Korean J Radiol.  2007 Oct;8(5):382-389. 10.3348/kjr.2007.8.5.382.

Breast MRI for Evaluating Patients with Metastatic Axillary Lymph Node and Initially Negative Mammography and Sonography

• Ko EY
• Han BK
• Shin JH
• Kang SS

• KMID: 1734286
• DOI: http://doi.org/10.3348/kjr.2007.8.5.382

Abstract

OBJECTIVE
We wanted to investigate the ability of breast MR imaging to identify the primary malignancy in patients with axillary lymph node metastases and initially negative mammography and sonography, and we correlated those results with the conventional imaging. MATERIALS AND METHODS: From September 2001 to April 2006, 12 patients with axillary lymph node metastases and initially negative mammography and sonography underwent breast MR imaging to identify occult breast carcinoma. We analyzed the findings of the MR imaging, the MR-correlated mammography and the second-look sonography. We followed up both the MR-positive and MR-negative patients. RESULTS: MR imaging detected occult breast carcinoma in 10 of 12 (83%) patients. Two MR-negative patients were free of carcinoma in the ipsilateral breast during their follow-up period (39 and 44 months, respectively). In nine out of 10 patients, the MR-correlated mammography and second-look sonography localized lesions that were not detected on the initial exam. All the non-MR-correlated sonographic abnormalities were benign. CONCLUSION: Breast MR imaging can identify otherwise occult breast cancer in patients with metastatic axillary lymph nodes. Localization of the lesions through MR-correlated mammography and second-look sonography is practically feasible in most cases.

Keyword

Axilla; Breast, MR; Breast neoplasms; Lymph nodes

MeSH Terms

Adenocarcinoma/*diagnosis
Adult
Aged
Axilla
Biopsy
Breast/pathology
Breast Neoplasms/*diagnosis/secondary
Contrast Media/administration & dosage
Feasibility Studies
Female
Follow-Up Studies
Gadolinium DTPA/diagnostic use
Humans
Image Processing, Computer-Assisted
Lymph Nodes/*pathology
Lymphatic Metastasis/diagnosis
Lymphoma, Large B-Cell, Diffuse/*diagnosis
Magnetic Resonance Imaging/*methods
Mammography/*methods
Middle Aged
Neoplasms, Unknown Primary/*diagnosis
Ultrasonography, Mammary/*methods

Figure

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  Fig. 1 A 78-year-old woman with palpable left axillary lymph node metastasis. The initial mammogram (A) and US showed negative findings in the breast. Two small enhancing nodules (arrows) with a washout pattern were visible in the left lower breast on the contrast enhanced-MR images (B, C). Subsequent MR-guided second-look US examinations revealed two small low echoic nodules (3-4 mm) with indistinct margins (arrows) that were not seen on the prior US study (D, E). US-guided core needle biopsy revealed invasive ductal carcinomas.

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  Fig. 2 A 43-year-old woman with palpable left axillary lymph node metastasis. The mammogram and US images from another hospital showed negative findings. On the maximun intensity projection image of the contrast enhanced-MRI (A), segmental clumped or stippled enhancements (box) were noted in the left lower breast. MR-correlated mammography (B) showed the segmental distribution of faint amorphous microcalcifications in that area (box). Breast conserving surgery after mammography-guided wire localization revealed multifocal invasive A B ductal carcinomas up to 3 mm in size.

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  Fig. 3 A 53-year-old woman with palpable left axillary lymph node metastasis. The mammogram (A) and US showed no abnormal findings in the breast. The contrast-enhanced MR image (B) showed 5 mm nodular enhancement without a washout pattern (arrow) in the left lower outer breast. On the MR-guided second-look US examination (C), a well-defined flat nodular lesion (arrow) was identified, and invasive ductal carcinoma was diagnosed by US-guided localization and excision.

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  Fig. 4 A 42-year-old woman with palpable left axillary lymph node metastasis. The mammogram (A) showed extremely dense breast parenchyma without abnormal findings in the breast. The initial screening US was normal. The standard subtraction image (B) of the contrast-enhanced breast MRI showed an enhancing nodule, about 7 mm in size, in the left lower breast (arrow) with a washout pattern. The MR-guided second look US examination localized a few benign cysts in that area (arrows) (C). US-guided fine needle aspiration revealed malignant cells.

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  Fig. 5 A 57-year-old woman with palpable right axillary lymph node metastasis. The mammogram (A) and US showed negative findings in the breast. The standard subtraction image of the contrast enhanced-MRI (B) showed a 1.8-cm sized area of linear enhancement with an early washout pattern, suggesting malignancy in the outer portion of the right breast. MR-guided second-look US (C) and spot-compression with magnification mammography (D), which targeted the areas of MR-detected lesion through the use of a vitamin E capsule attached to the surface of the right breast overlying the MR-detected lesion, could not find the corresponding lesion. After modified radical mastectomy, ductal carcinoma in situ (0.9 cm in extent) was found in the right outer breast.

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