Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Ultrafast MR Imaging Findings of Two Different Subtypes in a Male Patient with Bilateral Breast Cancer Kyle Kleiman, OMS-III; CerenYalniz, MD; Stefanie Woodard, DO. Edward Via College of Osteopathic Medicine – Carolinas; The University of Alabama at Birmingham, Department of Radiology

Introduction

Imaging

Discussion

Bilateral breast cancer in males is an exceedingly rare diagnosis, accounting for less than 0.015% of breast cancer cases. Mammography and ultrasound are the most common modalities used in breast cancer imaging. MRI is sometimes used to assess disease extent prior to surgery. Ultrafast (UF) breast MRI is a new technique, acquiring high temporal resolution images in the first two minutes after contrast injection. UF MRI can help to differentiate malignant and benign lesions, as well as predict tumor aggressiveness and inform prognosis. A 94-year-old male presented with bilateral palpable areas in his breasts. He had a personal history of cancer, specifically bladder cancer, melanoma, and squamous cell carcinoma. He tested negative for BRCA mutation. A clinical physical exam was performed and bilateral breast masses and left axillary lymph nodes were palpated. The nipples were inverted bilaterally, and the left nipple was almost fully eroded. These are concerning physical exam findings for breast cancer. No other abnormal lymph nodes were detected. Diagnostic mammography and ultrasound images demonstrated bilateral irregular masses with nipple retraction. Biopsies were performed and the histopathologic examination revealed invasive ductal carcinoma (IDC) of no special type (NST) in the left breast and IDC with micropapillary features in the right breast. Staging MRI with UF sequence showed significant enhancement differences between two different subtypes, correlating with the different levels of tumor aggressiveness. The MRI demonstrated a round, enhancing mass with irregular margins in the right breast and an irregular mass with spiculated margins in the left breast with nipple and chest wall invasion. Both cancers were found to be estrogen (ER) and progesterone (PR) positive, HER2 negative . Subsequent CT examination of the chest, abdomen and pelvis (not shown) demonstrated extensive metastatic disease, likely from breast origin. Standard of care treatment was extrapolated from female breast cancer due to rarity of male breast cancer and the patient was started on combination therapy. Report of Case

References The ultrafast sequence findings were highlighted to show the differences between a more aggressive subtype (micropapillary) and a relatively less aggressive subtype (IDC NST). In conclusion, ultrafast technique is an important tool for breast cancer evaluation and can help predict tumor aggressiveness. malignant breast lesions from benign lesions of the breast. Different ultrafast metrics, such as time-to-enhancement (TTE) and maximum slope (MS), may help to differentiate between several subtypes of breast cancer and serve as prognostic indicators. These metrics represent how early/fast a lesion enhances. A shorter TTE and a greater MS are associated with more aggressive tumor features. In our case, UF MRI showed significant enhancement differences between two different subtypes, correlating with the more aggressive micropapillary type on the right and the less aggressive IDC NST on the left. Conclusion & Impact IDC NST is the most common type of breast cancer. Invasive micropapillary IDC is rarer but often is more aggressive. Mammographic appearance of invasive micropapillary IDC is often nonspecific and underestimates the true disease burden. Tumor size and the disease extent is important for proper surgical planning. MRI can be used for this purpose, due to both physiologic information and soft tissue characterization. Ultrafast MRI is an imaging modality that can help to differentiate I would like to thank Dr. Woodard, Dr. Yalniz, and the Department of Radiology at University of Alabama Birmingham for allowing me to write up this case report. Acknowledgements 1. Hungness ES, Safa M, Shaughnessy EA, Aron BS, Gazder PA, Hawkins HH, et al. Bilateral synchronous breast cancer: mode of detection and comparison of histologic features between the 2 breasts. Surgery. 2000 Oct;128(4):702–7. 2. Gao Y, Heller SL. Abbreviated and ultrafast breast MRI in clinical practice. Radiographics. 2020 Oct;40(6):1507–27. 3. Shin K, Martaindale S, Whitman GJ. Male breast magnetic resonance imaging: when is it helpful? our experience over the last decade. Curr Probl Diagn Radiol. 2019;48(3):196–203. 4. Shin SU, Cho N, Kim S-Y, Lee SH, Chang JM, Moon WK. Time-to-enhancement at ultrafast breast DCE-MRI: potential imaging biomarker of tumour aggressiveness. Eur Radiol. 2020 Jul;30(7):4058–68. 5. Mann RM, Mus RD, van Zelst J, Geppert C, Karssemeijer N, Platel B. A novel approach to contrast-enhanced breast magnetic resonance imaging for screening: high-resolution ultrafast dynamic imaging. Invest Radiol. 2014 Sep;49(9):579–85.

A

B

Figure 1. Full-protocol dynamic contrast enhanced (DCE) breast MRI with ultrafast sequence. A. Subtraction images demonstrate a round, enhancing mass with irregular margins in the right breast, consistent with IDC with micropapillary features and an irregular mass with spiculated margins in the left breast with nipple and chest wall invasion, consistent with IDC NST. B. Both lesions show rapid contrast uptake on ultrafast sequence; however, the enhancement is more avid during the early phase of UF sequence for the right breast malignancy.

22

2024 Research Recognition Day