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. 2022 May 25;12(6):867.
doi: 10.3390/jpm12060867.

Diagnostic Challenge of Invasive Lobular Carcinoma of the Breast: What Is the News? Breast Magnetic Resonance Imaging and Emerging Role of Contrast-Enhanced Spectral Mammography

Melania Costantini  1   2 , Rino Aldo Montella  1 , Maria Paola Fadda  1 , Vincenzo Tondolo  3 , Gianluca Franceschini  4   5 , Sonia Bove  6 , Giorgia Garganese  6   7 , Pierluigi Maria Rinaldi  1
Affiliations

Diagnostic Challenge of Invasive Lobular Carcinoma of the Breast: What Is the News? Breast Magnetic Resonance Imaging and Emerging Role of Contrast-Enhanced Spectral Mammography

Melania Costantini et al. J Pers Med. .

Abstract

Invasive lobular carcinoma is the second most common histologic form of breast cancer, representing 5% to 15% of all invasive breast cancers. Due to an insidious proliferative pattern, invasive lobular carcinoma remains clinically and radiologically elusive in many cases. Breast magnetic resonance imaging (MR) is considered the most accurate imaging modality in detecting and staging invasive lobular carcinoma and it is strongly recommended in pre-operative planning for all ILC. Contrast-enhanced spectral mammography (CESM) is a new diagnostic method that enables the accurate detection of malignant breast lesions similar to that of breast MR. CESM is also a promising breast imaging method for planning surgeries. In this study, we compare the ability of contrast-enhanced spectral mammography (CESM) with breast MR in the preoperative assessment of the extent of invasive lobular carcinoma. All patients with proven invasive lobular carcinoma treated in our breast cancer center underwent preoperative breast MRI and CESM. Images were reviewed by two dedicated breast radiologists and results were compared to the reference standard histopathology. CESM was similar and in some cases more accurate than breast MR in assessing the extent of disease in invasive lobular cancers. Further evaluation in larger prospective randomized trials is needed to validate our preliminary results.

Keywords: breast cancer; breast magnetic resonance imaging; contrast-enhanced spectral mammography; invasive lobular carcinoma.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
A 47-year-old women with multifocal CLI. Patient performs mammography and ultrasound examinations for annual prevention check. (a) At ultrasound examination, two small suspicious hypoechoic lesions are visualized. Needle biopsy was performed on both lesions and invasive lobular carcinoma was diagnosed in both cases. (b) CESM CC and (c) CESM MLO views show some suspicious small-enhanced masses in the upper quadrants of the right breast suggesting a multifocal disease (T1bm N0 M0, ER 90%, PgR 5%, Ki67 20%, G2). (d) BMR axial MIP reconstruction and (e) BMR sagittal MIP reconstructions show only one small-enhanced mass lesion. In this case, BMR missed the real extent of the disease. (f,g) Postoperative specimen histology including one of the lesions previously described, Hematoxilin & Eosin stain. (f) Low power magnification showing invasive breast carcinoma with sparse, poorly cohesive neoplastic cells, associated with stromal desmoplasia (magnification 100×). (g) At higher magnification, the neoplastic cells are small sized, with scant cytoplasm and mild nuclear pleomorphism, arranged in single cells or small cords, consistent with the diagnosis of CLI (magnification 400×).
Figure 1
Figure 1
A 47-year-old women with multifocal CLI. Patient performs mammography and ultrasound examinations for annual prevention check. (a) At ultrasound examination, two small suspicious hypoechoic lesions are visualized. Needle biopsy was performed on both lesions and invasive lobular carcinoma was diagnosed in both cases. (b) CESM CC and (c) CESM MLO views show some suspicious small-enhanced masses in the upper quadrants of the right breast suggesting a multifocal disease (T1bm N0 M0, ER 90%, PgR 5%, Ki67 20%, G2). (d) BMR axial MIP reconstruction and (e) BMR sagittal MIP reconstructions show only one small-enhanced mass lesion. In this case, BMR missed the real extent of the disease. (f,g) Postoperative specimen histology including one of the lesions previously described, Hematoxilin & Eosin stain. (f) Low power magnification showing invasive breast carcinoma with sparse, poorly cohesive neoplastic cells, associated with stromal desmoplasia (magnification 100×). (g) At higher magnification, the neoplastic cells are small sized, with scant cytoplasm and mild nuclear pleomorphism, arranged in single cells or small cords, consistent with the diagnosis of CLI (magnification 400×).
Figure 2
Figure 2
A 74-year-old women with synchronous bilateral breast cancer. Patient performs mammography and ultrasound examinations because a palpable mass in the upper quadrant of the right breast. (a) CESM CC views show an irregular-enhanced mass in the right breast and an irregular-enhanced mass in the left breast. They were an invasive ductal carcinoma in the right breast (27 mm in size) and an invasive lobular carcinoma in the left (18 mm in size). (b) BMR, axial MIP (Maximum intensity projection) reconstruction shows bilateral breast cancer. Note the similarities with the CESM images (morphology of the masses and increased local vascularity in the right breast). (c) BMR, first post-contrast axial T1-weighted fat saturation dynamic axial sequence (Vibrant). Measurements of the lesions show good agreement with CESM (16 mm).
Figure 3
Figure 3
Pearson correlations of index cancers sizes of (a) breast magnetic resonance (r = 0.945, p < 0.001) and (b) contrast-enhanced spectral mammography (r = 0.937, p < 0.001) versus micro-histology.
Figure 4
Figure 4
Strategy of the study, flowchart diagram. MR: magnetic resonance; CESM: contrast-enhanced spectral mammography; BMR: breast magnetic resonance; BCS: breast conserving surgery; MFMC: multifocal–multicentric.
Figure 5
Figure 5
A 49-year-old women with large CLI of the left breast. Patient performs mammography because of a nipple retraction of the left breast. (a) CESM CC views show non-mass pathological enhancement on the left breast extending to the nipple. (b) Axial and (c) sagittal post-contrast T1-weighted fat saturation dynamic sequence (Vibrant) show large clustered ring regional non-mass enhancement consistent with pleomorphic CLI (T3 N2 M0, ER 90%, PgR 50%, Ki-67 35%, G3).
Figure 6
Figure 6
A 44-year-old women with large CLI of the left breast. Patient performs mammography because of a nipple retraction of the left breast. (a) CESM CC views show non-mass pathological enhancement on the left breast extending to the nipple. (b) Axial post-contrast T1-weighted fat saturation dynamic sequence (Vibrant) shows homogeneous non-mass enhancement consistent with classic CLI (T2, N1, M0, ER 90%, PgR 85%, Ki67 35%, G2). Pathological enhancement reaches the nipple. In right breast, BMR shows marked homogenous enhancement of the parenchyma of the external quadrants, that is not visible in CESM. Core needle biopsy was performed to confirm the absence of bilateral disease.
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