Medullary carcinoma of the breast: Role of contrast-enhanced MRI in the diagnosis of multiple breast lesions
1 Department of Radiology, Universiti Putra Malaysia, Selangor, Malaysia.
2 Department of Biomedical Imaging, University of Malaya, Kuala Lumpur, Malaysia
Medullary carcinoma is a rare breast carcinoma with a
syncytial growth pattern and high-grade cytology. It can be difficult to
diagnose and may be missed on conventional imaging as the findings may overlap
with benign lesions i.e. fibroadenomas. The authors report a case of a
25-year-old female who presented with multifocal breast lumps diagnosed with
medullary carcinoma and fibroadenomas. Imaging and pathological correlation
with contrast-enhanced MRI are presented in the diagnosis of these lesions. � 2009
Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Fibroadenoma, medullary carcinoma breast,
Medullary carcinoma of the breast is a rare subtype of
invasive breast carcinoma with a high-grade cytology but has been reported to
have a good prognosis. It is an uncommon type of invasive breast cancer
accounting for 5 - 7% of all breast cancers, occurring most frequently in women
in their late 40s and early 50s. It is also more common in women who have a
BRCA1 mutation. Radiologically, it can be difficult to diagnose and may be
missed as the imaging findings may overlap with benign lesions i.e.
fibroadenomas on conventional mammography and ultrasonography. The authors
report a case of a 25-year-old female who presented with multifocal breast
lumps diagnosed with medullary carcinoma and fibroadenomas. Imaging and
pathological correlation with contrast-enhanced MRI are presented in the
diagnosis of these lesions. This case highlights the usefulness of utilizing
contrast-enhanced MRI in the characterization of multiple breast lesions when
conventional imaging findings are equivocal.
A 25-year-old female presented to the Breast Physician in
April 2007 with a 2-month history of a painless lump in the right breast. She
had no associated nipple discharge or other constitutional symptoms. Physical
examination revealed a 3 cm, non-mobile mass in the upper outer quadrant of the
right breast. It was non-tender and the overlying skin was normal. There was no
axillary lymphadenopathy. Prior to this presentation, the patient first
presented to a private medical center with bilateral breast lumps in 2002. A
few of these lumps were surgically removed and histologically proven to be
fibroadenomas. During this period, her maternal aunt had developed breast
cancer and was undergoing treatment.
Breast examination and ultrasound follow-up was performed
every 12 months. She was symptom free until she developed a painful lump in the
left breast in 2004. As this lesion clearly demonstrated typical benign
features characteristic of a fibroadenoma, the lesion was followed up with
ultrasound and had remained essentially unchanged for the next 3 years. She
subsequently developed a new lump in the right breast for which she presented
Ultrasound examination of the right breast demonstrated a
well-circumscribed lobulated hypoechoic mass with smooth margins corresponding
to the palpable lump at the 9 o�clock position (Figure 1). There were
inhomogeneous internal echoes associated with posterior enhancement which was
suggestive of proteinaceous materials or internal haemorrhage. Colour Doppler
imaging showed some demonstrable internal vascularity. On the basis of these
morphological features, the lesion was categorized as suspicious finding
BI-RADS 4. The previously known stable nodule in the left breast had remained
unchanged in size and appearance; however two new benign looking lesions had
been identified. Bilateral mammograms was subsequently performed which was of
limited diagnostic value due to the dense breast parenchymal pattern (Figure
2). No microcalcifications or axillary lymphadenopathy was demonstrated. The
fine needle aspiration biopsy (FNAC) performed under ultrasound guidance was
consistent with medullary carcinoma.
Contrast-enhanced MRI (Siemens 1.5 Tesla), which was
performed to exclude multifocal / multicentric carcinomas, showed a
corresponding lobulated mass with smooth margins in the right upper outer
quadrant. (Figure 3). The lesion was deep seated, lying adjacent to the
pectoralis major with no evidence of infiltration into the underlying muscles.
It demonstrated rapid homogenous enhancement in the early dynamic phase with an
early washout pattern (Figure 4a). The other three nodules seen in the left
outer quadrant showed gradual persistent enhancement throughout the dynamic
study which were in favour of benign pathology (Figure 4b). The examination
concluded the presence of a solitary right breast carcinoma with multiple left
breast benign lesions. At the request of the surgeon, core biopsies were also
performed on all the three lesions in the left breast under ultrasound guidance
which were confirmed to be fibroadenomas.
After discussing the treatment options with the patient,
breast conservation surgery of the right breast with axillary clearance was
performed in June 2007. Gross examination of the resected specimen revealed a
smooth, well circumscribed solid mass measuring 2.0 cm � 1.8 cm
with bloody foci. It also had a fairly homogenous appearance with lack of dense
fibrous stroma. Histopathological examination revealed lymphocytic infiltration
with solid sheets of large anaplastic cells and syncytial growth consistent
with medullary carcinoma (Figure 5).
Medullary breast carcinoma is a rare breast malignancy
comprising less than 5% of breast carcinomas in majority of studies . It has
a predilection for women of a younger age group and in a study by Rosen et
al.  it was found to constitute 11% of all breast malignancies among
women aged 35 and younger. Some studies have revealed a similar degree of
prognosis between medullary carcinoma and infiltrating ductal carcinoma of the
same stage [3-5] whereas others have observed equal survival rates among these
two types of carcinoma [6,7].
Medullary carcinoma is a subtype of infiltrating ductal
carcinoma. Therefore, the radiographic features are indistinguishable from the
other tumours in the same subgroup. On gross examination, these groups of
tumours are often well circumscribed with a median size of about 2.0-3.0 cm. It
is a moderately firm, discrete tumour with a lobulated or nodular cut surface
and may have necrosis or haemorrhagic changes . Histologically, medullary
carcinoma demonstrates syncytial growth pattern of poorly differentiated tumor
cells with a high mitotic rate. Prominent lymphocytic infiltrates with a
circumscribed microscopic appearance of desmoplastic inflammatory reaction
involving mainly the periphery was also diffusely present throughout the
substance of the tumor - this is another characteristic feature, which may
account for its clinical and biological behaviour .
Normally, no glandular or fatty breast tissue should be
found within the invasive portion of the tumour. IgG cells predominate with
many T-lymphocytes and more than 90% of these tumours are estrogen- and
progesterone-receptor negative . Histopathological examination in this
patient revealed lymphocytic infiltration with solid sheets of large anaplastic
cells and syncytial growth consistent with medullary carcinoma. Medullary
carcinoma of the breast is considered to carry a more favourable or equal
prognosis compared to other subtypes of infiltrating ductal carcinoma . This
is a biological paradox because its clinical behavior contrasts with its
anaplastic morphology. The main characteristic feature of a medullary carcinoma
is the dense lymphocytic infiltrate. The presence of increased numbers of
activated cytotoxic lymphocytes in medullary carcinoma of the breast may be a
key mechanism active in the host versus tumour response leading to improved
Based on several studies done previously, medullary
carcinoma of the breast is usually described as an irregular shaped mass with
microlobulation and least frequently with posterior acoustic shadowing
sonographically . Calcification is usually not present on mammographic
imaging. Sonographic features of medullary carcinoma and other subtypes group
do not differ substantially.
In a study conducted by Cho and colleagues, they found
that their cases of medullary carcinoma were larger with a greater L/AP ratios
than the fibroadenomas . Their medullary cancers were round or lobular in
shape and demonstrated thick walls with anechoic cystic space. Medullary
carcinomas generally demonstrate a lesser degree of sound attenuation as
compared to other malignant tumours on ultrasound. Other sonographic features
include smooth contours, weak internal echoes and oval or round shape .
Typical fibroadenomas appear well circumscribed, homogeneous, hypoechoic with
edge shadowing and gentle lobulations with occasionally coarse calcification
within . It is also a recognized fact that medullary carcinoma mimics a
fibroadenoma sonographically .
In this patient, the medullary carcinoma was shown on
ultrasound to be a well-defined lobulated hypoechoic mass with posterior
acoustic enhancement, or increased through transmission deep to it. This
finding may be due to a homogenous population of tumor cells in the mass that
have few acoustic interfaces, which would facilitate the transmission rather
than the reflection of ultrasound. On mammogram, medullary carcinoma commonly
appears uniformly dense, round or oval, non-calcified and with lobulated
margins . The width of the lobulations measured at the base, ranged from 2
to 3 mm, in some cases larger, solitary or multiple indentations were noted
. Some lesions, exhibited a halo sign at mammography, which until recently
was considered strong evidence of a benign lesion . In this patient, the
lesion was not visualised on mammogram due to the dense stromal pattern that
had obviously obscured the cancer as well as the fibroadenomas. No axillary
lymphadenopathy was seen in this patient either.
Young et al  have reported cases of bilateral
medullary carcinomas in about 3-18% of patients as well as multicentric
medullary carcinoma in one breast [8, 10]. In this case, MRI of both breasts
was performed to rule out multiplicity as she had a total of 4 lesions in both breasts.
However, only one malignant lesion was identified in the right breast. The
washout enhancement pattern on the dynamic study combined with the lesion
margin is regarded as a highly specific diagnostic tool in characterizing the
lesion as malignant. Peripheral rim enhancement demonstrated in this lesion was
also strongly associated with malignancy.
The other lesions were shown to have benign MR features
based on the morphology and pattern of enhancement. It is difficult to
differentiate the different subtype of infiltrating ductal carcinoma based on
MRI findings alone. Majority of the lesions showed a strong or moderate degree
of enhancement with peripheral enhancement and an early washout enhancement
pattern in the dynamic sequence . However, there are no specific features
to suggest medullary carcinoma based on these findings, therefore other
supportive features like size of lesion, margin, lobulation and correlation
with ultrasound and mammogram are useful supporting parameters [15, 16]. At the
time of writing this article, the protocol of breast MR that had been used in
the authors� institution was as follows:
- Axial T1W fat sat,
- Axial T2W PD/STIR,
- Sagittal T2W STIR,
- Dynamic post-gadolinium T1W (Axial) study with 1 minute intervals,
- Axial post-gadolinium T1W fat sat.
Fibroadenomas are benign breast tumours that represent
proliferative process in the ducts and are considered to be an aberration of
the normal breast development. They are not considered to have any malignant
potential. However, in a study done by Dupont et al., they found that
the risk of invasive breast cancer was twice as likely to occur in patients
with fibroadenomas . The relative risk was also found to be higher in women
who have atypical fibroadenomas, proliferative disease, or a familial history
of breast cancer. Although there is no literature pertaining to the association
of medullary carcinoma of the breast and fibroadenomas, this case illustrates
an example of how a medullary carcinoma can mimic a fibroadenoma. Follow up and
good clinical history correlation is recommended for any patients on follow up
for fibroadenomas. Any fibroadenomas with significant increase in size or
develops atypical features on follow up or measures more than 3-4 cm in
diameter should be surgically excised and biopsied regardless of patient�s age
and results of triple testing. . In this case, the patient had a family
history of breast carcinoma and multiple fibroadenomas, both of which were risk
factors in the development of breast carcinoma.
The 5-year survival rate for medullary carcinoma is
approximately 78% . Death secondary to this disease is only 10% though. The
20-year disease free survival for stage I and II patients is approximately 95%
and 61%, respectively . Breast conservation surgery is the treatment of
choice for lesions less than 3.0 cm with no more than 3 nodes involved. A right
breast conservation surgery and axillary clearance was done for this patient.
She is currently on chemotherapy and is to be followed by course of
radiotherapy. In conclusion, this case demonstrates the importance of MR
correlation to characterize breast lesions and exclude multiplicity of
malignant lesions before surgery.
Figure 1 Ultrasound examination of the right breast showing a well circumscribed hypoechoic mass (white arrow) with internal echogenicity and acoustic enhancement with lobulated margins.
Figure 2 Mammograms showed dense breast parenchymal pattern limiting the sensitivity of the examination. No suspicious masses, architectural distortion or microcalcifications were present.
Figure 3 MRI study of the breasts showing the medullary carcinoma in the right breast adjacent to the pectoralis muscle (long white arrow) appearing (a) isointense on T2W STIR axial (TR: 5450, TE: 60), (b) isointense on T1W fat sat axial sequence (TR: 11.2, TE: 5), (c) demonstrated homogenous enhancement during the early dynamic post-gadolinium sequence at 1 minute, and (d) delayed peripheral enhancement during the dynamic post-gadolinium at 6 minutes, suggestive of a malignant lesion. Note the smaller three enhancing fibroadenomas in the left breast (short white arrows) in (c) and (d), which demonstrated gradual homogenous enhancement throughout the dynamic phases.
Figure 4 Dynamic contrast-enhanced time intensity curves of (a) the right breast mass with early wash-in and early wash-out pattern, (b) the benign left breast lesions with gradual enhancement pattern throughout the dynamic phases.
Figure 5 Histopathology slide showing lymphocytic infiltration with solid sheets of large anaplastic cells with syncytial growth.
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|Received 20 April 2009; received in revised form 28 July
2009, accepted 29 July 2009
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Kartini Rahmat).
Please cite as: Abdul Rashid SN, Rahmat K, Jayaprasagam KJ, Alli K, Moosa F,
Medullary carcinoma of the breast: Role of contrast-enhanced MRI in the diagnosis of multiple breast lesions, Biomed Imaging Interv J 2009; 5(4):e27