Antonio Pio MasciotraCampobasso – Molise – Italy

Email

antoniomasciotra@yahoo.it

Website

www.masciotra.net

YouTube Channel

https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ

Sometimes while you're looking for something

you find something different and unexpected…………….

Breast cancer as incidental finding on CT scan of the chest

Clinical Case

74 years old woman undergoingunenhanced CT scan of the chest for the

evaluation of cough ad dyspnea

Incidental finding of a solid mass of about 3 cm in max diameter in herright breast, inhomogeneous with irregular margins and infiltratinggrowth.

Mammography gives the samemorphologic information

(irregular margins and infiltratinggrowth).

US and Shear Wave elastographyparticularly in 3D show the features

of the mass in its morphology, growth pattern (with spiculae) and

mechanical properties. All with a great detail.

We have always to well consider that in SWE images what appears ‘black colored’ is so cause one of 2 possible phenomena : Black area contains fluid in which Shear Waves don’t propagate

(and sometimes the necrotic part of a tumor becomes almost fluid, like the pus in an abscess) Black area contains tissue too stiff generating shear waves so fast that the detection US cannot ‘see’ them

(like an autovelox calibrated to a maximum speed of 200 km/h doesn’t see a car passing at a speed of 300 km/h)

Colorscale 0-180 kPa Colorscale 0-85 kPa Colorscale 0-130 kPaTuned on factory preset Tuned on highest mean value Tuned on highest maximum value

The factory preset of colorscale (0-180 kPa) for breast in my opinion can be misleading cause the eye is conditioned to consider mainly the blue part of the scale, toward an erroneously ‘soft’ judgment.

I think that a better ‘immediate’ perception of the real stiffness in the ROI can be given tuning the colorscale on highest mean value (red image) or on the highest maximum value (green image) of the stiffness.

Another ‘trick’ with equivalent result for the eye could be found in shifting the ‘opacity’ tool to the maximum, like in the different case below.

PHASE ROI 1 ROI 2 ROI 3

Unenhanced 29,0 31,8 33,7

Arterial phase 40,2 41,2 42,8

Late enhancement (6 min) 46,2 46,6 46,5

Then a total body and head CT scan with contrast enhancement was performedfor the staging of the disease.

In comparation to the classic featuresof contrast enhancement pattern and

kinetics in MR study of breastcancer…………………………..

MR contrast enhancement pattern of a breast mass

Homogeneous enhancementis uniform and confluent enhancement throughout the mass

Dark internal septationsrefers to non-enhancing septations in an enhancing mass. These are typical for fibroadenomas, especially when the lesion has smooth or lobulated margins.

Heterogeneous enhancementis nonuniform enhancement, which varies within the mass

Enhancing internal septationsare usually a feature of malignancy.

Rim enhancementis enhancement mainly concentrated at the periphery of the mass. This type of enhancement is frequently a feature of high-grade invasive ductal cancer, fat necrosis, and inflammatory cysts. A lesion with rim enhancement that is not a typical cyst has a 40% chance of malignancy.

Central enhancementis pronounced enhancement of a nidus within an enhancing mass. Central enhancement has been associated with high-grade ductal cancer. Central enhancement has been associated with high-grade ductal cancer.

MR non-mass contrast enhancement

Non-mass enhancement is enhancement without three-dimensional characteristics.It is important because it occurs in a significant number of cancers.You need to look at its distribution, its enhancement pattern and its symmetry or asymmetry.The table on the left summarizes the terms used to describe the distribution of non-mass enhancement in the breast.

Temporal Resolution - Kinetic Analysis (Curves)

Type 1On the image on the left is a type 1 curve.There is a slow rise and a continued rise with time.A lesion with a type 1 curve has a chance of 6% of being malignant.

Type 2Then there is the type 2 curve, which is in the middle: a slow or rapid initial rise followed by a plateau in the delayed phase, which is allowed a variance of 10% up or down.The chance of a lesion with a type 2 curve being malignant lies somewhere between the 6% of the type 1 curve and the 29-77% of the type 3 curve.Many physicians will biopsy lesions with type 2 curves.

Type 3The type 3 curve shows a rapid initial rise, followed by a drop-off with time (washout) in the delayed phase.A lesion with this type of curve is malignant in 29-77%.

PHASE ROI 1 ROI 2 ROI 3

Unenhanced

29,0 31,8 33,7

Arterial phase

40,2 41,2 42,8

Late enhancement (6 min)

46,2 46,6 46,5

0 min 2 min 6 min

ROI 1 29,0 40,2 46,2

ROI 2 31,8 41,2 46,6

ROI 3 33,7 42,8 46,5

0,05,0

10,015,020,025,030,035,040,045,050,0

HU

Breast cancer CT contrast enhancement pattern

Compared to MR CE kinetics curve, the CT CE of this case would be intermediate between Type 1 and Type 2 (relatively not indicative of malignancydespite all clear morphologic features).

In this case also the density increment (onlyabout 17 HU) is relatively not indicative of malignancy and closer to the one more typical of benign lesions (11-24 HU) than to the one more typical of DCIS (56-62 HU) or IDC (52-60 HU).

But total body CT shows the presence of an endometrial cancer too (a well known possible concurrent disease)

Main features of malignancies found in CT scan of the chest

• The largely most prevalent malignancies are female primitive breast cancers, although it’s important to take in account that breasts could be the site of metastasis, of lymphomas and of primitive cancer in males too

• The overall prevalence of incidentally CT detected breast malignancies varies from 1% to 2%

• The detectability of malignancies at CT like in mammography also in CT is conditioned by the background density of the surrounding parenchima

• So it’s easier to detect it in adipose background while in dense fibroglandularbackground malignancies can be detected only at contrast enhanced scans and often share the pattern of non-mass-like-enhancement well known in breast MR

Galileo Galilei

"Any problem that wantsto be solved

starts with curiosity."

"Knowing is not enough, we must apply.

Willing is not enough, we must do."

Johann Wolfgang von Goethe

Antonio Pio MasciotraCampobasso – Molise – Italy

Email

antoniomasciotra@yahoo.it

Website

www.masciotra.net

YouTube Channel

https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ

Breast cancer as incidental finding on CT scan of the chest

Sometimes while you're looking for something

you can find something different and

unexpected…………….

But remember that your eyes can detect it only

if your mind is trained to search for it!