Magnetic resonance imaging breast: An essential imaging modality in metastatic axillary lymphadenopathy with unknown primary

Nitin Gupta; Mitusha Verma; Amit Choudhari; Deepak Patkar

doi:10.4103/jrcr.jrcr_17_18

CASE REPORT

Year : 2018 | Volume : 9 | Issue : 3 | Page : 125-127

Magnetic resonance imaging breast: An essential imaging modality in metastatic axillary lymphadenopathy with unknown primary

Nitin Gupta, Mitusha Verma, Amit Choudhari, Deepak Patkar
Department of Radiodiagnosis, Nanavati Super Speciality Hospital, Mumbai, Maharashtra, India

Date of Web Publication

27-Sep-2018

Correspondence Address:
Dr. Nitin Gupta
Department of Radiodiagnosis, Nanavati Super Speciality Hospital, Mumbai, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jrcr.jrcr_17_18

Abstract

Occult primary breast carcinoma with axillary lymph node metastasis is a rare disorder accounting for 0.1%–0.8% of all the cases of breast cancer in females. Magnetic resonance imaging (MRI) of the breast detects primary tumor in nearly 70% of patients. We are presenting three cases of postmenopausal females, who presented with metastatic axillary lymphadenopathy and primary could be diagnosed only on MRI breast.

Keywords: Axillary lymph node metastasis, carcinoma with unknown primary, magnetic resonance imaging breast, unknown primary

How to cite this article:
Gupta N, Verma M, Choudhari A, Patkar D. Magnetic resonance imaging breast: An essential imaging modality in metastatic axillary lymphadenopathy with unknown primary. J Radiat Cancer Res 2018;9:125-7

How to cite this URL:
Gupta N, Verma M, Choudhari A, Patkar D. Magnetic resonance imaging breast: An essential imaging modality in metastatic axillary lymphadenopathy with unknown primary. J Radiat Cancer Res [serial online] 2018 [cited 2023 Mar 23];9:125-7. Available from: https://www.journalrcr.org/text.asp?2018/9/3/125/242367

Introduction

Occult primary breast carcinoma (OPBC) with axillary lymph node is a condition characterized by the presence of regional or distant disease that is histologically consistent with primary breast carcinoma in the absence of a demonstrable tumor in breast based on clinical evaluation, B-mode ultrasonography, and X-ray mammography. This form of presentation is rare accounting for 0.1%–0.8% of all breast cancers in females.^[1],[2],[3]

There is no consensus on the investigation of these cases, owing to their rarity.

We are presenting a case series of three cases of OPBC, which could be diagnosed only on magnetic resonance imaging (MRI) breast. Purpose of this presentation is to emphasize the role of MRI breast in these cases.

Cases

Case 1

A 76-year-old lady presented with a history of right axillary swelling, for 1 year. On clinical examination, she had a right hard and mobile axillary nodal mass. Ipsilateral and contralateral breast, as well as supraclavicular fossa, did not reveal any abnormality.

On X-ray mammogram and B-mode ultrasonography, no lesion could be identified in either of the breasts. Tru-cut biopsy of the nodal mass revealed the presence of mucinous adenocarcinoma. Immunohistochemistry revealed ER +ve, PR +ve, CKT +ve. Positron emission tomography-computed tomography (PET-CT) revealed uptake in right axillary nodal mass but no other site of primary or metastatic disease.

MRI was offered, and it revealed a 2 cm × 2 cm-sized area of mass-like enhancement in the superolateral quadrant in the posterior portion of the right breast (10 'o' clock) with micro lobulations. It was hypointense on T1-weighted and hyperintense on T2-weighted (T2W). T2W hyperintensity was probably due to its high mucin content.

On dynamic postcontrast evaluation, the breast lesion showed heterogeneous persistent early intense enhancement followed by a progressive increase in signal intensity. Multiple foci of enhancement were also seen scattered in the right breast. MRI features were consistent with the multicentric disease.

Case 2

A 59-year-old female presented with the history of right axillary swelling, for 8 months. On clinical examination, she had hard and mobile right axillary nodal mass. Ipsilateral and contralateral breast, as well as supraclavicular fossa, did not reveal any abnormality.

On X-ray mammogram and B-mode ultrasonography, no lesion could be identified in either of the breasts. Tru-cut biopsy of the nodal mass was suggestive of adenocarcinoma. Immunohistochemistry revealed ER +ve, PR +ve. PET-CT revealed low uptake in right axillary nodal mass, but no other site of primary or metastatic disease.

MRI was offered, and it revealed a regional area of nonmass-like enhancement in the central and outer portion of the right breast, measuring approximately 4.7 cm × 3.3 cm in size consistent with primary neoplasm [Figure 1].

Figure 1: (a) Right axillary lymphnode in CT. (b) Right breast lesion on pet CT. (c) Right breast lesion on MRI. (d) Right breast lesion on MRI (processed image)

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Case 3

A 65-year-old female presented with the history of right axillary swelling of 6 months duration. On clinical examination, she had a right axillary nodal mass of 5 cm × 4 cm, which was hard, matted, and mobile. Ipsilateral and contralateral breast, as well as supraclavicular fossa, did not reveal any abnormality.

On X-ray mammogram and B-mode ultrasonography, no lesion could be identified in either of the breasts. Tru-cut biopsy of the nodal mass revealed the presence of malignant epithelial cells. Immunohistochemistry revealed ER −ve, PR +ve, HER 2 −ve.

MRI revealed spiculated mass-like an area of enhancement in a posterior portion of the right breast, inferolateral quadrant at 8 'o' clock position, infiltrating chest wall on the right side (pectoralis major muscle), suggestive of the neoplasm [Figure 2]. There is accentuated regional non-mass enhancement in the outer half of the right breast, This pattern is often seen with infiltrating ductal carcinoma.

Figure 2: (a) Right breast lesion showing diffusion restriction. (b) Right breast lesion (yellow arrow) and right axillary node (red arrow) on MRI. (c) Right breast lesion on MRI

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Discussion

OPBC with axillary nodal metastasis is a rare entity, first described by Halsted in 1907.^[4] In general, 0.1%–0.8% of all breast cancers are occult.^{[2],[3],[4],[5]} Optimum workup of the patient with OPBC is yet to be established. Although the primary imaging modality for evaluating breast lesion is mammography, a false-negative rate of up to 30% has been reported for mammography.^[6],[7] The sensitivity of mammography further decreases in patients with dense breast parenchyma.

MRI of the breast is a promising tool in such cases. It can identify primary tumor in 70% of patients of OPBC.^{[5],[6],[8],[9],[10],[11]} In addition, it was found that negative breast MRI predicted low tumor yield at mastectomy and hence could improve breast conservation rates in these patients.

Olson et al.^[11] study revealed, 12 cases of metastatic axillary lymph node with negative MRI results, five underwent breast surgery, but no primary lesion was detected in four cases (80%). These findings substantiate the high sensitivity of MRI and its value in the clinical application.

PET scan has revolutionized the management of carcinoma with unknown primary at other subsites. However, it has not been extensively evaluated in OPBC. In our case series of two out of 3 patients underwent PET scan, which did not reveal any site of primary disease.

Conclusion

The purpose of presenting this case series was to emphasize the role of breast MRI, in metastatic axillary lymph nodes with unknown primary. MRI seems superior to other imaging modalities including fluoro-deoxyglucose PET-CT in cases of OPBC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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