Mammographic Appearance of Axillary Lymph Node Calcification in Patients with Metastatic Ovarian Carcinoma

Lymph node microcalcifications after neoadjuvant chemotherapy: A therapeutic response marker

Lymph node microcalcifications are rare events, and when they are accompanied by neoplasia, they usually seem to be associated with a metastatic condition. We present a case of a patient with breast cancer and lymph node microcalcifications undergoing neoadjuvant chemotherapy (NCT). A change in the calcification pattern towards becoming coarse was observed. Calcification represented a marker of axillary disease, and it was resected after NCT. This is the first report of a patient with lymph node microcalcification undergoing NCT. We observed a change in the calcification format, which facilitated lymph node sentinel identification. Pathological evaluation indicated metastatic disease.

Calcified Axillary Lesions on Mammography: Review and Management

When interpreting mammography, breast radiologists may identify radiopaque densities in the axilla on the mediolateral oblique or lateral projections. When such densities are encountered, true calcifications must be differentiated from pseudocalcifications (artifact). Using imaging, breast radiologists should be able to localize the finding as being dermal, within the soft tissues, within a lymph node, or intramuscular. By combining the anatomic location with the clinical presentation and any other imaging findings, breast radiologists will be able to determine the most appropriate management.

Axillary lymph node "bubbly" calcifications and body tattoo: A case series and proposed algorithm to minimize lymph node biopsies

The presence of mammographically evident hyperdense foci within axillary lymph nodes elicits concern for calcium deposits, which in turn have a wide differential diagnosis including both benign and malignant entities. Tissue sampling, most commonly by way of image-guided core needle biopsy, is needed in many cases when a definite etiology cannot be clinically established. In this case series we present history, imaging findings, and pathology results (or long term follow-up stability as biopsy surrogate) of several women with body tattoos who at mammography were noted to have a characteristic pattern of "bubbly" pseudo-calcifications within axillary lymph nodes, and absence of other mammographic, sonographic and clinical abnormalities.

Ink on the move: tattoo pigment resembling axillary lymph node calcifications

High-density foci within axillary lymph nodes are associated with a number of potential diagnoses. In this case series, we present four tattooed patients who had mammographic findings that demonstrated high-density material in axillary lymph nodes, indicative of tattoo pigment migration. The aim of presenting these cases is to highlight the importance of recognizing such pigment migration in order to help breast radiologists form an appropriate differential diagnosis that might include this entity.

Ultrasound Evaluation of the Axilla in the Breast Imaging Setting

ABSTRACT

Ultrasound evaluation of the axilla plays a critical role in the setting of newly diagnosed breast cancer as surgical management evolves toward more targeted axillary nodal resection. Regional nodal involvement by metastatic carcinoma is one of most important prognostic factors in breast cancer and guides local, regional, and systemic treatment. Ultrasound also evaluates response to neoadjuvant chemotherapy. This article will review ultrasound techniques and the anatomy and the morphology of axillary lymph nodes. Lymph node staging in breast cancer will also be discussed. Ultrasound-guided interventions and localizations and emerging technologies of elastography and contrast-enhanced ultrasound will be discussed. In addition, this article will discuss the role of ultrasound as it applies to management of the axilla since the American College of Surgeons Oncology Group Z011 and Z1071 trials. Finally, other causes of benign and malignant axillary lymphadenopathy, not related to breast cancer, are discussed.

Value of High-resolution MRI in Detecting Lymph Node Calcifications in Patients with Rectal Cancer

RATIONALE AND OBJECTIVES

To analyze CT and high-resolution MRI findings of nodal metastasis calcifications and determine the value of high-resolution MRI in detecting nodal calcifications in rectal cancer patients.

MATERIALS AND METHODS

In total, 229 rectal cancer patients were included. The CT was reviewed for the presence of nodal calcifications by two radiologists. High-resolution two-dimensional turbo spin-echo T2-weighted imaging (2D-TSE-T2WI) and fat-suppressed gadolinium-enhanced isotropic high-resolution three-dimensional gradient-echo T1-weighted imaging (3D-GRE-T1WI) were independently reviewed for nodal calcifications by the two radiologists at one-month and two-month intervals, respectively. The sensitivities, specificities and accuracies of the two high-resolution MRI in detecting nodal calcifications were calculated using CT results as a reference.

RESULTS

Regional calcified metastatic lymph nodes were found in 28 patients. The node-to-node evaluation revealed that 55 (98.2%) of the 56 calcified lymph nodes were metastatic. Fifty-one (92.7%) calcified metastatic lymph nodes displayed scattered fine punctate calcifications to different degrees on CT. In both types of high-resolution MRI, the calcifications demonstrated a patchy area of markedly reduced signal intensity in corresponding areas that were larger than those on CT. The sensitivity and accuracy of fat-suppressed gadolinium-enhanced isotropic high-resolution 3D-GRE-T1WI were significantly higher than those of high-resolution 2D-TSE-T2WI (76.8% vs 58.9%, P = 0.013; 98.3% vs 97.9%, P = 0.007; respectively).

CONCLUSION

Metastatic nodal calcifications are characteristic imaging findings in rectal cancer. Calcifications are indicated by markedly reduced signal on high-resolution MRI, which will alert radiologists to scrutinize CT for nodal calcifications and aid in the accurate diagnosis of metastatic lymph nodes.

Tattoo pigment mimicking axillary lymph node calcifications on mammography

Axillary lymph nodes can appear abnormal on mammography due to uptake of tattoo pigment and a malignant cause must be excluded through diagnostic workup. Furthermore, tattoo pigment can mimic malignant pathology at surgery or confound appropriate staging of breast cancer. We present the case of a 47-year-old female with left axillary lymph nodes demonstrating new coarse densities suspicious for malignant calcifications on screening mammogram. Stereotactic guided biopsy was performed which demonstrated pigment from a recent tattoo located on the patient's back and/or flank. Awareness of current or prior tattoos in a patient is helpful to properly manage such cases.

Metachronous vulvar ectopic breast cancer, a case report and literature review

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When two or more primary tumors arise at the same time, they are considered synchronous.

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A metachronous tumor in a new primary that develops after an initial cancer diagnosis.

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The diagnosis of vulvar breast cancer is primarily histopathologic, based on morphology and immunostaining.

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Identifying a cancer as a metastasis versus as synchronous/metachronous significantly impacts staging and treatment.

Ovarian cancer initially presenting with supra-clavicular lymph node metastasis: A case report

Supra-clavicular lymph node metastasis from ovarian cancer is rare. The present study reports the unique case of a 43-years-old patient who initially presented with left supra-clavicular lymph node metastasis, and was nulliparous. According to fine-needle aspiration cytology of the metastatic left supra-clavicular lymph nodes and 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) scan, the patient was diagnosed with poorly differentiated serous carcinoma of ovarian cancer, stage IV. Following two cycles of platinum-based chemotherapy, PET/CT showed that the patient had achieved a complete response. Next, cytoreductive surgery was performed and the postoperative histological findings showed that the patient had achieved a complete pathological response. According to NCCN Clinical Practice Guidelines in Oncology, the patient was stage IV and four cycles of chemotherapy were provided, with no recurrence observed during 3 years of follow-up. This case indicates that patients who initially present with distant metastatic lymph nodes and are nulliparous might have a better prognosis and avoid overtreatment.

CT Findings of Axillary Tuberculosis Lymphadenitis: A Case Detected by Breast Cancer Screening Examination

We report the first description of CT findings of axillary tuberculous lymphadenitis confirmed by the pathological specimen. The breast cancer screening examination is one of the prime methods of detection of axillary tuberculous lymphadenitis. The most common site of axillary tuberculous lymphadenitis is the deep axilla. Screening mammography often fails to cover the whole axilla. The presence on the contrast-enhanced CT of unilateral multiple circumscribed dense nodes, some of which have large and dotted calcifications, might suggest tuberculous lymphadenitis in axillary region.

Hypermetabolic Calcified Lymph Nodes on 18Fludeoxyglucose-Positron Emission Tomography/Computed Tomography in a Case of Treated Ovarian Cancer Recurrence: Residual Disease or Benign Formation?

The contribution of positron emission tomography/computed tomography (PET/CT) with 18F-fludeoxyglucose (FDG) in evaluating ovarian cancer recurrence even after a prolonged disease-free interval, and in therapy response is well-described. Calcifications observed in CT, although usually attributed to benign conditions, may actually represent active disease. Such an example of calcified formations is psammoma bodies. We present a case of 56-y. o. patient with ovarian cancer relapse at the supraclavicular area 18 years after complete response and disease-free interval. The patient received chemotherapy and underwent 18F-FDG-PET/CT for the evaluation of treatment response. Both CT corrected and uncorrected PET images showed hypermetabolism in the massively calcified lymph nodes in the neck, mediastinum, axilla and abdomen, indicative of active residual disease.

Unusual presentation of metastatic ovarian carcinoma as an enlarged intramammary lymph node

Metastasis to the breast most commonly arises from a contralateral primary breast malignancy; however, metastatic disease can also result from extramammary malignancies by hematogenous or lymphatic dissemination. This case report reviews an unusual presentation of primary ovarian carcinoma with metastasis to an intramammary lymph node.

Ductal carcinoma arising from ectopic breast tissue following microcalcification observed on screening mammography: a case report and review of the literature

Ectopic breast tissue can occur anywhere along the incompletely regressed mammary ridge. Among the various types of breast choristoma, ectopic breast tissue, which has only glandular tissue without a nipple or areola, is most commonly detected in axillary areas. However, ectopic breast cancer is often not detected until significant clinical symptoms have been revealed, or diagnosis is delayed. Furthermore, an examination of ectopic breast tissue tends to be omitted from a screening mammography. Especially, the microcalcifications of ectopic breast tissue are difficult to delineate on mammography. Herein, the authors report a case of ectopic breast carcinoma that showed clustered microcalcifications on screening mammography, and discuss the interpretation and implications of microcalcification in ectopic breast tissue.

Percutaneous tattoo pigment simulating calcific deposits in axillary lymph nodes

The isolated finding of calcific deposits within axillary lymph nodes on mammography suggests a broad range of differential diagnoses, from benign causes such as granulomatous reaction secondary to previous histoplasmosis infection to malignancies such as breast cancer and metastatic disease from extramammary primary malignancies. Therefore, the isolated finding of intranodal calcium may warrant biopsy for a definitive diagnosis when a benign etiology is not apparent. We present a patient with isolated axillary lymph node densities on mammography and chest computed tomography, which were subsequently proven to represent deposition of tattoo pigment.

Ovarian cancer initially presenting as intramammary metastases and mimicking a primary breast carcinoma: a case report and literature review

BACKGROUND

Ovarian cancer usually spreads intra-abdominally. Supradiaphragmatic metastases are rare, and axillary lymph node metastases are exceptional. Here, we present the first case of ovarian carcinoma detected at screening mammogram as intramammary lymph node metastases.

CASE REPORT

A 44-year-old obese woman underwent core biopsy of a suspicious mammographic finding histologically consistent with lymph node metastases from breast cancer. Serum tumor markers, including CA 125, were normal, and clinical staging was negative. The patient underwent quadrantectomy and axillary dissection that revealed four involved lymph nodes but no primary breast carcinoma. Accurate re-evaluation of the histological specimens suggested the possible ovarian origin of the tumor. An [(18)F]-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography revealed a 33-mm solid mass with intense metabolic FDG uptake in the right groin and a small simple ovarian cyst with normal FDG uptake. The ovarian cyst was removed laparotomically and was malignant on frozen section. Surgical staging revealed a well-differentiated serous ovarian carcinoma microscopically involving the omentum and massively infiltrating the groin node. After chemotherapy, the patient developed metastases in the contralateral axilla that was removed surgically. The patient is alive with no evidence of disease 20 months after surgical removal of the primary tumor.

CONCLUSIONS

Surgeons should be aware that ovarian cancer may rarely metastasize to intramammary and axillary nodes, mimicking a primary breast carcinoma.

Mammographic signs of systemic disease

Although mammography is primarily used for the detection of breast cancer, it can occasionally reveal breast abnormalities related to extramammary disease. Cardiovascular diseases such as congestive heart failure and central venous obstruction may manifest as venous engorgement and breast edema at mammography. Pathologic arterial calcifications seen at mammography can indicate an underlying risk factor for accelerated atherosclerosis such as chronic renal failure. Connective tissue diseases including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis-polymyositis, and systemic scleroderma typically manifest with bilateral axillary lymphadenopathy, and stromal calcifications are also seen in the latter three disease processes. Some diseases such as neurofibromatosis type 1 and filariasis may manifest with pathognomonic findings at mammography, whereas other systemic diseases such as Wegener granulomatosis, sarcoidosis, and amyloidosis can manifest as nonspecific breast masses that are indistinguishable from breast cancer and usually require tissue biopsy for confirmation. Knowledge of the imaging characteristics of various systemic diseases affecting the breast will aid the radiologist in differentiating systemic disease from suspect breast lesions, thereby helping ensure appropriate follow-up. Furthermore, recognition of systemic diseases such as Cowden syndrome that are associated with an increased risk of breast cancer will allow the radiologist to recommend appropriate surveillance.

Supra-clavicular lymph node metastatic spread in patients with ovarian cancer disclosed at 18F-FDG-PET/CT: an unusual finding

Tumoral dissemination of ovarian cancer most commonly occurs through the intra-peritoneal route; nevertheless, although it is rare, ovarian cancer may also metastasise through the lymphatic channels. Lymphatic diffusion of ovarian cancer usually involves pelvic and retro-peritoneal lymph nodes. Extra-abdominal lymph nodes are rarely involved and their detection may represent a challenge for the oncologist. We describe here two patients studied for ovarian cancer by [18F]fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT): one case during pre-operative staging, the other for restaging after surgery. In both cases PET examination identified extraabdominal lymph node tumoral spread in the left supra-clavicular space; biopsy led to a final diagnosis of recurrent ovarian cancer. Previous reports in the literature on tumoral spread of ovarian cancer to the supra-clavicular nodes are rare, however this possible site of metastatic involvement has to be kept in mind by oncologists and our data show that the 18F-FDG PET/CT may be useful to disclose this unusual supra-diaphragmatic lymphatic diffusion of metastatic lymphatic ovarian cancer.

Bone scan demonstrating metastasis to the breast from an ovarian carcinoma and a review of the literature

Breast metastasis from a primary ovarian neoplasm is very rare. We report a case of breast metastasis along with involvement of the liver, spleen, and pelvis from ovarian carcinoma in a 54-year-old woman demonstrated by whole-body bone scanning. Ovarian metastatic deposits frequently show calcification, and a Tc-99m MDP bone scan could be useful in determining the extent of calcified soft tissue metastatic spread in these patients. A review of the literature of breast metastases form ovarian carcinoma is discussed.