The Role of Preoperative MRI in Patients With Invasive Lobular Carcinoma

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The Role of Preoperative MRI in Patients With
Invasive Lobular Carcinoma
Golan.O, Sperber.F, Shalmon.A, Weinstein.I,
Gat.A Breast Imaging Department Tel-Aviv Medical
Center
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Invasive lobular carcinoma (ILC) was first
described in 1946 by Foote and Stewart. ILC
accounts for 5-14 of breast malignancies. Diagno
stically ILC is challenging because of its veiled
presentation on clinical examination and on
imaging.
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Histology ILC spreads through the breast
parenchyma by means of diffuse infiltration of
single rows of malignant cells in a linear
fashion (Indian-file pattern) around
nonneopolastic ducts. Little disruption of the
underlying anatomic structures, Little
surrounding connective tissue reaction
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Invasive lobular carcinoma (ILC) of the breast is
known to be substantially underestimated by
mammography
Because ILC frequently does not form a
demonstrable mass or distort the architecture or
commonly produce calcifications, and is
frequently isodense with normal tissue, it is not
unusual for ILC to go undetected on sequential
mammograms until it becomes clinically evident.
False negative 3-16
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Mammographic Characteristics of ILC (Ellen
B.Mendelson et al AJR)
Asymmetric density without definable margins. A
Mass with spiculated margins. No tumor
discernible by mammography especially in dense
breast tissue . Microcalcifications
(rare)
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Ultrasound Appearance
ILC cannot be distinguished from ductal carcinoma
by ultrasound. Hypoechoic tissue is seen with
varying degrees of posterior enhancement. In
their retrospective review, Selinko et al found
that ILC lesions were more easily seen on
ultrasound than mammography.
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Measurement of tumor size plays a pivotal role in
treatment planning of breast cancer
Breast conserving surgery VS Mastectomy Neoadjuva
nt chemotherapy ?
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Objective To evaluate MRI ability to determine
the extent of ILC compared to mammography and
ultrasound, and to determine if ILC, as depicted
on MRI, correlated with histopathological
findings.
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Materials and methods

• Retrospective study of 22 patients with biopsy
  proven ILC who underwent MRI (7/2005-9/2007)
• Age 32-67 years (median 50 )

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MRI technique MRI was performed using 1.5T magnet
(signa GE) using 4 channels breast coil Imaging
protocol Bilateral parallel imaging T2 weighted
sagittal fat suppressed T1 weighted dynamic
sagittal fat suppressed 3D FSPGR before and
following contrast Subtraction, curves of
enhancement and MIP. Typical section thickness
2-2.5 mm
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Results
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Mammographic findings Mass 55 Asymmetrical
density 27 Calcifications 9 No mammographic
findings 9
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Mammographic /ultrasound correlation

• No mammographic finding-multifocal irregular
  solid masses bilateral.
• Masses on mammography- irregular solid masses on
  US on 33 multifocal (versus 17 on mammography).
  
• Asymmetrical density on mammography- irregular
  solid masses on US.
• Calcifications on mammography- multifocal
  irregular solid masses on US .

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MRI findings Pattern of enhancement Masses
91 Focal irregular enhancement with no dominant
mass 9 . In 27 irregular ductal enhancement
was also present.
73 irregular spiculated 18 mass with irregular
thick ring enhancement

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Size The median diameter of the dominant mass
on MRI was 5.6cm (2.2-9cm) versus 2.7 cm
(1.7-5.3cm) on US and 2.5 cm (2-5cm) on
mammography.
Extension of the disease In 64 more than one
mass versus 54 on US and 17 on mammography
3 multifocal
4 multifocal multicentric
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MRI findings Curves of enhancement A strong and
fast enhancement with washout 45 A more benign
curve 55 (speed, intensity, washout)
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Pathologic correlation

• 27 had a mastectomy the tumor size and the
  extent of the disease was much bigger than those
  we saw on mammography and US and had a good
  correlation with MRI findings.
• 73 were operated after neoadjuvant chemotherapy
  (3 mastectomy) better correlation to the MRI
  than mammography and us.

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54 years old who presented with a palpable mass
on the right (UOQ) breast
RT
LT
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RT
RT
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LT
LT
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42 years old who presented with a palpable mass
on the right (uoq) breast
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45 years old who presented with a palpable mass
on the right (uoq) breast. BRCA carrier.
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MIP
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43 years old who presented with a palpable mass
on the right (uoq) breast
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MIP
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Conclusions
Invasive lobular carcinoma is the second most
frequent invasive breast cancer. It is unusually
discovered on screening mammography and the
presenting symptom is commonly a palpable
mass. Mammography is disappointing with a high
rate of false negative. US improves the imaging
of ILC but still does not show the full extent of
the disease. MRI provides the most accurate
estimation of tumor size and the extent of the
disease, commonly showing us a multifocal disease
which is underestimated by the conventional
methods. MRI often modify the therapeutic
strategy ruling out conservative procedures.
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MRI of the breast should be considered as a
preoperative routine patients diagnosed with
Invasive lobular carcinoma.
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