Atlas of Mammography

Chapter 10

The Axilla

On routine mammography, the low axilla is visualized, and a variety of normal and abnormal findings in this region may be identified. Physical examination is extremely important in the evaluation of the axilla, particularly in the assessment of adenopathy and fixation of nodes associated with breast carcinoma. In addition to lymph nodes, a breast lesion occurring in the axillary tail may be identified as a mass on mammography.

Axillary Lymph Nodes

The axillary lymph nodes are divided into three levels based on their anatomic relationship to the pectoralis minor muscle: level I nodes are inferior to the pectoralis minor muscle, level II nodes are posterior to the muscle, and level III nodes are medial to the muscle.

On the routine mediolateral oblique (MLO) view, lymph nodes in the low to middle axillary region can normally be identified. An additional axillary view can yield more information about the upper aspect of the axilla, which may not be seen on the routine MLO projection. This is particularly important when a palpable mass is present and is not identified on mammography. However, three-dimensional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) are superior to mammography in visualizing the level I, II, and III nodal systems (1). Even so, CT has been found to have a sensitivity for tumor detection in axillary nodes of 50%, because in about one half of cases of metastases to the axilla, the tumor is a micrometastasis and occurs in normal-sized nodes (2).

Normal axillary nodes are very-well-defined, medium- to low-density nodules that are less than 1.5 cm in diameter (3) unless fatty replaced. Lymph nodes are round, ovoid, elliptical, or bean shaped. A lucent notch or center is often seen, representing fat in the hilum. This finding helps to confirm the diagnosis of a lymph node (Figs. 10.1,10.2,10.3). On ultrasound, normal nodes are well-defined, oval, hypoechoic masses with a central echogenic area representing the fatty hilum (Fig. 10.4). Malignant nodes may have eccentric cortical widening (4), an irregular border, and be enlarged, particularly in anteroposterior diameter (Fig. 10.5).

Lipomatosis or fatty infiltration occurs in axillary nodes and is commonly seen in older patients. The fat distends the capsule and enlarges the node, and the surrounding lymphoid tissue atrophies (5). On mammography, these nodes are crescentic and mainly fat containing, often demonstrating only a thin rim of cortex. The node may be 3.5 cm or more in length and be normal when fatty replaced (1,6,7).

In 1965, Leborgne et al. (5) described six patterns of fatty infiltration of nodes. The fatty replacement may occur centrally or eccentrically, producing densities of nodal tissue described as ring, sickle, or crescent in shape. As the fatty infiltration increases, the rim of the lymphoid tissue narrows, eventually leaving a distended capsule surrounding a fatty center (5). Large fatty-infiltrated nodes are more commonly seen in elderly obese women (3).

Adenopathy

When approaching adenopathy in the axillae, it is important to try to determine if the process is unilateral or bilateral (Table 10.1). Bilateral adenopathy suggests a systemic etiology that is benign or malignant. Unilateral adenopathy suggests a local or regional abnormality related to the breast or arm, such as breast cancer, mastitis, or an infection in the arm. Although systemic conditions may be associated with nodes that are asymmetrically enlarged, the approach to adenopathy based on unilateral versus bilateral involvement is most helpful in suggesting further management.

In a review of 94 patients with axillary abnormalities, Walsh et al. (7) found that in most cases, benign and malignant nodes could not be differentiated from each other by mammography. In this study, 76 of 94 patients had axillary lymphadenopathy, and the causes were as

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follows: benign lymphadenopathy in 29%, metastatic breast cancer in 26%, chronic lymphocytic leukemia or well-differentiated lymphocytic lymphoma in 17%, and other causes (including collagen vascular disease, human immunodeficiency virus [HIV], sarcoidosis, nonbreast metastases) in 28%. Lymph nodes that were not fatty replaced and larger than 33 mm, those that had spiculated margins, and those that contained intranodal microcalcifications were likely malignant.

 

Figure 10.1 HISTORY: A 68-year-old woman for screening.

MAMMOGRAPHY: Bilateral MLO views (A) show prominent lymph nodes in both axillae. A coned-down image (B) shows the nodes to have a normal appearance. They are well defined, reniform, with central fatty hila, all features of benign nodes.

IMPRESSION: Normal axillary nodes.

 

Figure 10.2 HISTORY: A 64-year-old woman for screening.

MAMMOGRAPHY: Bilateral MLO views (A) and enlarged images of the axillae (B) show normal-appearing nodes. These nodes are crescentic and well circumscribed with fatty hila.

IMPRESSION: Normal axillary nodes.

 

Figure 10.3 HISTORY: A 61-year-old woman for screening.

MAMMOGRAPHY: Right MLO view (A) shows multiple normal-sized lymph nodes in the axilla. On the enlarged image (B), the very-well-defined reniform shapes are seen.

IMPRESSION: Normal fatty-replaced axillary nodes.

 

Figure 10.4 HISTORY: A 48-year-old woman for screening.

ULTRASOUND: Ultrasound of a low axillary mass shows it to be hypoechoic, elliptical, with a hyperechoic focus, consistent with the fatty hilum of a node.

IMPRESSION: Lymph node.

 

Figure 10.5 HISTORY: A 72-year-old woman with a large palpable mass in the left breast and a lump in the axilla.

ULTRASOUND: Sonography of the axillary mass shows a large hypoechoic lesion that is taller than wide. The margins are somewhat indistinct, and the lesion is markedly hypoechoic, all features suspicious for malignancy.

IMPRESSION: Metastatic disease in the axillary node.

HISTOPATHOLOGY: Metastatic ductal carcinoma involving a node.

TABLE 10.1 Etiologies of Axillary Adenopathy

Unilateral Adenopathy

Metastatic breast cancer

Mastitis

Infection in the ipsilateral arm

Metastases from nonbreast primaries (melanoma)

Silicone induced adenitis

Bilateral Adenopathy

Lymphoma

Metastases

Sarcoidosis

Rheumatoid arthritis

Systemic lupus erythematosus

Scleroderma

Psoriasis

Sjögrens disease

Cat-scratch disease

Mononucleosis

Human immunodeficiency virus

Tuberculosis

Silicone-induced granulomatous adenitis

Lymphoid hyperplasia

When unilateral lymph nodes enlarge on otherwise normal mammograms, the etiology is most often benign. This is particularly so if there is no history of malignancy, the change in node size is small, and the node maintains a benign appearance (8). Lee et al. (8) in a study of 24 patients with unilateral enlarging nodes found that two had malignant biopsies. One of these patients had lymphoma and one had melanoma, and in both patients the size increase was greater than 100%.

Inflammatory nodes are usually dense, enlarged, and with defined margins (3). Coarse calcification may occur particularly with granulomatous infections. In sarcoidosis, enlarged axillary lymph nodes may occur as a manifestation of the generalized adenopathy that occurs in 23% to 50% of patients (9) (Figs. 10.6,10.7,10.8). Another inflammatory cause of axillary adenopathy is tuberculosis (10,11). The affected nodes in tuberculosis are usually unilateral and are large and dense on mammography. The margins are variable, and the nodes may be matted.

In patients with silicone implants, the rupture of the implant with extravasation of silicone may be associated with painful ipsilateral lymphadenopathy (Fig. 10.9). The nodes often contain the hyperdense deposits of free silicone that are associated with the leaking implant. Histologic evaluation of these nodes may reveal “silicone-induced granulomatous adenitis” (12). Other

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inflammatory or infectious conditions associated with adenopathy include mastitis or infections in the arm, cat scratch disease, HIV (Figs. 10.10 and 10.11), and mononucleosis.

 

Figure 10.6 HISTORY: A 38-year-old woman with a history of sarcoidosis for screening mammography.

MAMMOGRAPHY: Bilateral MLO views (A) show mildly enlarged lymph nodes in both axillae. On the enlarged image (B), the nodes are dense and very well defined. On ultrasound of the left (C) and right (D) axillae, the nodes are hypoechoic and lobulated, with fatty hila evident.

IMPRESSION: Mild adenopathy secondary to sarcoidosis.

 

Figure 10.7 HISTORY: A 71-year-old gravida 2, para 2 woman with a lump in the left breast.

MAMMOGRAPHY: Right MLO (A) and enlarged (1.5÷) axillary (B) views. There is an enlarged, fatty-replaced lymph node in the right axilla. Coarse calcification is present, consistent with previous granulomatous infection.

IMPRESSION: Granulomatous cal- cification in an axillary node.

 

Figure 10.8 HISTORY: A 61-year-old gravida 0 woman for screening.

MAMMOGRAPHY: Left axillary view. There are three nodes in the left axilla that contain calcifications. Two of the nodes are completely calcified, and the third contains dense round calcifications. The finding is most consistent with old granulomatous infection.

IMPRESSION: Calcified axillary nodes secondary to old granulomatous changes.

 

Figure 10.9 HISTORY: A 51-year-old woman with saline implants who previously had silicone implants that were removed.

MAMMOGRAPHY: Left MLO view (A) and enlarged image (B) show a prepectoral saline implant. There is residual free silicone present in the axillary tail, with silicone-laden lymph nodes being noted as well.

IMPRESSION: Silicone-laden lymph nodes from prior rupture.

Axillary lymphadenopathy occurs in patients with rheumatoid arthritis (13,14,15), along with the generalized lymphadenopathy that occurs in about 50% to 80% of patients with the disease. Palpable enlarged nodes have been found in a majority of patients with rheumatoid arthritis (Figs. 10.12 and 10.13) and are mostly located in the axillae (15). Abnormal axillary nodes in patients with rheumatoid arthritis are characterized by rounded shapes, higher density, little or no fatty replacement, and sizes of greater than 1 cm (14). Other arthritides and collagen vascular diseases associated with axillary adenopathy are psoriasis (Figs. 10.14 and 10.15), systemic lupus

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erythematosus (Figs. 10.16 and 10.17), scleroderma (14), and Sjögren's disease (Fig. 10.18). The frequency of palpable adenopathy in patients with lupus has been found to be 69%. In most cases of adenopathy related to collagen vascular disease, the nodes are slightly enlarged and more dense than normal nodes.

 

Figure 10.10 HISTORY: Baseline screening mammogram on a patient who is HIV positive.

MAMMOGRAPHY: Left (A) and right (B) MLO views show mildly enlarged axillary lymph nodes bilaterally. No breast abnormalities were found. The findings are consistent with the patient's history of acquired immunodeficiency syndrome (AIDS).

IMPRESSION: Adenopathy related to AIDS.

Malignant involvement of axillary nodes may occur as a result of primary lymphomatous tumors, metastatic disease from breast cancer, and metastatic disease from nonbreast primaries. An important first step in the evaluation of axillary adenopathy is to determine if the finding is unilateral or bilateral. Bilateral adenopathy is more typical of lymphoma, and unilateral adenopathy raises the concern for metastatic breast cancer that is involving the axilla.

In lymphoma, the involved axillary nodes are enlarged (greater than 2.5 cm) and dense (Figs. 10.19,10.20,10.21,10.22,10.23). The pericapsular fat line bordering the nodes is not obliterated (16). This finding is important in differentiating a primary lymph node tumor from metastatic involvement. The nodes are dense but retain their shape and are well marginated (3). Most often, the adenopathy is bilateral, and the nodes may be quite large and bulky, but they retain their smooth margination. In lymphoid hyperplasia, the adenopathy demonstrated on mammography cannot be distinguished from that found in lymphoma.

Metastatic nodes from breast carcinoma are generally enlarged (2–2.5 cm or more) (3), dense, and rounded (17)

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(Figs. 10.24,10.25,10.26). The normal architecture is lost, and the pericapsular fat line is obliterated as the borders of the node are infiltrated by tumor (3). Metastatic nodes may be multiple and matted together, and nodes involved by metastatic breast cancer often have an indistinct or spiculated margin (18).

 

Figure 10.11 HISTORY: A 64-year-old for screening mammography. Patient had a history of being HIV positive.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show a high-density indistinct mass in the left breast at 11 o'clock. Two spiculated masses are seen in the left breast medially (white arrows) on the enlarged left CC (C) view. Bilateral adenopathy is seen, which may be related to the patient's history of AIDS or to metastatic breast cancer. On the right at 3 o'clock are multiple groups of amorphous microcalcifications (arrow).

IMPRESSION: Left breast carcinoma, right breast calcifications, suspicious for malignancy. Bilateral adenopathy which may be related to AIDS or metastatic breast cancer.

HISTOPATHOLOGY: Invasive ductal carcinoma left breast; ductal carcinoma in situ and lobular carcinoma in situ right breast; negative left axillary nodes for metastatic disease.

 

Figure 10.12 HISTORY: A 70-year-old woman with a history of rheumatoid arthritis, for screening mammography.

MAMMOGRAPHY: Right MLO view (A) shows multiple mildly enlarged lymph nodes in the axilla. On the enlarged image (B), the nodes are very well defined, and in some the fatty hila are noted. The finding of enlarged lymph nodes was present bilaterally.

IMPRESSION: Mild adenopathy consistent with history of rheumatoid arthritis.

 

Figure 10.13 HISTORY: A 46-year-old woman with a history of rheumatoid arthritis, for screening mammography.

MAMMOGRAPHY: Left MLO (A) and right MLO (B) views. The breasts are dense for the age and parity of the patient. In the axillae bilaterally are non–fatty-replaced lymph nodes. The node on the right is not, by strict criteria, enlarged, but the node on the left is clearly greater than 1.5 cm. The adenopathy is consistent with the patient's known history of rheumatoid arthritis and is not suspicious.

IMPRESSION: Bilateral adenopathy secondary to rheumatoid arthritis.

 

Figure 10.14 HISTORY: A 67-year-old gravida 4, para 4 woman with a history of psoriasis, for screening mammography.

MAMMOGRAPHY: Bilateral MLO views. Dense parenchyma is present bilaterally, with the right breast being smaller than the left. There are enlarged lymph nodes in both low axillary areas, consistent with benign adenopathy related to the patient's known psoriasis.

IMPRESSION: Benign adenopathy secondary to psoriasis.

 

Figure 10.15 HISTORY: Screening mammogram on a patient with a history of psoriasis.

MAMMOGRAPHY: Left (A) and right (B) MLO views show mildly enlarged lymph nodes in both axillae. This appearance is consistent with the adenopathy related to psoriasis.

IMPRESSION: Adenopathy secondary to psoriasis.

 

Figure 10.16 HISTORY: A 41-year-old woman with a history of lupus erythematosus for screening mammography.

MAMMOGRAPHY: Right MLO (A) and axillary (B) views show mildly enlarged lymph nodes in the axilla, consistent with the history of lupus.

IMPRESSION: Mild adenopathy secondary to lupus.

 

Figure 10.17 HISTORY: A 51-year-old woman with a history of systemic lupus erythematosus.

MAMMOGRAPHY: Bilateral MLO views (A) demonstrate mildly enlarged lymph nodes in both axillae. On ultrasound (B), the typical reniform shape and hyperechoic hilum of a node are noted.

IMPRESSION: Adenopathy secondary to lupus.

 

Figure 10.18 HISTORY: A 60-year-old woman for screening mammography. Her only medical problem was Sjögren's disease.

MAMMOGRAPHY: Bilateral MLO views show mild adenopathy in the low axillary regions. This degree of adenopathy suggests a benign etiology, such as is found in a connective tissue disorder.

IMPRESSION: Mild adenopathy related to Sjögren's disease.

 

Figure 10.19 HISTORY: A 65-year-old woman with a history of chronic lymphocytic leukemia for screening mammography.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show large dense nodes in both axillae. The size of these nodes suggests a neoplastic process. Multiple prominent intramammary nodes are also present bilaterally (arrows). Core biopsy was performed for the central posterior mass on the right (open arrow), and a clip was placed.

IMPRESSION: Recurrent leukemia.

HISTOPATHOLOGY: Chronic lymphocytic leukemia in axillary and intramammary nodes, including the right breast mass.

 

Figure 10.20 HISTORY: A 63-year-old woman with a history of lymphoma, for screening mammography.

MAMMOGRAPHY: Right MLO (A) and axillary (B) views. There are smoothly marginated, enlarged solid nodes in the axilla. An intramammary node is also present. The smoothly marginated, round enlarged nodes are more typical of lymphoma than of metastatic breast carcinoma. The findings are consistent with recurrence of lymphoma.

IMPRESSION: Recurrent lymphoma.

 

Figure 10.21 HISTORY: A 67-year-old woman with a history of lymphoma.

MAMMOGRAPHY: Left MLO view shows heterogeneously dense breast tissue and adenopathy in the axilla. The nodes are dense, enlarged, and very clearly marginated.

IMPRESSION: Adenopathy, suspicious for recurrence of lymphoma.

CYTOLOGY: Lymphoma.

 

Figure 10.22 HISTORY: A 38-year-old woman presented with a mass in the right axilla and hoarseness.

MAMMOGRAPHY: Right MLO (A) and axillary (B) views show a normal-appearing subpectoral silicone implant. There are greatly enlarged, dense, circumscribed nodes in the axilla. There is no evidence for silicone rupture or free silicone adjacent to the implant or in the nodes. The constellation of findings and history are most suggestive of lymphoma involving the right axilla and mediastinum.

IMPRESSION: Lymphoma.

HISTOPATHOLOGY: Non-Hodgkins lymphoma.

In a comparison of clinical examination and mammography with pathologic examination of axillary nodes, Kalisher et al. (19) found no significant difference in clinical examination and radiography in predicting metastatic involvement of nodes. When nodes were dense and greater than 2.0 cm in diameter, the true positive rate in predicting metastases was 85%, and the false negative rate was 37%. When the criterion for abnormality was a nodal size of greater than 2.5 cm, the rates were 100% and 41%, respectively (19).

When metastatic carcinoma is found in axillary nodes, the primary breast cancer is usually seen, but occasionally it may not be identified (20,21,22) (Fig. 10.27). Occasionally, the patient presents with a palpable axillary mass that on biopsy is found to be a lymph node containing adenocarcinoma. The mammogram may reveal the clinically occult primary (23). Sometimes, however, the source of the metastasis is not evident, and screening ultrasound or MRI are used to search for the primary carcinoma.

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Figure 10.23 HISTORY: An 84-year-old woman with a history of left breast cancer and lymphoma, presenting with increasing adenopathy in the right axilla.

MAMMOGRAPHY: Right exaggerated CC lateral (A) and axillary views (B). There is massive solid adenopathy in the right axilla. Note the haloes that surround these large lobulated masses. Although one could not exclude involvement with metastatic breast cancer, this degree of adenopathy is more typical of lymphoma.

IMPRESSION: Lymphoma involving right axillary nodes.

HISTOPATHOLOGY: Malignant lymphoma.

Although microcalcifications are uncommon in an axillary node, this finding is most consistent with metastatic involvement (Fig. 10.28). Gold deposits can occur in axillary nodes of patients treated with chrysotherapy for rheumatoid arthritis and may simulate microcalcifications (24). The gold deposits appear stippled, fine, and dense compared with the calcifications that are associated with metastases (Fig. 10.29). Lymphadenopathy in patients with rheumatoid arthritis treated with gold has also been found to be related to lymph node infarction (25). Rarely, metastases from nonbreast primaries, such as mucin-producing tumors, may appear as adenopathy with fine psammomatous microcalcifications (Fig. 10.30).

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Figure 10.24 HISTORY: A 34-year-old woman who is 28 weeks pregnant and who presents with a large left breast mass.

MAMMOGRAPHY: Left CC view (A) shows a large, lobular, very-high-density mass with indistinct margins. On ultrasound (B), the mass is solid, irregular, and inhomogeneous in echo pattern, all features of malignancy. Ultrasound of the axilla (C) showed multiple enlarged nodes with irregular margins and thickened cortices.

IMPRESSION: Carcinoma, metastatic to axillary nodes.

HISTOPATHOLOGY: Invasive ductal carcinoma, metastatic to the axilla.

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Figure 10.25 HISTORY: A 45-year-old gravida 4, para 4 patient with a 3 ÷ 3-cm mass in the right breast.

MAMMOGRAPHY: Right MLO (A) and CC (B) views. There is a large, high-density spiculated mass with linear extensions toward the nipple, having an appearance typical of carcinoma. Additionally, in the axillary tail there is a second smaller ill-defined mass (arrow)(A and B). Although this could be a second primary lesion, because of its location and appearance, a metastatic node would be more likely diagnosis.

IMPRESSION: Carcinoma with metastatic adenopathy in the low axilla.

HISTOPATHOLOGY: Infiltrating ductal carcinoma, with 7 of 14 nodes with macroscopic foci of metastatic carcinoma.

 

Figure 10.26 HISTORY: A 57-year-old woman with a large, firm palpable mass in the left breast.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a lobular high-density mass with indistinct margins in the 12 o'clock position of the left breast. There is also a large, dense, circumscribed node in the axilla.

IMPRESSION: Carcinoma, with nodal metastasis.

HISTOPATHOLOGY: Infiltrating ductal carcinoma with multiple positive axillary nodes.

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Figure 10.27 HISTORY: A 41-year-old woman who presents with a palpable mass in the right axilla and a normal breast examination otherwise.

MAMMOGRAPHY: Bilateral MLO views (A) show adenopathy in the right axilla corresponding to the palpable lump. On the right CC view (B), a vague distortion is noted medially (arrow). Sonography of the axilla (C) shows an enlarged, slightly irregular hypoechoic mass consistent with an abnormal node. Sonography of the area of distortion (D) shows an irregular hypoechoic mass, highly suspicious for malignancy.

IMPRESSION: Highly suspicious for carcinoma, metastatic to the axillary nodes.

HISTOPATHOLOGY: Invasive lobular carcinoma with positive axillary nodes.

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Figure 10.28 HISTORY: Patient recalled from a screening mammogram for microcalcifications.

MAMMOGRAPHY: Right MLO (A) and exaggerated CC lateral (B) views show highly pleomorphic microcalcifications in the subareolar area. There is also an oval mass with indistinct margins and associated pleomorphic microcalcifications in the low axilla. On the magnification view of the axilla (C), the pleomorphic microcalcifications within the mass are noted, suggestive of metastatic carcinoma.

IMPRESSION: Ductal carcinoma with metastatic involvement of an axillary node.

HISTOPATHOLOGY: Invasive ductal carcinoma and ductal carcinoma in situ, positive axillary node.

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Figure 10.29 HISTORY: A 62-year-old woman treated with gold for rheumatoid arthritis.

MAMMOGRAPHY: Bilateral MLO views (A) show mildly prominent lymph nodes in the axillae. Within these are faint calcificlike densities, seen best on the magnified image (B). These findings are typical of gold deposits in a patient treated with chrysotherapy for rheumatoid arthritis.

IMPRESSION: Gold deposits in axillary nodes.

 

Figure 10.30 HISTORY: A 74-year-old woman with a history of carcinoma of the umbilicus, who presents with a palpable mass in the right axilla.

MAMMOGRAPHY: Right MLO view (A) shows a fatty-replaced breast with a large, lobulated, dense circumscribed mass in the axilla. On magnification (B), the mass is noted to contain innumerable fine powdery microcalcifications.

IMPRESSION: Highly suspicious for malignancy, metastasis versus breast carcinoma.

HISTOPATHOLOGY: Mucin-producing carcinoma of the umbilicus, metastatic to an axillary node.

NOTE: Mucin-producing tumors may be associated with the formation of psammomatous calcifications.

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Figure 10.31 HISTORY: A 72-year-old gravida 0 woman for screening.

MAMMOGRAPHY: Left axillary view. There is a relatively well-circumscribed nodule (arrow) in the left axilla. Although a non–fatty-replaced node would be the most likely etiology of this mass, examination of the patient showed the nodule to correspond in location to a sebaceous cyst.

IMPRESSION: Sebaceous cyst.

 

Figure 10.32 HISTORY: A 53-year-old woman with a history of neurofibromatosis.

MAMMOGRAPHY: Right MLO view shows a heterogeneously dense breast. Numerous skin lesions were marked with BBs. There is a large, dense circumscribed mass in the axilla (arrow), which could represent an enlarged node, a cancer, or a skin lesion. Inspection of the skin showed a large pedunculated skin lesion.

IMPRESSION: Skin lesion, neurofibroma.

Other lesions that may occur in the axilla or axillary tail and that must be differentiated from lymph nodes are sebaceous cysts (Fig. 10.31), skin lesions (Fig. 10.32), hidradenitis suppurativa (Fig. 10.33), breast tumors (malignant and benign), cysts, lipomas, and ectopic breast tissue (Fig. 10.34). Ectopic breast tissue in the tail of Spence, or axillary tail, develops in the primitive milk streak. Ectopic breast tissue may be present with or without an overlying nipple or areola and is thought to occur in as many as 6% of women (26). It may be impossible to differentiate a primary tumor from an enlarged lymph node when a solitary, relatively well-defined mass in the axillary tail or axilla is present. Unless a patient has a reason to have generalized adenopathy, solid masses of greater than 1.5 cm in the axilla or smaller lesions without characteristic features of nodes should be regarded with suspicion.

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Figure 10.33 HISTORY: History of longstanding skin infections in the axillae bilaterally.

MAMMOGRAPHY: Left (A) MLO and right (B) axillary tail views show multiple nonenlarged lymph nodes in the axillae. There are also round, low-density, relatively circumscribed masses in the subcutaneous area bilaterally (arrows) consistent with the cystic inflammatory changes of hidradenitis suppurativa.

IMPRESSION: Hidradenitis suppurativa.

 

Figure 10.34 HISTORY: A 35-year-old asymptomatic woman for screening.

MAMMOGRAPHY: Bilateral MLO views (A) show a focal asymmetric area of glandular tissue in the left axilla. On the axillary tail view (B), the glandularity is better seen.

IMPRESSION: Ectopic breast tissue in the tail of Spence.

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