Atlas of Mammography

Chapter 7

Prominent Ductal Patterns

Linear densities on the mammogram may represent arteries, veins, and lactiferous ducts. There should be no confusion between vascular shadows and ducts.

Lactiferous ducts are linear, slightly nodular densities that radiate back from the nipple into the breast. The normal lactiferous ducts are thin, measuring 1 to 2 mm in diameter, and often are not evident as separate structures on mammography. Enlarged ducts may occur in benign and malignant conditions. When ducts are enlarged, correlation with clinical examination as to the presence of discharge is important. Galactography is of help in providing further information in the evaluation of a nipple discharge, with or without dilated ducts being seen on mammography.

A diffusely prominent ductal pattern bilaterally (Fig. 7.1), associated with small nodular densities, has been described by Wolfe et al (1,2) as placing the patient at higher-than-average risk for developing breast cancer. According to Wolfe, the breast parenchyma was classified into four patterns: N1 or fatty replaced, and P1, P2, or DY with increasing amounts of ductal or glandular tissue. Because of surrounding collagen, individual ducts may not be identified; instead, a dense, triangular fan-shaped density is present beneath the areola (3). The association between a prominent ductal pattern and breast cancer incidence has been debated, with some authors (4,5) agreeing with the association and others (67) finding no reliable indicator of risk by mammographic pattern. Ernster et al. (9) suggested that nulliparous women and women with a family history of breast cancer are more likely to have dense breasts and a prominent ductal pattern and that breast parenchymal pattern may be related to other risk factors. Funkhouser et al. (10) found a twofold increase in breast cancer risk in women with a P2 or DY Wolfe pattern in comparison with an N1 pattern (fatty breasts). Andersson et al. (11) also found an increased frequency of the dense ductal patterns with advancing age at first pregnancy and with nulliparity. Brisson et al. (12) assessed breast cancer risk as related to parenchymal pattern in a study of 3,412 women and found that parenchymal pattern was strongly correlated with risk. The authors found that the risk of breast cancer was five- to sixfold greater in women who had breasts that were composed of 85% or more dense tissue than in women who had no density on mammography.

Duct Ectasia

Another cause of bilateral ductal prominence is duct ectasia (Figs. 7.2,Figs. 7.3,Figs. 7.4,7.5). Haagenson (13) described the condition as beginning with bilateral dilation of the main lactiferous ducts in postmenopausal women. Amorphous debris within the ducts is irritating and causes periductal inflammation and fibrosis without epithelial proliferation. Retraction of the nipple may occur secondary to fibrosis in the periductal space. In a more recent study, Dixon et al. (14) found that periductal inflammation around nondilated ducts occurred in younger patients and that older patients had ductal dilatation as the main feature. Neither parity nor breastfeeding was found to be an important etiologic factor in this condition (14).

Dilated ductal structures may also be associated with inflammatory or infectious etiologies (Fig. 7.6). In a patient with a breast abscess or with chronic mastitis, there may be intraductal extension of the infection. This may appear as dilated ducts around an indistinct mass or as dilated subareolar ducts with overlying skin thickening. Sonography may depict the abscess cavity and the extension of fluid into ducts surrounding the cavity.

Papillomatosis

Intraductal papillomatosis is a benign lesion characterized by a papillary proliferation of the epithelium that may fill and distend the duct (15). This lesion is distinguished from a solitary intraductal papilloma. Papillomatosis tends to be scattered throughout the parenchyma and is within the

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spectrum of fibrocystic change. Sometimes papillomatosis is also called intraductal hyperplasia of the common type. On mammography, the finding of a prominent ductal pattern may be evident, and fine microcalcifications are sometimes seen. On galactography, an irregular filling defect or multiple filling defects are found (Fig. 7.7).

 

Figure 7.1 HISTORY: A 74-year-old gravida 4, para 4 patient for screening.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show heterogeneously dense breasts. These are diffuse small areas of nodularity and linear structures consistent with a prominent ductal pattern.

IMPRESSION: Prominent ductal pattern bilaterally, within normal limits.

 

Figure 7.2 HISTORY: A 64-year-old patient who is status post–right breast biopsy, for routine screening of the right breast.

MAMMOGRAPHY: Right CC view shows extensive ductal dilatation extending from the subareolar area centrally and medially. Architectural distortion is present in the area of surgical scar. This pattern had been stable for many years and is consistent with duct ectasia.

IMPRESSION: Duct ectasia.

Papillary duct hyperplasia is an unusual lesion that occurs in children and young adults (16). Three patterns have been described: a solitary papilloma, papillomatosis, and sclerosing papillomatosis. The condition causes a distention of the duct or ducts.

 

Figure 7.3 HISTORY: A 58-year-old gravida 8, para 8 woman for screening mammography.

MAMMOGRAPHY: Left (A) and right (B) CC views show the breasts to contain scattered fibroglandular densities. There are prominent ducts present bilaterally (arrows), appearing as tubular nodular structures extending back from the nipples.

IMPRESSION: Bilateral ductal ectasia.

Solitary or Focally Dilated Ducts

When asymmetrically dilated ducts or a solitary duct are found on mammography, the possibility of ductal malignancy must be considered. Huynh et al. (17), in a review of 46 women with asymmetrically dilated ducts, found that 24% had ductal carcinoma. Factors associated with malignancy in dilated duct patterns were the presence of associated microcalcifications, a nonsubareolar location, and interval change. The benign causes for the appearance of dilated ducts include a solitary papilloma, multiple papillomas, papillomatosis, ductal hyperplasia, and ductal adenoma.

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Figure 7.4 HISTORY: A 62-year-old woman for screening.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show scattered fibroglandular densities. There are prominent tubular densities in both subareolar areas, radiating back from the nipple.

IMPRESSION: Bilateral duct ectasia.

NOTE: Because the ducts are evident as discrete tubular structures, and because of their widened diameter, the finding represents dilated ducts or duct ectasia.

 

Figure 7.5 HISTORY: A 56-year-old woman for screening.

MAMMOGRAPHY: Bilateral MLO views show relatively fatty-replaced breasts. There are enlarged subareolar ducts bilaterally in a symmetrical distribution. The ducts can be observed as individual structures, and they radiate back from the nipple in a typical pattern of duct ectasia.

IMPRESSION: Duct ectasia.

Dilated ducts are an uncommon presentation of carcinoma but occasionally may be the only sign of this disease. A unilateral dilated duct or ducts, especially those with associated microcalcifications, are suspicious for the possibility of malignancy (18). Dilated ducts located deeper in the breast may be of greater concern for a hyperplastic or malignant lesion; a subareolar duct is more commonly seen in an intraductal papilloma (18).

Intraductal Papilloma

A solitary intraductal papilloma often presents when small and nonpalpable with a serosanguineous or bloody nipple discharge. Papillomas are usually situated beneath the nipple in a major duct; in 90% of cases, they arise within 1 cm of the nipple (19). The papilloma is connected to the duct by a thin connective tissue stalk that contains the blood supply, and it is covered by a frondlike epithelium. Because of the tenuous blood supply, these lesions tend to undergo infarction and sclerosis (20,21). When a papilloma infarcts, it may produce a bloody discharge, identified on clinical examination, and it may calcify.

Depending on the size of the papilloma, it may not be seen on mammography, and a galactogram may be necessary to identify the location of the lesion. When papillomas are identified on the mammogram, they appear as a dilated duct or as a well-defined mass (20) (Figs. 7.8,Figs. 7.9,Figs. 7.10,Figs. 7.11,Figs. 7.12,7.13). In a study of 51 patients with solitary papillomas, Cardenosa and Eklund (22) found that 37 were symptomatic; 36 presented with spontaneous nipple discharge, and 1 had a palpable mass. Ductography was performed in 35 patients and was positive in 32. In some patients, prominent asymmetric ducts were noted at mammography, yet galactography was more useful in diagnosis by

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showing a dilated duct with an intraluminal filling defect. Woods et al. (23) reviewed the clinical and imaging findings in 24 women with solitary intraductal papillomas and found that 88% presented with nipple discharge. In 42% of patients, mammography was abnormal, including showing dilated ducts in 26% of women. Galactography was successfully performed in 13 patients and showed an intraluminal defect in 12 (92%) and a duct obstruction in 1 patient.

 

Figure 7.6 HISTORY: Patient presents with a very tender, red right breast with a palpable subareolar mass.

MAMMOGRAPHY: Right MLO (A) and CC (B) views show a dense microlobulated mass in the immediate subareolar area. There are numerous tubular structures extending from the mass posteriorly into the breast. Ultrasound (C) shows a markedly hypoechoic mass with microlobulated borders.

IMPRESSION: Large mass with intraductal extension: carcinoma versus abscess.

NOTE: The lesion was drained and represented on large breast abscess. Follow-up mammography was negative.

 

Figure 7.7 HISTORY: A 46-year-old woman with a bloody left nipple discharge.

MAMMOGRAPHY: Left galactogram magnification view. The cannulated duct is dilated. There is a smooth filling defect (arrowheads)involving two branches of the lactiferous duct, without evidence for distortion of architecture or encasement of the ducts. The finding suggests intraductal papilloma or papillomatosis, although a papillary carcinoma cannot be excluded.

HISTOPATHOLOGY: Intraductal papillomatosis. (Case courtesy of Dr. George Oliff, Richmond, VA.)

 

Figure 7.8 HISTORY: A 52-year-old woman for screening.

MAMMOGRAPHY: Left CC view shows a lobular mass with relatively circumscribed margins located laterally. There is a tubular extension from the mass posteriorly, suggesting that this could be a dilated duct. Excisional biopsy was performed.

IMPRESSION: Suspicious mass, possibly an intraductal lesion.

HISTOPATHOLOGY: Papilloma.

On ultrasound, a papilloma may be observed as a small hypoechoic solid mass. Often the dilated duct containing fluid is seen, and a solid component representing the papilloma is evident. The sonographic distinction between benign or malignant papillary lesions is not reliable (24). Women who are diagnosed with solitary intraductal papilloma are thought to have a 1.5 to 2 times relative risk of developing breast cancer (25). However, women who have multiple small papillomas, a condition

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often involving several ducts, have a 7.4 times relative risk of developing breast cancer (26).

 

Figure 7.9 HISTORY: A 48-year-old woman with a small palpable left breast mass.

MAMMOGRAPHY: Left CC view (A) shows a fatty-replaced breast. There is a markedly dilated duct containing microcalcifications(arrow) in the immediate subareolar area, at the site of palpable abnormality. On the magnified image (B), the somewhat pleomorphic appearance of these intraductal calcifications is noted.

IMPRESSION: Dilated duct, suspicious for DCIS.

HISTOPATHOLOGY: Intraductal papilloma.

Ductal Carcinoma In Situ

Unilateral dilated ducts, with or without microcalcifications (27), or a solitary dilated duct (28,29) may be the only mammographic indication of a malignancy (Figs. 7.14,Figs. 7.15,Figs. 7.16,Figs. 7.17,Figs. 7.18,Figs. 7.19,Figs. 7.20,Figs. 7.21,Figs. 7.22,Figs. 7.23,Figs. 7.24,7.25). Usually, no mass is palpable (29); however, in an extensive area of ductal dilatation associated with ductal carcinoma in situ (DCIS), palpable thickening may be noted. In some patients, a uniorificial serous or bloody nipple discharge is observed. The solitary duct has a tubular, slightly nodular shape that tapers as it proceeds into the parenchyma (29). When the lesion is associated with microcalcifications, the level of suspicion is greater. Although the presentation of a nonpalpable cancer as a solitary dilated duct is not common (30,31), this finding should not be overlooked. In a series of 73 women with intraductal carcinoma in whom no microcalcifications were present on mammography, Ikeda and Andersson (32) found that 12 presented with focal ductal-nodular patterns, and 2 had dilated retroareolar ducts.

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Figure 7.10 HISTORY: A 47-year-old asymptomatic woman for screening mammography.

MAMMOGRAPHY: Left MLO view (A) and histopathology (B and C). The breast is heterogeneously dense. In the upper aspect of the breast, there is a linear, slightly nodular density representing a solitary duct. A solitary dilated duct is one of the least common signs of nonpalpable breast cancer. Other possible diagnoses in this case are a papilloma, papillomatosis, or duct ectasia.

IMPRESSION: Solitary dilated duct: intraductal carcinoma versus papilloma.

HISTOPATHOLOGY: Intraductal papilloma.

NOTE: The papilloma projects into the ductal lumen; its dense, central, connective-tissue core is covered by the papillary epithelium (12.5÷) (B). A cross section through the duct (C) shows a less sclerotic portion of the papilloma with complex branching and prominent fibrovascular stalks (50÷).

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Figure 7.11 HISTORY: A 65-year-old gravida 3, para 3 woman with a family history of breast cancer, presenting with a right nipple discharge and a subareolar mass of at least 10 years' duration.

MAMMOGRAPHY: Right MLO (A) and CC (B) views. The breast is mildly glandular. There is a large, high-density circumscribed mass in the immediate subareolar area. The posterior margin of the lesion is contiguous with a tubular density containing coarse calcifications(B). The shape of the lesion suggests that this is a dilated duct, obstructed and mostly fluid filled. The calcification may be related to chronic hemorrhage. The chronicity of findings is more consistent with a benign lesion, such as an intraductal papilloma, although a neoplasm cannot be entirely excluded.

IMPRESSION: Massive duct dilatation secondary to an obstructing lesion.

HISTOPATHOLOGY: Intraductal papilloma, cystic dilatation of duct.

Ductal dilatation may also be evident on sonography in some cases of DCIS. In a study of 60 patients with symptomatic DCIS, Yang and Tse (33) found that 22% of patients had ductal dilatation and/or extension on ultrasound. Sonography may also demonstrate as intraductal solid component within a distended, fluid-filled duct. This finding has the appearance of a complex cyst when observed in cross section. On magnetic resonance imaging, DCIS may have an appearance of segmental, linear clumped enhancement, which represents the involved dilated ducts.

Papillary carcinoma constitutes 1% to 2% of breast cancers in women (34) and presents with bloody nipple discharge in 22% to 34% of cases (34,35). On histology, papillary cancers are characterized by a frondlike growth pattern on a fibrovascular core that lacks a

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myoepithelial layer. Intraductal papillary carcinoma may be multifocal and present as dilated ducts or as multiple clusters of microcalcifications (35). An appreciation of the indirect and subtle signs of malignancy is key in making the diagnosis of breast cancer at an early stage.

 

Figure 7.12 HISTORY: A 58-year-old woman with left bloody nipple discharge.

MAMMOGRAPHY: Left spot ML view shows a dilated duct (arrow) in the left subareolar area. There are punctuate and dystrophic calcifications within the duct, a finding that may be present in an infarcted papilloma or DCIS.

IMPRESSION: Dilated duct, papilloma versus DCIS.

HISTOPATHOLOGY: Intraductal papilloma.

Ductal Adenoma

Another cause of focally dilated ducts or a solitary dilated duct is ductal adenoma (Fig. 7.26). These are benign glandular tumors that fill and distend the ductal lumen (36). The lesion may present as a palpable mass and is not associated with a nipple discharge. It can simulate malignancy both radiographically and macroscopically. Microcalcifications may occur and may be irregular in a linear orientation (37). Pathologically, two forms have been described: a solitary adenomatous nodule within a ductal lumen and a more complex form with apparent encroachment on the ductal wall (36).

Adenoma of the nipple is a rare benign tumor also called florid papillomatosis of the nipple ducts (38). Clinical presentation in nipple discharge is uncommonly associated with a crusted or ulcerated nipple. On pathology, the lesion is composed of a proliferation of ducts varying in size and shape with prominent fibrosis (38). A papillary growth pattern of intraductal hyperplasia is present as well (38).

Other Linear Densities

Vascular structures also appear as linear densities on mammography and should not be confused with a prominent ductal pattern (Fig. 7.27). Vessels are smooth and undulating. Arteries are smaller than veins and may be seen extending into the upper aspect of the breast and the axillary area. Tramline calcifications occur often in the arteries of elderly women. Prominence of venous structures has been described as a secondary sign of malignancy (39), but this is not common and is nonspecific. Other causes of dilated veins include (a) obstruction of the subclavian vein with development of venous collaterals over the breast (40) (Fig. 7.28) and (b) superior vena cava obstruction causing development of bilateral collaterals over the breasts.

Mondor disease or superficial thrombophlebitis of the breast and upper abdominal wall (41) (Figs. 7.29 and 7.30) may cause a mildly prominent-appearing vein on mammography, but often the mammogram is normal. Patients with Mondor disease may report a history of trauma, surgery, or excessive lifting or exercise. The vein most commonly involved is the lateral thoracoepigastric vein, which crosses over the upper abdominal wall and the lateral aspect of the breast. The findings are most characteristic on clinical examination: namely, a firm cordlike structure beneath the skin, having a reddened appearance. The thrombosed vein is tender to palpation; the disease is treated with aspirin or nonsteroidal anti-inflammatory medications.

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Figure 7.13 HISTORY: A 54-year-old woman for screening mammography.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show focally dilated ducts (arrows) in the 6 o'clock position of the left breast. These were markedly asymmetric in comparison with the contralateral breast. There are some associated ductal pleomorphic calcifications at the proximal end of the duct seen best on the magnification CC (C) and ML (D) views (arrow).

IMPRESSION: Dilated ducts, suspicious for DCIS. Recommend excision.

HISTOPATHOLOGY: Atypical ductal hyperplasia, intraductal papilloma.

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Figure 7.14 HISTORY: A 67-year-old woman with bloody nipple discharge.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a segment of dilated ducts in the 6 o'clock position of the left breast. Tubular-nodular densities extend from the nipple posteriorly into the breast (arrows) and are suspicious for an intraductal filling process.

HISTOPATHOLOGY: DCIS.

 

Figure 7.15 HISTORY: Elderly woman for screening.

MAMMOGRAPHY: Right CC view shows a fatty-replaced breast. In the medial aspect of the subareolar area is a focal area of branching ductal dilatation (arrow). No similar finding was present on the left.

IMPRESSION: Focally dilated ducts. Recommend biopsy.

HISTOPATHOLOGY: DCIS.

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Figure 7.16 HISTORY: A 56-year-old woman for screening mammography.

MAMMOGRAPHY: Bilateral CC views (A) show asymmetrically dilated ducts in the left subareolar area. The duct bifurcates centrally(arrow) in the breast. On the MLO view (B), the unilateral duct is located at 6 o'clock.

IMPRESSION: Solitary dilated duct, papilloma versus DCIS. Recommend excision.

HISTOPATHOLOGY: DCIS.

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Figure 7.17 HISTORY: An 81-year-old woman for screening.

MAMMOGRAPHY: Left ML view shows a prominent segment of dilated ducts in the inferior aspect of the breast (arrows). These have a tubulonodular appearance, and a small mass is present within this region of abnormality. The findings were unilateral.

IMPRESSION: Focally dilated ducts. Recommend excision.

HISTOPATHOLOGY: DCIS and invasive ductal carcinoma.

 

Figure 7.18 HISTORY: A 74-year-old patient with a palpable right breast marked with a BB.

MAMMOGRAPHY: Right CC view (A) shows two round isodense masses, one of which is marked with a BB. Extending into the lateral aspect of the breast are tubular structures (arrow) with associated microcalcifications, seen best on the magnification CC view (B). On ultrasound (C), the masses are complex with a solid component, raising the possibility of a papillary lesion or DCIS.

IMPRESSION: Dilated ducts with intracystic solid components, suspicious for papillary carcinoma.

HISTOPATHOLOGY: DCIS, micropapillary type.

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Figure 7.19 HISTORY: A 55-year-old woman with a palpable mass in the left breast.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show a high-density, indistinct lobular mass in the left breast at 6 o'clock with associated dilated ducts (B) (arrow). On the coned-down MLO view (C), the lesion is associated with adjacent dystrophic calcifications and linear extensions anteriorly (arrows), suggesting intraductal extension of tumor. A prominent lymph node (arrowheads) is present in the left axilla.

IMPRESSION: Invasive carcinoma with DCIS.

HISTOPATHOLOGY: Invasive duct carcinoma and micropapillary DCIS, with no metastatic carcinoma in the axillary nodes.

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Figure 7.20 HISTORY: A 42-year-old woman for screening.

MAMMOGRAPHY: Left coned-down CC view shows a branching dilated duct (arrows) in the left breast. This finding was unilateral and asymmetric. Needle localization with excision was performed.

IMPRESSION: Dilated duct, DCIS versus papilloma.

HISTOPATHOLOGY: DCIS cribriform type, and intraductal papilloma.

 

Figure 7.21 HISTORY: A 65-year-old woman for screening mammography.

MAMMOGRAPHY: Left CC view shows moderate glandularity present. In the central posterior aspect of the breast, there are well-defined tubular nodular densities that represent focally dilated ducts. The focal nature of these ducts—particularly the location, apart from the main ducts at the nipple—suggests an area of localized intraductal activity. The differential includes multiple papillomas, papillomatosis, intraductal carcinoma, and ductal hyperplasia.

IMPRESSION: Focally dilated ducts, moderately suspicious for carcinoma.

HISTOPATHOLOGY: Extensive multifocal intraductal carcinoma with papillomatosis.

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Figure 7.22 HISTORY: A 65-year-old woman with a scaling, ulcerating lesion of the right nipple.

MAMMOGRAPHY: Bilateral CC views. The breasts show fatty replacement. There is a fan-shaped asymmetric density radiating back from the right nipple, corresponding to the location of the subareolar lactiferous ducts. The asymmetric ductal dilatation should be regarded with suspicion, and particularly with the nipple lesion, this finding is highly compatible with that of Paget disease and intraductal carcinoma. There are also two groups of microcalcification deeper in the right breast that are suspicious for other foci of intraductal carcinoma (arrow).

IMPRESSION: Paget disease, ductal carcinoma.

HISTOPATHOLOGY: Intraductal papillary small cell carcinoma and large cell carcinoma with pagetoid spread.

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Figure 7.23 HISTORY: A 70-year-old woman for screening mammography.

MAMMOGRAPHY: Left MLO (A), left CC (B), and magnification CC (C) views. There are several dilated ducts (arrows) in the left subareolar area (A, B). Within these ducts are fine linear and punctate microcalcifications (arrow) (C). No similar findings were noted in the opposite breast. Focal ductal dilatation is one of the less common signs of breast cancer. With the associated ductal calcifications in this case, the degree of suspicion that this was a malignant lesion was increased.

IMPRESSION: Ductal carcinoma.

HISTOPATHOLOGY: Intraductal small cell carcinoma.

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Figure 7.24 HISTORY: A 78-year-old woman with family history of breast cancer, for screening mammography.

MAMMOGRAPHY: Left MLO view (A), magnified CC view (B), and histopathology (C). There is a relatively well-defined, high-density tubular structure (A, arrow) in the lower aspect of the breast. The lobulated fusiform shape of the lesion is also demonstrated on the CC view (B). Sonography of the lesion showed it to be solid and hypoechoic. The shape of the lesion suggests a dilated duct. The lesion had appeared since a previous mammogram 6 years earlier. Because of this, a fibroadenoma would not be likely, and primary considerations are carcinoma, possibly localized within a dilated duct, or focal fibrocystic disease.

IMPRESSION: Solitary dilated duct in the left breast, highly suspicious for carcinoma.

HISTOPATHOLOGY: Intraductal carcinoma.

NOTE: The histopathologic section shows the dilated duct filled with intraductal carcinoma (C).

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Figure 7.25 HISTORY: A 44-year-old gravida 4, para 4 woman with a positive family history of breast cancer, presenting with a “heavy” sensation in the left breast. Clinical examination showed a thicker left breast, without a dominant palpable mass.

MAMMOGRAPHY: Bilateral MLO (A), CC (B), and enlarged (1.5÷) left CC (C) views. There is marked asymmetry in the appearance of the breasts (A and B). In the left upper quadrant, there are numerous tubular and rounded densities (arrows) radiating back from the nipple. This pattern of tubular structures represents markedly dilated ducts. In addition, within these ducts and extending more medially into the central aspect of the left breast (C) are extensive granular irregular microcalcifications (arrows). This finding alone is highly suspicious for carcinoma and, in combination with the prominent duct pattern, is even more so.

IMPRESSION: Highly suspicious for extensive ductal carcinoma, left breast.

HISTOPATHOLOGY: Intraductal and infiltrating ductal carcinoma.

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Figure 7.26 HISTORY: A 52-year-old woman for screening mammography.

MAMMOGRAPHY: Left MLO (A) and CC (B) views. In the 12 o'clock position of the left breast, there is a 5-cm area of focal ductal dilatation and proliferation in a bizarre shape. Fine granular microcalcifications are associated with this lesion. The differential was thought to include ductal carcinoma, papillomatosis, or other epithelial proliferation.

HISTOPATHOLOGY: Ductal adenoma, complex form. (Case courtesy of Alexander Girevendulis, Richmond, VA.)

 

Figure 7.27 HISTORY: Screening mammogram on a 34-year-old woman.

MAMMOGRAPHY: Bilateral MLO show essentially fatty-replaced breasts. There are circuitous tubular structures that extend over the breast and are oriented toward the axilla, typical of normal vascular structures (arrows).

IMPRESSION Normal arteries and veins.

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Figure 7.28 HISTORY: A 38-year-old woman with a tender swollen left breast and axilla.

MAMMOGRAPHY: Bilateral MLO views. There are asymmetric circuitous linear densities (arrows) in the left breast, extending into the left axilla. These represent asymmetrically dilated veins. The patient was sent for venography of the left upper extremity, which showed thrombosis in the left subclavian vein and dilated venous collaterals over the left breast.

IMPRESSION: Dilated venous collaterals secondary to subclavian vein thrombosis.

 

Figure 7.29 HISTORY: A 35-year-old nurse who, after excessive lifting, developed severe pain, tenderness, and swelling of the upper aspect of the left breast.

IMAGE: A palpable cord (curved arrow) extended from the nipple toward the upper outer quadrant. The vein was focally tender. The mammogram showed a normal vein and no other abnormalities.

IMPRESSION: Mondor disease (superficial thrombophlebitis).

NOTE: On this mammogram, the pertinent finding is the lack of abnormalities with the exception of the vein in the area of palpable thickening. This condition may occur after trauma or repeated exercise and regresses on anticoagulants and anti-inflammatory medications.

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Figure 7.30 HISTORY: A 57-year-old woman who is 3 months status postlumpectomy and -brachytherapy for left breast cancer. She presents with a tender, hard palpable cord extending from the periumbilical area up over the lateral aspect of the thorax on the left side.

IMAGE: The photograph of the left anterior thoracoabdominal wall shows a linear structure extending up along the lateral aspect of the abdomen toward the axilla. The structure appears to bifurcate and is located very superficially. Clinical examination showed this to be quite firm on palpation and tender.

IMPRESSION: Mondor disease.

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