Werner A. Kaiser
Signs in MR-Mammography
Werner A. Kaiser
Signs in MR-Mammography
123
Werner Alois Kaiser, M.D., M.S. Professor and Chairman Department of Diagnostic and Interventional Radiology Friedrich-Schiller University Hospital Erlanger Allee 101 07740 Jena Germany www.mediteach.de www.uni-jena.de/med/idir
[email protected] Received: 8 May 2007; Corrected: 27 September 2007
ISBN 978-3-540-73292-1 Springer Berlin Heidelberg New York Library of Congress Control Number: 2007933374 This work is subject to copyright. All rights are reserved, wether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broad-casting, reproduction on microfilm or any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in it current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. Springer-Verlag is a part of Springer Science+Business Media springer.com © Springer-Verlag Berlin Heidelberg 2008 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Dr. Ute Heilmann, Heidelberg, Germany Desk Editor: Wilma McHugh, Heidelberg, Germany Reproduction, typesetting and production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Cover design: Frido Steinen-Broo, eStudio, Calamar, Spain Printed on acid-free paper 21/3180/YL 5 4 3 2 1 0 SPIN 12078301
Preface A teacher of mine once said, “If we had a diagnostic method that enabled us to detect and remove all breast cancers 5 to 10 mm in size, we could practically eliminate breast cancer deaths.” Large screening studies in Scandinavia and other countries have documented the truth of this statement. The 20-year survival rate is very high (over 95%) when the initial tumor size is less than 1 cm. We are faced with a major medical problem. Breast cancer is the leading cause of cancer-related deaths in women, and its incidence and prevalence have been steadily rising in recent decades. It commonly affects young women and the mothers of small children – a segment of the population that “ought not to die.” The medical problem becomes even more tragic when we consider the relatively slow growth rates of most breast carcinomas. As a rule, breast cancers are very slow-growing tumors that take years or decades to reach a size of 1 cm. Nature has actually given us a very large time window for detecting and treating breast cancer. This is quite different from pancreatic cancer or glioblastoma, where almost all patients die within a year after diagnosis. Magnetic resonance imaging (MRI) of the breast, known also as magnetic resonance mammography (MRM), can solve the problem of high breast cancer mortality. MRM is sensitive enough to detect breast tumors as small as 3 mm in diameter. The problem with MRM is its long learning curve. The method is still relatively new, somewhat complicated, has numerous pitfalls, and requires experience in analyzing more than 1000 images per breast. Benjamin Franklin once said, “Beware of young doctors and old barbers.” I have had to learn a great deal since 1983. It has been like a long trek through the jungle, where you first hack out a path with a machete, then make a road, and finally build a highway. Sometimes I wonder why it took me so long to make these discoveries. But today I understand the many mistakes that have been made in the past, and I know that we are still making mistakes that will have to be understood and corrected in the future. Albert Salomon first described the x-ray appearance of breast cancer in 1913. When I consider how far modern x-ray mammography has come with special x-ray tubes, compression, digital technology, very high spatial resolution, computer postprocessing, etc., I realize that even after 20 years, MRM is still in its infancy. There is still a long way to go before MRM becomes an established, routine imaging procedure throughout the world. I wrote my first book (MR Mammography, Springer, 1993) 10 years after I began working with this modality, but even then it was much too soon. Scarcely any book was criticized as harshly as mine: “By the time readers buy this book, probably all of the material will prove to be obsolete” (Radiology 191,1:148 1994). In the years since then, however, MRI has become widely utilized in the diagnosis of breast cancer. More than 3000 publications on breast MRI are listed in PubMed, and I know of no publication during the past 5 years that has not documented the substantial value of MRM relative to conventional mammograms or even the combination of mammograms and breast ultrasound. Nevertheless, I am struck by the problem that there are still no recognized international standards for performing MRM, and that much of the morphologic and dynamic information contained in breast MR images has not yet been adequately explored or utilized. Too many women today are still
a Preface undergoing unnecessary breast biopsies and excisions that may cause significant disfigurement and distress, not to mention the tremendous costs. The experience of the past 20 years has shown that when the information supplied by MRM is fully utilized, this modality can detect even small lesions and can reliably discriminate between benign and malignant tumors. The goal of this book is to describe and qualitatively interpret all previously known morphologic and kinetic signs in breast MRI. I am well aware that some indications are well evaluated through numerous investigations and studies, while others are based on observations of relatively small numbers of patients. Most of these indications should have been published by now, so many diagnosticians can find them on the images, and thus a faster global evaluation can ensue. There is a saying: „You only see what you know“. The quantitative accuracy of these signs will be addressed in future publications, with the object of making our interpretations as accurate as possible and minimizing the rates of false-negative and false-positive diagnoses. Unnecessary biopsies, with their attendant costs, complications and distress, should be reduced to an absolute minimum. Basically, MRM images a breast with the highest possible spatial and temporal resolution following the injection of a contrast agent so that early morphologic and pathophysiologic signs of malignancy, such as tumor angiogenesis, can be recognized and identified. A consistent scheme is used throughout this book for describing the morphologic and kinetic signs of a breast lesion: 1. Definition of the sign 2. Explanatory diagram 3. Clinical example 4. Medical interpretation The sequence in which the signs are described is purely arbitrary and is simply based on the methodology that I have followed over the years when reading breast images. MR mammography is still evolving, but at a relatively slow pace – typical of any evolutionary process in medicine. Yet women deserve a better and more expeditious application of this technology so that they can live longer, happier lives free of breast cancer. This book is intended to help broaden and expedite the clinical application of MRM so that as many physicians as possible can make more accurate and confident diagnoses. In the future, the results of MRM will be subjected to a computerbased data analysis to further improve its accuracy. I have to express sincere thanks to: – my wife Ursula for her love and patience during the past 34 years and for her constant support and discussions both as a partner and as a patient, even at times when I was heavily engaged in scientific debates. – my children Clemens, Simon, Daniel, Birgit, and Ulrich for our wonderful family life, past and present. – I especially received many valuable suggestions from my son Clemens, who studies medicine with utmost interest. All of my former and present colleagues at the Nuremberg Hospital, Bonn University Hospital, Würzburg University Hospital, and Jena University Hospital.
VI
– my secretary Mrs. Maren Mihlan for her valuable help in typing this manuscript. – Springer Publishers for their support in the publication and layout of this book. I hope that my readers will enjoy this book and that as many patients as possible will benefit from its use. Jena, May 2007 Werner Alois Kaiser, M.D., M.S.
VII
Contents
General Information .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Sign 1 Sign 2 Sign 3 Sign 4 Sign 5 Sign 6 Sign 7 Sign 8 Sign 9 Sign 10 Sign 11 Sign 12 Sign 13 Sign 14 Sign 15 Sign 16 Sign 17 Sign 18 Sign 19 Sign 20 Sign 21 Sign 22 Sign 23 Sign 24 Sign 25 Sign 26 Sign 27 Sign 28 Sign 29 Sign 30
No enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Slow wash-in .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medium wash-in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fast wash-in .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plateau curve .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rising curve .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Washout curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Round shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oval shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lobulated shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Irregular shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Well-circumscribed margins .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Irregular margins .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blooming sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constant sharpness sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Homogeneous enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heterogeneous enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Centrifugal enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Centripetal enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dark internal septations .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enhancing internal septations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Segmental enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inflow enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regional unilateral enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiple unilateral regional enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiple bilateral regional enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffuse unilateral enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffuse bilateral enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stippled enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cobblestone enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64
IX
a Contents Sign 31 Sign 32 Sign 33 Sign 34 Sign 35 Sign 36 Sign 37 Sign 38 Sign 39 Sign 40 Sign 41 Sign 42 Sign 43 Sign 44 Sign 45 Sign 46 Sign 47 Sign 48 Sign 49 Sign 50 Sign 51 Sign 52 Sign 53 Sign 54 Sign 55 Sign 56 Sign 57 Sign 58 Sign 59 Sign 60 Sign 61 Sign 62 Sign 63 Sign 64 Sign 65 Sign 66 Sign 67 Sign 68 Sign 69 Sign 70
Reticular (dendritic) enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypointensity on T2-weighted TSE images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Isointensity on T2-weighted TSE images .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperintensity on T2-weighted TSE images .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hook sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Root sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pectoralis muscle invasion .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral perifocal edema .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intact ligament sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disrupted ligament sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prepectoral unilateral edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intact nipple line .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disrupted nipple line .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral precontrast high intraductal signal on T1-weighted images .. . . . . . . . . Bilateral precontrast high intraductal signal on T1-weighted images .. . . . . . . . . . . Nipple retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Asymmetric nipple enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffuse unilateral skin thickening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normal lymph nodes .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Small round lymph nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Large lymph nodes .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pleural effusion < 7 mm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pleural effusion > 7 mm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eclipse sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signet ring sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shot-through sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unchanged enhancement curve .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Changed enhancement curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Taller than wide” sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Wider than tall” sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Punched-out sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bilateral symmetric edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Skin retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased choline .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADC < 1.4 × 10–3 mm2/s .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADC > 1.4 × 10–3 mm2/s .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Half-moon sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shrinking star sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clustered ring enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 110 112 114 116 118 120 122 124 126 128 130 132 134 136 138 140 142 144
Sign 71 Sign 72 Sign 73 Sign 74 Sign 75 Sign 76 Sign 77 Sign 78 Sign 79 Sign 80 Sign 81 Sign 82 Sign 83 Sign 84 Sign 85 Sign 86 Sign 87 Sign 88 Sign 89 Sign 90 Sign 91 Sign 92 Sign 93 Sign 94 Sign 95 Sign 96 Sign 97 Sign 98 Sign 99 Sign 100 Sign 101 Sign 102 Sign 103 Sign 104 Sign 105 Sign 106 Sign 107 Sign 108 Sign 109 Sign 110
Decrescendo sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crescendo sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Staccato sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interrupted retroglandular fat layer .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Continuous vessel sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotic response sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotic nonresponse sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vessel sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comet sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Focal skin thickening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Permanent asymmetry of the breasts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing asymmetry of the breasts .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Precontrast signal too low . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Precontrast signal too high . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maximum initial signal increase lower than the malignant threshold .. . . . . . . . . . Maximum initial signal increase within the malignant range .. . . . . . . . . . . . . . . . . . Maximum initial signal increase above the malignant threshold . . . . . . . . . . . . . . . Pseudocentric enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clip sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fat-water cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral hormone reversal sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bilateral hormone reversal sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hormone nonreversal sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intravascular contrast sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pectoralis pseudolesion .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumor recovery sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incorrect shimming sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patchwork sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased unilateral subcutaneous vascular density . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased bilateral subcutaneous veins .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special STIR signal intensity pattern .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Linguine sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pull-away sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Keyhole sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extracapsular silicone sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pouch sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wavy line sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gel bleed sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Focal ductal fluid sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Two-chamber sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
146 148 150 152 154 156 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 194 196 198 200 202 204 206 208 210 212 214 216 218 220 222 224 226
XI
a Contents Sign 111 Sign 112 Sign 113 Sign 114 Sign 115 Sign 116 Sign 117 Sign 118 Sign 119 Sign 120 Sign 121 Sign 122 Sign 123 Sign 124 Sign 125 Sign 126 Sign 127 Sign 128 Sign 129 Sign 130 Sign 131 Sign 132 Sign 133 Sign 134 Sign 135 Sign 136 Sign 137 Sign 138 Sign 139 Sign 140 Sign 141 Sign 142 Sign 143 Sign 144 Sign 145 Sign 146 Sign 147
Blood-water cyst .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Blackberry sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tram lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fat separation sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bilateral pectoralis degeneration sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral pectoralis atrophy sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intact retroglandular fat layer .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STIR-selective perifocal edema .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Border sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-talk sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral subcutaneous rim enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intense peripheral rim on postcontrast STIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased unilateral nipple enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Small perifocal enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Large perifocal enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dark heart sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unilateral subcutaneous edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stacked beads sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corona sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drapery sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crossing edema sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Duct obstruction sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Duct nonobstruction sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Donut sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Camouflage sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissolving cancer sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melting candies sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constant candies sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bright T2w cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enhancing pectoralis .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resolving edema sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recurrent border cancer .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bright round lymph nodes on T2-weighted TSE images .. . . . . . . . . . . . . . . . . . . . . . Normal cardiac and aortic enhancement .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing unilateral vessel sign .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing bilateral vessel sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lesion with high precontrast signal intensity .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
228 230 232 234 236 238 240 242 244 246 248 250 252 254 256 258 260 262 264 266 268 270 272 274 276 278 280 282 284 286 288 290 292 294 296 298 300
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
XII
General Information This book describes morphologic and kinetic signs that are important in the analysis of breast MR images before and after contrast administration and in various pulse sequences. During the period from 1985 to 2006, many authors repeated the almost mantra-like claim that “MR mammography has high sensitivity but low specificity.” But it is quite possible – and by that I mean very probable – that by utilizing all the information contained in MR data sets, we can greatly increase the specificity of MRM. This would give MRM a very high overall accuracy in the diagnosis and differential diagnosis of breast lesions, making it possible to detect cancers as small as 3 mm with a high degree of confidence. Based on all available scientific information, it is even reasonable to expect that the use of MRM can significantly reduce mortality rates from breast cancer while also reducing the extent of surgical procedures and the use of costly chemotherapeutic agents. If the quality of the diagnostic information can be increased, this will also justify the higher costs of MRM compared with x-ray mammography and breast ultrasound. Most of the signs described in this book were identified by analyzing numerous images and correlating the findings with the “gold standards” of histology and follow-up. Some of the signs have been gleaned from the literature. The importance of an individual sign in the overall interpretation – that is, the “weight” of a particular sign – is highly variable. Some signs are seen very often, and some are seen very rarely. Some signs are found both in benign and malignant lesions, some are usually found in malignant or benign lesions, and some are found only in malignant or benign lesions. The “power” of a sign depends on how well the sign can discriminate between benign and malignant lesions and how frequently the sign is encountered. In order to make a quantitative mathematical description, we must introduce a “weighting factor” (WF), which is defined as the logarithm of the ratio of the prevalence of a sign in malignant lesions and in benign lesions. A positive weighting factor is strongly suggestive of a malignant lesion, while a negative weighting factor is strongly suggestive of a benign lesion. For example, if a sign is 100 times more prevalent in malignant lesions than in benign lesions, the weighting factor would be the logarithm of 100, which is +2. If a sign is 100 times more prevalent in benign lesions than in malignant lesions, the weighting factor would be the logarithm of 1 over 100, which is –2. The weighting factor correlates quantitatively with the likelihood of malignancy. The “sign factor” (SF) was introduced to express the presence or absence of a sign in a quantitative way. It simply indicates whether or not a sign is present. A sign factor of 1 means that the sign is present and can therefore be detected in images. SF = 0 means that the sign is not present and is not detectable in images. The overall analysis of a lesion is quantified with an “identification factor” (IDF), which represents the sum of the products of all the weighting factors and sign factors. The IDF takes into account all the signs that can be identified in a patient and their relative contribution to the diagnosis. It is conceivable that, by broad international consensus, an IDF with a value less than minus x would be considered to have no therapeutic implications. There could also be other ranges of IDF values that would warrant long-term follow-up, short-term follow-up, or breast biopsy.
Fig. 1 Definition of the weighting factor of a sign. The weighting factor is the logarithm of the ratio of the percentage prevalence of a sign in malignant lesions to the prevalence of that sign in benign lesions
Above a certain IDF of plus y, it would be appropriate to proceed with chemotherapy, surgical excision, or radiotherapy or a combination of treatment modalities (see Fig. 3). At present, it is still too early to establish a definitive, quantitative scheme for lesion analysis. Nevertheless, it would definitely be helpful to have a “number” instead of a descriptive diagnosis – one that would encompass all available signs and take into account the relative impact of those signs. Of course, this still leaves open the possibility that other signs may be discovered in the future that will factor into the interpretation, and indeed this would be a welcome development. The advantage of using the IDF is that its numerical value correlates with malignancy. Because the prevalence ratio of benign and malignant lesions in a patient population enters into the IDF, this factor is independent of technical parameters over a broad range of values. The IDF can also be applied to other modalities such as serologic and clinical parameters. All aspects of the image data, history, and clinical and serologic information contribute to the overall diagnosis. It is highly relevant, for example, to determine whether a patient with a unilateral enhancing breast lesion also has a fever or elevated inflammatory serologic markers. The IDF could be expanded in accordance with future medical advances to encompass all signs relating to the patient’s history, imaging findings, clinical findings, and serology. Because it is based on quantitative standards, which ideally correlate with solid objective standards (histology, longterm follow-up), it has high validity and is examiner-independent. The IDF could be used as a basis for therapeutic decisions, standardization, guidelines, and computer-based systems (CAD).
Fig. 2 Definition of the identification factor (IDF)
These goals are still a long way off, however. We need to establish a data base for this analytical scheme covering large numbers of patients whose diagnoses have been validated either by histologic correlation or by long-term follow-up. During the initial phase, the data for the IDF will probably underestimate benign lesions because they cannot be histologically classified with the same degree of certainty as malignancies. Ideally, the signs should be evaluated within a screening population consisting of asymptomatic “clinically healthy” women. In the past, all of these signs have been interpreted independently of one another. It is quite likely, however, that a combination of multiple signs will improve diagnostic accuracy. For example, a lesion that displays irregular margins, malignant wash-in, washout, low T2w signal intensity, perifocal edema, a hook sign, a blooming sign, elevated choline, and a low ADC is almost certainly a carcinoma. Significant advances have been made in the molecular genetic research of breast cancer in recent years, and striking differences have been noted among different types of carcinoma. “Genomics,” “microchips,” and “proteomics” are buzzwords for new discoveries suggesting that, in the future, we will be able to analyze molecular subgroups in order to obtain specific information about an individual cancer. More than 600 genes are over- or underregulated in a tumor. A carcinoma is like a “new life in a living patient.” This genetic information determines the aggressiveness of the tumor, the likelihood of metastasis, and the organs to which the tumor will metastasize (bone, liver, brain, lung, etc.), thus critically influencing the prognosis. Breast cancers are not all the same. They are a
Fig. 3 Possible therapeutic implications of an identification factor for a breast lesion
very heterogeneous group of diseases that vary greatly in their aggressiveness and prognosis. In the future, we will probably be able to custom-design a “drug cocktail” for each patient that is optimum for that patient’s tumor. I think it is quite possible that the MRI signs described in this book will correlate with the molecular genetics of tumors; this hypothesis will need to be tested in the future. Several years from now, perhaps a carcinoma with a blooming sign will be treated differently from a carcinoma with a hook sign or perifocal edema – who knows? In the future, the importance of these signs in MRM should be tested in a multicenter study. It would also be prudent to include additional measuring techniques that are not currently in routine use, and to take into account other modalities such as ultrasound, PET, and clinical parameters. The influence of medications, hormones, and chemotherapies should also be considered. In the general analysis of breast diseases, a basic distinction is drawn between the description of focal breast lesions, called “mass lesions,” and regional or infiltrative lesions, called “non-mass lesions”. In this book we will use a consistent scheme for describing the morphologic and kinetic signs of a breast lesion: (1) definition of the sign, (2) an explanatory diagram, (3) an example, and (4) an explanation of how the sign is interpreted. The sequence of the signs is arbitrary. For a comprehensive diagnosis, the morphologic and kinetic signs should always be interpreted together. They should never be analyzed separately.
Fig. 4 Explanation of the images (an orange colour in the diagrams means “enhancement”, a blue colour reflects “water”, e.g. in cysts, ducts etc.
Sign
1
a No enhancement
1. Definition MRI signal intensity increases by less than 2% after the injection of 0.1 mmol/kg body weight gadolinium-DTPA or a similar contrast agent during the first 90 seconds after contrast injection and also within the first 7 minutes.
2. Diagram
3. Examples
4. Interpretation Sign 1 basically describes the response of normal, nonstimulated breast parenchyma to intravenous contrast administration. It can also be seen in scar tissue that is more than 6 months old. Basically this sign is a very strong indicator of a benign condition (adenosis, fibrous fibroadenoma, scar, fat necrosis, etc.). It should be noted, however, that this sign may also occur in malignant lesions following a technically flawed or inadequate contrast injection or if the patient has received chemotherapy in the recent past (i.e., weeks or months before the examination). It should be easy to identify these mitigating factors, however, and therefore sign 1 is considered a very strong indicator of benignancy.
Sign
2
a Slow wash-in
1. Definition (“Wash-in” describes the maximum rise of signal intensity that occurs during the first 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA or a similar contrast agent.) In cases with slow wash-in, the MRI signal intensity increases by less than 50% over the precontrast signal intensity within 90 seconds after injection of the contrast agent.
2. Diagram
3. Examples
4. Interpretation Sign 2 basically describes a slow rate of initial contrast enhancement. This pattern is typically seen in fibrous fibroadenomas, scars, and foci of adenosis. Hormonal effects relating to the normal menstrual cycle may cause a 10% to 20% change in this sign, with less enhancement occurring during the initial phase of the cycle and greater enhancement occurring during the second half of the cycle. The presence of sign 2 in a mass lesion most likely indicates a fibrous fibroadenoma or a scar. The presence of this sign in a non-mass lesion indicates either normal parenchyma, fibrosis, or mild inflammation (mastitis). Very rarely, carcinoma in situ may also display this sign, in which case the enhancement is asymmetrical and unilateral. It should be noted, however, that gradual enhancement may occur in carcinomas as a result of incomplete contrast injection, excessive compression, or chemotherapy in the recent past. It should also be noted that sign 2 depends strongly on the type of contrast agent that is used. An intravascular macromolecular contrast agent will have different wash-in characteristics than a smaller amount of extravascular contrast agent that can enter the interstitial space. Basically, however, sign 2 is considered a strong indicator of a benign lesion.
Sign
3
a Medium wash-in
1. Definition (“Wash-in” describes the maximum rise of signal intensity that occurs during the first 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA or a similar contrast agent.) Signal intensity increases by 50% to 90% over the precontrast level within 90 seconds after injection of the contrast agent.
2. Diagram
10
3. Examples
4. Interpretation The moderately intense initial enhancement of a mass lesion is most commonly seen in a fibroadenoma or papilloma. Less frequently it occurs in carcinomas after chemotherapy. Medium wash-in occurring in a non-mass lesion may indicate mastitis, a fresh scar, or a hormonal effect. If sign 3 is combined with a unilateral reticular dendritic pattern of enhancement, the lesion may be DCIS or an intralobular carcinoma with reticular growth.
11
Sign
4
a Fast wash-in
1. Definition A maximum signal increase of more than 90% occurs within 90 seconds after injection of the contrast agent (0.1 mmol/kg body weight gadolinium-DTPA). This sign is also known as the “90/90 rule.”
2. Diagram
12
3. Examples
4. Interpretation Rapid initial enhancement immediately after contrast administration is typical of invasive carcinoma but may also been seen in focal components of noninvasive carcinoma (DCIS). Approximately 20% of papillomas and myxoid fibroadenomas exhibit a fast wash-in curve. These benign tumors generally have well-circumscribed margins, a negative blooming sign, and usually have higher signal intensity than the surrounding parenchyma in T2-weighted turbo spin-echo (TSE) sequences. Sign 4 is also seen in severe inflammatory foci, but these lesions do not appear dark in T2-weighted TSE sequences. Foci of invasive carcinoma generally have irregular margins, a positive blooming sign, and appear dark on T2-weighted TSE images. On the whole, the presence of sign 4 is suggestive of malignancy, especially when combined with a plateau enhancement curve and/or a subsequent washout.
13
Sign
5
a Plateau curve
1. Definition No further rise of signal intensity occurs in the enhancement curve after 90 seconds or after the curve has started to change.
2. Diagram
3. Examples
14
4. Interpretation When the enhancement curve of a mass lesion plateaus after the initial upslope, a carcinoma or papilloma should be considered. This pattern is less commonly seen in myxoid fibroadenoma. Sign 5 is particularly common in papillomas, often developing from high initial precontrast signal intensities and often plateauing at any level, including levels above and below the range typical for carcinomas (see signs 85 to 87).
15
Sign
6
a Rising curve
1. Definition Progressive rise in the enhancement curve occurs after 90 seconds or after the curve has started to change.
2. Diagram
3. Examples
16
4. Interpretation Signal intensity that continues to increase after the initial wash-in most likely indicates a benign mass lesion such as myxoid fibroadenoma or papilloma. This sign is seen in only about 10% of carcinomas, mostly invasive lobular carcinoma or foci for DCIS.
17
Sign
7
a Washout curve
1. Definition A decline in signal intensity occurs after the initial upslope during the first 90 seconds or when the curve has started to change.
2. Diagram
18
3. Examples
4. Interpretation Washout, defined as a decline of signal intensity occurring after an initial rise, is the main kinetic criterion for breast cancer. The rapid washout of Gd-DTPA from these lesions is most likely caused by the arteriovenous shunts that exist within the network of tumor vessels. Rarely, washout is also seen in papillomas (approximately 20%) and myxoid fibroadenomas. The latter tumors are distinguished, however, by their significantly greater initial wash-in or their higher signal intensity on T2-weighted TSE images. Generally these lesions also have well-circumscribed margins, a negative blooming sign, no hook sign, and no perifocal edema. When a washout effect is observed, the breast should be surveyed by repeatedly changing the region of interest (ROI). The entire lesion should be described as having “positive washout.” Inflammatory carcinomas show washout in only a small portion of the tumor (approximately 10% of the total tumor area), while the rest of the tumor often shows a slower wash-in with a progressive rise in signal intensity.
19
Sign
8
a Round shape
1. Definition The round or spherical shape is defined in the first postcontrast image, usually 90 seconds after injection of the contrast agent.
2. Diagram
20
3. Examples
4. Interpretation A round mass lesion is frequently a cyst, myxoid fibroadenoma, or papilloma. Less commonly a myxoid or medullary carcinoma may appear round, although carcinomas will show at least some evidence of peripheral infiltration into surrounding tissues (positive hook sign, see signs 35 and 36). Very small invasive carcinomas approximately 5 mm in diameter may also appear relatively round and well-circumscribed. Carcinomas usually have low signal intensity on T2-weighted TSE images, however, and display a positive blooming sign.
21
Sign
9
1. Definition An elliptical or egg shape.
2. Diagram
22
a Oval shape
3. Examples
4. Interpretation Elliptical or oval shapes may occur with cysts, myxoid fibroadenomas, and papillomas. Myxoid carcinomas also have relatively well-defined rounded or oval margins. Circumscribed mastitis or a small noninvasive carcinoma (DCIS, approximately 5 mm in size) may have an oval shape with ill-defined margins. Generally these lesions will have a positive blooming sign or perifocal edema.
23
Sign
10
1. Definition An undulating contour.
2. Diagram
24
a Lobulated shape
3. Examples
4. Interpretation A wavy, lobulated contour is generally the hallmark of a benign lesion, as malignancy generally does not allow for regular, harmonious, undulating contours. The biochemical enzyme apparatus of a malignancy enables the tumor to grow aggressively into neighboring tissues. Cancer proteinases such as matrix metalloproteinases and cathepsins would obliterate well-defined contours. Lobulated contours are a frequent sign of complex cysts, complex papillomas, or myxoid fibroadenomas, which contain various compartments filled with mucus or mucus-like fluid of variable density. Sign 10 may also occur in fat necrosis, and in rare cases it may reflect a mucinous carcinoma that has not yet invaded its surroundings.
25
Sign
11
a Irregular shape
1. Definition An uneven shape; not round, oval, or lobulated.
2. Diagram
26
3. Examples
4. Interpretation Irregular contours of a mass lesion are generally the hallmark of invasive cancers such as invasive ductal carcinoma, lobular carcinoma, and other types. Some noninvasive carcinomas may also have at least partially irregular margins. Benign lesions that may produce sign 11 are fibrosis or perifocal inflammation around a percutaneously aspirated cyst. Of course, carcinomas generally show rapid initial wash-in and washout in addition to other typical malignant signs (blooming sign, hook sign, etc.). It should be reemphasized that a definitive diagnosis is always based on a comprehensive analysis of all observed signs.
27
Sign
12
a Well-circumscribed margins
1. Definition Lesion margins are assessed in the first postcontrast image, usually 90 seconds after the injection of 0.1 mmol/kg body weight gadolinium-DTPA. (Should not be confused with the blooming sign described below.)
2. Diagram
28
3. Examples
4. Interpretation Sharp, well-circumscribed margins are the hallmark of a cyst, fibrous fibroadenoma, myxoid fibroadenoma, or papilloma. Carcinomas rarely have margins that are truly well-circumscribed (e.g., occasional mucinous, tubular or medullary carcinomas), and very fine marginal infiltration can usually be seen in high-resolution images with a 512 matrix. Other signs of benignancy or malignancy (signal intensity on the T2-weighted TSE image, hook sign, root sign, wash-in, washout, etc.) will suggest the correct diagnosis.
29
Sign
13
a Irregular margins
1. Definition Uneven margins, may be round or spiculated; characterized by thin infiltrating lines.
2. Diagram
30
3. Examples
4. Interpretation Irregular margins are typical of invasive carcinomas as well as fibrotic scars with adenosis. Inflammatory masses also tend to have irregular margins (mastitis, abscess), especially after percutaneous biopsy.
31
Sign
14
a Blooming sign
1. Definition The lesion margins are sharply defined in the first postcontrast image, then become increasingly unsharp just outside the lesion.
2. Diagram
3. Examples
32
4. Interpretation Very rare in benign lesions, the blooming sign is a typical feature of invasive carcinoma. It may be caused by closely adjacent perifocal inflammation or the activation of tumor angiogenesis. An extensive blooming sign (see signs 124 and 125) may represent a perifocal noninvasive tumor component (DCIS).
33
Sign
15
a Constant sharpness sign
1. Definition The lesion remains sharply defined throughout the dynamic study. Sharp margins are maintained until the last dynamic postcontrast image (usually 7 minutes after contrast injection).
2. Diagram
34
3. Examples
4. Interpretation Constant sharpness throughout the dynamic study generally signifies a benign lesion, i.e., a fibroadenoma or papilloma. Rarely, medullary carcinomas may also appear sharp throughout the dynamic scans, but in most cases they display subtle infiltrative signs and a blooming sign. Most lymphomas are sharply circumscribed initially but show increasing peripheral unsharpness by the third or fifth image.
35
Sign
16
a Homogeneous enhancement
1. Definition Complete, uniform enhancement in all portions of the mass.
2. Diagram
36
3. Examples
4. Interpretation Homogeneous contrast enhancement throughout a mass lesion is not characteristic of carcinomas. Some very small cancers may have this appearance, but most will show centripetal ring enhancement and fine peripheral spiculations. Homogeneous enhancement is far more common in benign lesions such as papilloma and myxoid fibroadenoma. A fibroadenoma is particularly likely if the lesion also has higher signal intensity than the rest of the parenchyma on the T2-weighted TSE image and does not exhibit a blooming sign.
37
Sign
17
a Heterogeneous enhancement
1. Definition Mixed granular enhancement within the mass; nonspecific enhancement that does not show a ring pattern.
2. Diagram
38
3. Examples
4. Interpretation Heterogeneous enhancement is typical of calcified macrofibroadenoma. Benign or malignant lesions may also display this sign following percutaneous biopsy or hemorrhage. A non-ring pattern of heterogeneous enhancement is generally less common in malignant lesions but may be seen in lobular carcinoma.
39
Sign
18
a Centrifugal enhancement
1. Definition The enhancement is initially more pronounced at the center of the mass and then spreads toward the periphery (“filling in from inside to outside”).
2. Diagram
40
3. Examples
4. Interpretation Centrifugal enhancement does not support a diagnosis of carcinoma and is much more consistent with a benign lesion. This suspicion is strengthened by noting additional benign signs such as wellcircumscribed margins, a negative blooming sign, absence of perifocal edema, a constant sharpness sign, increased signal intensity on the T2-weighted TSE image, etc.
41
Sign
19
a Centripetal enhancement
1. Definition Peripheral ring enhancement occurs initially and then spreads toward the center of the mass (“filling in from outside to inside”).
2. Diagram
42
3. Examples
4. Interpretation Centripetal enhancement is the classic enhancement pattern of carcinoma. The portions of the tumor that are most viable and have the best blood supply are located at the periphery of the mass and show the greatest contrast uptake. The center of the tumor, meanwhile, is an area of necrosis, fibrosis, or hemorrhage, causing a delay in contrast uptake. The diagnosis of carcinoma is supported by additional malignant signs such as fast wash-in, washout, low T2-weighted TSE signal intensity, a blooming sign, root sign, hook sign, perifocal edema, elevated choline, and a low ADC.
43
Sign
20
a Dark internal septations
1. Definition Sharp, low-intensity, nonenhancing lines visible within the mass throughout the dynamic study.
2. Diagram
44
3. Examples
4. Interpretation Hypointense, nonenhancing septations within a lesion are generally a benign sign, because a carcinoma wound tend to erode, infiltrate, or break down internal septa. The diagnosis of a benign lesion is further supported by additional benign signs such as high signal intensity on the T2-weighted TSE image, a negative blooming sign and root sign, absence of perifocal edema, high ADC, etc.
45
Sign
21
a Enhancing internal septations
1. Definition Lines within a mass that enhance after contrast administration.
2. Diagram
46
3. Examples
4. Interpretation Enhancing septations within a mass lesion are very suspicious for an inflammatory process (abscess) or a malignant tumor. Generally they do not indicate invasive ductal carcinoma, however. They are more characteristic of a metastasis, lymphoma, medullary carcinoma, lobular carcinoma, or an illdefined linear necrotic area within a carcinoma. I have seen several metastases from cervical carcinoma, ovarian carcinoma, renal carcinoma, or lymphoma that had some benign morphologic features such as sharp margins and an intact retromammary fat layer between the breast and pectoralis muscle, but also had enhancing internal septations. Some compartments in these metastases were even hyperintense on the T2-weighted image. The only malignant signs were enhancing internal septa and a washout effect in viable tumor tissue.
47
Sign
22
a Segmental enhancement
1. Definition Granular, triangular area of enhancement pointing toward the nipple. This sign may be present in one or more ducts. All types of enhancement curve may be seen. Usually limited to one breast.
2. Diagram
48
3. Examples
4. Interpretation A segmental, usually triangular area of enhancement pointing toward the nipple is a typical sign of noninvasive carcinoma (DCIS), particularly when it is unilateral and is relatively well demarcated from other, unaffected areas of the breast parenchyma. The segmental pattern refers to the overall collection of small foci and/or infiltrative changes, which have a granular or reticular appearance. Mastitis may appear as a triangular enhancing area, but this is uncommon. Generally the inflammatory segmental enhancement has a hazier, more confluent appearance than DCIS and is most clearly demonstrated on axial and coronal images.
49
Sign
23
a Inflow enhancement
1. Definition Segmental bilateral enhancement, usually in the upper outer quadrant, showing a continuous, synchronous, symmetrical increase of signal intensity in both breasts throughout the dynamic study.
2. Diagram
50
3. Examples
4. Interpretation Bilateral, symmetrical, synchronous, continuous enhancement in the upper outer quadrant reflects the bilateral, physiologic inflow of contrast material through the lateral thoracic artery, which mainly supplies the upper outer quadrant. It is almost always a benign sign. Bilateral DCIS or upper outer quadrant mastitis would be extremely unlikely, and I have never observed the inflow sign in either condition. In rare cases the breast parenchyma may be asymmetrically distributed on one side relative to the opposite side, resulting in a unilateral inflow sign. But a look at the precontrast images or T2-weighted images will quickly explain the unilateral inflow enhancement. Inflow enhancement may occur through the internal mammary artery in young women with very dense breast parenchyma, producing an inflow sign in the upper inner quadrant of both breasts.
51
Sign
24
a Regional unilateral enhancement
1. Definition Enhancement in a large tissue volume not confined to a ductal distribution. Present only in one breast, absent in the contralateral breast.
2. Diagram
52
3. Examples
4. Interpretation Regional unilateral enhancement may reflect an anomalous parenchymal structure in which some parenchymal areas have increased density. It may also be a sign of focal inflammation or noninvasive carcinoma (DCIS), but in rare cases it may reflect inflammatory carcinoma or lobular carcinoma. In these cases, however, additional kinetic and morphologic signs such as wash-in, washout, T2-weighted signal intensity, and other signs will suggest the correct diagnosis.
53
Sign
25
a Multiple unilateral regional enhancement
1. Definition Enhancement occurring in at least two large tissue volumes not confined to a ductal distribution. Multiple patchy, geographic areas of enhancement are present only in one breast and are absent in the contralateral breast.
2. Diagram
54
3. Examples
4. Interpretation Unilateral, patchy, regional enhancement patterns may occur in multifocal bacterial inflammation, usually with staphylococci (Staphylococcus aureus), as well as in inflammatory carcinoma, lobular carcinoma, and extensive areas of DCIS. Inflammatory carcinoma will also display other signs of inflammation such as diffuse edema, prepectoral edema, a punched-out sign, etc. Inflammatory carcinoma and mastitis, unlike lobular and noninvasive carcinoma, are generally associated with elevated inflammatory serologic markers (CRP, etc.). On careful questioning, the patient may give a recent history of inflammation elsewhere in the body (sinusitis, mastoiditis, bronchitis, etc.) and state that one breast is slightly tender to palpation and compression while the other is not. Pronounced clinical signs of inflammation such as skin redness, orange-peel skin, and breast enlargement are rare. In cases where sign 25 coexists with clinical and serologic parameters, anti-inflammatory therapy should be initiated (e.g., antibiotics), and a relatively short-term MRI follow-up should be scheduled in approximately 2–3 months. This is one of the few indications for short-term follow-up, due to the possibility of shortterm changes in the MRI findings. This does not occur with most breast cancers due to their relatively slow doubling rates, and hence there is no need to reexamine cancer patient at close intervals.
55
Sign
26
a Multiple bilateral regional enhancement
1. Definition Patchy areas of enhancement in both breasts.
2. Diagram
56
3. Examples
4. Interpretation Multiple areas of regional enhancement in both breasts is the classic manifestation of hormone replacement therapy (HRT), especially if regional enhancement disappears when the therapy is discontinued. Less frequently, bilateral inflammation or bilateral lobular or inflammatory carcinoma should be considered. Generally the diagnosis is established by a positive history of HRT, and it may be confirmed if needed by the determination of serologic parameters such as CRP. I have also seen patients on HRT who additionally had bilateral breast cancer. In these cases, however, a persistence of bilateral multifocal enhancement is noted even after hormone therapy is withdrawn. (Unlike malignant signs, HRT-related effects are always reversible after the hormones are discontinued for more than 1–3 months.)
57
Sign
27
a Diffuse unilateral enhancement
1. Definition Uniform enhancement is present in one breast and is absent in the contralateral breast.
2. Diagram
58
3. Examples
4. Interpretation Diffuse, unilateral enhancement in one breast with absence of enhancement in the opposite breast is generally a sign of severe inflammation or diffuse tumor infiltration (e.g., by lymphoma). Advanced inflammatory carcinoma is another possibility. Rare causes are contralateral vascular anomalies (unilateral atrophy or malformation of an internal mammary artery, unilateral or contralateral vascular obstruction due to radiotherapy, scarring). I remember one case of unilateral enhancement in which the patient had received radiotherapy as an infant for puerperal mastitis, resulting in severe hypomastia with associated hypovascularity.
59
Sign
28
a Diffuse bilateral enhancement
1. Definition Enhancement distributed uniformly throughout both breasts in a simultaneous, symmetrical, synchronous pattern.
2. Diagram
60
3. Examples
4. Interpretation Diffuse, bilateral breast enhancement that goes well beyond physiologic enhancement may result from the overadministration of contrast material (e.g., a triple dose instead of a single dose). A much less frequent cause is severe bilateral mastitis due to bilateral sepsis or bilateral tumor involvement (e.g., by lymphoma).
61
Sign
29
a Stippled enhancement
1. Definition Finely speckled or sand-like pattern of punctate enhancement.
2. Diagram
62
3. Examples
4. Interpretation Numerous punctate foci of enhancement often reflect a focal inflammation or postbiopsy finding at the affected site, with or without associated hemorrhage. A noninvasive carcinoma (DCIS, LCIS) may have the same appearance in rare cases. This finding is not typical of invasive carcinomas, except for occasional lobular cancers that show gradual contrast enhancement in their initial stage. Differentiation is usually accomplished by noting response to a trial of antibiotic therapy: focal inflammation will resolve with an approximately 3-month course of antibiotics, whereas carcinoma will not.
63
Sign
30
a Cobblestone enhancement
1. Definition Cobblestone pattern of enhancement with occasional confluent areas.
2. Diagram
64
3. Examples
4. Interpretation Cobblestone-like enhancing foci are typical of lobular cancer nests that are linked together in a reticular pattern. Invasive intraductal cancer accompanied by noninvasive cancer (mixed invasive and noninvasive cancers) may also show this pattern on histologic examination, and pure nests of DCIS may have a cobblestone appearance on postcontrast images. Less likely possibilities are focal inflammation and localized infection secondary to fine-needle or core biopsy. In the absence of inflammatory serologic markers, all areas of cobblestone enhancement in the breast should be histologically investigated.
65
Sign
31
a Reticular (dendritic) enhancement
1. Definition Enhancement with finger-like or reticular projections extending toward the nipple.
2. Diagram
66
3. Examples
4. Interpretation Linear or branched patterns of enhancement in the breast are a hallmark of noninvasive carcinoma (DCIS, LCIS). Rarely they may also be an initial sign of lobular carcinoma, but these cases will show additional malignant signs such as malignant-type wash-in, washout, etc. In very rare cases, reticular dendritic enhancement may reflect the selective inflammation of a single duct system following biopsy or duct obstruction by an intraductal papilloma.
67
Sign
32
a Hypointensity on T2-weighted TSE images
1. Definition The signal intensity of the viable portions of the lesion on T2-weighted turbo spin-echo images is lower than the signal intensity of normal surrounding breast parenchyma.
2. Diagram
68
3. Examples
4. Interpretation A mass lesion whose T2-weighted signal intensity is less than or at most equal to that of the normal glandular tissue may be a carcinoma or fibrous fibroadenoma. The latter, of course, shows entirely different wash-in and washout kinetics. Carcinomas produce a classic wash-in and washout curve and display additional malignant signs such as a hook sign, root sign, perifocal edema, etc. All scars, including radial scars, also have low signal intensity on T2-weighted images.
69
Sign
33
a Isointensity on T2-weighted TSE images
1. Definition The signal intensity of the viable parts of the lesion on T2-weighted turbo spin-echo images is in the same range as that of normal surrounding breast parenchyma.
2. Diagram
70
3. Examples
4. Interpretation Carcinomas may have the same signal intensity as the surrounding glandular tissue on the T2weighted TSE image, but they are usually hypointense to breast parenchyma. Isointensity is typically seen in fibrous fibroadenomas and myxoid fibroadenomas that have slight intralesional hemorrhage after biopsy. Most myxoid fibroadenomas have considerably higher signal intensity on T2-weighted images. Fibroadenomas generally have well-circumscribed margins and typical wash-in and washout kinetics that distinguish them from carcinomas.
71
Sign
34
a Hyperintensity on T2-weighted TSE images
1. Definition The signal intensity of the viable parts of the lesion on T2-weighted turbo spin-echo images is higher than that of normal surrounding breast parenchyma. Areas of intratumoral necrosis, if present, are disregarded.
2. Diagram
72
3. Examples
4. Interpretation If a lesion is described as hyperintense or “bright” on T2-weighted images, this means that it has higher signal intensity than the surrounding breast parenchyma. It does not necessarily have extremely high signal intensity like that occurring in cysts with fluid contents of varying proton density and protein concentration. Hyperintensity is an important differentiating criterion between myxoid fibroadenomas and carcinomas. Carcinomas are dark on the T2-weighted TSE image, while myxoid fibroadenomas are generally brighter than the glandular tissue. T2-weighted hyperintensity is a very strong indicator of myxoid fibroadenoma. The mucous component of this benign tumor is responsible for the high signal intensity. Rarely, increased signal intensity is also found in papillomas and sometimes in the mucous portions of mucinous carcinoma. By contrast, the viable portions of mucinous carcinoma have low signal intensity, probably due to microhemorrhages in the network of tumor vessels. This sign is very useful in the differential diagnosis of intensely enhancing mass lesions, as more than 98% of malignant tumors are iso- or hypointense. It should be reemphasized that only the viable portions of a carcinoma are evaluated. Necrotic areas, which generally have high T2-weighted signal intensity, should be ignored.
73
Sign
35
a Hook sign
1. Definition The hook sign is a fine, thread-like connection passing from the lesion to the pectoralis muscle. Usually this line shows little or no enhancement after contrast administration.
2. Diagram
74
3. Examples
4. Interpretation The hook sign in a lesion with a malignant-type enhancement curve strongly supports a diagnosis of carcinoma. Found in many carcinomas, the hook sign may be quite small and may even extend a considerable distance from the pectoralis muscle. We can only speculate as to the cause. It may be that even a small carcinoma has a biochemistry capable of producing all aggressive changes necessary for initiating metastasis and uses this “hook” process to establish a connection to the pectoralis. With current technology, it is not always clear whether this very thin line between the tumor and pectoralis muscle enhances after contrast administration. If it does enhance, peritumoral lymphangiosis is generally detected on subsequent histologic examination. It is difficult to confirm the hook sign histologically because the gross cutting edge of the surgeon’s scalpel tends to slice through the region between the carcinoma and pectoralis, and pathologic processing must be extremely precise to preserve and identify this sign. The hook sign is not confirmed pathologically in 50% of cases. In the other 50% the pathologist may describe either a “desmoplastic reaction” or subtle “carcinomatous lymphangiosis.” The hook sign may also result from postoperative scarring or from a healed inflammation. In these cases, however, it almost never enhances and represents a thin fibrotic line. These cases can be identified from the patient’s history and from information in the previous operative report. 75
Sign
36
a Root sign
1. Definition The root sign refers to a localized irregularity, usually enhancing, in the margins of a lesion.
2. Diagram
76
3. Examples
4. Interpretation The root sign is a small irregularity in the margins of a lesion that is otherwise sharply circumscribed. This feature may represent a fibroadenoma with localized peripheral fibrosis or a well-circumscribed carcinoma, usually of the medullary type, with an associated DCIS border. Of course, the lesion is more likely to be carcinoma if it shows ring enhancement with typical wash-in and washout kinetics.
77
Sign
37
a Pectoralis muscle invasion
1. Definition Thick, mostly enhancing connections passing from the lesion into the pectoralis muscle, much larger than the hook sign.
2. Diagram
78
3. Examples
4. Interpretation If a lesion already has conspicuous, enhancing connections with the pectoralis muscle, it is almost always an invasive cancer. This finding signifies carcinomatous lymphangiosis in an untreated, previously unoperated breast. If the breast was previously operated (determined from the history) and these infiltrating strands show little or no contrast enhancement, the lesion is most likely a recent or older scar, depending on the enhancement and the time that has elapsed since the operation. The intensity of the enhancement is inversely proportional to the degree of fibrosis, and thus to the time since the operation. Another possibility is the presence of residual or recurrent carcinoma combined with a fibrotic area within a scar.
79
Sign
38
a Unilateral perifocal edema
1. Definition Small, complete or incomplete ring of edema around an enhancing lesion.
2. Diagram
80
3. Examples
4. Interpretation An edematous area around a lesion in a previously untreated breast is a strong indicator of carcinoma. It suggests a high grade of malignancy and a relatively poor prognosis. A likely explanation is the increased activity of tumorspecific angiogenic enzymes – like matrix-metallo-proteinases – in close proximity to the tumor or in the ipsilateral breast. If the patient has had previous breast surgery or radiation to the breast, this may be another cause of unilateral edema around a lesion.
81
Sign
39
a Unilateral edema
1. Definition The presence of edema in one breast (detectable in T2w-TSE or – better – in STIR-images).
2. Diagram
82
3. Examples
4. Interpretation Edema that occupies practically an entire breast is typical of inflammatory carcinoma and occurs occasionally with lobular carcinoma. Generally the extent of edema is appreciated more clearly in a STIR sequence than in a T2-weighted TSE sequence. But if there has been previous surgery or radiotherapy to the breast, this might also explain unilateral edema. Edema is particularly common after radiotherapy and may persist for many years. I have seen cases of unilateral edema lasting for 12–16 years after radiotherapy. Lobular carcinoma and inflammatory carcinoma should, however, contain at least one area that displays malignant-type wash-in or washout kinetics or decreased signal intensity on T2-weighted images.
83
Sign
40
a Intact ligament sign
1. Definition Ligament continuity is not disrupted by an enhancing lesion. The lesion does not interrupt or “dissolve” the ligament. This sign is best appreciated on T2-weighted images.
2. Diagram
84
3. Examples
4. Interpretation The intact ligament sign generally indicates a benign lesion. This type of lesion does not have proteolytic enzymes (cathepsins, matrix metalloproteinases, etc.) that dissolve surrounding structures; instead it conforms to the parenchymal architecture. Most of these lesions are fibroadenomas or papillomas. Fibroadenomas also present the typical signs of either a fibrous fibroadenoma, which shows gradual progressive enhancement and low T2-weighted signal intensity, or a myxoid fibroadenoma, which shows very intense initial enhancement, a continuous signal rise, and high T2-weighted signal intensity.
85
Sign
41
a Disrupted ligament sign
1. Definition Ligament continuity is disrupted by an enhancing lesion. The lesion appears to have “dissolved” the ligament (opposite to the intact ligament sign). This sign is best appreciated on T1-weighted images.
2. Diagram
86
3. Examples
4. Interpretation If a lesion can dissolve surrounding ligaments, this generally signifies malignant tumor angiogenesis, i.e., an invasive carcinoma. A small focal abscess is extremely rare.
87
Sign
42
a Prepectoral unilateral edema
1. Definition Edema located directly in front of the pectoralis muscle.
2. Diagram
88
3. Examples
4. Interpretation Edema directly in front of the pectoralis muscle in an untreated breast is another reasonably strong indicator of carcinoma. The cause is probably incipient invasion and increased activity of angiogenic enzymes along the front of the pectoralis muscle. Like all edematous signs, this sign is seen more clearly in STIR sequences than in T2-weighted TSE sequences. As with other signs, prepectoral unilateral edema in a previously operated or irradiated breast is most likely iatrogenic and does not indicate a need for treatment in the absence of other enhancing breast lesions. Postirradiation edema may be detectable for a very long time (we have seen cases lasting 16 years). It remains unclear why the prepectoral location of the edema is relatively typical of tumors but extremely rare in mastitis. Like malignant wash-in and washout, centripetal ring enhancement, and the blooming, hook and root signs, sign 42 is considered very typical of breast malignancies.
89
Sign
43
a Intact nipple line
1. Definition Slowly enhancing line along the base of the nipple, usually hypointense. Any disruption of this line is abnormal.
2. Diagram
90
3. Examples
4. Interpretation Less enhancement is seen around the base of the nipple than at its tip. This sign most likely correl ates with fibrosis, but partial volume averaging may also be contributory. This zone of relatively low enhancement should always be detectable and is the criterion for a normal nipple. If carcinoma-type wash-in or washout is seen within this zone, it is reasonable to assume that tumor has invaded the nipple (Paget disease).
91
Sign
44
a Disrupted nipple line
1. Definition Focal area of enhancement within the normally hypointense, slowly enhancing line at the base of the nipple.
2. Diagram
92
3. Examples
4. Interpretation Any disruption of the hypointense nipple circumference by an adjacent enhancing lesion, especially one showing malignant wash-in or washout kinetics, signifies tumor involvement of the nipple, usually in the form of Paget disease or DCIS. This interpretation is supported by additional signs of malignancy.
93
Sign
45
a Unilateral precontrast high intraductal signal on T1-weighted images
1. Definition Branched or unbranched lines of high signal intensity located directly behind the nipple of one breast on unenhanced T1-weighted images.
2. Diagram
94
3. Examples
4. Interpretation High signal intensity within a duct system on the unenhanced T1-weighted image is considered to represent milk or blood. This sign is most commonly found in a duct system obstructed by papilloma or in a lactating breast. Unilateral high intraductal signal occurs in cases where an interventional procedure (surgery or radiotherapy) has been done in the opposite breast or the patient was treated with radiation in early childhood (e.g., for puerperal mastitis). This sign may also result from residual intraductal bleeding after ductography or attempted ductography.
95
Sign
46
a Bilateral precontrast high intraductal signal on T1-weighted images
1. Definition Branched or unbranched lines of high signal intensity located directly behind the nipple of both breasts on unenhanced T1-weighted images.
2. Diagram
96
3. Examples
4. Interpretation Bilateral increased signal intensity in both duct systems on unenhanced T1-weighted images (T1-weighted FLASH, FFE or GRASS sequences) is a normal finding in lactating women. Rare alternative causes are bilateral papillomas or a pituitary adenoma with elevated prolactin levels stimulating both duct systems and leading to engorgement.
97
Sign
47
a Nipple retraction
1. Definition The nipple is withdrawn into the retroareolar tissue. No specific nipple profile is detectable.
2. Diagram
98
3. Examples
4. Interpretation Retraction of the nipple is particularly suspicious in cases that show unilateral nipple enhancement or even a malignant-type enhancement pattern. A nonenhancing retracted nipple is either a normal variant or a sequel to prior inflammation (puerperal mastitis), irradiation, or postoperative scarring.
99
Sign
48
a Asymmetric nipple enhancement
1. Definition The nipple in one breast enhances more (faster or longer) than the nipple of the contralateral breast (measured at the same time after contrast injection, without breast compression).
2. Diagram
3. Examples
100
4. Interpretation Ordinarily both nipples enhance at the same rate and with the same intensity in any given patient. There are normal variants, however, relating to the size of the breast and possible compression of the mammary artery or lateral thoracic artery. Local inflammation may also underlie asymmetric enhancement. Today this condition is often found in athletic patients whose clothing rubs against their nipple during exercise (“jogger’s nipple”). Asymmetric enhancement, often associated with malignant-type wash-in and washout curves and low signal intensity on T2-weighted TSE images, is suggestive of malignant invasion (Paget disease or DCIS).
101
Sign
49
a Diffuse unilateral skin thickening
1. Definition The skin of one breast is thicker than the skin of the contralateral breast.
2. Diagram
102
3. Examples
4. Interpretation Diffuse thickening of the skin of one breast is a common sequel to radiotherapy, surgery, or previous inflammation. It may also be seen with inflammatory carcinoma, but generally this disease is associated with other enhancing lesions and edema (especially prepectoral) in the affected breast. Previous surgery or irradiation is readily determined from the history. Inflammation should be associated with elevation of CRP or other serologic markers. Inflammatory carcinoma is characterized by enhancing lesions and often displays a punched-out sign (sign 62).
103
Sign
50
a Normal lymph nodes
1. Definition Oval lymph nodes less than 1 cm in size with a detectable hilar sign.
2. Diagram
104
3. Examples
4. Interpretation Normal lymph nodes are generally displayed best on axial T2-weighted TSE images, which are less affected by cardiac phase-encoding artifacts than gradient-echo images from the dynamic scans. Lymph nodes can be identified in other planes as well (coronal or lateral sagittal). Today the analysis of lymph nodes is based chiefly on their morphology. Normal criteria include an oval shape, small short-axis diameter usually (less than 5 mm, but at least less than 1 cm), and a detectable hilar sign with a hyperintense center on T2-weighted TSE images. These criteria do not exclude the presence of tiny micrometastases, however. The use of specific iron-based contrast agents (USPIO = ultrasmall particles of iron oxide) may hold a future solution to this problem.
105
Sign
51
a Small round lymph nodes
1. Definition Round, enhancing lymph nodes less than or equal to 1 cm in diameter, with homogeneous signal intensity on T1- and T2-weighted images. A hilar sign is not detectable.
2. Diagram
106
3. Examples
4. Interpretation The interpretation of this sign depends strongly on the prior history (what was done in this breast, and when?) and on the presence of carcinoma in the ipsilateral breast. Small round lymph nodes are best appreciated on T2-weighted TSE images in axial or coronal planes of section. They may result from reactive lymphadenopathy due to surgery or radiotherapy or enlargement due to inflammation. Small inflammatory carcinomas or micrometastases are another possibility, and USPIO contrast agents may one day be used to confirm this diagnosis. If lymph nodes show malignant-type wash-in and washout kinetics after the injection of Gd-DTPA and carcinoma has been found in the ipsilateral breast, operative treatment should definitely include the removel of these nodes.
107
Sign
52
a Large lymph nodes
1. Definition Round, enhancing lymph nodes greater than 1 cm in diameter, with homogeneous signal intensity on T1- and T2-weighted images. A hilar sign is not detectable.
2. Diagram
108
3. Examples
4. Interpretation Large lymph nodes are almost always malignant or metastatic when they are round, have no detectable hilum, and enhance intensely after contrast administration. This diagnosis is essentially confirmed by the presence of carcinoma in the ipsilateral breast. It is my personal belief that when large enhancing lymph nodes are found in the presence of ipsilateral carcinoma and all morphologic and kinetic signs (wash-in, washout, root sign, hook sign, perifocal edema, low T2-weighted signal intensity), there is probably no need for a sentinel lymph node dissection. As it is extremely likely that the sentinel node is positive, it should be removed and histologically examined.
109
Sign
53
a Pleural effusion < 7 mm
1. Definition The thickness of the pleural effusion on T2-weighted images, with the patient lying prone in the scanner, is less than 7 mm in the anteroposterior direction.
2. Diagram
110
3. Examples
4. Interpretation When the patient lies prone, pleural fluid flows anteriorly and can be detected in the retrocostal and retropectoral planes, appearing as a crescent-shaped hyperintense zone on T2-weighted images. A fluid layer up to 7 mm thick (measured anteroposteriorly) is considered normal.
111
Sign
54
a Pleural effusion > 7 mm
1. Definition The thickness of the pleural effusion on T1-weighted images, with the patient lying prone in the scanner, is greater than 7 mm in the anteroposterior direction.
2. Diagram
112
3. Examples
4. Interpretation A pleural effusion thicker than 7 mm in the anteroposterior direction is no longer considered normal. It may represent a pleural metastasis, pneumonia (with concomitant increased signal intensity in the lung), or severe congestive heart failure (especially when bilateral).
113
Sign
55
a Eclipse sign
1. Definition Sharply demarcated enhancement around a cyst, resembling a solar eclipse, following percutaneous cyst aspiration (may persist for months).
2. Diagram
114
3. Examples
4. Interpretation A sharply circumscribed ring of enhancement encircling a conspicuous cyst, combined with a history of previous needle biopsy, almost always indicates perifocal inflammation. We know from experience that these inflammations are much more common than was once believed (before MR mammography). They may be left alone unless postcontrast images show solitary, nodular enhancing lesions with malignant wash-in and washout kinetics. These lesions are most likely accompanying carcinomas (or, less commonly, focal abscesses) and should be extirpated. I have found that a round, thin, well-defined crescent-shaped border with a continuous enhancement curve almost always signifies a benign (lymphocytic, inflammatory) infiltrate. In patients with clinical manifestations such as tenderness to palpation, anti-inflammatory or antibiotic therapy should be initiated.
115
Sign
56
a Signet ring sign
1. Definition Sharply demarcated ring enhancement around a cyst, plus an attached enhancing nodule.
2. Diagram
116
3. Examples
4. Interpretation The signet ring sign is often seen following a cyst biopsy. Usually there are no clinical manifestations of infection such as fever or tenderness, but the ring enhancement, adjacent enhancing nodule, and history of cyst biopsy clearly suggest the correct diagnosis. The only other possibility to be considered is a tumor adjacent to a cyst. If a cyst biopsy has not been performed, the signet ring sign is strongly suggestive of mucinous carcinoma, as this tumor has both a solid enhancing component and a cystic component. This is an urgent indication for excision and histologic confirmation.
117
Sign
57
a Shot-through sign
1. Definition Two or more enhancing spots on opposite sides of an enhancing cyst after biopsy (may persist for months).
2. Diagram
118
3. Examples
4. Interpretation In patients with a history of percutaneous biopsy, this sign almost always results from penetration of a cyst by a biopsy needle at two opposing sites in the cyst wall. In the absence of clinical symptoms, the patient should be reexamined in approximately 2 years. If clinical symptoms are present (e.g., local pain and tenderness, subfebrile temperatures, inflammatory signs), anti-inflammatory or antibiotic therapy is recommended. In theory, a shot-through sign could be seen in a mucinous carcinoma with two separate solid foci on different sides of a cystic component, but I have never encountered this. This type of case would be marked by an absence of clinical inflammatory signs.
119
Sign
58
a Unchanged enhancement curve
1. Definition No change in the tumor enhancement curve after chemotherapy.
2. Diagram
120
3. Examples
4. Interpretation Even an initial cycle of chemotherapy should markedly reduce tumor wash-in and should round off the “cancer breakpoint” in the enhancement curve. If the breakpoint is still present even after two chemotherapy cycles, this strongly indicates that the cytostatic therapy has basically been ineffective and should be modified.
121
Sign
59
a Changed enhancement curve
1. Definition Definite change in the tumor enhancement curve after chemotherapy, resulting in decreased wash-in and rounding of the cancer breakpoint.
2. Diagram
3. Examples
122
4. Interpretation A significant change in the enhancement curve after one or two chemotherapy cycles is very strong evidence that initial chemotherapy has been highly effective. The rapid wash-in, cancer breakpoint, and subsequent washout seen prior to chemotherapy are transformed after chemotherapy into a gently rising curve. It should be noted that the analysis of enhancement curves is always based on the most intensely enhancing portion of a tumor. For example, 90% of the tissue in a patchy carcinoma may show a progressively rising enhancement curve. But if approximately 10% of the lesion shows malignant-type wash-in and washout, the entire tumor should be interpreted as malignant. The shape of the curve may be so radically altered that almost no enhancement is registered after the completion of chemotherapy. We know from experience, however, that this does not mean that all the tumor cells have been destroyed. It is more likely that the toxic action of the cytostatic drugs has damaged vascular structures to such a degree that there is no longer any detectable uptake of GdDTPA by the tumor. I have seen cases with a complete loss of enhancement in which at least some tumor cells were still discovered on histologic examination. Additional signs such as the “camouflage sign” and “dissolving cancer sign” (signs 135 and 136) should also be considered in these cases.
123
Sign
60
a “Taller than wide” sign
1. Definition The anteroposterior (vertical) diameter of a lesion is larger than its left-right (transverse) diameter.
2. Diagram
124
3. Examples
4. Interpretation The “taller than wide” sign was first used in ultrasonography to describe the relationship of the anteroposterior diameter of a lesion to its transverse diameter. If the anteroposterior diameter parallel to the ductal structures is greater than the diameter antiparallel to the ductal structures, the lesion is more likely to be malignant. This orientation means that the lesion is directed toward the nipple and is growing parallel to the duct system. This sign should always be interpreted within the context of other signs, as it is relatively nonspecific; a substantial minority of carcinomas are “wider than tall.” But if additional malignant signs are present such as wash-in, washout, low T2-weighted signal, hook sign, root sign, perifocal edema, high choline, low ADC, etc., this would support the diagnosis of a malignant lesion.
125
Sign
61
a “Wider than tall” sign
1. Definition The anteroposterior (vertical) diameter of a lesion is smaller than its left-to-right (transverse) diameter.
2. Diagram
126
3. Examples
4. Interpretation This sign, like the previous one (sign 60), originated in ultrasonography. If the left-right or transverse diameter of a lesion is larger than its anteroposterior or vertical diameter, this means that the lesion is not growing parallel to ductal structures. This pattern is more characteristic of benign lesions. As with the previous sign, however, it is important to consider additional signs of benignancy (slow wash-in, progressive enhancement, higher T2-weighted signal intensity, no blooming sign, hook sign, or root sign, constant sharpness sign, no choline, high ADC, etc.) to confirm the diagnosis.
127
Sign
62
a Punched-out sign
1. Definition Focal, circumscribed initial enhancement within thickened skin, showing a malignant-type pattern with strong initial wash-in followed by a plateau or washout curve. All other portions of the thickened skin show gradual, progressive enhancement.
2. Diagram
128
3. Examples
4. Interpretation Focal initial enhancement within thickened skin, usually showing all the kinetic signs of carcinoma such as strong wash-in and a plateau or washout curve, is a very strong sign of inflammatory carcinoma, especially when other malignant-type lesions are present in the breast. The initial malignanttype enhancing lesion is subsequently “absorbed” by progressive enhancement of the surrounding thickened skin, with delayed images showing high signal intensity throughout the skin. I have seen this punched-out sign in only one case of true mastitis; otherwise I have seen it only in association with inflammatory carcinoma. When present, it is highly specific for cancer.
129
Sign
63
a Bilateral symmetric edema
1. Definition Symmetric edema in both breasts.
2. Diagram
130
3. Examples
4. Interpretation Bilateral symmetric edema is best demonstrated in fat-saturated STIR sequences but is also appreciated in T2-weighted TSE sequences. Generally it results from a systemic underlying disease such as heart failure. Exceptions (suggested by the typical patient history) are cases that have had bilateral breast surgery and/or bilateral radiotherapy.
131
Sign
64
a Skin retraction
1. Definition Local indentation or dimpling of the skin.
2. Diagram
132
3. Examples
4. Interpretation The new occurrence of skin retraction is a classic sign of carcinoma, especially if a malignant-type enhancing mass is detected in the same breast. In the absence of a detectable mass and with no prior history of surgery or irradiation, skin retraction most likely represents a scar or a sequel to chemotherapy. Thin fibrotic lines are generally detectable between the lesion and skin, and sometimes the lines may show faint contrast enhancement. In rare cases with technical problems (e.g., faulty contrast injection), skin retraction may represent carcinoma in the absence of a correlative enhancing lesion. Of course, skin retraction may also occur after surgery and radiotherapy. In these cases it will be accompanied by additional signs such as generalized cutaneous edema or ipsilateral breast edema with scar formation and obliteration of the fat plane over the pectoralis muscle.
133
Sign
65
a Increased choline
1. Definition Elevated phosphocholine level (3.22 ppm by proton spectroscopy).
2. Diagram
134
3. Examples
4. Interpretation Elevated (phospho)choline levels that measure 3.22 ppm by proton spectroscopy are a strong indicator of a malignant tumor. Because phosphocholine is a component of cell membranes, phosphocholine levels are elevated in cancer patients due to the increase in cell turnover. Rare exceptions are mastitis and the lactating breast.
135
Sign
66
a ADC < 1.4 × 10–3 mm2/s
1. Definition Apparent diffusion coefficient in diffusion-weighted images (b = 1500 s/mm2) is less than 1.4 × 10–3 mm2/s.
2. Diagram
3. Examples
136
4. Interpretation A decrease in the apparent diffusion coefficient (ADC) provides strong evidence of malignant-type changes in the microstructure of a tissue. Relatively few data have been published worldwide, however, and so the specificity of this sign is still uncertain.
137
Sign
67
a ADC > 1.4 × 10–3 mm2/s
1. Definition Apparent diffusion coefficient in diffusion-weighted images (b = 1500 s/mm2) is greater than 1.4 × 10-3 mm2/s.
2. Diagram
3. Examples
138
4. Interpretation ADC values above a threshold of 1.4 × 10-3 mm2/s are very characteristic of fibroadenoma, papilloma, and other benign mass lesions. Mucinous carcinoma is the only malignancy that may show elevated ADC values in rare cases. On the whole, however, the ADC value determined in diffusionweighted images is a very useful differentiating sign that appears to be as powerful an indicator as wash-in, washout, T2-weighted signal intensity, and morphologic signs. Further studies are needed to substantiate these initial results.
139
Sign
68
a Half-moon sign
1. Definition Crescent-shaped enhancement bordering a cystic lesion.
2. Diagram
140
3. Examples
4. Interpretation Crescent-shaped enhancement on one side of a cystic lesion is strongly suggestive of an aspirated cyst, especially in patients with a history of percutaneous aspiration. In rare cases it may represent a phylloides tumor or mucinous carcinoma. Not infrequently, a half-moon sign is caused by motion artifacts or surgical clip artifacts with small signal fluctuations during the dynamic scan, producing crescent-shaped areas of “pseudoenhancement” on subtraction images (as in the examples above).
141
Sign
69
a Shrinking star sign
1. Definition Shrinkage of a cancer in all directions during chemotherapy, resembling a “shrinking star” or “melting star.”
2. Diagram
142
3. Examples
4. Interpretation A lesion that dwindles from outside to inside during chemotherapy not only signifies an excellent response to chemotherapy. This sign is mainly seen in carcinomas with negative estrogen and/or progesterone receptors and/or a positive HER2 status and also in nuclear grade 3 tumors. Generally, then, it occurs in relatively undifferentiated carcinomas with a rapid growth rate and unfavorable prognosis. A shrinking star sign also means that the tumor must be completely removed with adequate margins. Whether the tumor has responded to chemotherapy, has recurred, or has been completely eradicated can be determined by a kinetic analysis (signs 58 and 59) and/or by noting the “camouflage sign” (no. 135) or “dissolving cancer sign” (no. 136).
143
Sign
70
a Clustered ring enhancement
1. Definition A lesion that enhances after contrast administration shows not just one “ring” but multiple combined or “clustered” rings within the whole lesion.
2. Diagram
144
3. Examples
4. Interpretation Clustered ring enhancement generally signifies a very aggressive (nuclear grade 3) carcinoma in which multiple richly vascularized areas of tumor angiogenesis are present around areas of central necrosis.
145
Sign
71
a Decrescendo sign
1. Definition The signal intensity in fat or parenchyma declines continuously in dynamic scans.
2. Diagram
146
3. Examples
4. Interpretation A steady decline in signal intensity during the dynamic study is based entirely on technical or methodologic problems (tuning of the coil, radiofrequency artifacts, etc.). No type of tissue in the breast will show fading signal intensity during dynamic scanning. It is essential to recognize this sign in dynamic scans to ensure that the kinetic and morphologic signal changes will not be misinterpreted. It is extremely important to identify these technical problems, because the fading signal intensity will affect all breast lesions equally. The decrescendo sign may lead to a false-negative cancer diagnosis if signal increases are underinterpreted or go undetected.
147
Sign
72
a Crescendo sign
1. Definition The signal intensity of fat rises continuously in dynamic scans.
2. Diagram
148
3. Examples
4. Interpretation It is also important to recognize technical problems (tuning problem, radiofrequency artifacts) that may cause a steady rise of signal intensity. Fat should display the same, constant signal intensity throughout the dynamic study. As with the previous sign, the crescendo sign may lead to diagnostic errors due to the masking of signal changes caused by pathophysiologic phenomena relating to tumor angiogenesis.
149
Sign
73
a Staccato sign
1. Definition The signal intensity of fat or parenchyma shows up-and-down changes in dynamic scans.
2. Diagram
150
3. Examples
4. Interpretation The staccato sign also refers to signal changes based on technical or methodologic problems. It should be recognized so that the morphologic and kinetic parameters of lesions can be accurately interpreted. A staccato-like pattern of up-and-down changes in the fat or parenchyma should not occur and must be considered in the evaluation of lesions. If the fat next to a lesion shows a rise or fall in signal intensity, this effect must also be considered in evaluating the adjacent lesion. For example, if a lesion shows a 70% increase in signal intensity after contrast injection while the adjacent fat shows a 30% decrease, the actual signal change in the lesion is equal to 100% (70% + 30%).
151
Sign
74
a Interrupted retroglandular fat layer
1. Definition A discontinuity is present in the thin fatty layer between the breast parenchyma and pectoralis muscle.
2. Diagram
152
3. Examples
4. Interpretation Normally a thin layer of fat separates the breast parenchyma from the pectoralis muscle. This fat layer is clearly displayed on T1- and T2-weighted images. Interruption of this fat layer is almost always abnormal and often represents scar tissue following surgery, irradiation, or trauma. Older scars should show very little contrast enhancement. But if the fat layer is interrupted in a previously unoperated, tumor-bearing breast or if the linear connections between the tumor and pectoralis muscle show contrast enhancement, it is reasonable to assume that the fat layer has been breached by an invading malignant tumor. This is particularly likely if there has been no prior breast surgery or postoperative scarring during the previous six months.
153
Sign
75
a Continuous vessel sign
1. Definition A hyperintense spot occupies a similar position in neighboring slices and can be tracked in its course from one slice to the next.
2. Diagram
154
3. Examples
4. Interpretation Small vascular sections cut by the imaging plane should not be mistaken for small mass lesions or malignancies. Vascular sections are relatively easy to identify as round, oval, or serpentine structures that enhance after contrast administration and can be tracked through neighboring slices. The course of these vessels is clearly displayed in a three-dimensional maximum-intensity projection (MIP). Moreover, vessels often show refocusing effects on T2-weighted TSE images, producing a relatively high signal intensity unlike that of malignant tumors. It is important to realize that vessels may show all types of enhancement patterns including plateau and washout effects. As a result, the continuous vessel sign and increased T2-weighted signal intensity are often the only definite signs that can distinguish vessels from a very small carcinoma.
155
Sign
76
a Antibiotic response sign
1. Definition A previously enhancing lesion or group of lesions in a breast shows no enhancement or greatly decreased enhancement following antibiotic therapy.
2. Diagram
3. Examples
156
157
Sign
158
76
a Antibiotic response sign
4. Interpretation Unilateral or bilateral areas of patchy enhancement in the breast may result from a unilateral or bilateral inflammation. These cases should be managed with anti-inflammatory or antibiotic therapy and require MRI follow-up at 3 to 6 months. The loss of enhancement indicates a positive therapeutic response. It is advisable to schedule the follow-up examination during a similar phase of the menstrual cycle as in the previous examination. The disappearance of formerly enhancing lesions after antibiotic therapy essentially confirms the inflammatory nature of the lesions, eliminating the need for further surgical and histologic diagnosis. It has been my experience that subclinical, unilateral inflammatory processes are much more common in the breast than traditional textbooks would indicate. If inflammation is present anywhere in the body, apparently the breast is susceptible to inflammatory involvement even if there are no clinical manifestations of mastitis. In some cases the patient will report slight tenderness to palpation of the affected breast.
159
Sign
77
a Antibiotic nonresponse sign
1. Definition Anti-inflammatory or antibiotic therapy has no effect on previously enhancing lesions.
2. Diagram
160
3. Examples
4. Interpretation If one or more enhancing areas remain unchanged after antibiotic therapy, either the antibiotics were ineffective or the lesions were not inflammatory, consisting instead of multifocal DCIS or multi focal lobular carcinoma. If antibiotic therapy has not altered their enhancement characteristics, the enhancing lesions should be excised and histologically examined due to the very high likelihood of malignancy.
161
Sign
78
a Vessel sign
1. Definition Vessels are more numerous in a breast with an enhancing lesion and may even be directed toward the lesion.
2. Diagram
162
3. Examples
4. Interpretation The vessel sign is present when one or more vessels are visible in a tumor-bearing breast and the number of vessels is markedly increased relative to the contralateral breast. This sign is strongly suggestive of a malignant lesion in the affected breast. The most likely explanation is increased tumor angiogenesis, which is known to be detectable even at a distance of several centimeters from the tumor. Increased vascularity is considered an early sign of carcinoma formation. Rare exceptions to this rule would be very severe infectious foci, which also are well vascularized. These foci would cause conspicuous edema throughout the breast, however, and would be accompanied by clinical or serologic signs of inflammation.
163
Sign
79
a Comet sign
1. Definition An enhancing lesion has a (usually less enhancing) “tail” extending into the parenchyma and often directed toward the nipple (like the tail of a comet).
2. Diagram
164
3. Examples
4. Interpretation A “comet tail” arising from an enhancing lesion is a strong indicator of early DCIS, especially when the tail is directed toward the nipple or along the ductal system. Less likely alternatives (easily identified from the history) are biopsy or surgery during the preceding months. The surgeon should be reminded to excise the entire enhancing lesion, including the tail, to ensure that all DCIS foci are removed.
165
Sign
80
a Focal skin thickening
1. Definition The skin of one breast shows focal thickening while other portions of the skin are normal.
2. Diagram
166
3. Examples
4. Interpretation The history is very important in the interpretation of focal skin thickening. In patients with a history of biopsy, surgery, or trauma to the breast, focal skin thickening that does not enhance is caused by a scar. If the thickened area is extensive and shows moderate enhancement, it may represent keloid formation. Focal skin thickening that enhances, especially when located near an enhancing lesion, signifies tumor invasion. Again, it is important in these cases to inform the surgeon of the associated focal skin thickening to ensure that the excision will fully encompass the tumor tissue.
167
Sign
81
a Permanent asymmetry of the breasts
1. Definition A marked size discrepancy between the breasts has been present since puberty.
2. Diagram
168
3. Examples
4. Interpretation A minor size discrepancy between the breasts is very common and is essentially a normal finding. Marked asymmetry, however, implies an abnormality of breast development, usually as a result of previous trauma and/or radiation during childhood (the irradiated breast is smaller). Asymmetry since puberty is almost never the result of a malignant process. Other possible causes of permanent breast asymmetry include traumatic injury and/or biopsy of the breast bud during childhood. Rare cases may result from unilateral hypertrophy of the breast in pectoral dysplasia or atrophy in the setting of Poland syndrome (see sign 116).
169
Sign
82
a Increasing asymmetry of the breasts
1. Definition A marked size discrepancy between the breasts has developed in the recent past (days or months).
2. Diagram
170
3. Examples
4. Interpretation Increasing asymmetry of one breast in favor of the other breast signifies either an inflammatory or neoplastic process. Thus, the cause may be a developing mastitis with its associated clinical and serologic signs or, more commonly, an inflammatory carcinoma or diffuse tumor infiltration, most likely by lymphoma. Another possibility is the relative enlargement of one breast because the other breast is “shrinking” due to tumor invasion with subsequent consolidation and skin retraction.
171
Sign
83
a Precontrast signal too low
1. Definition The signal intensity of breast parenchyma in the precontrast T1-weighted GRE sequence is lower than the usual range of breast signal intensity for this technique (same sequence, coil, magnet, etc.).
2. Diagram
3. Examples
172
4. Interpretation The signal intensity of the breast parenchyma in the unenhanced image varies little from one patient to the next. Only the relative proportion of fat and the architectural features of the breast show substantial variations. The signal intensity depends on the type of pulse sequence used (2D GRE sequence, 3D GRE sequence, fat-saturated sequence, VIBRANT, VIBE, etc.) and on the coil and magnet design. Once the signal intensity of the unenhanced breast parenchyma has been established for a given sequence and scanner, it should be repeated in the glandular tissue of all subsequent patients. If this is not the case and the initial signal intensity before contrast injection is too low, the cause is a technical problem relating to a tuning artifact, coil design, coil tuning, coil deformation, or a metal clip artifact. Subtle clip artifacts may occur even with “nonmagnetic” clips, especially in gradient echo sequences. If a technical problem is ruled out, the cause may be an old hemorrhage with hemosiderin deposits following biopsy, surgery, or radiotherapy. This sign is extremely important because the relative changes in signal intensity after contrast administration naturally depend on the initial signal intensity in the precontrast image. It may be the source of many false-positive or false-negative findings. It is advisable, then, to acquire a calibration sequence with an initial signal intensity that deviates toward lower or higher values (darker or lighter shades of gray). This would be an indication for the use of 2D gradient echo sequences over 3D gradient echo sequences, because most 2D GE sequences use longer repetition times (approximately 100–300 ms) than 3D sequences, in which the breast parenchyma has very low signal intensity and appears almost black due to the very short repetition time (less than 5–10 ms). Before analyzing the signal kinetics, the radiologist should check for proper calibration of signal intensity in the precontrast image since all relative signal changes are based on the precontrast signal intensity.
173
Sign
84
a Precontrast signal too high
1. Definition The signal intensity of breast parenchyma in the precontrast T1-weighted GRE sequence is higher than the usual range of breast signal intensity for this technique (same sequence, coil, magnet, etc.).
2. Diagram
174
3. Examples
4. Interpretation If the initial signal intensity in the precontrast image is too high, this generally indicates a technical problem relating to coil tuning, coil design, coil deformation, etc. or a relatively fresh hemorrhage several days old with associated hemoglobin formation. Another possibility would be an hormonal effect relating to pregnancy or lactation. The same principle applies here as in the previous signs: If the baseline signal intensity in the precontrast image is not within the usual range, this will cause a relative change in all postcontrast signal intensities and will alter the analysis of kinetic parameters in the enhancement curve.
175
Sign
85
a Maximum initial signal increase lower than the malignant threshold
1. Definition The maximum percentage initial signal increase in a breast lesion after contrast injection is below the usual increase for invasive cancers.
2. Diagram
3. Examples
176
4. Interpretation Besides initial signal intensity, it is extremely important to consider the amplitude of the initial signal increase up to the breakpoint in the enhancement curve. The vascularity that is induced within a malignant tumor by angiogenesis has a very consistent structure due to the similarity of the relative enzyme changes that occur in malignancies. Indeed, this is a universal law of nature. When signal changes are detected within an area that is suspicious for cancer (see sign 86), this is considered very typical tumor behavior. But if, as in this sign, the initial signal increase is markedly below the typical range, it is likely that the lesion is benign (papilloma or fibroadenoma). The differential diagnosis should also include a technical problem related to incorrect settings (incorrect ROI that includes nonenhancing glandular tissue or fat). A biopsied carcinoma may also show a loss of initial enhancement due to microhemorrhages. A fourth possibility for this initial enhancement pattern could be a carcinoma during or after chemotherapy. This cause is easily determined from the prior history.
177
Sign
86
a Maximum initial signal increase within the malignant range
1. Definition The maximum initial signal increase in a breast lesion after contrast injection is within the usual range for invasive cancers.
2. Diagram
178
3. Examples
4. Interpretation Invasive cancers that grow larger than 2 mm induce tumor angiogenesis leading to an increase in vascularity and the formation of tumor vessels. The latter are primitive vessels or “tubes” that lack a media and adventitia and have numerous defects in the basal membrane. This universal process of tumor angiogenesis is demonstrable in all carcinomas and in all mammals. Because the initial signal kinetics reflect this tumor angiogenesis, carcinomas typically fall within a characteristic range of initial enhancement, and a given technique can measure this range with high reproducibility. Of course, this relative increase is also influenced by the type and dosage of contrast material and especially by the selection of the pulse sequence, coil, and MR scanner. Once established, practically all viable portions of invasive cancers will enhance within this initial range. Fibroadenomas (myxoid or fibrous) and papillomas are generally below or above this range and rarely fall within this initial “malignant” zone of enhancement.
179
Sign
87
a Maximum initial signal increase above the malignant threshold
1. Definition The maximum initial signal increase in a breast lesion after contrast injection is above the usual increase for invasive cancers.
2. Diagram
180
3. Examples
4. Interpretation Extremely intense initial enhancement during the first 1–2 minutes that is well above the usual range for invasive cancers is not typical of carcinomas. It is found in myxoid fibroadenomas, which also have a rich blood supply. Cancers are less likely to show this high initial peak unless there is an associated technical defect causing a false-low initial signal intensity (clip artifact, old hemorrhage, etc.) that alters the relative percentage increase. Nevertheless, the most likely diagnosis with this enhancement pattern is myxoid fibroadenoma.
181
Sign
88
a Pseudocentric enhancement
1. Definition A lesion with initial uniform enhancement shows decreasing peripheral signal intensity (washout) while the center maintains its high initial postcontrast signal.
2. Diagram
182
3. Examples
4. Interpretation There are lesions that show very rapid wash-in and equally dramatic washout at their periphery while the center remains constant after the wash-in phase. As a result, the periphery shows a rapid relative decline in percentage signal intensity while the center shows a more gradual decline or even maintains a constant intensity. This pattern indicates a well-vascularized aggressive cancer, usually a grade 3 neoplasm, that has not yet undergone central necrosis. At first glance, the center appears to show relatively greater enhancement but this is an optical illusion caused by signal washout from the tumor periphery.
183
Sign
89
a Clip sign
1. Definition Signal distortion in all sequences (T1-weighted, T2-weighted, pre- and postcontrast), stronger in GE sequences than in TSE sequences.
2. Diagram
184
3. Examples
4. Interpretation Surgical clips may produce signal voids in all sequences, with “nonmagnetic clips” causing less pronounced signal voids than paramagnetic clips. It is important to recognize clip artifacts and accurately describe the location and size of the signal void so that the surgeon will not conclude the absence of cancer based on a negative MRI finding. Clip artifacts are much more pronounced in gradient-echo sequences due to the lack of refocusing than in spin-echo sequences. They also depend on the orientation of the imaging plane. Clip artifacts are not only seen with properly applied clips but may sometimes result from intraoperative metallic wear debris. Hemosiderin deposits associated with bleeding or biopsy may be so massive that they create signal voids similar to clip artifacts in all sequences. Clip artifacts are relatively easy to identify from the patient’s history, however.
185
Sign
90
a Fat-water cyst
1. Definition A double fluid layer (fat and water) within a cyst.
2. Diagram
186
3. Examples
4. Interpretation A cystic structure in which lipid- and water-containing fluid components can be detected on preand postcontrast T1-weighted images and T2-weighted TSE images is usually a result of percutaneous biopsy and in rare cases may result from trauma (a fall down stairs, motor vehicle accident, seat belt injury), inflammation, or anticoagulant use (aspirin, etc.). Several of these causes may be operative in some patients. I have never personally seen a bilocular fat-water cyst in an “untreated” breast, nor have I encountered a cystic carcinoma following intralesional hemorrhage or biopsy.
187
Sign
91
a Unilateral hormone reversal sign
1. Definition Previous bilateral areas of enhancement disappear after the patient has stopped hormone replacement therapy (for at least 1–3 months), but only in one breast and not the other.
2. Diagram
188
3. Examples
4. Interpretation If bilateral areas of enhancement are found in a patient on hormone replacement therapy, and they disappear in one breast after therapy is discontinued but are still present in the other, this is considered strong evidence of residual DCIS or invasive lobular carcinoma in the enhancing breast. A far less likely explanation would be an inflammation in the enhancing breast (in which case there would be corresponding clinical and serologic findings) or the effect of a hormone patch on the skin of the enhancing breast. This is easily determined by visual inspection and from the history.
189
Sign
92
a Bilateral hormone reversal sign
1. Definition Previous bilateral areas of enhancement disappear in both breasts after the patient has stopped hormone replacement therapy (for at least 1–3 months).
2. Diagram
190
3. Examples
4. Interpretation Ordinarily, bilateral enhancing areas due entirely to hormonal effects will disappear in 1–3 months after the withdrawal of hormone replacement therapy. This would be a compelling sign that the previous enhancing areas were due entirely to the effects of HRT. Based on this experience, we do not order routine MR mammography for patients on HRT due to frequent problems of diagnosis and differential diagnosis (in approximately 85% of these patients).
191
Sign
93
a Hormone nonreversal sign
1. Definition Previous bilateral areas of enhancement are still present after the patient has stopped hormone replacement therapy (for at least 1–3 months).
2. Diagram
192
3. Examples
4. Interpretation The differential diagnosis of this sign includes bilateral DCIS and bilateral invasive lobular carcinoma. Another possibility is continued hormone exposure from a patch, ointment, etc. due to a lack of patient cooperation or comprehension. Bilateral benign lesions and inflammation are also conceivable but rare.
193
Sign
94
a Intravascular contrast sign
1. Definition A lesion shows a strong wash-in and washout curve after the injection of an extravascular contrast agent (e.g., Gd-DTPA) but shows continuous, progressive enhancement after the injection of an intravascular contrast agent.
2. Diagram
3. Examples
194
4. Interpretation If a lesion shows a “classic” malignant enhancement curve with strong initial wash-in and subsequent washout, this means that the lesion contains a network of small vessels and arteriovenous shunts that permit rapid clearance of the extravascular contrast agent Gd-DTPA. If the same lesion shows progressive enhancement after the administration of an intravascular contrast agent, it may be assumed that “leaks” are present within the angiogenesis network. This is a very strong sign of carcinoma.
195
Sign
95
a Pectoralis pseudolesion
1. Definition Lesion or spot at the lateral border of the pectoralis muscle, isointense to muscle and often bilateral, which “melts” into the muscle on neighboring slices.
2. Diagram
196
3. Examples
4. Interpretation Nodular soft-tissue masses that are isointense to muscle, generally with a detectable fibrous structure and/or muscular extensions with lipid elements, are normal anatomic findings in the lateral portions of the pectoralis major and minor muscles. They should not be misinterpreted as lymph nodes or carcinoma. Their enhancement characteristics are identical to muscle, and they do not show malignant-type wash-in or washout.
197
Sign
96
a Tumor recovery sign
1. Definition A new focus with malignant-type enhancement (wash-in, washout, ring, etc.) is detected during or after chemotherapy.
2. Diagram
198
3. Examples
4. Interpretation If a tumor initially shrinks or ceases to enhance in response to chemotherapy but then develops new areas that show classic wash-in and washout effects not previously recorded, this is an extremely poor prognostic sign. It means that the tumor has “recovered” and is inducing new and effective angiogenesis. This should prompt reconsideration and revision of the current treatment, as a tumor displaying new malignant features on MRI should be considered a very aggressive lesion.
199
Sign
97
a Incorrect shimming sign
1. Definition Water-filled compartments in a breast implant should appear dark on silicone images but instead show varying degrees of brightness.
2. Diagram
200
3. Examples
4. Interpretation Ordinarily, fat and water signals should be completely saturated in silicone images. But if this saturation is incomplete, a water component in the silicone image will show signal levels of varying intensity, usually trending from light to dark in one direction. Typically there is also a detectable thin pleural fluid layer in silicone images that shows similar high signal intensity. This signifies incomplete, incorrect shimming of the water signal. This effect is most apparent in patients with a unilateral implant where shimming is done over both breasts, causing the “silicone signal” to appear too low. In this case the scan should be repeated after the imaging frequency has been manually tuned to the silicone gel. A gradual trend in the signal intensity of a water component in a silicone implant should not prompt a false-positive diagnosis of intracapsular rupture. The examination should be repeated using a standard silicone frequency and perfect saturation, preferably by manually shimming only the breast that contains the implant.
201
Sign
98
a Patchwork sign
1. Definition Different compartments in a lesion, separated by septations, enhance homogeneously but at markedly different levels of intensity.
2. Diagram
202
3. Examples
4. Interpretation A lesion that does not show classic ring enhancement and consists of multiple, relatively well-defined compartments separated by nonenhancing septa and showing a “patchwork” enhancement pattern is almost certainly a fibroadenoma made up of areas with varying degrees of fibrosis or vascularity. This interpretation is supported by additional signs of benignancy (benign wash-in, no washout, no blooming sign, no hook or root sign, no perifocal edema, no choline increase, high ADC, etc.).
203
Sign
99
a Increased unilateral subcutaneous vascular density
1. Definition More subcutaneous vessels in one breast than in the opposite breast.
2. Diagram
204
3. Examples
4. Interpretation The presence of increased subcutaneous vascular density in one breast generally represents a healing phase after radiotherapy or surgery. The differential diagnosis should also include an early neoplasm, especially in patients who did not have an invasive procedure. When cancer is detected in the ipsilateral breast, this sign may also indicate increased vascularization. However, I have rarely seen increased subcutaneous vessels in a tumor-bearing breast as an isolated sign, unaccompanied by the detection of additional intraparenchymal vessels. Vascular thrombosis in the contralateral breast (internal mammary artery and vein or lateral thoracic artery and vein) is also possible but is very rare (see also Sign 145 and 146).
205
Sign
100
a Increased bilateral subcutaneous veins
1. Definition More subcutaneous veins in both breasts.
2. Diagram
206
3. Examples
4. Interpretation Increased bilateral density of subcutaneous veins generally results from venous congestion due to heart failure. Most patients state that they also have edema in other body regions (e.g., the limbs) or are taking medication for heart failure. This sign might also result from previous bilateral irradiation (e.g., for Hodgkin disease) or the radiotherapy of a different intrathoracic tumor in which both breasts were exposed to scattered radiation.
207
Sign
101
a Special STIR signal intensity pattern
1. Definition A lesion shows homogeneous low signal intensity on T1-weighted GRE images and T2-weighted TSE images, but both high and low signal intensity are seen in different compartments of the lesion on STIR images.
2. Diagram
208
3. Examples
4. Interpretation If a lesion appears homogeneous on T1- and T2-weighted images and is heterogeneous on STIR images, this indicates better visualization of details in the STIR images, especially with regard to subtle tissue changes with an increased fluid content. Malignant tumors have protease activity that can dissolve surrounding tissues, creating fissures in which water can accumulate (analogous to ground fissures in an earthquake). These fluid collections are clearly visualized on STIR images, which can discriminate between the more liquid and more solid tumor components. Sharply marginated components are more consistent with a fibroadenoma, whereas ill-defined margins are more typical of carcinoma. Sign 101 may also result from a technical problem due to signal inhomogeneities, HF pulse asymmetries, etc. Further studies are needed to determine the exact significance of this sign.
209
Sign
102
a Linguine sign
1. Definition An isolated, curved, dark line with clearly definable ends floating within an implant (or within the component of an implant).
2. Diagram
210
3. Examples
4. Interpretation The linguine sign is produced by collapsed, free-floating remnants of the implant shell and is considered a sign of intracapsular rupture.
211
Sign
103
a Pull-away sign
1. Definition A localized separation of the inner membrane of an implant with gel on both sides.
2. Diagram
212
3. Examples
4. Interpretation Separation of the inner membrane or a layer of the inner membrane, with silicone gel on both sides of the detached membrane (but still contained within the outer membrane), is a sign of early intracapsular rupture. This sign is so common, however, that the term “rupture” should be used with caution, as it prompts many patients and doctors to take immediate action. In my experience, it is safe to follow the patient for several years to see how the sign develops. I have seen cases in which the pull-away sign remained unchanged for years.
213
Sign
104
a Keyhole sign
1. Definition Separation of the inner membrane of an implant, creating a radial fold that resembles a keyhole.
2. Diagram
214
3. Examples
4. Interpretation The keyhole sign is basically a continuation or progression of the pull-away sign in which the separated layer of the inner membrane looks like a keyhole. Like sign 103, it signifies an incipient intracapsular separation of the membrane layers, or “rupture.”
215
Sign
105
a Extracapsular silicone sign
1. Definition Silicone is detected outside the implant.
2. Diagram
216
3. Examples
4. Interpretation Silicone outside the capsule always signifies an extracapsular rupture. The gel can be identified on T2-weighted images and is seen even more clearly on silicone images. An extracapsular rupture generally requires treatment and is an indication for implant replacement. It is important, however, to exclude a shimming artifact (sign 97) to make sure that the extracapsular fluid is really silicone and is not water due to incorrect shimming. High signal intensity of pleural fluid in the silicone image would provide strong evidence of a shimming artifact.
217
Sign
106
a Pouch sign
1. Definition Silicone or water is detected within a fold of the shell, outside the implant.
2. Diagram
218
3. Examples
4. Interpretation The pouch sign is a fairly reliable sign of rupture, as it shows that implant contents are definitely outside the implant or a component of the implant. It is an indication for close-interval follow-ups or implant replacement.
219
Sign
107
a Wavy line sign
1. Definition A portion of the shell floats freely inside the implant, producing a wavy line (sometimes called the “C sign” because it resembles the letter C).
2. Diagram
220
3. Examples
4. Interpretation Actually an abbreviated form of the linguine sign, the wavy line sign is formed by a piece of freefloating membrane within the implant. Generally it is only a separated layer, and the rest of the shell appears intact. Like the linguine sign, the wavy line signifies an intracapsular separation (“rupture”) of the membrane layers.
221
Sign
108
a Gel bleed sign
1. Definition Silicone is detected between the implant and fibrous capsule.
2. Diagram
222
3. Examples
4. Interpretation The gel bleed sign is relatively difficult to detect without silicone images, as both the shell and fibrous capsule have low signal intensity. But silicone-selective images can clearly demonstrate a collection of silicone gel that protrudes through the shell but is still within the fibrous capsule. It signals incipient silicone penetration through the outer wall of the implant and represents an early stage of extracapsular rupture.
223
Sign
109
a Focal ductal fluid sign
1. Definition A focal collection of nonenhancing fluid within a duct system on T2-weighted images.
2. Diagram
224
3. Examples
4. Interpretation Visible fluid stasis within a single duct or duct system indicates an obstruction of the duct system by an intraductal mass, i.e., a benign tumor such as papilloma or a malignant tumor such as intraductal carcinoma or DCIS. Generally a carcinoma would also show marked enhancement. A papilloma may show little or no enhancement, however, in which case the focal ductal fluid sign would be the only evidence of an intraductal tumor. Intraductal inflammation with incipient abscess formation is less common. (See also signs 132 and 133).
225
Sign
110
a Two-chamber sign
1. Definition Sharply delineated enhancing lesions that are interconnected and show high T2-weighted signal intensity.
2. Diagram
3. Examples
226
4. Interpretation The two-chamber sign generally results from intraductal inflammation in the form of focal ductitis or incipient mastitis. A small mucinous carcinoma may also have this presentation in rare cases, but this lesion would have a large soft-tissue component with malignant-type enhancement kinetics in addition to the two-chamber sign.
227
Sign
111
a Blood-water cyst
1. Definition A double fluid layer (blood and water) within a cyst.
2. Diagram
228
3. Examples
4. Interpretation A blood-water fluid level is often found in cysts following fine-needle aspiration or core biopsy. The cyst may also show peripheral inflammation (see Eclipse sign). In rare cases this sign may also be found in an unbiopsied cyst, usually following palpation or the initiation of anticoagulant use (aspirin, etc.). A simple, asymptomatic blood-water cyst does not require treatment.
229
Sign
112
a Blackberry sign
1. Definition A cluster of small, round, sharply circumscribed, enhancing nodules resembling a blackberry.
2. Diagram
230
3. Examples
4. Interpretation The blackberry sign is almost invariably a sign of benignancy and suggests multiple small papillomas or fibroadenomas, especially when completely surrounded by fat. An early noninvasive carcinoma (DCIS) may produce a blackberry sign within the parenchyma, but this is very rare.
231
Sign
113
a Tram lines
1. Definition Thin lines of fat intensity on both sides of a linear enhancing structure.
2. Diagram
232
3. Examples
4. Interpretation Tram lines almost always represent a sectional view of a blood vessel. A small incipient DCIS is extremely unlikely. A sectional view of a DCIS is a conceivable alternative to intravascular enhancement, but a vessel would have high signal intensity on T2-weighted TSE images (due to the 180° refocusing pulses), whereas DCIS would be hypointense.
233
Sign
114
a Fat separation sign
1. Definition A lesion is separated from the breast parenchyma by a usually thin, noninfiltrated layer of fat (also called the “FAT-HALO-sign”).
2. Diagram
234
3. Examples
4. Interpretation If a lesion, whether enhancing or nonenhancing, is separated from the rest of the parenchyma by a relatively sharp, noninfiltrated, nonenhancing layer of fat, it is most likely a benign lesion such as fibroadenoma, phylloides tumor, or papilloma. By contrast, even a small carcinoma would already have infiltrated the adjacent fatty layer.
235
Sign
115
a Bilateral pectoralis degeneration sign
1. Definition The presence of fatty spots within both pectoralis muscles, which are thin and atrophic.
2. Diagram
236
3. Examples
4. Interpretation Bilateral atrophy, hypotrophy, or fatty degeneration of both pectoralis muscles is generally a sign of muscular disease (muscular dystrophy, etc.).
237
Sign
116
a Unilateral pectoralis atrophy sign
1. Definition One pectoralis muscle is atrophic while the other is normal.
2. Diagram
238
3. Examples
4. Interpretation Unilateral pectoralis muscle atrophy is a feature of Poland syndrome. Unilateral breast asymmetry or hypoplasia of the ipsilateral breast may also be present in these cases.
239
Sign
117
a Intact retroglandular fat layer
1. Definition A thin, intact fatty layer is present between a lesion near the pectoralis muscle and the muscle itself.
2. Diagram
240
3. Examples
4. Interpretation With a deep retroglandular lesion located very close to the pectoralis muscle, a malignant lesion will almost always show signs of penetrating the thin fat layer and invading the muscle. A benign lesion, on the other hand (fibroadenoma, cyst, etc.), will leave the fat layer intact. Consequently, this sign is very helpful in discriminating between benign and malignant lesions.
241
Sign
118
a STIR-selective perifocal edema
1. Definition Band of edema around a lesion, visible only on STIR images and not on T2-weighted TSE images.
2. Diagram
242
3. Examples
4. Interpretation It is still unclear why edema is detectable on STIR images but not on T2-weighted TSE images. Presumably this results from the greater sensitivity of the STIR sequence to edema. In the few cases where we have observed this sign, all the lesions were fibroadenomas.
243
Sign
119
a Border sign
1. Definition The border of a lesion can be discerned, even within a small area of parenchyma, following contrast injection.
2. Diagram
244
3. Examples
4. Interpretation With this sign, the border of a lesion can be clearly discerned and characterized, even within a very small area of parenchyma. An irregular border is suggestive of carcinoma, while a smooth, regular border suggests fibroadenoma or papilloma. In all cases the lesion is clearly definable and does not represent adenosis.
245
Sign
120
a Cross-talk sign
1. Definition The presence of thin, thread-like connections (sometimes enhancing) between two enhancing lesions.
2. Diagram
246
3. Examples
4. Interpretation Two small, enhancing lesions that are interconnected by thin lines that also enhance (usually more intensely then the lesions) are almost always malignant. The only other possibility is severe inflammatory foci, which may exhibit this sign in rare cases.
247
Sign
121
a Unilateral subcutaneous rim enhancement
1. Definition Thin line of peripheral enhancement beneath the skin of one breast and not the other.
2. Diagram
248
3. Examples
4. Interpretation Peripheral subcutaneous enhancement in one breast is generally a sign of severe inflammation or inflammatory carcinoma. Another possibility is postirradiation change in a patient who has undergone radiotherapy.
249
Sign
122
a Intense peripheral rim on postcontrast STIR
1. Definition Lesion shows a narrow rim of high signal intensity on a postcontrast STIR image.
2. Diagram
250
3. Examples
4. Interpretation Peripheral high signal intensity on postcontrast STIR images appears to represent very active peripheral areas of tumor angiogenesis around a high-grade carcinoma. To date, we have not detected this sign in association with benign lesions.
251
Sign
123
a Increased unilateral nipple enhancement
1. Definition The nipple of a previously untreated, cancerous breast shows increased enhancement relative to the contralateral nipple.
2. Diagram
252
3. Examples
4. Interpretation When a previously untreated breast harbors a suspicious lesion and the ipsilateral nipple also shows unilateral enhancement, this is a strong sign of DCIS involvement close to the carcinoma. An alternative explanation in a treated breast would be prior radiotherapy inciting an inflammatory reaction in the nipple.
253
Sign
124
a Small perifocal enhancement
1. Definition The ratio of the radius of perifocal enhancement to the radius of the core lesion is less than 1.6.
2. Diagram
254
3. Examples
4. Interpretation Perifocal enhancement around a carcinoma is itself a sign of carcinoma. A detailed analysis of these lesions has shown, however, that inflammatory processes consistently occur within a very small radius around a carcinoma. The differential diagnosis would include concomitant DCIS, but this is more likely to occur at a greater distance from the main lesion (see sign 125).
255
Sign
125
a Large perifocal enhancement
1. Definition The ratio of the radius of perifocal enhancement to the radius of the core lesion is greater than 1.6.
2. Diagram
256
3. Examples
4. Interpretation A larger area of perifocal enhancement measuring more than 1.6 times the radius of the core lesion is unlikely to be perifocal inflammation and is more consistent with concomitant DCIS. The size and location of the DCIS should be accurately reported to the surgeon to ensure that all tiny malignant foci are removed.
257
Sign
126
a Dark heart sign
1. Definition The heart does not enhance after contrast administration.
2. Diagram
258
3. Examples
4. Interpretation If the heart does not enhance after contrast injection, this simply means that an insufficient amount of contrast agent is reaching the heart. The contrast injection was either omitted or technically flawed, eliminating the possibility of a meaningful kinetic analysis. A “dark heart” means that the examination should be repeated.
259
Sign
127
a Unilateral subcutaneous edema
1. Definition Fluid in the subcutaneous region of one breast.
2. Diagram
260
3. Examples
4. Interpretation Unilateral subcutaneous edema is best appreciated on T2-weighted TSE or STIR images and may be a result of radiotherapy or inflammation. This is easily determined from the patient’s history. If radiotherapy and inflammation can be excluded, an inflammatory carcinoma should be suspected.
261
Sign
128
a Stacked beads sign
1. Definition Sharply circumscribed round masses that form a stacked arrangement within a duct.
2. Diagram
262
3. Examples
4. Interpretation Small, round, sharply circumscribed masses that appear to form a stacked arrangement within a duct system and usually enhance markedly after contrast injection are most likely to be papillomas, especially if they do not blend to form an intraductal “cord” on delayed dynamic images. Usually the surrounding duct system is visible on T2-weighted images as a result of ductal dilatation and engorgement. The masses within the duct may show all types of enhancement patterns ranging from gradual progressive enhancement to malignant-type wash-in and washout.
263
Sign
129
a Corona sign
1. Definition Small, ill-defined enhancing spots around an enhancing mass, resembling a corona or dandelion.
2. Diagram
264
3. Examples
4. Interpretation An annular or crown-like array of spots around an enhancing, malignant-type lesion very often represent small satellite lesions of intraductal carcinoma (DCIS, LCIS). It very rarely signifies perifocal inflammation.
265
Sign
130
a Drapery sign
1. Definition Focal, linear subcutaneous enhancement with folds.
2. Diagram
266
3. Examples
4. Interpretation With some cancers the subcutaneous region of the breast enhances in a circumscribed area and appears to be “thrown into folds” like a drape. Histologic examination in past cases has revealed subcutaneous lymphangiosis or subcutaneous tumor spread. We have seen no cases in which this sign was caused by inflammation.
267
Sign
131
a Crossing edema sign
1. Definition Edema crosses over the presternal fat into the opposite breast.
2. Diagram
268
3. Examples
4. Interpretation As a rule, edema associated with a breast lesion is confined strictly to the ipsilateral breast. The pathobiochemical and pathophysiologic changes caused by the tumor affect that breast while sparing the opposite breast. Bilateral edema may occur in association with bilateral breast cancer or in systemic diseases such as heart failure. We have seen cases, however, in which unilateral edema documented before chemotherapy “migrated” into the opposite breast after the start of chemotherapy. We have not yet found an adequate pathophysiologic explanation for this phenomenon. Tumor breakdown during chemotherapy or the spread of carcinomatous lymphangiosis to the contralateral side has been confirmed in a few isolated cases but has not been found in other cases.
269
Sign
132
a Duct obstruction sign
1. Definition A duct is enlarged and obstructed by an intraductal mass.
2. Diagram
270
3. Examples
4. Interpretation Intraductal masses may obstruct the duct lumen, leading to dilatation and engorgement. In our experience, the obstructing lesions are almost always papillomas and almost never intraductal carcinomas, and therefore this sign is more likely to indicate a benign lesion. Malignant lesions are apparently “permeable” and do not tend to cause duct obstruction.
271
Sign
133
a Duct nonobstruction sign
1. Definition The duct is not obstructed or enlarged by an intraductal mass, i.e., the mass is permeable.
2. Diagram
272
3. Examples
4. Interpretation The duct nonobstruction sign is basically the opposite of the duct obstruction sign. In our experience, an intraductal mass lesion that does not cause duct obstruction should be interpreted as intraductal carcinoma (DCIS, LCIS), especially if it shows additional malignant signs (unilateral linear or branched enhancement pattern, often with wash-in and washout). Based on current information, it is reasonable to assume that benign lesions like papillomas lead to duct obstruction while malignant lesions such as DCIS are permeable and do not obstruct the ductal system.
273
Sign
134
a Donut sign
1. Definition A small enhancing ring that is sharply demarcated in all dynamic images.
2. Diagram
274
3. Examples
4. Interpretation A small ring that is sharply delineated throughout the dynamic study and does not “fill in” is inconsistent with carcinoma and is more likely to be a sharply circumscribed benign lesion, generally a papilloma or fibroadenoma. Carcinomas also show ring enhancement, but generally only in the initial dynamic sequence. Later the enhancement fills in the central portion of the lesion (sign 19), culminating in more or less homogeneous enhancement of the entire mass.
275
Sign
135
a Camouflage sign
1. Definition A lesion is smaller and no longer enhances after chemotherapy but is still detectable as a mass on T1weighted precontrast and T2-weighted images.
2. Diagram
276
3. Examples
4. Interpretation As a rule, successful chemotherapy leads to a loss of tumor enhancement suggesting that viable tumor has been eradicated. But if T1-weighted precontrast images and/or T2-weighted images still demonstrate a hypointense lesion at the same location, often with a slightly reduced size, this generally means that the carcinoma is only “camouflaged.” When these lesions were examined histologically, it was found that residual cancer cells were still present within the mass and were still viable in some cases. Thus, the tumor may be described as a severely damaged but “sleeping” cancer that may continue to grow in subsequent months and years. It may eventually produce a new clone of viable cancer cells and again show malignant-type enhancement, usually appearing first at the periphery of the original tumor as a small area of centripetal ring enhancement (see sign 142, Recurrent border cancer).
277
Sign
136
a Dissolving cancer sign
1. Definition A cancer does not enhance and is not detectable after chemotherapy in T1-weighted precontrast and T2-weighted scans.
2. Diagram
278
3. Examples
4. Interpretation If the tumor no longer enhances after chemotherapy and is no longer detectable as a mass lesion in T1-weighted precontrast and T2-weighted images, this is an extremely positive sign suggesting that the tumor has been completely destroyed and replaced by fibrous tissue. Histologic correlations in our cases have detected no viable, residual surviving tumor cells.
279
Sign
137
a Melting candies sign
1. Definition A stack of enhancing intraductal lesions is sharply defined on early dynamic images but “melt together” on later images.
2. Diagram
280
3. Examples
4. Interpretation If intraductal lesions appear sharp on initial dynamic scans, like a stack of beads, and increasing blend together on delayed scans, this suggests a string of small intraductal malignant lesions (DCIS, LCIS), especially if the duct system is not obstructed.
281
Sign
138
a Constant candies sign
1. Definition A stack of enhancing intraductal lesions is sharp on early dynamic images and still have a sharp, beaded appearance on late images.
2. Diagram
282
3. Examples
4. Interpretation A well-defined “stacked” arrangement of small, round, enhancing intraductal lesions on both early and late dynamic scans is inconsistent with intraductal malignancies and is strongly suggestive of intraductal papillomas or diffuse papillomatosis within the duct system. Most cases show associated obstruction and dilatation of the duct system (sign 132, Duct obstruction sign).
283
Sign
139
a Bright T2w cancer
1. Definition An ill-defined enhancing lesion has a positive blooming sign and/or hook sign but is bright on T2weighted images.
2. Diagram
284
3. Examples
4. Interpretation A few mucinous carcinomas have such a large mucus or mucin content (more than 90% of the mass) that the entire mucinous carcinoma appears bright on T2-weighted images. Ordinarily, mucinous carcinomas are clearly detectable as mass lesions with accompanying cystic components. But if the solid components make up less than 10% of the total lesion area, contrast enhancement may appear relatively slow and the lesion may even appear hyperintense on T2-weighted images, thus contradicting the principle of sign 32 (cancers are hypointense on T2-weighted TSE images). In more than 20 years of practice, however, we have seen only one instance of a “bright T2W cancer.” The rest were clearly detectable carcinomas with malignant wash-in and washout kinetics and adjacent or intratumoral cystic mucinous components. Sign 139 should remind us that enhancing lesions with ill-defined margins and high signal intensity on T2-weighted TSE images may possibly be malignant: a mucinous carcinoma containing abundant mucin. This is particularly the case if the lesion shows a positive blooming sign, hook sign, or both.
285
Sign
140
a Enhancing pectoralis
1. Definition Enhancing infiltration of one pectoralis muscle, usually on the same side as a cancerous breast.
2. Diagram
286
3. Examples
4. Interpretation Enhancing infiltration of the pectoralis muscle behind a breast that contains a cancerous tumor usually signifies malignant invasion of the muscle by the cancer.
287
Sign
141
a Resolving edema sign
1. Definition Edema in a cancerous breast clears after chemotherapy.
2. Diagram
288
3. Examples
4. Interpretation The resolution of edema in a cancer-bearing breast after chemotherapy is a sign of successful chemotherapy with an effective cytostatic agent. Generally there will be complete, unilateral resolution of edema in the affected breast.
289
Sign
142
a Recurrent border cancer
1. Definition After chemotherapy, a strongly enhancing (small) cancer reappears at the border of the previous (successfully treated) cancer, which is still visible on T2-weighted TSE images.
2. Diagram
290
3. Examples
4. Interpretation The recurrent border cancer sign is a bad omen. It means that a new clone of aggressive cells has developed that is resistant to the previous chemotherapy regimen, which therefore must be changed. Generally the border cancer first appears at the periphery of the original tumor, which has been “successfully treated” in the first round of chemotherapy but is still visible on T1- and T2-weighted images (see Camouflage sign). Now, however, the cancer displays all kinetic signs of malignancy such as wash-in and washout and is very aggressive.
291
Sign
143
a Bright round lymph nodes on T2-weighted TSE images
1. Definition Rounded, enhancing lymph nodes that are hyperintense to breast parenchyma on T2-weighted TSE images.
2. Diagram
292
3. Examples
4. Interpretation Normal lymph nodes present a reniform or bean shape, have a well-defined hilar notch, and are less than 10 mm (preferably less than 5 mm) in size. If a lymph node assumes a round shape and loses its hilar notch or shows marked enhancement, this usually signifies metastatic involvement of the node. Metastatic lymph nodes generally have low signal intensity on T2-weighted images, however. So far we have observed “bright lymph nodes” only in patients with inflammatory breast disease; we have never seen then in association with cancer. Apparently this is a sign of benign lymphadenopathy.
293
Sign
144
a Normal cardiac and aortic enhancement
1. Definition A region of interest (ROI) in the left ventricle and aorta shows a typical wash-in/washout curve after the injection of 0.1 mmol/kg body weight gadolinium-DTPA.
2. Diagram
294
3. Examples
4. Interpretation Rapid initial enhancement by approximately 100% (wash-in) followed by a sharp decline of signal intensity (washout) in the left ventricle and aorta is typical of the successful injection of contrast material. This curve indicates that the contrast injection was technically correct and that a complete dose has been injected into the body. If this curve is not detected, it should be assumed that the injection was incomplete or unsuccessful. In this case the kinetic data cannot be meaningfully interpreted.
295
Sign
145
a Increasing unilateral vessel sign
1. Definition An increasing number of vessels can be detected in (usually one) breast during follow-up examinations.
2. Diagram
296
3. Examples
4. Interpretation A unilateral increase in breast vascularity, usually subcutaneous, has been viewed as a very early sign of carcinoma formation that was later documented in follow-up examinations. Generally it took six months to two years before cancer was detected in that breast at follow-up. It is also conceivable that this sign is a precursor of inflammation (mastitis), but so far the pronounced form has been observed only in breasts that went on to develop cancer.
297
Sign
146
a Increasing bilateral vessel sign
1. Definition An increasing number of vessels can be detected in both breasts during follow-up examinations.
2. Diagram
298
3. Examples
4. Interpretation A bilateral increase in vascularity compared with previous images is generally not a manifestation of breast disease but of a systemic underlying disease such as developing heart failure.
299
Sign
147
a Lesion with high precontrast signal intensity
1. Definition The precontrast signal intensity of a breast lesion is higher than the normal signal intensity of breast parenchyma.
2. Diagram
300
3. Examples
4. Interpretation Increased signal intensity in the precontrast image is almost always a benign sign. It may signify fat necrosis (oil cyst) or hemorrhage with methemoglobin formation (after biopsy, anticoagulant medication, a fall onto the breast, etc.). This sign may also represent an intramammary lymph node, which should be interpreted as benign. Lymph node metastases are generally hypointense in the precontrast image and enhance intensely after contrast administration. In very rare cases, liposarcoma may present with increased precontrast signal intensity (due to fatty tissue). This would be the only, very rare example of a malignant lesion with this sign.
301
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