Diffuse Breast Cancer on Imaging

  • There are two main groups of diffuse breast cancers:
    • That present as large areas of architectural distortion on the mammogram:
      • Neoductgenesis
      • Diffusely infiltrating carcinoma:
        • Which makes up approximately 5% of all breast cancers
  • When the tumor is e-cadherin negative:
    • It is usually called invasive “lobular” carcinoma
  • When it is e-cadherin positive:
    • It is called infiltrating “ductal” carcinoma
  • The designation based on e-cadherin staining is arbitrary:
    • Because the behavior of diffusely invasive carcinoma:
      • Is the same regardless of the staining
  • Lacking calcifications and a central tumor mass:
    • These cancers are notoriously difficult to perceive on mammogram:
      • Even when they are large and palpable or when they occur in fatty involuted breasts:
        • However, the associated connective tissue response:
          • Makes this type of cancer quite visible with ultrasound
  • In contrast to diffusely infiltrating cancers:
    • Circular (Image 1) and spiculated (Image 2):
      • Tumors arising in the terminal ductal lobular units (TDLU) have:
        • Bulging, convex contours protruding into the adipose tissue
  • The solid variety of infiltrating lobular carcinoma:
    • Most probably arises within the TDLU:
      • Has a circular / oval shape on breast imaging (Images 3)

Image 1: Lobulated spherical tumor mass


Image 2: Multifocal stellate invasive breast cancer


Image 3: Mammographic, MRI and pathologic images of the solid form of invasive lobular

  • There are two other variants of invasive lobular carcinoma that arise in the TDLUs:
    • The tubulolobular variant:
      •  Is either a unifocal or multifocal spiculated lesion on the mammogram (Image 5)

Image 4: Mammogram and large format histology of a multifocal tubulolobular breast

  • The alveolar type of invasive lobular carcinoma:
    • Is usually mammographically occult;
      • Or it can be seen as a subtle, asymmetric density (Image 5)

Image 5: Mammogram and large format histology alveolar type invasive lobular carcinoma

  • The various forms of invasive lobular carcinoma that develop in the TDLUs and present as localized lesions:
    • Have a significantly better prognosis than the diffusely infiltrating type breast cancer
  • Complex sclerosing lesions:
    • Present mammographically as non-palpable architectural distortion with no central tumor mass and lucent radiating structures, the so called “black star”:
      • As opposed to cancers originating from the TDLU:
        • Which have a dense central tumor mass surrounded by radiopaque spiculation, giving the impression of looking at a “white star
  • Malignant phyllodes tumors:
    • Present as large, high density masses:
      • The borders may be circumscribed or ill defined
  • Fat necrosis:
    • Also presents as a hypoechoic, high-density mass
  • References
  • Tot T. Diffuse invasive breast carcinoma of no special type. Virchows Arch. 2016;468(2):199-206.
  • Tabár L, Dean PB. Teaching Atlas of Mammography. New York, NY: Thieme; 2011.
  • sity mass.

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