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Imaging–Histologic Discordance at MRI-Guided 9-Gauge Vacuum-Assisted Breast Biopsy

¹ Breast Imaging Section, Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021
² Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —60-year-old woman 15 years after right lumpectomy, with recent left breast bloody nipple discharge. Sagittal contrast-enhanced T1-weighted subtraction diagnostic MR image of left breast shows bilobed, irregularly shaped, irregularly marginated mass with rim enhancement in left breast upper inner quadrant that was nonpalpable and occult to mammography and sonography, for which MRI-guided vacuum-assisted biopsy was suggested. MRI also revealed ductal enhancement in lateral retroareolar region (not shown) for which preoperative ductography, localization, and duct excision were planned.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —60-year-old woman 15 years after right lumpectomy, with recent left breast bloody nipple discharge. Sagittal contrast-enhanced T1-weighted MR image of left breast obtained immediately after completing tissue acquisition at MRI-guided vacuum-assisted biopsy of left breast mass. Note obturator (arrow) at posterior aspect of lesion. MRI appearance of upper inner quadrant mass is not substantially altered when comparing images obtained before and after MRI biopsy, suggesting that target lesion may have been missed.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —60-year-old woman 15 years after right lumpectomy, with recent left breast bloody nipple discharge. Sagittal contrast-enhanced T1-weighted MR image of left breast immediately after tissue acquisition in this slice obtained in same sequence as B shows hematoma superiorly (straight arrow) and ductal enhancement in retroareolar region (curved arrows). Note that this slice is approximately 1 cm lateral to slice containing target lesion (B). Presence of hematoma at different depth from target lesion suggests that target may have been missed. Histologic analysis of vacuum-assisted biopsy samples yielded fibrocystic changes, which was considered discordant with imaging features.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —60-year-old woman 15 years after right lumpectomy, with recent left breast bloody nipple discharge. Sagittal contrast-enhanced T1-weighted MR image of left breast on day of preoperative MRI-guided localization reveals persistence of bilobed left breast upper inner quadrant mass, although mass appears somewhat retracted, perhaps due to adjacent postbiopsy change.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —60-year-old woman 15 years after right lumpectomy, with recent left breast bloody nipple discharge. Sagittal contrast-enhanced T1-weighted MR image of left breast after preoperative MRI-guided localization shows low signal from wire that has deployed at target lesion (arrow). Mass yielded 0.5-cm invasive ductal carcinoma, mixed mucinous and not-otherwise-specified type, histologic grade III and nuclear grade II, and ductal carcinoma in situ. Retroareolar ductal enhancement (shown in C) yielded intraductal papilloma and atypical ductal hyperplasia. Breast-conservation surgery was performed; sentinel nodes were negative.

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —63-year-old asymptomatic woman with family history of breast cancer who had abnormal right breast MRI performed at outside facility. Sagittal T1-weighted contrast-enhanced scout image of right breast on day of MRI-guided biopsy shows segmental clumped enhancement (arrows) in right breast lower outer quadrant for which MRI-guided vacuum-assisted biopsy was suggested.

View larger version (170K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —63-year-old asymptomatic woman with family history of breast cancer who had abnormal right breast MRI performed at outside facility. In sagittal T1-weighted contrast-enhanced image obtained after biopsy and clip placement at MRI-guided vacuum-assisted biopsy, lesion shows washout of contrast material, but no definite biopsy site changes are appreciated on this image.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —63-year-old asymptomatic woman with family history of breast cancer who had abnormal right breast MRI performed at outside facility. Sagittal T1-weighted contrast-enhanced image after biopsy and clip placement shows signal void from marker in retroareolar region (arrow) in this image obtained during same sequence but just lateral to slice seen in B. Histologic analysis of material obtained at MRI vacuum-assisted biopsy yielded benign breast parenchyma with dense stromal fibrosis, discordant with imaging.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —63-year-old asymptomatic woman with family history of breast cancer who had abnormal right breast MRI performed at outside facility. Sagittal T1-weighted scout image on day of MRI-guided localization shows persistence of segmental clumped enhancement (arrows).

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —63-year-old asymptomatic woman with family history of breast cancer who had abnormal right breast MRI performed at outside facility. Sagittal T1-weighted MR image after needle localization shows signal void from placement of three MRI-compatible bracketing wires (arrows) to assist surgeon in wide excision. Histologic analysis revealed extensive multifocal ductal carcinoma in situ (DCIS), micropapillary, flat (clinging), and focally solid types, intermediate nuclear grade, arising in background of atypical ductal hyperplasia, with multiple positive margins. Mastectomy was performed, yielding residual DCIS with negative sentinel nodes.

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