Antonio Pio MasciotraCampobasso – Molise – Italy

Website www.masciotra.net

YouTube channelhttps://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ

dr. MasciotraCase of the day n.1

06/02/2014

50 years old woman No familiar history for

breast cancer Menarche at age of 14

years 2 normal pregnancies

with 18 monthsoverall breastfeeding

Actually in menopausesince 6 months

This mammography wasdone 1 year ago,considered normal,besides very dense breasttissue

10/02/2015

2 months ago she feltsomething strange,sligthly painful in upperouter quadrant of herleft breast

This mammography hasbeen done today

06/02/2014 10/02/2015

Images of left breastaxillary tail in the 2exams are shown incomparison

The nodule in very densebackground shows anincrease in its density,almost doubling of itsvolume, but it seemsaround 1 cm

Left breast 3D US

Skin and preglandular fat

Glandular tissue

Retroglandular fat tissue

Pectoral muscle and fascia

Cancer

Skin and preglandular fat

Glandular tissue

Retroglandular fat tissue

Pectoral muscle and fascia

Cancer

Left breast 3D US

Right and left axillary tails breast MRI

Right breast MRI

Skin and preglandular fat

Glandular tissue

Retroglandular fat tissue

Pectoral muscle and fascia

Left breast MRI

Skin and preglandular fat

Glandular tissue

Retroglandular fat tissue

Pectoral muscle and fascia

Cancer

First levelintramammary node

At mammography and MRI the cancer seems far from skin and pectoralfascia

3D US give large higher morphological and spatial details, showing thatthe posterior margin of the cancer is at only 1.3 mm from the pectoralfascia

Left axilla

At US the nodule is large wider than inmammography (3 cm vs 1 cm)

At shear wave elastography the stifftissue extends beyond the boundariesof the nodule as seen in bidimensionalimage and the mean stiffness is around100 kPa

At least 2 axillary nodes show marginalnodule deforming the capsula, highlysuggestive for embolic metastasis

At shear wave elastography the stiffnessof the node is homogeneous, with meanvalue of around 16 kPa, large lower thanthe 100 kPa of the primitive cancer

At least 2 axillary nodes show marginalnodule deforming the capsula, highlysuggestive for embolic metastasis

At shear wave elastography the stiffnessof the node is homogeneous, with meanvalue of around 16 kPa, large lower thanthe 100 kPa of the primitive cancer

At Color, Directional Powerdoppler andPowerdoppler Imaging the feedingvessels of the cortical nodule are clearlyshown

Keypoints of the case and ‘take home messages’

One more time high breast density is an absolute risk factor for br. ca. by itself and often hides thecancer

This is the reason why an objective volumetric breast density measurement tool (Volpara) had to beused for the quantification of the breast cancer risk and the best planning of the modalities to beused in the screening of these women (considering the very low sensitivity shown by mammography)by adding volumetric US and/or MRI

One more time the size of a cancer at mammography in dense breast is smaller than the one shownby Bidimensional US (echogenicity based) and by SWE (mechanical properties of tissue based).

SWE shows that the cancer is even larger than in US B-scan and at MRI too (hence the question onwhich one of these modalities is the more 'realistic' to correctly grade the 'T' feature in the TNMstaging).

Very stiff primitive breast cancers not necessarily give stiff axillary nodes mets

Axillary nodes status is possibly best assessed by high quality B-scan and CDI of the nodal vessels(density, morphology, distribution and perhaps spectral analysis of the flow).

Antonio Pio MasciotraCampobasso – Molise – Italy

Website www.masciotra.net

YouTube channelhttps://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ

dr. MasciotraCase of the day n.1

Thanks for your attention