Legacy Good Samaritan Hospital, Portland, OR
Clinical History – 48 year old with a previous negative biopsy of the right breast noted a dimpling near the nipple during self-examination.
Mammogram – No significant change from mammogram two years prior. No mass or spiculated lesion noted at the sight of the subtle dimpling and stable calcifications are noted in the medial aspect.
Ultrasound – A small cyst and a hypoechoic area likely representing scarring from the previous procedure are noted BIRADS 3. Patient is asked to return for a six-month follow up.
Clinical Note – The patient returned eight weeks later reporting increased perception of dimpling. No palpable area is noted in the clinical examination.
Follow-up Ultrasound – Right breast - there is fibrocystic change with a large number of cysts. No discrete mass is found.
BSGI – Left breast – normal uniform distribution. Right breast – a large area of increased uptake in the upper-inner quadrant of the breast, measuring approximately 2 cm. A second, smaller and more intense focus is located retroareolar, measuring about 1 cm at the 6 o'clock position. In addition, there are areas of increased activity in the right axilla which may be nodal activity. Interpretation: Multifocal positive in the right breast and possible positive findings in the right axilla.
Targeted ultrasound and biopsy – Using the BSGI images as a reference, an irregular hypoechoic mass is noted in the 6 o'clock position and is consistent with the focal intensity noted in BSGI. Biopsy of this area is conducted resulting in a diagnosis of ductal carcinoma. In the area of the larger medial focal uptake, fibroglandular tissue with complex cysts are noted, but no mass or other distortion noted.
Breast MRI – There is a noticeable enhancement at the site of known cancer. Other areas of suspicious enhancement are noted. A broad, non-mass-like enhancement of the upper inner quadrant appears to correlate with the abnormal BSGI uptake, but is within normal limits. In addition, two areas of enhancement are seen in the left breast. MRI biopsy of the left breast enhancements showed normal findings.
Pathology – 1.2 cm moderately differentiated ductal carcinoma from the area of known cancer. Additional areas of focal MRI enhancement represent complex cysts and fibrocystic change. There is an area of ductal carcinoma in situ in the location of the 2 cm area of focal uptake in the upper inner quadrant of the BSGI study. 2 cm DCIS and patient axillary nodes were positive.
Clinical Summary – BSGI detected multifocal disease in a patient with a negative clinical examination, mammogram and ultrasound. Pathology revealed DCIS and positive axillary nodes. MRI enhancement in the right breast correlated with the known cancer and the area of intense focal uptake in the BSGI; and in the left breast, BSGI indicated normal uniform distribution while MRI indicated enhancement in an area later confirmed to be negative by pathology.