European Journal of Radiology Extra 71 (2009) e19–e22
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A typical invasive ductal carcinoma: Two cases Gokhan Gokalp ∗ , Ugur Topal 1 Department of Radiology, Uludag University Medical Faculty, Gorukle, Bursa, Turkey
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Article history: Received 15 May 2008 Received in revised form 15 August 2008 Accepted 30 January 2009 Keywords: Breast Invasive ductal carcinoma Atypical
a b s t r a c t As invasive breast carcinomas demonstrate various histopathologic characteristics, radiologic appearances are variable. Invasive ductal carcinoma typically manifests as a spiculated or irregular mass or as a new focal asymmetry. Occasionally, lesions present as oval, round shaped or complex cystic masses on mammography and ultrasonography. Doppler ultrasound and MR imaging can aid in diagnosis. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Invasive ductal carcinoma not otherwise specified (IDC-NOS) is the most common type of breast carcinoma [1]. It is generally identified as irregular and spiculated mass or as a new focal asymmetry on mammography and ultrasonography (US). The mass may distort the breast parenchyma and may contain malignant microcalcifications [2–6]. Rarely, it can be round to oval mass with regular or irregular margins although oval and well-circumscribed lesions are extremely rare. This is usually a feature of medullary, tubular or mucinous carcinomas. Invasive carcinomas may contain cystic areas due to the necrosis [7]. It is also a very rare presentation when the cystic component is prominent and contains mural nodules. In this report, two cases of IDC-NOS presented with unusual radiologic findings are discussed with imaging findings. 2. Case 1 A 55-year-old woman with a palpable mass in the left breast was referred to our department for mammography examination. The personal history of the patient was insignificant and she had no family history of the breast cancer. No abnormal finding was reported in her mammograms obtained an year ago. Mammography and US examinations were performed. An ovoid, dense, well-circumscribed with mild lobulations, 40 mm × 25 mm
mass was detected in the upper-outer quadrant of the left breast (Fig. 1A). Power Doppler US examination revealed irregular vascular elements and hypovascularity (Fig. 1B). Negative diastolic flow was observed in the spectral analysis (Fig. 1C). MR imaging was performed in order to demonstrate the presence of additional foci. There was another mass in the same quadrant close to the main lesion. Both lesions showed the similar enhancement characteristics and washout on time-signal curve at the dynamic imaging (Fig. 1D and E). The second lesion was demonstrated in the second-look US examination. Both lesions were sampled with US guided core needle biopsy and histopathologic diagnosis was IDC-NOS. 3. Case 2 A 48-year-old woman was presented with a palpable mass in the left breast. The patient mentioned of fine needle aspiration biopsy of a cystic lesion in the left breast an year ago resulting in hemorrhagic fluid and benign cytology. US examination was performed. A 30 mm × 20 mm, microlobulated complex cystic lesion with mural nodules was seen (Fig. 2A). Power Doppler US showed intense vascularization in the mural nodules with irregular course and characteristics that supported malignancy (Fig. 2B). US guided core needle biopsy of the mural nodules was performed. Histopathologic diagnosis was IDC-NOS (Table 1). 4. Discussion
∗ Corresponding author at: Uludag University Medical Faculty, Department of Radiology, 16059 Gorukle, Bursa, Turkey. Tel.: +90 22429553322; fax: +90 2244428142. E-mail addresses:
[email protected] (G. Gokalp),
[email protected] (U. Topal). 1 el.: +90 22429553323; fax: +90 2244428142. 1571-4675/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2009.01.011
Invasive breast carcinomas are usually discussed into three groups: IDC-NOS (60–80%), invasive lobular carcinoma (15%) and specific type ductal carcinomas (medullary, mucinous, papillary, tubular etc.). Ductal carcinomas arising from terminal ductolobular segments which have no characteristic findings are classified as not
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Fig. 1. 55-year-old woman presented with a palpable mass in the left breast. (A) Ovoid, well-circumscribed mass is seen on mammography. (B) Power Doppler US demonstrates ovoid, well-circumscribed mass with mild lobulation at the posterior margin and scant irregular vascular structures. (C) Negative diastolic flow is seen on spectral imaging. (D and E) MRI shows heterogenous enhancement, washout on time–intensity curve.
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Table 1 Imaging features of the lesions
Mammography
US
PDUS
MR imaging
Case 1
Dense, ovoid, well-circumscribed mass
Hypoechoic, ovoid, well-circumscribed mass with mild lobulations Complex cystic mass with irregular margins and mural nodules
Scant irregular vascular structures, negative diastolic flow Marked vascularization and vessels with irregular course
Heterogenous enhancement, washout on time–intensity curve
Case 2
PDUS: Power Doppler US.
otherwise specified. As invasive breast cancer demonstrates various histopathologic characteristics, radiologic appearances are variable. The anatomic and histologic differences like tumor cellularity, composition of extracellular matrix, fibrous stromal or inflammatory reaction against the lesion, water content, histologic grade, tissue of origin, necrosis and scar formation, extention of DCIS component, the localization and extension of the lesion affect the radiologic appearances. Usually, on mammography, they present as an asymmetric opacity, mass with or without microcalcification or architectural distortion [2,3,8]. IDC-NOS when presenting as a mass without calcification is usually spiculated with ill-defined margins. Rarely, they can be well-circumscribed masses but, indistinct, angular or microlobulated segments of their margins become apparent on spot compression or other modalities like US or MRI [3]. So, further evaluation should be carried out for any circumscribed lesion detected on mammography. Mucinous, medullary or papillary cancers generally present as well-circumscribed lesions. Non-carcinomatous malignancies like phylloides tumor, lymphoma, stromal tumors and metastases can also show well-circumscribed margins [7]. In fact, less than 2% of all well-circumscribed lesions are malignant [9]. Although ultrasonographic features like circumscribed margin, elliptical shape and orientation of long axis parallel to the skin are most likely to predict a benign diagnosis, any solid lesion that manifests after the age of forty is suspicious [10]. In our first case, the lesion had well-circumscribed margin on mammography. It was elliptical in shape and oriented parallel to the skin on US examination. Mild lobulation was noted on US. Our second case presented with a complex cystic mass containing irregular mural nodules. Intracystic mural nodules are generally seen as a part of fibrocystic changes especially apocrine metaplasia. Intracystic carcinomas, comprising less than 1% of breast cancers, are usually papillary carcinomas and rarely might have similar characteristics. High grade, fast growing IDC-NOS can present as complex cystic mass due to central ischemia and necrosis. Necrosis results from scant vascularization at the central portion and
it is generally seen as small cystic areas inside the lesion. Rarely IDC-NOS present as cystic cavities with tumor tissue confined to the periphery of the lesion as a result of acute necrosis. They are round or ovoid, well-circumscribed masses on mammography. Features like thin, echogenic capsule and uniform/smooth attachment of the nodule to the cyst wall support benignity on US examination. Nodules in carcinomas may cause irregularities of the wall and boundaries between the neighbouring structures may be obscured. Echo texture may be heterogenous with irregular borders at the cystic portion [3]. Color or power Doppler US examination can help in the differentiation of benign or malignant lesions according to their vascularization patterns. Hypervascularization, with the branching course and penetration of vessels into the tumor is generally a feature of malignant lesions [11,12]. Negative diastolic flow can also suggest high possibility of malignancy in spectral evaluation [13]. Lack of vascularization when combined with the other radiologic features can support benignity. In the first patient, irregular vascular structures and presence of negative diastolic flow were accepted as clues of malignancy though the lesion was hypovascular on Doppler US imaging. Also in our second patient, hypervascularity and irregular vessels were helpful findings for malignancy in addition to gray-scale US features. MR imaging has been shown to be of value in the determination of local extent of breast cancer, both preoperatively to assess the size of the primary tumor and to identify multifocal and multicentric disease, and postoperatively to identify and quantify residual tumor. In addition, MR imaging can be useful for evaluation of the inconclusive mammography and US examinations [14,15]. Features like irregular border and spiculated margin, washout one time–intensity curve (Type 3 enhancement pattern) and rim enhancement have the highest positive predictive value for malignancy [16–18] in breast MRI. In our first case, washout type time–intensity curve supported malignancy and additional tumor focus with similar enhancement pattern was detected.
Fig. 2. 48-year-old woman presented with a palpable mass in the left breast. (A) Gray-scale US image shows complex cystic mass with mural nodules in the cyst wall. (B) Marked vascularization and vessels with irregular course is seen on power Doppler US image.
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As a conclusion, radiologic features of invasive ductal carcinomas vary due to their different biological and histological properties. They can rarely present as ovoid, well-circumscribed masses with cystic component. Although mammography and US are the primary examinations followed by biopsy in suspicious cases, Doppler US and MRI can give additional diagnostic clues. Conflict of interest None or describe financial interest/arrangement with one or more organizations. There are no conflicts of interest References [1] Kopans DB. Pathologic, mammographic and sonographic correlation. In: Breast imaging. 2nd ed. Philadelphia: Lippincott-Raven; 2004. p. 511–615. [2] Cardenosa G. Malignant lesions. In: Breast imaging. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 239–279. [3] Stavros AT. Malignant Solid Nodules: Specific types. In: Breast ultrasound. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 597–688. [4] Chen SC, Cheung YC, Lo YF, et al. Sonographic differentiation of invasive and intraductal carcinomas of the breast. Br J Radiol 2003;76:600–4. [5] Skaane P, Engedal K. Analysis of sonographic features in the differentiation of fibroadenoma and invasive ductal carcinoma. AJR 1998;170: 109–14.
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