolateral oblique(B)mammogramsoftherightbreast

showarchitecturaldistortion(arrow)intheupperouterquadrantthatpersistsoncraniocaudal (C)and

mediolateral oblique(D)spotcompressionimages.Targeted ultrasoundimage(E)atthesiteofthe

mammographicabnormalityshowsnormalfindings.Stereotacticbiopsywasperformed.Postprocedure

craniocaudal mammogram(F)showsthebiopsyclipatthesiteofmammographicabnormality.


Concordant;recommend6monthfollowuppostbiopsy mammogram

Concordant;recommendsurgicalconsultationforexcision

Discordant;recommendbreastMRIforfurtherevaluationandmanagement

Discordant;

recommend

surgical

consultation

for

excision

A B C

E FD



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TeachingPoints:

Architecturaldistortionisdescribedasdistortionofthenormalarchitectureofthebreast

withoutadefinite

mass.

This

finding

often

appears

as

thin

lines

or

spiculation radiating

fromapointandfocalretractionordistortionoftheedgeoftheparenchyma.

Truearchitecturaldistortion,confirmedwithdiagnosticmammography,isasuspicious

findin If not definitivel secondar to sur er or trauma architectural distortion re uires

Case14

FinalDiagnosis:Concordant;recommendsurgicalconsultationforexcision

. ,

additionalevaluationwithbiopsyfortissuediagnosis,whetherornotacorrelative

sonographic findingismade.

Percutaneousbiopsyisoftenperformedforevaluationofarchitecturaldistortion.Radial

scarisaconcordant explanationformammographicarchitecturaldistortion;however,

surgicalexcisionoftenisperformedbecauseofunderestimationofmalignancyat

percutaneous coreneedlebiopsy.

Radialscardiagnosedatcoreneedlebiopsyismorelikelytobeupgradedtomalignancyat

surgicalexcisionifthereisassociatedatypia.However,studieshaveshowntheupgrade

rateofradialscarwithoutatypia isgreaterthan2%.Therefore,surgicalexcisionisoften

undertaken.

Case15

A B

DC

Case15:SurveillanceMRI,1yearpostBCT

History:68yearoldwomanundergoingscreeningMRI1yearafterlumpectomy

ImagingFindings:Fig.15Axial(A)andsagittal(B)contrastenhancedT1weightedfat

suppressedbreastMRimagesshowalobulatedmasswithirregularmarginsandrim

enhancement inthelowerouterrightbreast.T1weightedimageobtainedwithoutfat

suppression(C)showthatthecenterofthemasshashighsignalintensitylikethatofthe

surroundingbreastfat.Rightcraniocaudal mammogram(D)showsdystrophic andrim

calcificationssurroundingaradiolucentmassinthelateralbreast.


Fatnecrosis

Mucinouscarcinoma

RimenhancinginflamedcystA

D

B

C

TeachingPoints:

Imagingfindingsofcentraltissuethathasthesamesignal

characteristicsasfatinallsequencessupportthediagnosisoffat

Case15

FinalDiagnosis:FatNecrosis

necros s.

Ahistoryofsurgeryortraumacanbeakeyfactorinmakingthe

diagnosisoffatnecrosis.

Mammographyisacosteffectivemethodofevaluatingforthe

lucency ordystrophiccalcificationsassociatedwithfatnecrosis

suspectedonMRI.

Congratulationstothewinners!

Abike Durojaye

ToddEverett

Luciana

Tajara PhilipMurphy

Sridevi Ratakonda

Thankyou

En o

thelast

session

of

the

course!

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