Invasive Lobular Cancer of the Breast: A Pictorial Essay of Imaging Findings on Mammography, Sonography, and Magnetic Resonance Imaging Sarah L. Savaridas,

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Invasive Lobular Cancer of the Breast: A Pictorial Essay of Imaging Findings on Mammography, Sonography, and Magnetic Resonance Imaging Sarah L. Savaridas, MBChB, DTMH, Garry D. Bristow, BSc, PhD, BM, MRCS, FRCR, Julie Cox, MBBS, FRCS, FRCR Canadian Association of Radiologists Journal Volume 67, Issue 3, Pages 263-276 (August 2016) DOI: 10.1016/j.carj.2015.09.007 Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 1 The lobular cancer is readily identified in the involuted breast on the right (red circle). The lobular cancer in the relatively dense breast (left) is mammographically occult. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 2 Lobular cancer presenting as a spiculated mass on mammography (red circle). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 3 The lobular cancer (between the red arrows) is almost the same density as the surrounding breast tissue. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 4 Architectural distortion (red circle). This was only visible on the craniocaudal view. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 5 Left craniocaudal and mediolateral oblique views of the same patient demonstrating architectural distortion and a central mass. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 6 Craniocaudal mammogram of a patient with bilateral solitary tumours. The lobular cancer on the left (red circle) identifiable only as asymmetric increased density. The well-circumscribed mass on the left (green circle) was a papillary tumour. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 7 Subtle decrease in mammographic breast size on a patient with left upper hemisphere invasive lobular cancer. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 8 Invasive lobular cancer with decrease in mammographic breast size, spiculated mass (red circle), and nipple inversion. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 9 Invasive lobular cancer as a shadowing hypoechoic mass on ultrasound. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 10 Indistinct hypoechoic mass, not parallel to the breast stoma with posterior shadowing. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 11 Poorly defined hypoechoic mass with posterior shadowing. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 12 A mammographically occult invasive lobular cancer presenting as a non-shadowing ill-defined mass overlying a breast implant. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 13 Unusual presentation of invasive lobular cancer as a hyperechoic mass. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 14 Shadowing (between arrows) with no associated mass. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 15 Multicentric, bilateral invasive lobular cancer. The index lesion was in the right lateral breast (top right). The right central and left breast lesions were only identified on MRI. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 16 Mammography underestimated the size of this large lobular carcinoma. The full extent of the tumour is demonstrated on magnetic resonance imaging. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 17 Spiculated mass on magnetic resonance imaging. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 18 Clumped non–mass regional enhancement in a large invasive lobular cancer. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 19 Invasive lobular cancer as shown by non–mass ductal enhancement on magnetic resonance imaging. This presumably reflects the infiltrative manner in which invasive lobular cancer spreads. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions

Figure 20 Invasive lobular cancer demonstrating type II enhancement curve with plateau after initial enhancement and no washout. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2016 67, 263-276DOI: (10.1016/j.carj.2015.09.007) Copyright © 2016 Canadian Association of Radiologists Terms and Conditions