Invasive lobular carcinoma of the breast detected with real-time virtual sonography: a case report

Abstract

Background: Invasive lobular carcinoma (ILC) sometimes presents with unique clinical, pathologic, and radiographic features. In this case report, we describe a patient with ILC, whose initial presentation consisted with symptoms secondary to bone-marrow dissemination. In addition, the breast primary was revealed only by magnetic resonance imaging (MRI) followed by real-time virtual sonography (RVS).

Case presentation: A 51-year-old woman presented to our outpatient clinic with dyspnea on exertion. She had severe anemia (hemoglobin, 5.3 g/dL) and thrombocytopenia (platelet count, 31 × 10³/mL). Bone-marrow biopsy was performed to evaluate hematopoietic function. The pathologic diagnosis was bone-marrow carcinomatosis due to metastatic breast cancer. Initial mammography followed by ultrasonography (US) failed to detect the primary tumor. On MRI, a non-mass-enhancement lesion was observed. While second-look US also did not detect the lesion, it was clearly visualized with RVS. We were finally able to biopsy the breast lesion. The pathologic diagnosis was ILC positive for both estrogen receptor and progesterone receptor, with 1 + immunohistochemical staining for human epidermal growth factor receptor 2. This case of ILC was characterized by bone-marrow metastasis. Due to decreased cell adhesion, the risk of bone-marrow metastasis is higher in ILC than in invasive ductal carcinoma, the most prevalent type of breast cancer. Biopsy of the primary lesion, which was initially only detected with MRI, was successfully performed with clear visualization during RVS, which is based on the fusion of MRI and US images.

Conclusion: In this case report and literature review, we describe the unique clinical characteristics of ILC and a strategy for identifying primary lesions that are initially only visualized with MRI.

Keywords: Invasive lobular carcinoma; MRI; Non-mass-enhancement lesion; RVS.

Fig. 1

Pathological findings in the bone-marrow biopsy specimen. A Hematoxylin–eosin staining. Signet-ring cell carcinoma cells were widespread. There were very few hematopoietic cells. B Positive immunohistochemical staining with an anti-mammaglobin A antibody, indicating that breast cancer was the primary tumor. C Positive immunohistochemical staining with an anti-estrogen receptor antibody. (Magnification × 20 for all.)

Fig. 2

In the PET–CT scan image around the pelvis, diffuse FDG uptake is demonstrated

Fig. 3

Contrast-enhanced prone MRI depicted a region with NME in the right breast (arrow)

Fig. 4

A T1-weighted, contrast-enhanced additional supine MRI with multi planar reconstruction (MRI-MPR) showed an irregular enhancing mass (arrow). B View from the RVS monitor. Sonography showed a heterogeneous mass with low echogenicity and irregular shape. A pre-contrast MRI-MPR image is shown in (b). An early phase MRI-MPR image is shown in c. A late-phase MRI-MPR image is shown in d. Images (b–d) correspond to sonographic cutaway images in a