Radiological imaging of malignant breast diseases.

Dr/ ABD ALLAH NAZEER. MD.

Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of cancer cells that can grow into (invade) surrounding tissues or spread(metastasize) to distant areas of the body. The disease occurs almost entirely in women, but men can get it, too.

Breast cancer.

Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.

The lymph (lymphatic) system of the breast.

Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes inside the chest (internalmammary nodes) and those either above or below the collarbone (supraclavicular or infra-clavicular nodes).

Carcinoma:This is a term used to describe a cancer that begins in the lining layer (epithelial cells) of organs like the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).Adenocarcinoma:An adenocarcinoma is a type of carcinoma that starts in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissues (they make breast milk), so cancers starting in these areas are often called adenocarcinomas.Carcinoma in situ:This term is used for an early stage of cancer, when it is confined to the layer of cells where it began. In breast cancer, in situ means that the cancer cells remain confined to ducts (ductal carcinoma in situ). The cells have not grown into (invaded) deeper tissues in the breast or spread to other organs in the body. Ductal carcinoma in situ of the breast is sometimes referred to as non-invasive or pre-invasive breast cancer because it might develop into an invasive breast cancer if left untreated.

When cancer cells are confined to the lobules it is called lobular carcinoma in situ. This is not actually a true cancer or pre-cancer, and is discussed more in the section, “What are the risk factors for breast cancer?”Invasive (infiltrating) carcinoma:An invasive cancer is one that has already grown beyond the layer of cells where it started (as opposed to carcinoma in situ). Most breast cancers are invasive carcinomas—either invasive ductal carcinoma or invasive lobular carcinoma.Sarcoma (Fibrosarcoma, liposarcoma, leiomyosarcoma and malignant fibrous histiocytoma):Sarcomas are cancers that start in connective tissues such as muscle tissue, fat tissue, or blood vessels. Sarcomas of the breast are rare.Paget disease of the nipple(1%):Rare manifestation of breast cancer.Primary carcinoma of mammary duct that invaded the skin.Chronic eczematoid lesion of the nipple.It present with erythematous eruption and purities.

Breast lymphoma.Breast lymphomas can be either primary or secondary. Both are rare accounting for 0.3 - 1.1 % of all breast malignancies.Primary lymphoma of the breast is less common than secondary lymphoma, and is typically a B cell type of non-Hodgkin's lymphoma (NHL). Primary non-Hodgkin’s lymphoma of the breast represent only about 0.12 - 0.53% of all reported malignant breast tumors.Secondary lymphoma of the breast, is also more frequently NHL than Hodgkin's lymphoma. The axillary nodes are often large. It may present either as a palpable mass or as diffuse thickening of the breast.

Inflammatory carcinoma of the breast(1.5-3%).

Inflammatory carcinoma of the breast (or inflammatory breast cancer - IBC) is a relatively uncommon but aggressive form of invasive breast carcinoma which has a characteristic clinical presentation and unique radiographic appearances. Any pathological sub-type of breast cancer may be involved .

Non-invasive carcinoma:(10%).1- Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is considered noninvasive or pre-invasive breast cancer. DCIS means that cells that lined the ducts have changed to look like cancer cells. The difference between DCIS and invasive cancer is that the cells have not spread (invaded) through the walls of the ducts into the surrounding breast tissue. DCIS is considered a pre-cancer because some cases can go on to become invasive cancers. Right now, though, there is no good way to know for certain which cases will go on to become invasive cancers and which ones won’t. About 1 in 5 new breast cancer cases will be DCIS. Nearly all women diagnosed at this early stage of breast cancer can be cured.

2- Lobular carcinoma in situ.This is not a true cancer or pre-cancer, and is discussed in the section “What are the risk factors for breast cancer?”3- Paget's disease.

Invasive breast carcinoma(85%, 5%-year survival rate).There are some special types of breast cancer that are sub-types of invasive carcinoma.These are often named after features seen when they are viewed under the microscope, like the ways the cells are arranged.Some of these may have a better prognosis than standard infiltrating ductal carcinoma.These include:· Adenoid cystic (or adenocystic) carcinoma· Low-grade adenosquamous carcinoma (this is a type of metaplastic carcinoma)· Medullary carcinoma(4%).· Mucinous (or colloid) carcinoma(3%).· Papillary carcinoma(2%).· Tubular carcinoma(2%).Some sub-types have the same or maybe worse prognosis than standard infiltrating ductal carcinoma. These include:· Metaplastic carcinoma (most types, including spindle cell and squamous)· Micropapillary carcinoma· Mixed carcinoma (has features of both invasive ductal and lobular).

Ductal Carcinoma in Situ.Seen as microcalcifications on mammogramConfined to ductal cells.No invasion of the underlying basement membrane.Chance of recurrence 25-50% in 5 years, of these 50% will be invasive

Ductal carcinoma in-situ (DCIS).

Ductal carcinoma in-situ (DCIS) with enlarged axillary lymph nodes.

Comparison of ss-DWI and rs-DWI in a 40-year-old woman with DCIS. Significantly stronger geometric distortion, image blurring and ghosting artifacts can be seen on ss-FDWI (a) compared with rs-FDWI (b). Rs-FDWI (b) also provides significantly higher anatomic detail than ss-FDWI (a) because of reduced T2* blurring. Arrows=DCIS

DCIS. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal linear nonmasslike high signal intensity in the medial lower quadrant of left breast (arrows). DCE-MRI (e) shows linear nonmasslike enhancement. Significantly stronger geometric distortion, image blurring and ghosting artifacts (arrowheads) can be seen on ss-DWI (a) and ss-FDWI (c). Rs-DWI (b) and rs-FDWI (d) show higher anatomic detail similar to DCE-MRI because of reduced T2* blurring

Lobular Carcinoma in Situ.Not detectable on mammographyMost commonly found incidentallyRisk of invasive breast cancer in 20 years is 15-20% bilaterally.

Invasive lobular carcinoma with lobular carcinoma in situ.

Paget’s Disease.UncommonUsually involves the nippleHistologically, vacuolated cells are seen in the epidermis of the nipple and result in an eczematous dermatitis of the nipple.It is generally associated with an underlying intraductal or invasive carcinoma.

Mammography should be performedAbout 30% of patients have axillary node metastasis at diagnosis.Mastectomy is the standard of treatment

80% have a 10 year survival rate if there is no mass present and no axillary nodes are involved.

Paget’s disease of the nipple.

Paget’s disease of the nipple.

Invasive breast cancer is cancer that spreads outside the membrane of the lobule or duct into the breast tissue. The cancer can then spread into the lymph nodes in the armpit or beyond.When breast cancer cells are found in other parts of the body, the cancer is called metastatic breast cancer.The two most common types of invasive breast cancer include:Invasive ductal carcinoma (IDC). With IDC, cancer cells start in a milk duct, break through the duct walls, and then invade fatty breast tissue. IDC can remain localized, which means it stays near the site where the tumor originated. Or the cancer cells may enter the bloodstream or lymphatic system and metastasize -- spread -- anywhere in the body. Invasive ductal carcinoma is the most common type of invasive breast cancer. It accounts for 80% of invasive cancers.lobular carcinoma (ILC). This cancer accounts for about 10% to 15% of Infiltrating (invasive) invasive breast cancers. ILC starts in the lobules or milk glands. It then spreads in a way similar to IDC. With ILC, most women feel a mass or thickening instead of a breast lump.There are mixed types of IDC and ILC and other less common types of invasive breast cancer.

T1, axial, postcontrast source (non-subtracted) images were obtained at 3T with 75-second temporal resolution (every second slice through lesion shown). The irregular mass shows classic rim enhancement and a signal void is noted (arrow), placed at the time of prior percutaneous needle core biopsy. The irregular shape and rim enhancement are characteristic of malignancy -- in this case, a high-grade invasive ductal cancer (IDC), triple-negative subtype.

High-grade intra-ductal carcinoma(IDC).

Irregular shaped hyperdense mass with spiculated margin in Rt. UOQ. (arrow) US: About 1.7cm sized microlobulated round mass is seen in Rt. breast 11o’clock direction, 5cm from nipple. MRI : Irregular margined and shaped mass (arrowhead) is seen in Rt. LIQ, about 2.2cm in maximal diameter. On dynamic study, the mass shows steady enhancement.

Left breast ILC. (a) This lesion as irregular margins and low signal intensity on axial T2-weighted images (arrow), and (b) show enhancement on axial dynamic studies. (c) In Diffusion weighted sequence (b=1000), water restriction produces hyperintensity in the tumor area , matching the low signal in the ADC map (d).

On MRI, the ILC corresponds to a mass with irregular margins and low signal intensity septa on axial T2-weighted images (arrows), (b) showing enhancement on axial dynamic studies and (c) axial subtraction images

On MRI, the ILC corresponds to a mass with irregular margins and low signal intensity septa on axial T2-weighted images and enhancement on axial dynamic studies .

Invasive ductal carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal high signal intensity mass (arrows) without intraductal spread in the lateral portion of right breast. DCE-MRI (e) shows masslike enhancement with heterogeneous internal enhancement and smooth margin. Significantly stronger geometric distortion, image blurring and ghosting artifacts (arrowheads) can be seen on ss-DWI (a) and ss-FDWI(c) compared with rs-DWI (b) and rs-FDWI (d). Rs-DWI (b) and rs-FDWI (d) provide significantly higher anatomic detail than ss-DWI and FDWI because of reduced T2* blurring.

Invasive ductal carcinoma of bilateral breasts in a 52-year-old woman. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal an irregular high signal intensity mass (arrows) in the lateral portion of left breast and a minimally irregular high signal intensity mass (arrowheads). DCE-MRI (e) shows the irregular enhancing mass in the left breast (arrow) and the minimally irregular enhanced mass in right breast (arrowhead) . Rs-DWI (b) and rs-FDWI (d) provide significantly higher anatomic detail than ss-DWI (a) and ss-FDWI (c) because of reduced T2* blurring. However, signal intensity of right breast lesion on ss-DWI (a) and ss-FDWI (c) is higher than that of left breast on rs-DWI (b) and rs-FDWI (d).

Invasive lobular carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c) and rs-FDWI (d) reveal segmental nonmasslike high signal intensity in the central portion of right breast. DCE-MRI (e) shows segmental nonmasslike enhancement. Rs-DWI (b) and rs-FDWI (d) show significantly higher anatomic detail than ss-DWI (a) and ss-FDWI (c) because of reduced T2* blurring

Right (a) CC (craniocaudal) and (b) MLO (mediolateral oblique) views show at 12 o’clock, a low-density circumbscribed mass with irregular margins (arrows). (c) On US scan this mass show heterogeneous echogenicity and posterior acoustic enhancement. Core needle biopsy revealed a mucinous carcinoma.

Right breast mucinous carcinoma. (a) This lesion has high signal intensity on axial T2-weighted images (ellipse), and show progressive enhancement on (b) axial dynamic studies and on (c) axial and (d) sagittal subtraction images.

Mucinous carcinoma. Ss-DWI (a), rs-DWI (b), ss-FDWI (c), rs-FDWI (d) and STIR (e) reveal marginal high signal intensity mass (arrows) in the lateral portion of right breast. DCE-MRI (f) shows marginal enhancement with heterogeneous internal enhancement (arrow). Significantly stronger geometric distortion and image blurring can be seen on ss-DWI (a) and ss-FDWI(c) compared with rs-DWI(b) and rs-FDWI (d) . Rs-DWI (b) and rs-FDWI (d) provide significantly higher anatomic detail than ss-DWI (a) and ss-FDWI (c) because of reduced T2* blurring. However, incomplete fat suppression can be seen on rs-DWI(b) and rs-FDWI (d) (arrowhead).

Invasive lobular carcinoma of the breast.

Invasive lobular carcinoma of the breast.

Two cases of invasive lobular carcinoma

Invasive lobular carcinoma

Left (a) CC and (b) MLO mammographic views show a large and relatively circumscribed ovalar lesion in the upper outer quadrant, with high-density. (c) On US scan it consists on a complex cyst (*) with a parietal ill-defined mass (arrows). US-guided core needle biopsy of the intracystic mass revealed a malignant phyllodes tumor.

Mammographic MLO projection shows a large irregular mass in the superior right breast (arrow) and enlarged axillary lymph nodes. This mass is also seen on the sagittal contrast-enhanced MR image (arrow) and on the axial angiomap (arrow). Contrast enhancement is also evident in the chest wall muscles shown on the sagittal MR image (circle) and the axial angiomap (circle), indicating chest wall invasion. Muscle or chest wall enhancement is indicative of invasion

The images above are from a recent breast MRI patient that detail a cancerous lesion in the left breast. The graph to the right is called a washin/washout curve. When it spikes rapidly, this generally indicates cancer.

Inflammatory breast carcinoma (IBC), a rare and aggressive form of breast cancer, has an incidence in the United States of between 1% and 6% . Primary IBC is characterized by the rapid development of aggressive inflammatory skin changes and tumor growth in a previously healthy breast. The clinical presentation of IBC is predominantly defined by the inflammatory component and has been extensively described. The diagnostic criteria for IBC as defined by the American Joint Committee on Cancer include nonspecific findings of diffuse erythema, edema, or peau d’orange changes in the breast, frequently without an underlying palpable mass or primary breast lesion identified by imaging and with the biopsy diagnosis of invasive cancer. The most characteristic pathologic feature of tumor emboli within dermal lymphatic vessels is not always detected on skin biopsy.

Right inflammatory breast carcinoma. Axial contrast-enhanced T1-weighted VIBRANT MP (GE Healthcare) (top) and subtraction (bottom) images show enlarged right breast with global skin thickening and asymmetric diffuse non mass like parenchymal enhancement (arrows).

Inflammatory breast carcinoma. Sagittal unenhanced T2-weighted image with fat suppression shows hyperintensity of breast parenchyma and chest wall (arrows) as a result of diffuse tissue edema.

Inflammatory breast carcinoma. Sagittal contrast-enhanced T1-weighted VIBRANT MP image shows enhancing lesions (arrows) within thickened skin. Time–signal intensity curve shows delayed persistent enhancement of skin lesion on delayed phase.

Inflammatory breast carcinoma and locoregional metastatic adenopathy. A, Sagittal maximum-intensity-projection image of left breast after IV contrast administration shows multiple heterogeneous enhancing breast masses (long arrows) and enlarged left axillary lymph node (short arrow). B, Left lateromedial mammogram shows neither mass nor architectural distortion. C, Extended-FOV ultrasound image shows multiple hypoechoic masses (long arrows) and marked overlying subcutaneous edema (short arrows).

Inflammatory breast carcinoma. Sagittal contrast-enhanced T1-weighted VIBRANT image shows mass lesion (arrows) with irregular shape, spiculated margins, and heterogeneous internal enhancement.

Colloid carcinoma.

Sarcoma with osseous differentiation.

Metaplastic carcinoma .

Breast lymphoma.Breast lymphomas can be either primary or secondary. Both are rare accounting for 0.3 - 1.1 % of all breast malignancies.Primary lymphoma of the breast is less common than secondary lymphoma, and is typically a B cell type of non-Hodgkin's lymphoma (NHL). Primary non-Hodgkin’s lymphoma of the breast represent only about 0.12 - 0.53% of all reported malignant breast tumors.For a tumour to be labeled as a primary breast lymphoma it is required to fulfill the following criteria :disease should be in the breast or in close proximity to breast tissueno evidence of widespread disease should be thereno previous history of lymphoma ipsilateral lymph nodes may be involved if developing simultaneously with primary breast tumor.Secondary lymphoma of the breast, is also more frequently NHL than Hodgkin's lymphoma. The axillary nodes are often large. It may present either as a palpable mass or as diffuse thickening of the breast.

Core biopsy shows diffuse large B-cell lymphoma of right breast.

Lymphoma of Both breast

HIV infection with bilateral breast lymphoma.

Metastatic Neuroendocrine carcinoma to the breast

Metastases to the breast.

Metastases to the breast from non-mammary primary tumours are uncommon and account for 0.5-2.0% of all breast malignancies.

Primary sites:The most frequent source of a metastatic breast lesion is the contralateral breast .The most common extra-mammary cancers that metastasise to breast are:lymphoma / leukaemia: most common extra mammary source.melanomasarcomasprostate cancer: considered on the most frequent primary sites in men.lung cancergastric cancerovarian cancerrenal cell cancer

Metastatic cervical carcinoma.

Metastatic Malignant melanoma to the breast

Metastatic Non-Hogkin Lymphoma to the breast.

Metastatic Rhabdomyosarcoma to the breast.

Metastatic Multiple Myeloma to the breast.

Monitoring of Neoadjuvant Chemotherapy by MR Spectroscopy.

pre- and post-chemotherapy MRI appearance of breast cancer in a patient who had complete response to therapy.

Pet scan showing breast cancer )(red arrows)

Thank You.