劉佩芳，鮑潤(rùn)賢

MRI成像技術(shù)具有極好的軟組織分辨率和無(wú)射線(xiàn)輻射特點(diǎn)，對(duì)乳腺檢查具有獨(dú)到的優(yōu)勢(shì)，已有的大量研究結(jié)果表明乳腺M(fèi)RI檢查對(duì)于乳腺良、惡性腫瘤的診斷和鑒別診斷、對(duì)乳腺癌分期、治療后隨訪(fǎng)以及評(píng)估腫瘤血管生成和腫瘤生物學(xué)行為及預(yù)后方面，與乳腺X線(xiàn)和超聲檢查相比可獲得更多、更準(zhǔn)確的信息，在某些方面起著后兩者不能替代的作用[1-4]。本文結(jié)合臨床病例從影像學(xué)角度重點(diǎn)闡述乳腺M(fèi)RI對(duì)首發(fā)癥狀以腋淋巴結(jié)轉(zhuǎn)移癌患者尋找乳腺原發(fā)灶、對(duì)乳腺癌保乳術(shù)前評(píng)估、對(duì)一側(cè)已確診為乳腺癌檢出對(duì)側(cè)同時(shí)性乳腺癌以及MR引導(dǎo)下乳腺病變定位和活檢在乳腺癌個(gè)體化治療方面的作用。

1 乳腺M(fèi)RI對(duì)首發(fā)癥狀以腋淋巴結(jié)轉(zhuǎn)移癌患者尋找乳腺內(nèi)原發(fā)灶的作用

臨床上約近1.0%的乳腺癌患者僅表現(xiàn)為腋淋巴結(jié)腫大，經(jīng)活檢病理及免疫組化診斷為轉(zhuǎn)移癌并提示原發(fā)灶可能來(lái)自乳腺，而臨床乳腺觸診、X線(xiàn)和超聲檢查均為陰性[5]。以往臨床上對(duì)部分這類(lèi)患者的傳統(tǒng)治療手段為行同側(cè)乳腺根治術(shù)或改良根治術(shù)，以期切除其原發(fā)腫瘤，但術(shù)后并非所有病例的病理結(jié)果都能檢出癌灶。2005年美國(guó)乳腺外科醫(yī)師協(xié)會(huì)(American Society of Breast Surgeons，ASBS)對(duì)776名醫(yī)師的調(diào)查結(jié)果表明：約43%的醫(yī)師對(duì)這類(lèi)患者選擇手術(shù)治療；37%選擇放療；其余則選擇觀(guān)察或由患者選擇治療方案或行PET進(jìn)一步檢查等[6]。因此對(duì)首發(fā)癥狀為腋淋巴結(jié)轉(zhuǎn)移癌患者術(shù)前了解乳腺內(nèi)是否存在癌灶以及對(duì)癌灶的準(zhǔn)確定位和范圍評(píng)估對(duì)臨床進(jìn)一步制訂個(gè)體化的治療方案至關(guān)重要。近年來(lái)隨著乳腺M(fèi)RI檢查越來(lái)越多的應(yīng)用于臨床，對(duì)于腋淋巴結(jié)轉(zhuǎn)移癌患者尋找乳腺內(nèi)原發(fā)癌灶已成為臨床醫(yī)生公認(rèn)的乳腺M(fèi)RI檢查適應(yīng)證之一，已有研究表明MRI對(duì)檢出腋淋巴結(jié)轉(zhuǎn)移癌患者的乳腺內(nèi)原發(fā)癌灶具有較高敏感性，約80%的病例可通過(guò)MRI檢查檢出乳腺內(nèi)原發(fā)癌灶[7-9]。筆者一組研究結(jié)果顯示[10]，以腋淋巴結(jié)轉(zhuǎn)移癌為首診且臨床乳腺觸診、X線(xiàn)和超聲檢查均為陰性的33例患者，MRI檢出乳腺內(nèi)原發(fā)癌灶的準(zhǔn)確性為83.33%，相對(duì)于臨床常見(jiàn)的一般乳腺癌而言，以腋淋巴結(jié)轉(zhuǎn)移癌為首診且臨床乳腺觸診和X線(xiàn)、超聲檢查均為陰性的乳腺癌MRI表現(xiàn)以小灶性的腫塊性病變(圖1)和導(dǎo)管性或段性強(qiáng)化的非腫塊性病變(圖2)為常見(jiàn)表現(xiàn)類(lèi)型。乳腺M(fèi)RI檢查可作為腋淋巴結(jié)轉(zhuǎn)移癌且臨床乳腺觸診、X線(xiàn)和超聲檢查均為陰性患者尋找乳腺內(nèi)原發(fā)灶的常規(guī)檢查手段。

圖1 患者系右腋下淋巴結(jié)轉(zhuǎn)移性癌，雙乳臨床觸診、X線(xiàn)和超聲檢查均未發(fā)現(xiàn)惡性病變，乳腺M(fèi)RI診斷右側(cè)乳腺癌，行右乳腺根治術(shù)，經(jīng)全乳取材病理診斷為右乳外上非特殊型浸潤(rùn)性導(dǎo)管癌。圖1A～D分別為右乳腺M(fèi)RI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，顯示右乳外上方不規(guī)則強(qiáng)化結(jié)節(jié)(箭)；圖1E為動(dòng)態(tài)增強(qiáng)后病變時(shí)間-信號(hào)強(qiáng)度曲線(xiàn)圖，顯示為流出型曲線(xiàn)；圖1F為DWI圖像(b=500 s/mm2)，顯示該病變呈較高信號(hào)，ADC值為0.80×10-3 mm2/s；圖1G：雙乳X線(xiàn)內(nèi)外側(cè)斜位，雙乳未見(jiàn)明顯惡性病變征象Fig 1 Clinically,mammographically,and ultrasonographically (not shown) occult breast carcinoma visualized by MRI in the patient with axillary lymph node metastasis.Histology proved invasive ductal carcinoma of the right breast.MR images before(Fig 1A),1 min (Fig 1B),2 min (Fig 1C) and 8 min (Fig 1D) following injection of contrast medium showed a strong early enhancing nodule (arrow) with irregular shape in the right breast.Kinetic curve (Fig 1E) demonstrated rapid initial enhancement with washout pattern.Axial DWI (b=500 sec/mm2) (Fig 1F) showed obviously high signal intensity lesion with ADC value of 0.80×10-3 mm2/sec.Mediolateral oblique views of both breasts (Fig 1G) showed negative findings.

圖2 患者系左腋下淋巴結(jié)轉(zhuǎn)移性癌，免疫組化檢查提示原發(fā)灶來(lái)自乳腺，乳腺M(fèi)RI檢查考慮左側(cè)乳腺癌，行左乳腺根治術(shù)后經(jīng)全乳取材病理診斷為左乳外下非特殊型浸潤(rùn)性導(dǎo)管癌。圖2A～C分別為左乳腺M(fèi)RI平掃和動(dòng)態(tài)增強(qiáng)后1 min、8 min，顯示左乳下方不規(guī)則斑點(diǎn)狀異常強(qiáng)化病灶(箭)；圖2D為強(qiáng)化后延遲期橫斷面，顯示左乳強(qiáng)化病變沿導(dǎo)管走行分布(箭)Fig 2 Clinically,mammographically,and ultrasonographically (not shown) occult breast carcinoma visualized by MRI in the patient with axillary lymph node metastasis.Histology revealed invasive ductal carcinoma not otherwise specifi ed of the left breast.MR images before (Fig 2A),1 min (Fig 2B) and 8 min (Fig 2C) following injection of contrast medium showed clumped and stippled enhancement nodules (arrow) in the left breast.Axial delayed enhanced image (Fig 2D) demonstrated linear clumped and stippled enhancement (arrows).

圖3 (左乳腺)非特殊型浸潤(rùn)性導(dǎo)管癌，組織學(xué)Ⅱ級(jí)，淋巴管癌栓(+++)，乳頭(+)，腋下淋巴結(jié)11/25。圖3A為左乳X線(xiàn)頭尾位，圖3B為左乳X線(xiàn)內(nèi)外側(cè)斜位，顯示左乳中上方高密度不規(guī)則單發(fā)腫物。圖3C為左乳病變不同層面VR圖，圖3D～3F分別為左乳腺增強(qiáng)后病變不同層面圖；圖3G為左乳MIP圖，顯示左乳頭深面從內(nèi)側(cè)至外側(cè)均可見(jiàn)多發(fā)、大小不等不規(guī)則異常強(qiáng)化，其中較大腫塊(箭)相符于X線(xiàn)所見(jiàn)病變，其余多發(fā)的異常強(qiáng)化病變于X線(xiàn)上未顯示Fig 3 Invasive ductal carcinoma not otherwise specifi ed of the left breast (Grade II),nipple (+),axillary lymph node 11/25 (+).Craniocaudal (Fig 3A) and mediolateral oblique (Fig 3B) views of the left breast demonstrated a solitary irregular high density mass with ill-defi ned margins.Volume rendering images (Fig 3C),contrastenhanced images (Fig 3D-3F) at different slices,and MIP image (Fig 3G) showed multiple enhanced lesions in the left breast.The largest one (arrow) corresponds to the mass shown on mammogram.The other multifocal lesions could not be identifi ed on mammograms.

2 乳腺M(fèi)RI對(duì)乳腺癌患者保乳術(shù)前評(píng)估的作用

近年來(lái)隨著醫(yī)學(xué)的發(fā)展、綜合治療水平的提高和乳腺癌患者對(duì)生活質(zhì)量的要求，乳腺癌保乳手術(shù)以其兼顧乳腺癌療效和患者生活質(zhì)量的優(yōu)勢(shì)已成為乳腺癌治療中的幾種主要方法之一，但對(duì)保乳手術(shù)而言為了減少術(shù)后復(fù)發(fā)率，必須嚴(yán)格掌握適應(yīng)證，臨床醫(yī)師需在術(shù)前盡可能準(zhǔn)確判斷癌灶的位置、范圍和有無(wú)多灶或多中心腫瘤。相關(guān)研究和我們的臨床實(shí)踐表明，MRI對(duì)乳腺癌特別是對(duì)浸潤(rùn)性較強(qiáng)的乳腺癌范圍的評(píng)估與組織病理學(xué)結(jié)果最為接近，而臨床乳腺觸診和X線(xiàn)檢查對(duì)這類(lèi)病變范圍常常低估(圖3)，在浸潤(rùn)性小葉癌中，術(shù)前MRI檢查改變治療方案達(dá)24%[11-14]。關(guān)于乳腺癌中的導(dǎo)管原位癌(ductal carcinoma in situ,DCIS)，盡管其預(yù)后明顯好于浸潤(rùn)性癌且臨床多適合行保乳手術(shù)治療，但其生物學(xué)特性具有明顯的異質(zhì)性，另外，DCIS較浸潤(rùn)性癌易呈多中心性，DCIS的多中心性直接影響到保乳手術(shù)的效果并增加了局部復(fù)發(fā)的危險(xiǎn)性，MRI因其本身具有的成像優(yōu)勢(shì)不僅可對(duì)DClS特別是高核級(jí)DCIS早期檢出，更重要的是可對(duì)其準(zhǔn)確確定病變范圍，對(duì)僅表現(xiàn)為鈣化的DCIS或伴廣泛導(dǎo)管內(nèi)癌成分的浸潤(rùn)性癌，X線(xiàn)上很難依靠鈣化準(zhǔn)確評(píng)估病變范圍，即使聯(lián)合超聲檢查或進(jìn)行術(shù)前穿刺活檢，也難以保證局部切除范圍充足，而出現(xiàn)手術(shù)切緣反復(fù)陽(yáng)性或保乳手術(shù)失敗或術(shù)后復(fù)發(fā)等問(wèn)題，對(duì)此，MRI則有助于對(duì)病變范圍的準(zhǔn)確評(píng)估[15,16](圖4)。乳腺多灶或多中心性癌發(fā)生率為14%～47%，明確診斷乳腺癌是否為多灶或多中心性是臨床醫(yī)生考慮能否行保乳手術(shù)的一個(gè)最重要因素，文獻(xiàn)報(bào)道在擬行保乳手術(shù)前行動(dòng)態(tài)增強(qiáng)MRI檢查的病例中，約有11%～19.3%的病例因發(fā)現(xiàn)了多灶或多中心病變而改變了原來(lái)的治療方案，由局部切除術(shù)改為乳腺切除術(shù)，動(dòng)態(tài)增強(qiáng)MRI、X線(xiàn)和超聲三種影像學(xué)檢查方法對(duì)于多灶、多中心性乳腺癌診斷的準(zhǔn)確性分別為85%～100%、13%～66%和38%～79%[11,17-20](圖5)，因此，對(duì)擬行保乳手術(shù)的患者術(shù)前行MRI檢查具有較高的臨床價(jià)值。Fischer等[21]對(duì)乳腺癌患者術(shù)前行MRI檢查價(jià)值評(píng)估的回顧性研究結(jié)果表明，保乳術(shù)前行MRI檢查和未行MRI檢查患者的術(shù)后復(fù)發(fā)率分別為1.2%和6.8%，其差異具有統(tǒng)計(jì)學(xué)意義，術(shù)前MRI檢查對(duì)保乳手術(shù)患者可降低復(fù)發(fā)率。Turnbull等[22]進(jìn)行的多中心研究結(jié)果表明術(shù)前行MRI檢查的816例患者中50例因MRI發(fā)現(xiàn)了其他病灶而改變了臨床處理方式，由腫瘤局部擴(kuò)大切除術(shù)改為全乳切除，其中35例病理證實(shí)MRI診斷正確，即70%的患者受益于術(shù)前乳腺M(fèi)RI檢查，臨床上得到了及時(shí)和正確的治療。此外，對(duì)于進(jìn)行保乳手術(shù)治療以及行放射治療后的患者，動(dòng)態(tài)增強(qiáng)MRI檢查亦有利于發(fā)現(xiàn)殘留病灶、鑒別手術(shù)或放療后瘢痕和腫瘤復(fù)發(fā)[23]。

圖4 (左乳腺)非特殊型浸潤(rùn)性導(dǎo)管癌(浸出成分較少，可見(jiàn)廣泛導(dǎo)管原位癌)。圖4A：左乳X線(xiàn)頭尾位，圖4B：左乳X線(xiàn)內(nèi)外側(cè)斜位，圖4C：左乳鈣化區(qū)局部放大，顯示左乳中上方多發(fā)不定形及模糊的細(xì)小鈣化，成簇和段性分布，局部腺體結(jié)構(gòu)不良，未見(jiàn)明確腫塊。圖4D～4G分別為MRI平掃和動(dòng)態(tài)增強(qiáng)后1、2、8 min，圖4H：動(dòng)態(tài)增強(qiáng)后病變時(shí)間-信號(hào)強(qiáng)度曲線(xiàn)圖,圖4I：矢狀面MIP圖,圖4J：橫軸面MIP圖，顯示左乳上方偏內(nèi)側(cè)局限片狀不均勻明顯強(qiáng)化，呈段性分布，病變區(qū)時(shí)間-信號(hào)強(qiáng)度曲線(xiàn)呈平臺(tái)型，病變范圍顯示清楚Fig 4 Invasive ductal carcinoma not otherwise specified associated with extensive ductal carcinoma in situ of the left breast.Craniocaudal(Fig 4A) and mediolateral oblique (Fig 4B) views of the left breast and magnifi cation view (Fig 4C)for the region of microcalcifications.Multiple clusters of amorphous microcalcifications with varying density demonstrated segmental distribution,no defi ned mass.MR images before(Fig 4D),1 min (Fig 4E),2 min (Fig 4F) and 8 min (Fig 4G) following injection of contrast medium and time-signal intensity curve (Fig 4H),sagittal (Fig 4I),and axial (Fig 4J) maximum intensity projection images demonstrated more extensive,segmental distribution marked enhanced lesion in the upper inner quadrant of the left breast.Kinetic curve demonstrated rapid initial enhancement with plateau pattern.

3 乳腺M(fèi)RI對(duì)一側(cè)已確診為乳腺癌患者檢出對(duì)側(cè)同時(shí)性乳腺癌的作用

在乳腺癌患者中，盡管部分患者僅以一側(cè)病變而就診，但存在雙側(cè)同時(shí)性乳腺癌的可能。MRI雙側(cè)乳腺同時(shí)成像可及時(shí)發(fā)現(xiàn)對(duì)側(cè)乳腺癌，為臨床醫(yī)生制訂合理、有效的治療方案提供影像學(xué)信息，使患者在一次手術(shù)中雙乳病變均可得到治療成為可能，既可早期發(fā)現(xiàn)對(duì)側(cè)臨床隱匿性乳腺癌改善預(yù)后，又能節(jié)省醫(yī)療資源、減輕患者負(fù)擔(dān)。已有研究結(jié)果表明，隨著MRI對(duì)乳腺癌術(shù)前分期應(yīng)用的增多，在對(duì)病側(cè)乳腺檢查的同時(shí)，對(duì)側(cè)乳腺癌MRI檢出率為2%～9%[22,24-26]，對(duì)一側(cè)已診斷為乳腺癌的患者，MRI可作為診斷對(duì)側(cè)是否存在臨床隱性乳腺癌的一種有效的檢查方法(圖6、7)。

圖5 (左乳腺)雙發(fā)癌，左乳外上非特殊型浸潤(rùn)性導(dǎo)管癌，組織學(xué)Ⅱ級(jí)；左乳中上浸潤(rùn)性篩狀癌。圖5A：右、左乳X線(xiàn)頭尾位，圖5B：右、左乳X線(xiàn)內(nèi)外側(cè)斜位，顯示雙乳腺呈多量腺體型乳腺，其中左乳內(nèi)可見(jiàn)高密度不規(guī)則單發(fā)腫塊(箭)。圖5C～5F分別為MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，圖5G～5J分別為不同層面MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，圖5K為左乳矢狀面MIP圖,圖5L為橫軸面MIP圖，圖5M、5N：左乳病變不同層面VR圖，顯示左乳稍外上和中上方兩個(gè)不規(guī)則明顯異常強(qiáng)化腫物，時(shí)間-信號(hào)強(qiáng)度曲線(xiàn)呈流出型Fig 5 Double lesions of the left breast cancer.Invasive ductal carcinoma not otherwise specifi ed localized in the upper outer quadrant and invasive cribriform carcinoma localized in the medially upper region.Craniocaudal (Fig 5A) and mediolateral oblique (Fig 5B) views of both breasts showed a solitary irregular high density mass (arrow) with ill-defi ned margins in the left breast.MR images before (Fig 5C,Fig 5G),1 min (Fig 5D,Fig 5H),2 min (Fig 5E,Fig 5I) and 8 min (Fig 5F,Fig 5J) following injection of contrast medium at different slices,sagittal (Fig 5K) and axial (Fig 5L) maximum intensity projection,and volume rendering images at different slices (Fig 5M,Fig 5N) demonstrated two irregular marked enhanced masses with spiculated margins.The kinetic curves (not shown) demonstrated rapid initial enhancement with washout pattern for the both lesions.

圖6 (雙側(cè)乳腺)同時(shí)性乳腺癌。該患者X線(xiàn)檢查可疑左乳癌，術(shù)前行MRI檢查以進(jìn)一步明確左乳診斷和病變范圍，MRI診斷雙則乳腺癌。手術(shù)病理診斷：(左乳腺)導(dǎo)管原位癌，組織學(xué)Ⅱ級(jí)，伴灶性早期浸潤(rùn)，乳頭(+)見(jiàn)灶性導(dǎo)管內(nèi)癌；(右乳腺)非特殊型浸潤(rùn)性導(dǎo)管癌，組織學(xué)Ⅱ級(jí)。圖6A：右、左乳X線(xiàn)頭尾位，圖6B：右、左乳X線(xiàn)內(nèi)外側(cè)斜位，圖6C：左乳鈣化區(qū)局部放大，顯示左乳外上局限多發(fā)細(xì)小鈣化。圖6D～6G分別為左乳MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，圖6H～6K分別為右乳MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，顯示左乳較大范圍段性分布異常強(qiáng)化，同時(shí)右乳上方可見(jiàn)不規(guī)則明顯強(qiáng)化腫物，邊緣毛刺Fig 6 Bilateral synchronous breast cancer.Histology revealed ductal carcinoma in situ associated with focal microinvasion of the left breast (grade II),nipple (+),and invasive ductal carcinoma not otherwise specifi ed of the right breast (grade II).Craniocaudal(Fig 6A),mediolateral oblique (Fig 6B),and magnifi cation (Fig 6C) for the region of microcalcifi cations views demonstrated multiple amorphous microcalcifications of varying density in upper outer quadrant in the left breast.MR images before (Fig 6D,Fig 6H),1 min (Fig 6E,Fig 6I),2 min (Fig 6F,Fig 6J) and 8 min (Fig 6G,Fig 6K) following injection of contrast medium demonstrated extensively segmental enhancement in the left breast corresponding to microcalcifi cations on mammograms and irregular enhanced mass with spiculated margins that could not be identifi ed on mammograms in the right breast.

4 MRI引導(dǎo)下乳腺病變定位和活檢

近年來(lái)隨著日趨發(fā)展成熟的乳腺M(fèi)RI檢查更多的應(yīng)用于臨床，MRI對(duì)乳腺觸診、X線(xiàn)和超聲檢查均為陰性即以往所謂的“隱匿性”乳腺病變發(fā)現(xiàn)的越來(lái)越多，明顯提高了乳腺癌的早期診斷率，同時(shí)MRI發(fā)現(xiàn)的“隱匿性”病灶往往屬臨床分期較早的病變?nèi)缛橄僭话?，適合行保乳手術(shù)，從而可減少創(chuàng)傷較大的根治性手術(shù)率，減輕患者和社會(huì)負(fù)擔(dān)并提高生活質(zhì)量，因此，2007年美國(guó)癌癥協(xié)會(huì)乳腺癌篩查指南中提出將MRI作為乳腺癌高危人群篩查的影像學(xué)檢查方法[27]。但伴隨的問(wèn)題是由于MRI對(duì)乳腺癌診斷具有高敏感性即高陰性預(yù)期值，對(duì)一個(gè)陰性乳腺M(fèi)RI檢查結(jié)果，一般具有較大把握排除乳腺癌，但高敏感性相應(yīng)帶來(lái)的假陽(yáng)性結(jié)果使部分患者可能接受了過(guò)度治療，為了避免出現(xiàn)這一問(wèn)題，就需要醫(yī)療機(jī)構(gòu)配備有MR引導(dǎo)下乳腺病變活檢裝置和經(jīng)驗(yàn)豐富的醫(yī)生，對(duì)MRI發(fā)現(xiàn)的可疑病灶行MR引導(dǎo)下的定位或組織病理學(xué)檢查，該技術(shù)能夠在MRI下準(zhǔn)確定位病變或獲取組織學(xué)標(biāo)本，從而避免不必要的外科過(guò)度治療，為臨床選擇和實(shí)施個(gè)體化治療方案起到保駕護(hù)航的作用。

總之，由于MRI成像特點(diǎn)，近年來(lái)我國(guó)開(kāi)展乳腺M(fèi)RI檢查的臨床和研究工作越來(lái)越多，其在臨床上發(fā)揮的作用也已得到了認(rèn)可，但乳腺M(fèi)RI檢查與乳腺X線(xiàn)攝影相比，起步較晚，為了使乳腺M(fèi)RI檢查在我國(guó)目前的國(guó)情下得到更佳合理的應(yīng)用，既能最大限度地發(fā)揮其特有的優(yōu)勢(shì)，又能避免由于不正確或不恰當(dāng)?shù)氖褂媒o患者和臨床醫(yī)生帶來(lái)困惑，節(jié)省醫(yī)療資源，還需國(guó)內(nèi)同行不斷的共同努力。

圖7 (雙側(cè)乳腺)同時(shí)性乳腺癌。該患者X線(xiàn)和超聲檢查診斷左乳癌，右乳正常，臨床準(zhǔn)備行左側(cè)保乳手術(shù)，手術(shù)前行MRI檢查診斷雙則乳腺癌。手術(shù)病理診斷雙乳腺非特殊型浸潤(rùn)性導(dǎo)管癌。圖7A：右、左乳X線(xiàn)頭尾位；圖7B：右、左乳X線(xiàn)內(nèi)外側(cè)斜位，顯示左乳中上腫塊(箭)，邊緣毛刺，未見(jiàn)鈣化，右乳未見(jiàn)腫物及鈣化。圖7C～7F分別為左乳MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，圖7G～7J分別為右乳MRI平掃和動(dòng)態(tài)增強(qiáng)后1 min、2 min、8 min，顯示左乳腺內(nèi)上不規(guī)則分葉狀腫塊，動(dòng)態(tài)增強(qiáng)后腫塊呈明顯強(qiáng)化；右乳腺中上方沿導(dǎo)管走行方向呈串珠狀異常強(qiáng)化Fig 7 Bilateral synchronous breast cancer.Histology revealed invasive ductal carcinoma not otherwise specifi ed bilaterally.As in this patient,MRI was proving helpful in establishing the presence of synchronous,clinically and mammographically unsuspected bilateral breast cancers.Craniocaudal (Fig 7A) and mediolateral oblique (Fig 7B) views of the both breasts showed an irregular high density mass (arrow) in the left breast and negative findings in the right breast.Ultrasound (not shown) diagnosed carcinoma in the left breast and normal in the right breast.MR images before (Fig 7C,Fig 7G),1 min (Fig 7D,Fig 7H),2 min (Fig 7E,Fig 7I) and 8 min (Fig 7F,Fig 7J) following injection of contrast medium of both breasts demonstrated irregular mass with spiculated margins in upper inner quadrant of the left breast corresponding to the lesion seen on the left mammogram and string enhancement nodules ductal distribution that could not be seen on mammograms in the right breast.

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