5th July 2021

ICRI CASE OF THE WEEK

Contributed By : Dr Jwala Srikala DMRD, DNB

Senior Consultant Radiologist
Krishna institute of medical sciences, Hyderabad

Copyright of the Case belongs to : Dr Jwala Srikala

History

• 59 year old lady presented with thickening in the outer half of
left breast

• No associated nipple discharge
• No fever

• No family history of breast cancer

Mammogram - CC View

Mammogram MLO View

USG - Upper & Outer Quadrant- Left Breast

What is your Diagnosis?

A) Acute mastitis
B) Chronic mastitis
C) Invasive ductal carcinoma
D) Invasive lobular carcinoma

Answer

D) INVASIVE LOBULAR CARCINOMA

CC & MLO Views
• Diffuse area of asymmetric

interstitial thickening &

architectural distortion in

upper & outer quadrant of

left breast with no discrete

mass or microcalcifications

(Thin arrows)
• A calcified benign lesion –

Hyalinising Fibroadenoma

is also seen (Thick arrow)
• There is diffuse thickening

of skin & subcutaneous

tissues of left breast .

CC & MLO Views
• Diffuse area of asymmetric

interstitial thickening &

architectural distortion in

upper & outer quadrant of

left breast with no discrete

mass or microcalcifications

(Thin arrows)
• A calcified benign lesion –

Hyalinising Fibroadenoma

is also seen (Thick arrow)
• There is diffuse thickening

of skin & subcutaneous

tissues of left breast .

USG – Upper & Outer Quadrant Left Breast

shows an area of heterogenous echotexture with
posterior acoustic shadowing, without an associated
discrete mass

USG guided Core biopsy was performed
from the area of maximal thickening and
altered echotexture, and final histology was

Invasive Lobular Carcinoma(ILC)

PET CT revealed –
Intense uptake in vertebral bodies & pelvic
bones, suggestive of extensive skeletal
metastases.
Only minimal uptake was seen in left breast,
with a metastatic axillary lymph node

PET CT revealed –
Intense uptake in vertebral bodies & pelvic bones, suggestive of extensive skeletal metastases
Only minimal uptake was seen in left breast, with a metastatic axillary lymph node

Discussion -Pathology

• Invasive lobular carcinoma is characterized microscopically by malignant
monomorphic cells that form loosely dispersed linear columns that invade the
normal tissues and encircle ducts. Compare this behavior with that of invasive
carcinoma of no special type (ductal not otherwise specified), which more
commonly presents as a mass with vigorous desmoplastic response. Cells of
invasive lobular carcinoma often preserve the architecture of the ducts, which
limits the sensitivity of detection using mammography

• Loss of E-cadherin is a specific biomarker for invasive lobular carcinoma as
opposed to invasive breast carcinoma of no special type

• The majority of invasive lobular carcinomas are estrogen receptor positive,
progesterone receptor positive and HER2 amplification negative

Discussion- Mammography

• Invasive lobular carcinoma ( ILC) is the 2nd most common type of breast
cancer, accounting for approximately 10%–15% of all invasive breast cancers.

• It is the most frequently missed breast cancer (difficult to detect mammographically).
Higher false-negative rates (up to 19%) are reported for ILC than for other invasive
cancers at mammography.

• Invasive lobular carcinoma is more often multicentric and bilateral (10-15%). Therefore
imaging evaluation of the contralateral breast is crucial. There can be very subtle
changes such as progressive shrinkage, enlargement or reduced compressibility of the
involved breast. Imaging often underestimates the disease. Invasive lobular carcinomas
are more commonly seen on the craniocaudal (CC) view, compared to the mediolateral
oblique (MLO) view.

• 16% of ILC are mammographically occult or benign.

• The sensitivity of mammography for the detection of ILC reportedly ranges between
57% and 81%

Discussion -Mammography

• Architectural distortion is the most common mammographic finding.
• Spiculated mass (16-28%).
• Asymmetry opacity in 8-19%.
• Microcalcifications in 0-24%. Microcalcifications are far less frequently

associated with ILC than with the usual type invasive ductal carcinoma.
• Retraction of skin (25%) and nipple (26%).
• Because of the limitations of mammography in detecting ILC, other

modalities, such as sonography and MR imaging should be used in
evaluating clinically suspicious findings and known cancers to assess the
extent of disease.

Discussion –USG

• US is a valuable adjunct to mammography, with reported sensitivities for the
detection of ILC ranging from 68% to 98%.

• The most common US manifestation of ILC is an irregular or angular mass with
hypoechoic and heterogeneous internal echoes, ill-defined or spiculated margins,
and posterior acoustic shadowing, findings that are seen in 54%–61% of cases.

• Lobular tumors can also manifest merely as an area of posterior acoustic
shadowing, without an associated visibly distinct mass.

• ILC is rarely seen sonographically as a well-circumscribed mass, reported in only
2 to 12 % of lobular tumors. As in mammography, ILC can escape detection on
sonographic interrogation and over 10 % of ILC tumors are sonographically
occult.

Discussion- MRI

• The most common MRI presentation of ILC is that of a mass with irregular or
spiculated margins, followed by a non-mass lesion in 20 to 40 % of cases.

• The distribution of non-mass-like enhancement on MRI is variable, and ILC may
present as ductal, segmental, regional or diffuse patterns.

• Maximum enhancement of ILC is attained at a slower rate than in IDC, but that
peak enhancement is independent of tumor histology. A smaller percentage of
ILC tumors show delayed-phase washout in comparison to IDC.

• Increased sensitivity for ILC, improvement in detection of ipsilateral &
contralateral lesions, and possible reduction of re-excision rates makes MRI an
important tool in combination with mammography and US in the preoperative
assessment of ILC.

References

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