劉佩芳(英文)：不可觸及的癌癥最初僅通過MRI檢測：綜合評估和解決方案

Non-palpable

Breast

Cancer

Initiallyonly

detected

by

MRI：comprehensiveevaluationandsolutions

TianjinMedicalUniversityCancerInstitute&HospitalPeifang

Liu,MD

MammographyUltrasoundMRI……PET-CTprimaryimagingmodalitiesforscreeningandevaluationofbreastlesion-nothingisabsolutelydiagnostic

Adjunctiveandsupplementalmodalities-尺有所短，寸有所長

!!!Overthepastfewyearsvariousimagingmodalitieshavebeenexploredwithregardtotheirabilitytodetectandcharacterizebreastcancer,including:Mammography：Morphology

(density

difference

between

lesions

and

glandular

tissue)Ultrasound：B-mode（Morphology）

Color

Doppler

Volume

imaging

Elastography

Contrast-enhanced

sonographyMRI：plain

scan

DCE（dynamiccontrast-enhancedMRI）

DWI

MRSPET-CT：combination

anatomical

with

functional

imaging

18F-FDG、estrogenreceptorimagingagent（18F-FES，18F-17β-estrogen）Morphology

+

FunctionFunctionalimagingcan

find

lesions

earlyand

accurately

beforemorphologicalchanges

of

lesions脂肪瘤纖維腺瘤乳腺癌超聲彈性成像技術(shù)乳腺浸潤性導(dǎo)管癌伴多發(fā)淋巴結(jié)轉(zhuǎn)移

“4

key

points”of

imaging

for

surgeon

Diagnostic

principle-尺有所短，寸有所長

!!!Positioning,qualitative,quantitative,staging

BI-RADS5,BI-RADS4C,BI-RADS4B,BI-RADS4A,……Doing

the

4

key

points

should

fully

understand

advantages

and

disadvantages

of

each

imaging

modalities!!!（1）confirm （2）not

sure（3）confirm

partly，and

make

a

suggestion

for

furtherprocessing

AdvantagesofMRIAdvantagesofMRIThe

high

resolution

for

soft

tissue

No

radiationMulti-sequence

imagingMulti-direction

imaging……The

highest

diagnostic

accuracy

of

breast

cancerFor

diagnostic

sensitivity,specificity

and

accuracy

of

breast

lesions,MRI

is

superior

to

mammography

and

ultrasoundThe

suspicious

lesions

detected

only

by

MRI

(prone),not

palpable,

and

negative

on

MG

and

US,

how

to

being

precise

position

in

clinical

biopsy

or

surgery(supine)to

the

next

individualized

intervention,this

is

an

urgent

imaging

problem

challengeImagingtosolvepracticalproblemsforsurgeons：The

suspicious

lesions

detected

only

by

MRI

(prone),not

palpable,

and

negative

on

MG

and

US,

especially

mass

lesions

with

less

than

1

cm

and

atypical

non-mass

lesions,how

to

being

precise

positionand(or)

biopsy(supine)?Imaging-guidedlocalizationorbiopsyofbreastlesionsMammography-guidedUltrasound-guided：firstchoiceMRI-guidedAmong

the

methods

of

localization

and

biopsy,the

ultrasound-guided

with

easy-operation,

low-cost,and

time-saving,hasbeenwidelyand

expertly

usedTheprocessingflowofbreastlesionsdetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular

processing：localization

and

biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization

and

biopsy3rdMRI-guided

localization

and

biopsyMRI-directedUSIndividualized

Treatment

GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLimitations

of

ultrasoundTypes

of

lesions:the

sensitivity

for

micro-calcification

is

lower

than

mammography,iso-echoiclesionsonUS,breastcancerwithnon-massenhancementLackofstandardizationDiagnosticaccuracydepends

ontheindividualexperience,responsibility,mumber

of

patientsandsoon……Reading

images

together

consultation

XMissed

diagnosisTheprocessingflowofbreastlesionsdetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular

processing：localization

and

biopsynegativeIndividualized

Treatment

GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not

palpable,

and

negative

on

MG

and

USCase:a

67-year-old

woman

with

left

axillary

mass,confirmed

a

metastatic

adenocarcinoma

with

histological

grade

2,originatingin

breast

by

immunohistochemistryMammographicfindings:negative1stMRIdirected“second-look”USMRI

showed

non-mass

enhancement

with

ductal

distribution

in

upper

outer

quadrant

of

left

breast,highly

suspicious

breast

cancer,and

lymph

nodes

metastases

in

the

left

axillary3.5mm

size

invasive

ductal

carcinomaSecond-lookUS

showed

two

0.4*0.3cmsize

hapoechoic,

regular,

well-circumscribedmass,with

theabsenceofvascularityHistopathology:3.5mm

size

invasive

ductal

carcinomaofno

specific

type

with

grade

IIUltrasonographicfindings(2011-5-5)

:negative

Case:a33-year-oldwomanwiththe

resection

of

mass

in

upper

outer

quadrant

of

left

breast

15

daysago,the

histopathologywas

atypical

hyperplasia

of

ductal

epitheliumMRI（2011-5-6）“Second-look”Ultrasound(2011-5-6)“Second-look”ultrasonographicfindings:As

the

enhancement

lesions

onMRIin

upper

inner

quadrant

of

left

breastedge,a0.9×0.6×1.0cmsizehepoechoic,regular,circumscribedmass,with

internal

and

peripheralvascularity

(Makeamarkonthebreastskinforlocalization)Macroscopy:atumor

with1.5×1×1cm

sizeshowedgrey-whitecutsurface

Histopathology:

DCIS,

gradeIICase:a

44-year-old

woman

with

mass

of

left

breastfor4years2011-11-25Mammographicfindings:aasymmetryinupperinnerquadrantofleftbreastImpression:highsuspicionformalignancy(BI-RADS:4C)2011-11-25Sonographicfindings：a1.5×1.3×0.8cmsizehepoechoic,irregular,indistinctmasswithinternal

vascularity

inupperinnerquadrantofleftbreastImpression:cancer(BI-RADS:5)2011-11-28“second-look”ultrasound

showed

a1.1x0.6x0.8cm

sizehypoechoic,irregular,indistinctmasswithinternal

vascularity

in

lower

outer

quadrant

of

left

breast(Makeamarkonthebreastskinforlocalization)Impression:cancer(BI-RADS:5)PathologicaldiagnosisAinvasiveductalcarcinomawithnucleargrade

1-2inupperinnerquadrantofleftbreastA

tubular

carcinoma

and

invasiveductalcarcinomawithnucleargrade1-2(10%)inlowerouterquadrantofleftbreast,lobularatypiaandflat

epithelialatypianeartotumor,andregionallymphnodes:axillary1/12Pathologicstaging：pT1cN1aMxCase：a

57-year-old

woman

with

left

massfor2months,skinedemaundertheareola,leftnippleretraction

without

dischargeMammographicimpression:inflammation(BI-RADS:3)2012-6-20First

ultrasonographic

impression(2012-6-20):hyperplasia

with

cysts2012-6-29“Second-look”ultrasound(2012-7-2)

showed

a2.7×1.3×2.6cm

sizehepoechoic,irregular,indistinctmasswithperipheralvascularityin

upper

outer

quadrant

of

left

breastImpression:cancer(BI-RADS:5)Histopathology:invasiveductalcarcinoma,grade

I—II(second-lookUS)The

reasons

of

missed

diagnosis

on

US：individual

dependence---experience,responsibility,onlyfocus

on

the

target

lesion

and

so

onThe

features

of

lesions

itself---microcalcification,iso-echoiclesions,non-massenhancement

Case：a

28-year-old

woman

with

mass

of

rightbreast

for4months,withoutdischargeMammographicimpression:

cancer(BI-RADS:5)2013-8-13ultrasonographical

findings:

a3.1×2.1cm

sizehepoechoic,irregular,indistinctmasswithcalcifications

and

internalandperipheralvascularityin

upper

outer

quadrant

of

right

breastImpression:cancer(BI-RADS:5)2013-8-15

MRI

findings:non-mass

enhancement

in

the

upper

of

right

breast,considering

cancer,

non-mass

enhancement

in

upper

inner

quadrant

of

right

breastImpression:suspicious

cancer

or

atypical

benign

lesion2013-8-15“Second-look”ultrasound

showed

a1.9×1.1cm

sizehepoechoic,ductal

distribution,indistinctlesion

withinternalvascularityin

upper

centralof

left

breastImpression:lowsuspicionformalignancyHistopathology(2013-8-20

)

：invasive

ductal

carcinoma

with

grade

II

of

right

breast,ductal

carcinoma

in

situ

with

microinvasive,grade

II

of

left

breastCase：F，63yRight

breastInvasive

ductal

carcinoma，tumor

emboli

in

the

lymph-vessel

Histopathology:invasive

papillary

carcinoma

of

left

breastLeft

breastlocalization

by

MRI-ditected“Second-lookUS”Case:a

60-year-old

woman

with

lymphadenopathyof

left

neck

2012-4-12

Surgicalexcisionconfirmeda

metastatic

adenocarcinoma

2012-4-23

Mammographicfindings:focal

asymmetry

in

upper

outer

quadrant

of

left

breastPET-CT

findings(2012-4-20)①Lymphadenopathyunderthechin,jaws,bilateralneck,theleftclavicleandbilateralaxillary,thelymphnodesoftheleftneck,theleftclavicleareasandtheleftaxillaryhave

metabolism

actively,consideringforlymphnodemetastasis,followingupforothers②The

increasing

metabolism

of

right

behind

8th

rib,left

front

5th

rib

and

the

1st

lumbar

vertebrae,no

bone

structure

destruction,considering

possibility

of

metastases,no

suspicious

findings

in

residual

PETandCTimagingarea2012-4-23

the

first

ultrasonographic

findings:

negativeLeft

supraclavicular

lymph

nodes

metastases

No

lymphadenopathy

of

axillary2012-5-7

MRI2012-5-7（at

the

same

time

as

MRI）“second-look”ultrasound

showed

a0.7×0.5cm

sizehepoechoic,architecturaldistortion

in

upper

centralof

left

breastImpression:lowsuspicionformalignancy,lymphadenopathyofleftaxillary2012-6-19

Ultrasound-guided

biopsy：invasive

ductal

carcinomaTheprocessingflowofbreastlesionsdetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular

processing：localization

and

biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRIpositiveUS-guidedlocalization

and

biopsyIndividualized

Treatment

GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not

palpable,

and

negative

on

MG

and

UScombiningreal-timeultrasoundandcontrast-enhancedMRI2.thevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRITheprocessingflowofbreastlesionsdetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular

processing:localization

and

biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization

and

biopsy3rdMRI-guided

localization

and

biopsyIndividualized

Treatment

GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not

palpable,

and

negative

on

MG

and

USMRI-guidedneedlelocalizationA

womanof25-year-oldwithhistoryofIDCintheleftbreast,leftbreastconservationfor4years,rightbreastmassseenfor6monthsMammographicimpression:rightbreastcancer,negativeofleftbreastUltrasound:nolesionsMRI:right

breast

cancer(multiplecarcinomas),

focal

enhancement

(1×1.5cm)in

upper

inner

quadrant

of

left

breast,thatis

lowsuspicionformalignancy3.MRI-guided

localization

and

biopsyCaseHistopathology：ductalcarcinomainsituTheprocessingflowofbreastlesionsdetectedbyMRI,not

palpable,

and

negative

on

MG

and

USLesionsdetectedbyMRI1stMRIdirected“second-look”USpositiveRegular

processing：localization

and

biopsynegative2edthevolumenavigationtechniqueforcombiningreal-timeultrasoundandcontrast-enhancedMRInegativepositiveUS-guidedlocalization

and

biopsy3rdMRI-guided

localization

and

biopsyIndividualized

Treatment

GuideTheprocessingflowofbreastlesionsinitiallyonlydetectedbyMRI,not

palpable,

and

negative

on

MG

and

USStandardizationforultrasoundABUSEmphasizing“Second-lookUS”ABUS：自動化全乳腺超聲檢查系統(tǒng)集體讀片、會診√Second-lookUS（MR-directedSonography,TargetedSonography）Carbognin1G,Girardi1V,Calciolari1C,etal.Utilityofsecond-lookultrasoundinthemanagementofincidentalenhancinglesionsdetectedbybreastMRimaging,Radiolmed,2010,115:1234–1245CandelariaR,.Fornage,B，Second-lookUSexaminationofMR-detectedbreastlesions，JournalofClinicalUltrasound，2010，29：115-121ParkVY,KimMJ,KimEK,etal.Second-lookUS:howtofindbreastlesionswithasuspiciousMRimagingappearance.Radiographics.2013,33(5):1361-1375*Conclusions:Second-lookU