Nipple to lesion distance

Case contributed by Dr Garth Kruger

Presentation

Routine screening images of the right breast

Patient Data

Age: 60 years old
Gender: Female
Mammography

MLO and CC views of the right breast. 

Mammography

It is obvious the lesion on the MLO view is not the lesion marked on the CC view. The distance between the nipple and the lesion is discrepant on the two views. There must be something else going on here.

Measure the distance between the nipple and the lesion with the 2nd finger and 5th finger of your right hand. It must be the same on both images if it is the same lesion.

You recall the patient for rolled CC and MLO views (to get orthogonal images to extrapolate on ) and right breast ultrasound. At this stage, it's a BI-RADS 0.

Mammography

On recall, ML and rolled CC views were performed. Look at the initial images first and then at the annotated images.

It is clear that there are two lesions in the right breast. On the initial imaging, the one lesion was marked on the MLO view and the second lesion on the CC view. The clue is the discrepant nipple to lesion distance on the original images.

Ultrasound

The ultrasound images of the right breast are normal. The technologist and the radiologist both scan the patient.

Q: What do you do now?

A: it is clear from the mammogram images there is something in the right breast. review with initial images of this patient (not shown) convincingly shows two small lesions in the right breast as shown above.

Repeat imaging ultrasound is done at a dedicated breast imaging center. See below...

Ultrasound

Repeat imaging right breast on ultrasound

Two small lesions are found at 11 o'clock and 9 o'clock. The second image is badly cropped to exclude patient demographics.

Pathology

Pathology report as received back from the lab, revealed both lesions are invasive ductal carcinoma.

Case Discussion

A rather laborious and long-winded  demonstration of two specific points:

1. The distance between the nipple and a "lesion" should be the same on both views. Use your right hand, the second and fifth fingers and plot the distance running up and down on the initial and then second image. A "real" lesion should lie on this line. It's a valuable aid to find a lesion on a second image. Try it, it works. And it is free.

2. The more you do something, the better you get. Breast imaging is like golf. If you do lots of breast ultrasounds you become proficient. And vice versa. If you work in a low volume ultrasound setting, do not hesitate to consult with a colleague and get a second opinion and if needs be (like in this case) another study.

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Case information

rID: 22184
Published: 17th Mar 2013
Last edited: 24th Apr 2021
System: Breast
Inclusion in quiz mode: Excluded

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