Breast Carcinoma

History:

28 year old female with a lump in the breast.

Studies:

Mammogram

Ultrasound breast

Findings and interpretation:

Mammograms:

• The breast tissue shows extremely dense fibro-glandular parenchyma.
• There is a spiculated lesion with grouped punctate and pleomorphic microcalcifications in the lateral and upper quadrant of the right breast.

MRI:

• In the right breast at the 10 o’clock position, there is an ill-defined and spiculated lesion showing iso-intense T1 and hyper-intense T2 signal.
• The lesion shows a central focus of signal void; this corresponds to a foreign body / biopsy marker.
• The lesion is hyperintense on the DWI images with corresponding low ADC values indicating restricted diffusion.
• On the dynamic contrast enhanced images, the lesion shows rapid early contrast enhancement, followed by retention of contrast in a plateau (type II) pattern.
• The enhancement appears somewhat linear, which is suggestive of infiltration along the ducts.

Incidental findings:

• In the upper, inner quadrant of the right breast, there is a well defined mass, showing hyper-intense T2 signal and progressive enhancement on the dynamic contrast enhanced images (type I pattern), likely representing a benign lesion. This is suggestive of a fibro-adenoma.

Pertinent negative findings:

• There are no axillary lymph nodes detected on mammography / MRI.

A lesion is detected on mammography with findings highly suspicious for breast carcinoma (M5). The MRI findings show a mass with features and an enhancement pattern highly suspicious for invasive ductal carcinoma.

Principal diagnosis:

M5 right breast lesion, likely invasive ductal carcinoma.

Differential diagnosis:

• Benign lesion such as fibroadenoma (this is extremely unlikely given the radiological findings).

Management:

Perform US of the breast and core biopsy if not already performed. If biopsy was already performed, check histopathology report.

Refer for breast MDT to discuss further management.

Findings and interpretation:

• There are two large smoothly thick walled pelvic cysts; the larger superior one is arising from the right adnexa and the smaller inferior one is arising from the left adnexa.
• The left adnexal cyst is hyperintense on the T1 fatsat images and hypointense on the T2 images.
• The right adnexal cyst shows normal fluid signal intensity, yet contains dependent debris that is hyperintense on the T1 images and hypointense on the T2 images.
• Uniform and mild enhancement of the walls of both cysts with no enhancing internal nodules or masses.
• There is bilateral hydronephrosis, caused by obstruction of the ureters by the pelvic cysts.

Pertinent negative findings:

• There is no evidence of a neoplastic soft tissue component.

There are bilateral cystic adnexal lesions containing blood products.

Principal diagnosis:

Bilateral (kissing) endometriomas

Differential diagnosis:

• Haemorrhagic cysts

Management:

Alert referring physician of findings.  

Recommend urology consultation with regards to obstructive hydronephrosis.

Recommend referral to gynaecology MDT to discuss further management (medical vs. surgical).

Findings and interpretation:

Chest radiograph:

• There is mediastinal and hilar lymph node enlargement.
• There are bilateral reticular opacities in the lungs with a midzone distribution.

HRCT:

• There are enlarged mediastinal and bilateral hilar lymph nodes, some of which show coarse calcifications.
• There is bilateral, perilymphatic reticulo-nodular thickening, with nodular thickening of the fissures and the interlobular septae.
• There are scattered nodules throughout both lungs, with a predominantly upper lung zone distributions.
• There are enlarged coeliac group lymph nodes.

Pertinent negative findings:

• There is no lung mass.
• No evidence of significant lung fibrosis / volume loss.

The findings represent a chronic, interstitial lung disease. The lymph node enlargement and calcification is likely granulomatous in nature.

Principal diagnosis:

Pulmonary sarcoidosis

Differential diagnosis:

• Lymphangitis carcinomatosis (the lymph nodes would not be calcified, and there is no history / evidence of a primary cancer)

Management:

Recommend tissue biopsy for histological diagnosis. The optimal method in this case would be endobronchial biopsy.

Recommend discussion at pulmonary MDT regarding further management / follow up imaging.

Findings and interpretation:

• There is a sub-hepatic hyperdense fluid collection within a large amount of ascites. There is also a pericardial effusion and right pleural effusion.
• The liver has irregular margins and heterogeneous appearance with multiple parenchymal lesions. These lesions are hyper-enhancing on the arterial phase and show contrast washout on the portal venous phase.
• The large lesion in segment VI of the liver has an irregular margin with rupture beyond the liver capsule.

Incidental findings:

• Right pleural effusion, cardiomegaly and left renal cyst.

The findings are characteristic of liver cirrhosis with multiple malignant parenchymal lesions representing hepatomas, one of which has ruptured beyond the liver capsule with active haemorrhage into a large volume of ascites.

Principal diagnosis:

Multifocal hepatocellular carcinoma with an active haemorrhage from one of the hepatomas in segment VI

Differential diagnosis:

None

Management:

Urgently contact referring physician and inform of findings.

Contact interventional radiologist for endovascular embolisation of the bleeding ruptured hepatoma.

Findings and interpretation:

• There are two focal, well defined, hypodense liver lesions, one in segment 7 and the other in segment 6, showing heterogeneous contrast enhancement.
• There is an enlarged right iliac fossa lymph node, immediately adjacent to and abutting the ileocecal junction, which contains punctate calcifications and shows avid contrast enhancement on the arterial phase. It has a surrounding mesenteric desmoplastic reaction.
• The terminal ileum appears focally thickened with avid arterial contrast enhancement.

Pertinent negative findings:

• There are no suspicious bony lesions to suggest bony metastases

The findings represent a malignancy in the right iliac fossa with spread to a local lymph node, as well as to the liver. This is most likely neuro-endocrine based on the imaging characteristics.

Principal diagnosis:

Metastatic carcinoid tumour of the terminal ileum

Differential diagnosis:

• Sclerosing mesenteritis (would not produce liver lesions; however, the liver lesions may represent unrelated pathology)
• Small bowel carcinoma (causes luminal obstruction and the mass is hypovascular)

Management:

Alert referring physician of findings.

Recommend In-111 octreotide scan / I-123 labelled MIBG scan, and image guided biopsy of one of the liver lesions.  

Correlate with chromogranin A and 5HIAA levels. 

Recommend discussion at surgical MDT to discuss possibility of resection.

Findings and interpretation:

• The ACL (anterior cruciate ligament) fibres are not visualised; there is heterogeneous high signal (T2 and STIR) in the expected location of the ACL.
• There is a supra-patellar knee joint effusion.
• The medial meniscus appears truncated on the coronal images; the bowtie appearance of the meniscus is not seen on the sagittal images. There is displacement of a medial fragment of the meniscus into the intercondylar notch.
• On the T1 images, there is signal hypointensity in the medial aspect of the medial tibial plateau, indicating oedema of the marrow.

Pertinent negative findings:

• The posterior cruciate, as well as medial and lateral collateral ligaments are intact.
• The lateral meniscus is intact.
• No bony fractures.

There is complete rupture of the ACL, as well as a bucket handle tear of the medial meniscus.  

Principal diagnosis:

Traumatic knee injury

Differential diagnosis:

None

Management:

Alert referring physician and recommend orthopaedic referral.