Skip to main content

Dramatic increase in volume versus length of invasive ductal carcinoma mimicking intramammary lymph node in a small nodular lesion



The tumor growth pattern in breast cancer appears to be variable and unpredictable. A minor increase in size in a pre-existing lesion, especially under 1 cm, corresponds to a more pronounced increase in volume.

Case presentation

We report a 63-year-old woman with a nodular density mimicking intramammary lymph node, diagnosed as invasive carcinoma of luminal B subtype. The lesion increased size and density over time in following mammograms until having indistinct margins. While the tumor volume was 12.7 mm3 at the first observation on mammography, it has increased approximately 6.7 times to reach 85.7 mm3 in four years. Finally, the patient diagnosed with early-stage breast cancer (T1N0M0) was treated with breast-conserving surgery.


Minor changes in size, density, and margin status of a lesion on serial mammograms are warning for breast cancer. Withal, a slight increase in lesion size in two dimensions can result in significant differences in volume. Therefore, comparative evaluation with previous mammograms and observing any difference in morphological features by screening are crucial for early diagnosis and optimal management of the disease.


Although breast cancer can be detected early by screening, it is the most common cause of death, especially in the pre-perimenopausal periods (Bray et al. 2021; Dogan et al. 2020). The most effective step to fight breast cancer is screening by mammography. Factors such as the quality of the mammography, the frequency of screening, and the radiologist's experience affect the success of the screening programme. Comparative evaluation with serial mammograms is particularly effective in detecting newly developed pathologies or changes in pre-existing lesions. As the tumor grows in all directions in a three-dimensional (3D) space, changes in volume will be more critical than the increase in size (Mao et al. 2019).

We reported the progressive volumetric enlargement of an invasive breast carcinoma over time that was false negatively evaluated as an intramammary lymph node (IMLN) by regular screening.

Case presentation

A 63-year-old postmenopausal woman presented to our clinic for annual breast screening. The patient had no family history of breast cancer, or interventional procedure or an operation related to the breast. She had a history of two live births, smoked 20 packs/year, and had no oral contraceptives or hormone replacement therapy. The patient was using levothyroxine only because of hypothyroidism. The patient had no complaints, and the physical examination findings were normal. All mammographic examinations, since 2011, were performed by a digital full-field mammography system (Selenia Dimensions®, Hologic Inc).

The breast structure of the patient was in type B pattern. A 3 mm in size nodular opacity with smooth borders was observed in the upper part of the right mediolateral oblique (MLO) radiograph for the first time in 2016 (Fig. 1a). For the following three years, this density was accepted as an intramammary lymph node (IMLN) due to its localization by different radiology residents because of the lack of an expert breast radiologist (Fig. 1b, c). When examined retrospectively, it is noteworthy that this density grows each year in the two-dimensional plane, albeit quite slowly. However, when 2018 was accepted as the breaking point, it was observed that the density of the lesion slightly increased, and the edges of the lesion were no longer smooth but partially obscured (Fig. 1c). When the patient, who did not participate in the screening program because of the COVID-19 pandemic, finally applied in late 2020, it was noted that the lesion became completely hyperdense in addition to enlargement (Fig. 1d). When looked carefully, the lesion borders were indistinct in all sections.

Fig. 1
figure 1

A millimetric density was observed in the upper quadrant of the right breast in annual serial mammograms. a A small nodular density mimics an IMLN. b Minor difference in size and density. c Increase in density and partially obscured margins. d Significant increase in size and density, indistinct margins, particularly at the anterior part of the lesion

A hypoechoic mass lesion was observed in the right breast at the 10 o'clock position on ultrasound (US) examination by a linear transducer (Aplio 500, Toshiba Medical Systems Corporation, Canon Inc, Japan) (Fig. 2a). The borders of the vertically located lesion were irregular and indistinct. The echogenicity of the adjacent parenchyma was slightly increased secondary to desmoplastic reaction. No significant vascularization was observed in the lesion on color Doppler images (Fig. 2b). High elasticity values were obtained simultaneously (Fig. 2c). The lesion evaluated in BI-RADS 5 category was sampled by US-guided core biopsy. The histopathological examination revealed as an invasive ductal carcinoma with nuclear grade 2, positive for estrogen receptor (ER) (100%), positive for progesterone receptor (PR) (10%) and negative for human epidermal growth factor receptor 2 (HER2). The Ki-67 labeling index was 16%.

Fig. 2
figure 2

Sonographic findings. a The vertically oriented hypoechoic lesion, irregular in shape with indistinct margins. b No vascular coding in color Doppler image. c High elasticity features with shear wave elastography

The experienced breast radiologist measured in consensus the largest tumor diameter on each mammogram using a calibrated built-in software tool (Syngo Mammoreport; Siemens, Erlangen, Germany). Caution was exercised to measure reproducibly, consistently and always in the same projection between the serial mammograms. The choice of the projection was based on where the tumor was most clearly discerned. While the lesion continued to grow quite insidiously over the years in the two-dimensional plane, we calculated how much the lesion enlarged in three dimensions retrospectively (Fig. 3).

Fig. 3
figure 3

Illustration of volumetric increase relative to serial mammograms. First line: The largest diameter of the density on mammography (mm) Second line: The volumetric measurement of the density (mm3)

The patient was operated on the breast-conserving surgery procedure. No lymphovascular or perineural invasion was detected. Sentinel lymph node biopsy was negative. No peri-postoperative complications developed. The treatment process was completed with chemo- and radiotherapy.


The main purpose of screening is to detect breast cancer at the early stage (Michaelson et al. 2003). Early detection of cancer at a small size directly prolongs life expectancy (Michaelson et al. 2003; Tabar et al. 2000). The meta-analyses based on the high-priority clinical studies have shown that the mortality rate is significantly reduced with regular screening (Smith et al. 2003, 2004). Also, it has been reported in various studies that the prognosis is better in breast cancer diagnosed by screening (Lehtimaki et al. 2011; Maiz et al. 2020; Coldman et al. 2014).

The lesions, mainly located in the upper outer quadrant, can be easily missed by confusing them with IMLN (Bitencourt et al. 2019). In the case we present, the lesion, which has existed for years, was evaluated as an IMLN at first glance by observers who did not have sufficient breast imaging experience. Small size increases in an existing lesion should not be underestimated. A minor difference in size in two-dimensional mammograms corresponds to more significant volume increases. A few studies stated that a tumor grows in a hemi-ellipsoid shape (Mao et al. 2019; Morrison et al. 1983; Faustino-Rocha et al. 2013). In the earlier phase of the cancer tumor grows slowly. However, after reaching a certain size, the growth shows an exponential increase. Although this growth pattern differs in different tumor subtypes, it can be represented by some complex formulas (Mao et al. 2019). It should be noted that tumors in non-aggressive subtypes, such as luminal ones, may grow slowly. We want to emphasize that the increase in size and density is an alerting finding for cancer in the comparative evaluation. And also, marginal features should be magnified and carefully evaluated, especially in sub-centimetric lesions. As Woods et al. pointed out, high-density masses are mostly associated with cancer, as well as findings indicating malignancy characteristically such as round shape, indistinct margins, and increased size (Woods et al. 2011). In addition, comparative evaluation with older mammograms in detecting newly developed pathologies or changes in pre-existing lesions is an indispensable part of screening. Two years and earlier comparisons may be more valuable if available. Although these findings are familiar to the literature, we believe that the highlighted clues are quite instructive and remarkable for all breast professionals from different disciplines. As in this case, a slight increase in lesion size may go unnoticed by the radiologist. However, more significant growth will occur in the 3D universe. Therefore, artificial intelligence algorithms can be used in screening and diagnosis of breast cancer for large case series, and some complex formulas for staging the disease.


Comparative evaluation is critical in breast imaging, no matter what purpose it is taken for screening or diagnostic purposes. It is valuable to compare with the oldest available images when comparing mammograms. Even a minor increase in size and density in an existing lesion should warn the radiologist. A slight increase in lesion size results in significant differences in the volume. In breast cancer, volumetric measurements may replace traditional methods based on the largest diameter of the breast lesion alone.

Availability of data and materials

All data used for this report are included in the text.



Breast imaging reporting and data systems


Coronavirus disease of 2019


Estrogen receptor


Human epidermal growth factor receptor 2


Intramammary lymph node


Mediolateral oblique


Progesterone receptor


Tumor node metastasis






  • Bitencourt A, Ferreira E, Bastos D, Sperandio V, Graziano L, Guatelli CS, Albuquerque ML, Souza JA, Marques EF (2019) Intramammary lymph nodes: normal and abnormal multimodality imaging features. Br J Radiol 92:20190517

    Article  Google Scholar 

  • Bray F, Laversanne M, Weiderpass E, Soerjomataram I (2021) The ever-increasing importance of cancer as a leading of premature death worldwide. Cancer 127:3029–3030

    Article  Google Scholar 

  • Coldman A, Phillips N (2014) Breast cancer survival and prognosis by screening history. Br J Cancer 110:556–559

    CAS  Article  Google Scholar 

  • Dogan N, Kacan T, Dogan I (2020) Analysis of trends in cancer-related mortality in Turkey. Turk J Oncol 35:52–57

    Google Scholar 

  • Faustino-Rocha A, Oliveira PA, Pinho-Oliveira J, Teixeira-Guedes C, Soares-Maia R, Costa RG, Colaço B, Pires MJ, Colaço J, Ferreira R, Ginja M (2013) Estimation of rat mammary tumor volume using caliper and ultrasonography measurements. Lab Anim 42:217–224

    Article  Google Scholar 

  • Lehtimäki T, Lundin M, Linder N, Sihto H, Holli K, Turpeenniemi-Hujanen T, Kataja V, Isola J, Joensuu H, Lundin J (2011) Long-term prognosis of breast cancer detected by mammography screening or other methods. Breast Cancer Res 13(6):134

    Article  Google Scholar 

  • Maiz C, Silva F, Dominguez F, Galindo H, Camus M, Leon A, Oddo D, Villarroel A, Razmilic D, Navarro ME, Medina L, Merino T, Vines E, Pena J, Maldonado D, Pinto MP, Acevedo F, Sanchez C (2020) Mammography correlates to better survival rates in breast cancer patients: a 20-year experience in a University health institution. Ecancer 14:1005

    Article  Google Scholar 

  • Mao X, Zhou M, Fan C, Chen B, Jin F (2019) Timescale of tumor volume of a young breast cancer patient with luminal B subtype. Medicine 98(43):e17659

    Article  Google Scholar 

  • Michaelson JS, Satija S, Kopans D, Moore R et al (2003) Gauging the impact of breast carcinoma screening in terms of tumor size and death rate. Cancer 98:2114–2124

    Article  Google Scholar 

  • Morrison SD (1983) In vivo estimation of size of experimental tumors. J Natl Cancer Inst 71:407–408

    CAS  PubMed  Google Scholar 

  • Smith RA, Duffy SW, Gabe R, Tabar L, Fen AM, Chen TH (2004) The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am 42:793–806

    Article  Google Scholar 

  • Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP, Foster RS, Hendrick E, Eyre HJ, Sener S, American Cancer Society High-Risk Work Group, American Cancer Society Screening Older Women Work Group, American Cancer Society Mammography Work Group, American Cancer Society Physical Examination Work Group, American Cancer Society New Technologies Work Group, American Cancer Society Breast Cancer Advisory Group (2003) American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin 53: 141–69

  • Tabar L, Vitak B, Chen HH, Duffy SW, Yen MF, Chiang CF, Krusemo UB, Tot T, Smith RA (2000) The Swedish two-county trial twenty years later. Updated mortality results and new insights from long-term follow-up. Radiol Clin North Am 38:625–651

    CAS  Article  Google Scholar 

  • Woods R, Sisney G, Salkowski L, Shinki K, Lin Y, Burnside ES (2011) The mammographic density of a mass is a significant predictor of breast cancer. Radiology 258:417–425

    Article  Google Scholar 

Download references


Not applicable.



Author information




Author 1—SAK has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data and involved in drafting the manuscript. Author 2—VC has managed the clinical and surgical procedures and supervised the report. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Seda Aladag Kurt.

Ethics declarations

Ethics approval and consent to participate

Ethics approval was not required for this report.

Consent for publication

Oral and written informed consent was obtained from the patient for the publication of the case report and accompanying images.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Aladag Kurt, S., Celik, V. Dramatic increase in volume versus length of invasive ductal carcinoma mimicking intramammary lymph node in a small nodular lesion. Bull Natl Res Cent 46, 136 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Breast cancer
  • Screening
  • Mammography
  • Intramammary lymph node
  • 3D