Endgames Picture Quiz

An occult breast mass

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b4316 (Published 05 November 2009) Cite this as: BMJ 2009;339:b4316
  1. C J Burke, specialist registrar radiology,
  2. R Thomas, specialist registrar radiology,
  3. D C Howlett, consultant radiologist
  1. 1Department of Radiology, Eastbourne General Hospital, Eastbourne, East Sussex BN21 2UD
  1. Correspondence to: C J Burke, 42 Arminger Road, London W12 7BB drchristopherburke{at}gmail.com

    A 69 year old woman was referred by her general practitioner to the rapid access breast clinic because of a two week history of painless swelling in the upper left breast. She had no history of nipple change or discharge, and she was otherwise well with no medical history of note. On clinical examination she had a firm, ill defined, and non-tender swelling above the left nipple, with no palpable axillary nodes. Free hand, fine needle aspiration was undertaken and she was referred for imaging. Bilateral mammography showed moderately dense breast tissue only, and no focal lesion was seen on ultrasound of the left breast.

    Results of needle cytology showed benign cells only. Because of persisting clinical concern and the dense breast tissue seen on mammography, breast magnetic resonance imaging was performed. Figure 1 is an axial post-contrast, fat saturated magnetic resonance image through the superior portion of the breasts. This is a sequence that removes the signal from normal breast tissue, thereby highlighting areas of enhancement only.

    Fig 1 An axial post-contrast, fat saturated magnetic resonance image through the superior portion of the breasts


    • 1 What radiological abnormalities are present?

    • 2 What is the likely diagnosis?

    • 3 What are the indications for breast magnetic resonance imaging in everyday practice?

    • 4 How should this patient be managed?


    Short answers

    • 1 The left breast has a large ill defined, lobulated, and enhancing lesion in the centre, with surrounding satellite nodules. The right breast has a smaller, medially located, ill …

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