Clinical Breast Imaging: A Patient Focused Teaching File, 1st Edition

Chapter 3 - Diagnostic Breast Imaging

 

Terms

·     Adenosis tumor

·     Air gap

·     Axillary lymph node dissection (ALND)

·     Cat scratch disease

·     Columnar alteration with prominent apical snouts and secretions (CAPSS)

·     Complex fibroadenoma

·     Complex sclerosing lesion (CSL)

·     Cyst

·     Diabetic fibrous mastopathy

·     Double spot compression magnification views

·     Ductal carcinoma in situ (DCIS)

·     Epidermal inclusion cyst

·     Extensive intraductal component (EIC)

·     Extra-abdominal desmoid

·     Extracapsular tumor extension

·     Fat necrosis

·     Fibroadenoma

·     Fibromatosis

·     Focal fibrosis

·     Focal spot

·     Galactocele

·     Granular cell tumor

·     Gynecomastia

·     Hematoma

·     Invasive ductal carcinoma not otherwise specified (NOS)

·     Invasive lobular carcinoma

·     Lactational adenoma

·     Lipoma

·     Lobular neoplasia

·     Lymphovascular space involvement

·     Male breast cancer

·     Mastitis

·     Medullary carcinoma

·     Metachronous carcinoma

·     Metaplastic carcinoma

·     Metastatic disease

·     Milk of calcium

·     Mucinous carcinoma

·     Multiple peripheral papillomas

·     Neoadjuvant therapy

·     Oil cyst

·     Papillary carcinoma

·     Papilloma

·     Perineural invasion

·     Peripheral abscess

·     Phyllodes tumor

·     Port-a-catheters

·     Posttraumatic change

·     Pneumocystography

·     Probably benign lesion

·     Psammoma bodies

·     Pseudoangiomatous stromal hyperplasia (PASH)

·     Radial scar

·     Sclerosing adenosis

·     Sebaceous cyst

·     Secretory calcification

·     Sentinel lymph node biopsy (SLNB)

·     Shrinking breast

·     Spot compression views

·     Spot tangential views

·     Subareolar abscess

·     Synchronous carcinoma

·     Touch imprints

·     Triangulation of lesion location

·     Tubular adenoma

·     Tubular carcinoma

·     Tubulolobular carcinoma

·     Tumor necrosis

·     Vascular calcification

Introduction

The diagnostic patient population is made up of women called back for potential abnormalities detected on a screening mammogram, patients who present with signs and symptoms of disease localized to the breast(s), patients with a history of breast cancer treated with lumpectomy and radiation therapy, and those undergoing follow-up during neoadjuvant chemotherapy for breast cancer. At some facilities, and according to the American College of Radiology (ACR) Practice Guideline for the Performance of Diagnostic Mammography, women with implants may also be included in the diagnostic patient population.

This chapter describes one approach to the diagnostic evaluation of patients with breast related findings, which I have developed and fine-tuned through years of experience and thousands of patient encounters. I provide the rationale for a common-sense, streamlined approach and illustrate principles that I think you will find practical, efficient, and helpful in minimizing a delay in a breast cancer diagnosis. Simplicity, creativity, and resourcefulness in problem solving are all components of the approach. Obviously, there are many different ways of approaching this patient population, and again my recommendation is that you select a method that works in your hands, and use it consistently. Do not short-circuit evaluations for the sake of expediency, be flexible and creative (but keep it simple) in sorting through dilemmas, make no assumptions, and demand the highest quality possible from yourself and those around you.

Although I provide the imaging algorithms I use, a dedicated breast imaging radiologist directs all diagnostic evaluations and can tailor the exam to the patient and the problem being evaluated. Results, impressions, and recommendations are discussed with the patient directly at the time of the evaluation. Tools available to evaluate patients include mammographic images, correlative physical examination, ultrasound, cyst aspiration, pneumocystography, ductography, imaging-guided fine-needle aspiration, and imaging-guided needle biopsy. If indicated, magnetic resonance imaging of the breast is scheduled at the time of the patient's diagnostic evaluation, including all patients diagnosed with breast cancer following an imaging-guided procedure.

Additional Mammographic Views

For patients called back after screening, additional mammographic images are almost always taken. Virtually all of the additional views imaged during diagnostic evaluations involve the use of the spot compression paddle and include spot compression, rolled spot compression, spot tangential, and double spot compression magnification views. Spot compression and rolled compression views are taken when trying to determine if a lesion is present (or is it merely an “imaginoma”), when establishing the marginal characteristics of a mass, or, with rolled views, for triangulating the location of a lesion seen initially on only one of the routine views. Spot tangential views are taken routinely in evaluating focal signs and symptoms. They are also used when a lesion is thought to be localized to the skin or to position postoperative skin changes following lumpectomy and radiation, in tangent to the x-ray beam so that they are not superimposed and potentially obscuring significant changes at the lumpectomy bed. Double spot compression magnification views are indicated when evaluating calcifications. The only diagnostic images that are sometimes done with the large compression paddle are lateral views (90-degree lateromedial or 90-degree mediolateral views) used to triangulate the location of a lesion on the orthogonal view. As with screening views, high-quality, well-exposed, high-contrast diagnostic images, with no blur or artifacts, are essential to minimize the likelihood of delaying or missing a breast cancer diagnosis.

Diagnostic Evaluation of Patients Over the Age of 30 Years Who Present with Focal Findings

When women over the age of 30 years present with a “lump” or other focal symptom (focal pain, skin change, nipple retraction, etc.), a metallic BB is placed at the site of focal concern. Then craniocaudal (CC) and mediolateral oblique (MLO) views are imaged bilaterally, as well as a spot tangential view of the focal abnormality. A unilateral study (CC and MLO views) of the symptomatic breast with the spot tangential view at the site of focal concern is done if the patient has had a mammogram within the preceding 6 months. Based on what is seen on these initial images, additional spot compression, or double spot compression magnification views, may be oftained. Depending on the location of the focal finding, and the appearance of this area on the spot tangential view, correlative physical examination and an ultrasound are usually indicated. The ultrasound may be deferred in patients in whom there is no chance that the lesion has been excluded from the field of view and completely fatty tissue, or a benign lesion (e.g., an oil cyst or a dystrophic calcification), is imaged corresponding to the area of concern.

Diagnostic Evaluation of Patients Under Age 30 Years, Pregnant, or Lactating, with Focal Findings

For women under the age of 30 years, or who are pregnant or lactating, who present with a “lump” or other focal symptom, we start by doing a physical examination and an ultrasound. In most of these patients, this is all that is required for an appropriate disposition. Rarely, if a breast cancer is suspected based on the physical exam and ultrasound findings, a biopsy may be indicated in this patient population. If cancer is suspected, a full bilateral mammogram is also done.

Our Goal and Approach Relative to Diagnostic Evaluations

When patients present for diagnostic evaluations, our goal is to establish the correct diagnosis, accurately and efficiently, so we do as much as is indicated and the patient desires, in one visit. For some women this may include mammographic images only, or additional views and an ultrasound; for other patients, additional mammographic views, an ultrasound, and a core biopsy are performed. In my experience, if a biopsy is indicated, the patient's immediate question is “How soon can I have it done?” and they are appreciative (and in many ways relieved) when I respond, “If you would like, we can do the biopsy now and have results by tomorrow.” Rarely, a patient requests time to discuss the recommendation with her family; in that case, we schedule the biopsy for a date that is convenient for the patient.

Histologic findings are discussed by the radiologist and the pathologist who review the cores within 24 hours of the core biopsy, so patients are asked to return the following business day to receive their results. The biopsy site is examined, biopsy results are discussed, and, based on the results, our recommendations regarding the need to return to screening guidelines, short-interval follow-up, excisional biopsy, or surgical consultation are discussed with the patient. If a surgical consultation is indicated, this is scheduled for the patient before she leaves our center. With a commitment from the breast surgeon, patients are seen within 48 hours of a breast cancer diagnosis.

BI-RADS® Assessment Categories Used Following Diagnostic Evaluations

Under the Mammography Quality Standards Act (MQSA), all reports involving mammographic images require an assessment category. Our approach, however, is to provide an assessment that reflects our recommendation following the completed diagnostic evaluation. This usually incorporates the findings and impression formulated following the physical examination, mammogram, and ultrasound (or other studies that may be done). So, in addition to using BI-RADS® categories 1 and 2, and category 3 (probably benign, short-interval follow-up), we also use category 4 (suspicious abnormality, biopsy should be considered) and category 5 (highly suggestive of malignancy—appropriate action should be taken), based on what is determined following the completed diagnostic evaluation. Based on the likelihood of malignancy, category 4 lesions can be subclassified into 4A (low suspicion for malignancy), 4B (intermediate suspicion for malignancy), or 4C (moderate concern, but not classic as in category 5). Category 0 is used for patients for whom we schedule magnetic resonance imaging for further evaluation, and BI-RADS® category 6 (known malignancy) is used primarily for patients with a breast cancer diagnosis who are receiving chemotherapy (e.g., neoadjuvant therapy) and are undergoing monitoring of chemotherapy response. Although in this text I use the ACR lexicon terminology, in our practice we have chosen to vary the verbiage provided with categories 4 and 5 to indicate that a “biopsy is indicated” rather than “should be considered” or “appropriate action should be taken” (more on this below).

Some Philosophical Considerations Regarding Patient Care and Diagnostic Evaluations: Are We Film Readers or Consultants?

Before going further, please indulge me in a short philosophical discussion about how we, as radiologists, choose to practice breast imaging. Although some are likely to disagree with several (and maybe all) of the concepts presented here, in generating a reaction, one way or the other, I accomplish my goal of getting you to think about issues that are not usually thought about—but perhaps should be.

As radiologists, we can effectively choose to delegate many of our responsibilities as physicians to others, thereby minimizing our direct role in the care of patients. We work hard during screening to identify small breast cancers, yet we routinely relegate the role of discussing our findings with patients to others. With this comes an obfuscation of our critical role in the detection of clinically occult early-stage breast cancer and possible misrepresentations to patients relative to the limitations of mammography and the generation of unrealistic expectations regarding the appropriateness of ultrasound and magnetic resonance imaging. We struggle during diagnostic evaluations to arrive at an answer, yet we dismiss patients with lines such as “You will get the results from your doctor,” as though we are incapable (or unwilling) to do it, or we avoid all direct contact with the patient and have one of our surrogates tell the patient that she should contact her physician for the results. We identify potential cancers, yet we won't do the biopsy while the patient is in our facility because it is not practical or expedient. Patients are asked to wait for days and sometimes weeks for a biopsy to be done and then for results. If we do the biopsy, we often relegate patient follow-up and the discussion of results to the referring physician or surgeon. How can this be acceptable? Imagine the anguish. Is it any wonder that radiologists are the physicians most commonly named in malpractice lawsuits for delays in the diagnosis of breast cancer? I would argue that, in breast imaging, we are in a position to revolutionize and substantially improve patient care. Carpe diem.

What, then, should our role be? Should our role be to interpret films in isolation, or should it be that of clinicians and consultants who interpret breast images? I consider my role to be that of a clinical consultant in breast imaging (rather than a radiology report, I dictate “breast imaging consultations”), and as such, the patients who come to see me are my patients. In the diagnostic setting, rather than accept the history and physical examination described by others, I talk to the patients directly and, when indicated, undertake a physical examination. As opposed to delegating the breast ultrasound study to a technologist, I view this as an opportunity to establish effective rapport with the patient, review the history provided, and undertake correlative physical examination (in effect, placing eyeballs at the tips of my fingers). Why not take this opportunity? We place a significant amount of importance on what our images show, but shun the information provided by the physical examination and by talking directly with the patient. This information can be just as critical and important in arriving at the right answer as any finding on our imaging studies. There are times when the imaging studies are negative or equivocal and a biopsy is indicated based on clinical findings.

As I scan during the ultrasound study, I examine and talk with the patient. In addition to the visual information from the ultrasound, I find that use of the ultrasound coupling gel to examine a patient enhances my ability to find, feel, and characterize palpable findings. During the real-time portion of the study, as I scan and examine the patient, I determine if a lesion is present. After making this determination, I take the images needed to adequately and appropriately document the features of the lesion and that support the impression I formulate during the real-time portion of the study (i.e., directed image taking). I do not take pictures of normal tissue. Time and time again, I am impressed with how often the history obtained during these interchanges yields critical information used to establish the “true” nature and significance of what is going on. The other critical aspect of these interchanges is that it allows me to gauge the reaction of the patient to my recommendations. I want patients to understand and feel comfortable with what is happening. There are some who say we cannot afford to do this (i.e., it is not cost-effective). My response is to ask how can we afford not to do this? I would argue that it is more efficient and cost-effective, and I am convinced that this approach actually expedites high-quality patient care.

For a moment, consider patients referred to any specialist for a consultation. If a gastroenterologist detects a polyp during a colonoscopy, does he pull the scope out and dictate: “suspicious abnormality, biopsy should be considered?” or “finding highly suggestive of malignancy—appropriate action should be taken”? Likewise, if a cardiologist detects a significant coronary lesion that can be managed effectively with an angioplasty, does she call the referring physician for “permission” to proceed with an indicated procedure? No, they go ahead and do what needs to be done to take care of the patient. Why do we not consider a patient being sent to a breast imaging radiologist for evaluation in a similar light as a patient being sent to a breast surgeon for evaluation? Surgeons routinely do fine-needle aspirations and excisional biopsies on patients referred to them for clinical findings, even when fatty tissue is imaged mammographically and sonographically. This is acceptable, yet, on a mammogram with pleomorphic, linear casting-type calcifications, or a clinically occult 6-mm spiculated mass, we are expected to say “biopsy should be considered” or “appropriate action should be taken”? Considered by whom and when? Appropriate action to be taken by whom and when?

As a consultant, therefore, I exercise the right to discuss all aspects of a patient's breast-related findings, options for diagnosis (and treatment when appropriate), and, most important, I make specific recommendations and manage patients accordingly. In conjunction with the patient's physician, I make referrals when indicated. Following biopsies, I provide all patients with my business card and cell phone number so they can contact me if they have questions or concerns, and I ask them to return the following business day for the results of the biopsy. During the post biopsy visit, I examine the biopsy site and, most important, discuss the results of the biopsy directly with the patient. I discuss all options with the patient, but I follow this with a specific recommendation for what I think is the next appropriate step. When indicated, and following a discussion with the patient's physician, I make referrals so that the patient is helped and expedited through the system. Our patients are hungry for time, a warm touch, information, guidance, and yes, what we think is indicated.

Considering Your Approach to Patients

Consider how you approach patients. I suggest that proper attire, including a white coat with your name badge clearly visible, is critical in sending a powerful message to patients. Scrubs belong in the operating room or the interventional suite, not when approaching a patient relative to a possible breast cancer diagnosis. Also, although things like jeans and chewing gum may be acceptable in recreational venues, they are not when you are doing an ultrasound or an imaging-guided biopsy on a patient who is watching you like a hawk, waiting for some feedback. Address patients by their title and last name; unless specifically requested by the woman, patients should not be addressed by their first name, and terms of endearment should not be used (this applies to the technologists as well). Introduce yourself to the patient and shake her hand. Before starting the examination, ask her one or two questions relative to her concerns. If the patient has been called back for a potential abnormality on the screening study, and you have done additional mammographic images, tell her what you have seen so far and explain what you would like to do next. If you are doing an ultrasound, let the patient watch the screen, and keep an eye on her. If she is watching the screen as you scan, involve her in the study by educating her on what you are looking at. The ribs can be used to show her what a “tumor” would look like. Try to make sure the patient understands and is comfortable with what you recommend, and never let an angry patient leave your facility. Talk to her and find out what you can do to make things better.

I think it is also important to consider some of the language that permeates our work. Although this sounds trivial, I think it negatively colors our perspective and helps impersonalize and distance us from our patients. Consider terms such as “cases,” “complaints,” “denies,” and “refuses.” Does it not subtly affect us if we view “cases as complainers who deny and refuse”? I see patients, not cases. Why do we choose to view what a patient presents with as a complaint? If you have a legitimate concern about something, does it not bother you even slightly if someone says you are complaining about it? If you have legitimate fears about something and want time to think and consider your options, or if you are afraid, is this refusing? Does it not turn us off when someone says, “She is refusing”? First, it is a patient's right not to want something done, and this should always be respected and never judged negatively. Second, maybe if we worked harder to understand the patient's concerns, we might be able to help her more effectively. Rather than close the door, leave it open so she feels she can walk back through it and you will be there to help her. Try never to judge patients and what they have chosen to do. Comments such as “How could she have let this go?” or “Can you believe that she is saying this just came up?” are not acceptable. Who are we to know what a patient is going through and what her reasons may be for making a decision? Little is accomplished, and I think we stand to lose much, by having a patient feel guilty about what she has chosen to do. Our job is not to judge her, but to help her today and put her in as positive a frame of mind as possible to deal with what she is facing. I urge you to consider and analyze everything that you say and do in approaching patients. Work hard and creatively to spin things in a positive light; rather than viewing what we do as a chore, we should view the trust patients place in us as an incredible privilege unlike few others afforded us in life. We should feel honored that patients have enough confidence in us to share some of their most personal information, fears, and concerns.

You set the tone for your facility, and insisting that everyone in your facility think of patients as presenting with legitimate concerns and having the right to forgo a procedure has a positive effect on how everyone approaches his or her job and our patients.

Communication and Documentation

Lastly, I want to emphasize the need for communication and appropriate documentation. Communicate directly with patients, referring physicians, pathologists, surgeons, and medical oncologists. Demand to speak directly with the physician (“I do not take no for an answer.”). It is critical that referring physicians be kept in the loop, particularly in relation to a breast cancer diagnosis in one of their patients. Relative to pathology results, talk directly with the pathologist signing out a fine-needle aspiration or core biopsy. If possible, visit the pathology lab and review the histology of some of the more interesting cases you may diagnose. These interchanges can be incredibly valuable learning tools, and by working together, decisions can be made as to the adequacy of sampling or any lingering concerns the pathologist may have that might alter your management of the patient. Discuss specimen radiography results directly with the surgeon while the patient is still in the operating room (e.g., are you concerned that a lesion may extend to the margins, or are you concerned that the lesion, or your localization wire, has not been excised?).

I document the date, time, and nature of all communication (if possible with direct quotes) on the patient's history form (not in the breast imaging consultation report). Invest time in teaching your clerical and technical staff how to document encounters with patients properly. Months or years down the road, appropriate documentation can be critical in dealing with unresolved patient issues. Documentation needs to be appropriate, factual, and nonjudgmental. Documentation should not be a reflection of how your employee felt or saw a situation but rather a narrative of what happened. Provide the information accurately and let the reader formulate the impression. These simple steps cost little and yet the rewards in good patient care, goodwill, and public relations can be significant (as intangible as they may seem).

 

Patient 1

Figure 3.1. Screening study, 52-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Spot compression paddle (C) used in my practice for diagnostic evaluations. F Diagram of craniocaudal views (D) illustrating a mass in the medial aspect of the right breast partially obscured by surrounding tissue. The tissue medial to the lesion is fatty, so if the lesion can be moved away from the glandular tissue into the fatty tissue, the margins may be better evaluated. On the diagram of the mediolateral oblique views (E), the lesion is inferior in location. So, rolling inferior tissue medially may move the lesion and surround it with fatty tissue. Inferior tissue is rolled medially, and a spot compression view is done (F). The lesion is now surrounded by fat so that more of the margins can be evaluated. Craniocaudal (G) and mediolateral oblique (H) spot compression views. Ultrasound images (I, J) through separate portions of the lesion at the 7 o'clock position, 4 cm from the nipple in the longitudinal (LON) projection.

 

What do you think, and what would you do next?

A mass is present in the right breast. Before recommending any additional evaluation, you should inquire about prior films. If prior films are available, and this mass is stable, decreasing in size, or has been previously evaluated, no additional intervention may be warranted at this time. Because this patient has no prior films, she is called back for additional evaluation, including spot compression views, correlative physical examination, and sonography.

BI-RADS® category 0: need additional imaging evaluation.

 

Why use a spot compression paddle, and what are the indications for spot compression views?

What is critical to consider when evaluating the adequacy of spot compression views?

Why?

The spot compression paddle enables the application of maximal compression to a small area of the breast so that tissue is spread out and the area of radiographic concern is brought closer to the film, thereby improving resolution and image quality; it can help reach areas that are otherwise difficult to include when the large compression paddle is used. Spot compression views are helpful in several different situations in the diagnostic evaluation of patients. In some patients, spot compression views are used to distinguish a mass or distortion from normal superimposed glandular tissue. If a mass is detected on routine views, spot compression views can help characterize the marginal characteristics of the mass by displacing obscuring superimposed tissue.

In screening and diagnostic situations, spot compression views can be helpful in evaluating the subareolar area, particularly if compression of the anterior aspect of the breast is limited by the thickness of the base of the breast. If there is an area of relatively dense tissue that is underexposed, using the spot compression paddle may be helpful in improving the exposure by effectively decreasing the thickness of the tissue requiring penetration. In evaluating spot compression views, it is important to ensure that the area in question is included on the view; masses can sometimes be “squeezed” (or pulled) out from under the paddle and not imaged. As with routine views, spot compression views need to be well exposed, high in contrast, and free of motion blur.

When are rolled spot compression views used?

Rolled spot compression (i.e., change-of-angle) views are an additional tool available for establishing the existence of a lesion. Most tumors are three-dimensional and maintain their tumorlike shape as tissue is rolled. In contrast, breast tissue and focal areas of parenchymal asymmetry change in size, shape, and overall density as tissue is moved. Rolled spot compression views can also be used to move (roll) lesions away from surrounding tissue so that the marginal characteristics can be demonstrated to better advantage (Fig. 3.1D–F). Lastly, rolled spot compression views can be used to establish the approximate location of a lesion in the breast. If a lesion is located in the medial aspect of the breast, it will move with medial tissue. Similarly, if a lesion is in the lower outer quadrant of the breast, it will move with the tissue in the lower outer quadrant of the breast.

 

 

How would you describe the imaging findings, and what differential would you consider?

The margins of this 1-cm mass are indistinct on the craniocaudal spot compression view and more circumscribed on the mediolateral oblique spot compression view. On ultrasound, this nearly isoechoic oval mass is well circumscribed with posterior acoustic enhancement and associated cystic changes.

Benign diagnostic considerations include fibroadenoma (tubular adenoma, complex fibroadenoma), phyllodes tumor, pseudoangiomatous stromal hyperplasia (PASH), focal fibrosis, papilloma, an inflammatory lesion, or, in certain clinical contexts (recent trauma or surgery), a hematoma. A granular cell tumor is a rare possibility. Malignant considerations include invasive ductal carcinoma not otherwise specified, mucinous carcinoma, papillary carcinoma, or a metastatic lesion. A biopsy is indicated.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

Rather than just consider a biopsy, one is performed, and a complex fibroadenoma is diagnosed. The patient is asked to return in 1 year for her next screening mammogram.

Complex fibroadenomas are defined as fibroadenomas with superimposed fibrocystic changes including cysts > 3 mm in size, sclerosing adenosis, epithelial calcifications, and papillary apocrine changes. They can be anticipated when cystic changes are noted in an otherwise well-circumscribed oval mass such as the one demonstrated here, or when round, punctuate, or amorphous calcifications are identified in an otherwise well-circumscribed mass mammographically (i.e., the punctate and amorphous calcifications reflect the presence of sclerosing adenosis). In some patients, no distinctive imaging features are identified to suggest a complex fibroadenoma. These lesions are benign and do not warrant any additional intervention following core biopsy. Approximately 33% of all fibroadenomas have been reported as complex. When proliferative changes are present in the stroma surrounding a complex fibroadenoma, the risk of breast cancer has been reported to be increased 3.88 times.

Patient 2

Figure 3.2. Diagnostic evaluation, 50-year-old patient who presents describing a “lump” in her left breast. She was told at another imaging facility that her mammogram and ultrasound are normal; she is adamant in wanting an explanation for what she feels. Craniocaudal (A) and mediolateral oblique (B)views, left breast. Spot tangential (C) view, palpable finding left breast. Ultrasound image in the radial (RAD) (D) projection at the site of the palpable finding in the left breast.

What is an appropriate approach to patients who describe a localized concern (a “lump,” focal skin changes, pinpoint tenderness, etc.)?

For patients who are 30 years of age or older and who present with a palpable abnormality (or other localized finding), a metallic BB is placed at the site of the focal finding and a bilateral mammogram is done; a unilateral study of the symptomatic breast is done if the patient has had a mammogram within the last 6 months. A spot tangential view at the site of the focal abnormality is obtained in conjunction with the routine views. In many patients, the tangential view is helpful in either partially or completely outlining the lesion with subcutaneous fat, enabling better visualization and characterization of the lesion. If needed, additional spot compression or spot compression magnification views can be done. Depending on the location of the focal finding, and the appearance of this area on the spot tangential view, correlative physical examination and an ultrasound are usually indicated. The ultrasound may be deferred in patients in whom there is no chance the lesion has been excluded from the field of view and completely fatty tissue, or a benign lesion (oil cyst, dystrophic calcification, etc.), is imaged corresponding to the area of concern. Aspiration or core biopsy may be indicated, depending on the clinical and imaging features of the lesion.

How would you describe the findings on the routine views of this patient, and with what degree of certainty can you make any recommendations?

Although there is a small island of tissue superimposed on the left pectoral muscle in close proximity to the metallic BB, no definite abnormality is apparent on the routine views of the left breast. At this point, we have an inadequate amount of information to make any justifiable recommendations. We need to review the spot tangential view of the “lump,” talk to the patient, undertake correlative physical examination, and do an ultrasound.

 

 

What do you think now?

A 7-mm spiculated mass associated with punctate, low-density calcifications is imaged on the spot tangential view corresponding to the palpable finding. A discrete, hard mass is palpated at the site indicated by the patient in the left breast. She has not had a prior biopsy or trauma to this site, and no tenderness is elicited on palpation. On ultrasound, a small hypoechoic mass with disruption of the Cooper ligament is identified at the 12 o'clock position, 8 cm from the left nipple, corresponding to the palpable abnormality. Although the finding is subtle on ultrasound, with careful and meticulous technique it is discernable and reproducibly imaged as the palpable area is scanned. In positioning patients for the ultrasound study, I try to thin the area of the breast being evaluated as much as possible. In evaluating lateral lesions, the patient is placed in an oblique position with a wedge under the ipsilateral arm, and for medial lesions she is supine. If the patient says she feels the “lump” more when she is upright, I will palpate and scan the area with her sitting as well as lying down. During the ultrasound study, I hold the transducer with my right hand and I place the pads of my left index, ring, and middle fingers at the leading edge of the transducer so that I am palpating the tissue as I rotate and move the transducer with my right hand. I apply varying amounts of compression as I manipulate the transducer directly over the area of clinical or mammographic concern.

What is your differential diagnosis, and what recommendation should you make to the patient?

Differential considerations for the findings include invasive ductal carcinoma not otherwise specified (NOS), tubular carcinoma, and invasive lobular carcinoma. Benign considerations include fat necrosis (posttrauma or postsurgery), sclerosing adenosis, papilloma, focal fibrosis, a complex sclerosing lesion, and inflammatory changes (mastitis). Other rare benign causes include granular cell tumor or an extra-abdominal desmoid.

A biopsy is indicated.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

An ultrasound-guided biopsy is done, and an invasive mammary carcinoma with features suggestive of tubular carcinoma is described on the core samples. A tubular carcinoma is confirmed following the lumpectomy. Sampled lymph nodes are normal (pT1b, pN0, pMX; Stage I).

In considering tubular carcinoma, what associated lesions may be seen and what should you look for mammographically?

The reported incidence of tubular carcinomas varies depending on detection method, tumor size, and the definition used to classify these tumors. Pure tubular carcinomas probably represent 1% to 2% of all breast cancers. Tubular carcinomas are usually detected mammographically as a small spiculated mass; less commonly, patients present with a palpable mass. Associated round, punctate, and amorphous calcifications may be seen, reflecting the presence of low-nuclear-grade ductal carcinoma in situ (solid, cribriform, and micropapillary), in an average of 65% of patients. Satellite lesions may also be seen, because these lesions may be multifocal or multicentric in 10% to 20% (reportedly as high as 56% in one small series) of patients. Lobular neoplasia (lobular carcinoma in situ), contralateral invasive ductal carcinomas NOS, and a history of breast cancer in a first-degree relative have been reported in as many as 15% (range 0.7% to 40%), 38%, and 40% of patients diagnosed with tubular carcinoma, respectively.

What distinguishes the glands seen in tubular carcinomas from normal glands?

Histologically, what are the differential considerations for this lesion?

Histologically, these lesions are characterized by the presence of oval and round, open tubules some with angulation. The glands in tubular carcinomas are lined by a single epithelial cell layer and, in contrast to normal glands, lack myoepithelial cells. Desmoplastic changes are noted in the surrounding stroma and probably explain the imaging features of these lesions (i.e., spiculation). Tubular carcinomas may be difficult to distinguish from radial scars/complex sclerosing lesions (in some patients, tubular carcinomas arise in radial scars/complex sclerosing lesions), sclerosing adenosis, and microglandular adenosis. Special immunohistochemical stains are sometimes needed to assess the presence of myoepithelial cells. These tumors are often diploid, estrogen- and progesterone-receptor-positive, and only rarely over-express HER-2 neu.

Why is listening, correlating physical and imaging findings, and establishing rapport with your patients so important?

Complete, thoughtful evaluations are indicated for all patients, but particularly those presenting with focal signs and symptoms. Radiologists as a group are the most commonly sued physicians, and delays in the diagnosis of breast cancer are the most common causes of malpractice claims filed. Interestingly, the suits are not usually (at least not yet) for missing subtle mammographic findings, but rather for clinically apparent findings the patient feels were ignored. I urge you to establish a good rapport with your patients, listen to their concerns, and make every effort possible to help them. Not only is this good medicine, it makes for a rewarding and fulfilling practice opportunity. You do not want patients leaving your facility angry and feeling that their concerns were ignored or not adequately evaluated. Do not short-circuit appropriate and logical mammographic workups. Make sure that what is seen mammographically correlates with the clinical findings. In making sure that what is seen on ultrasound correlates with the mammographic findings you are evaluating, determine the expected clock position of the lesion and its approximate distance from the nipplebefore going into the ultrasound room; this location should be the starting point for the ultrasound study.

While examining the patient and correlating clinical, mammographic, and ultrasound findings, I obtain a more detailed history from the patient. This is also a good time to convey to the patient what I am doing on her behalf, to discuss recommendations, determine if the patient is comfortable with my recommendations, and answer her questions. Although some consider it inefficient for a radiologist to do the ultrasound studies personally, I argue that it is more efficient and it makes for good patient care.

During the real-time scan, and before taking any images, I determine if there is an identifiable abnormality by examining the patient as I rotate the transducer and apply varying amounts of compression over the area of concern. The 360-degree rotation of the transducer is critical in excluding pseudolesions created by areas of fatty lobulation, which in one plane may look round or oval but elongate and fuse with surrounding tissue as you rotate the transducer. A real mass maintains a round or oval shape as you rotate the transducer directly over it. Applying variable amounts of compression over an area can help eliminate critical angle shadowing that may limit the evaluation of deeper tissue. If I determine that a lesion is present, I take orthogonal images (with and without measurements) that demonstrate representative features of the lesion. In some women, this may require radial and antiradial projections, whereas in others, transverse and longitudinal (i.e., sagittal) orientations show the lesion and its characteristics to better advantage. I use the images taken to support my impression and justify my recommendations. I take no images of normal tissue. In annotating the images, the breast being scanned is indicated, as is the clock position of the lesion and its distance in centimeters from the nipple.

 

 

Patient 3

Figure 3.3. Diagnostic evaluation, 80-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B) views. Spot tangential (C) view taken of the palpable finding (metallic BB on palpable finding). Ultrasound images (D, E) of the palpable mass at the inframammary fold of the right breast in an antiradial (ARAD) projection.

 

What is an acceptable approach to patients who present with focal findings?

In evaluating the adequacy of spot tangential views, what should you consider?

In patients who are 30 years of age or older and who present with a palpable abnormality (or other localized finding), a metallic BB is placed at the site of concern, and routine views are done bilaterally unless the patient has had a mammogram in the preceding 6 months, in which case a unilateral mammogram of the symptomatic breast is done. In addition, a spot tangential view of the focal finding is done. In many patients, the tangential view is helpful in either partially or completely outlining the lesion, with subcutaneous fat facilitating characterization. Depending on the location of the focal finding, and the appearance of this area on the spot tangential view, correlative physical examination and an ultrasound are usually indicated. Ultrasound may be deferred in patients in whom there is no chance the lesion has been excluded from the tangential view and completely fatty tissue, or a benign lesion, is imaged corresponding to the palpable abnormality.

In this patient, do you see the metallic BB on the routine views of the right breast? Why not? In this patient, the palpable finding is deep in the breast, just above the inframammary fold. The metallic BB was placed on the “lump” but has been excluded from the field of view. The metallic BB is seen on the spot tangential view, and predominantly fatty tissue is imaged on the spot tangential view. In this patient, the possibility that the lesion has been excluded from the images is a real concern. As with all spot compression views, you need to consider the possibility that the lesion has been squeezed out of the field of view or, because of its location, is not included on the images. Correlative physical examination in this patient confirms the presence of a palpable mass fixed at the inframammary fold. Also noted are arterial calcifications in the left breast and coarse, dense, benign-type calcifications anteriorly in the right breast.

 

How would you describe the ultrasound findings, and what is indicated in this patient?

A round, 1.2-cm hypoechoic mass with partially indistinct margins and associated posterior acoustic enhancement is imaged corresponding to the palpable finding at the 6 o'clock position, posteriorly (Z3) in the right breast. The lesion is just below the skin and snuggled in close proximity to the ribs (R). An invasive ductal carcinoma not otherwise specified, mucinous carcinoma, papillary carcinoma, or a metastatic lesion are the primary considerations in an 80-year-old patient presenting with these findings.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

A mucinous carcinoma is diagnosed on the ultrasound core biopsy. A 1.3-cm mucinous carcinoma with associated intermediate-grade ductal carcinoma in situ is confirmed on the lumpectomy specimen. The sentinel lymph node is negative for metastatic disease (pT1c, pN0(sn) (i—), pMX; Stage I).

What are some of the tools available in evaluating lesions possibly excluded from the routine views?

Lesions close to the chest wall (far superior, inferior, lateral, or medial) and lesions high in the axilla may not be included on routine or spot compression views of the breast. Anytime you suspect that a lesion is potentially excluded from the mammographic images, or there are potential factors limiting compression, correlative physical examination and ultrasound are wonderful adjunctive tools. Also, capitalize on basic concepts such as the use of various projections to position tissue as close to the film as possible. If you think a lesion is medial in location, consider a 90-degree lateromedial (LM) spot compression so that medial tissue is placed up against the film; this minimizes the possibility of exclusion because medial tissue is up against the film, and it improves resolution by placing the area of concern closest to the film. Likewise, if you think a lesion is high up in the breast, have the technologist do a from-below (FB) view such that superior tissue is now closest to the film. If you suspect a lesion is at, or just below, the inframammary fold (IMF), tell the technologist not to lift the breast as she positions for the craniocaudal (CC) view. She should place the film holder at the neutral position for the IMF, because as the breast is lifted at the IMF for the routine CC view, the mass may be able to slip out and not be included on the image. Remember, the use of the spot compression paddle usually makes it easier to include more posterior, superior, or axillary tissue in the field of view. In evaluating potential lesions in the axillary tail, an axillary view can be useful.

 

Patient 4

Figure 3.4. Diagnostic evaluation, 62-year-old woman called back for calcifications detected in the right breast on her screening study. Double spot compression magnification views (A–C) of calcifications, right breast. Setup for double spot compression magnification views (D). A Lexan® top magnification stand is used to minimize the amount of radiation absorbed by the stand itself. The built-in spot compression is combined with a spot compression paddle to obtain double spot compression of the tissue being evaluated. By reducing the amount of radiation absorbed by the magnification stand, maximizing compression by applying from above and below the lesion, and making adjustments in kilovoltage, well-exposed, high-contrast magnification views with no motion artifact can be obtained routinely.

What is an appropriate evaluation of patients with screening-detected calcifications that cannot be classified as benign on the routine views?

The next step should be magnification views. Specifically, our protocol uses double spot compression magnification views in orthogonal projections to evaluate women with indeterminate calcifications detected on routine mammographic views.

 

How is magnification obtained, and what are the resulting effects?

Magnification technique is accomplished by increasing the distance between the breast (i.e., object) and film. The resulting air gap helps to eliminate scatter radiation, so a grid is not needed for magnification views. Compared with the 0.3-mm focal spot used for routine (nonmagnified) mammographic views, a 0.1-mm focal spot is used for magnification views. The small focal spot is needed to minimize the penumbra effect that results as you increase the breast (object)-to-film distance. The use of the small focal spot, however, results in increased exposure times, so motion becomes a significant issue that may limit the usefulness of magnification views.

What can be done to minimize the likelihood of motion blur on magnification views?

Optimizing the system to obtain an adequate exposure in a short period of time is critical for routinely obtaining high-quality magnification views. An appropriate selection of voltage, a magnification stand that minimizes the amount of radiation absorbed, optimal focal compression, and working with the patient on controlling her breathing are simple steps that can improve overall image quality significantly.

As a general rule, the voltage used for exposure on magnification views is increased by 2 kV over that used for the routine, nonmagnified views. We do all of our magnification views using a Lexan®-top magnification stand (MammoSpot®, American Mammographics, Chattanooga, TN). Compared to standard carbon-top magnification stands, those made of Lexan® absorb less radiation, so exposure times can be decreased by as much as 40%.

Optimal compression is also critical for obtaining high-quality magnification views. This is why we advocate the use of double spot compression. The magnification stand has a built-in spot compression, which, when combined with the spot compression paddle, enables maximal compression of the tissue being evaluated (i.e., double spot compression). The technologist is also encouraged to work with the patient on breath holding (i.e., the patient should stop breathing when requested rather than taking a deep breath in) to minimize the likelihood of motion.

If you have determined that there is a need for magnification views, don't settle for suboptimal quality and hide behind disclaimers. If the magnification views are not optimal, step back and review what the technologist is doing. Does the voltage need to be increased further (accepting that as you increase voltage, contrast is decreased)? Is the correct focal spot being used? Can compression be increased? Can you work with the patient to improve breath holding? High-contrast, well-exposed, artifact-free magnification views are critical for assessing the morphology and extent of calcifications that may reflect the presence of ductal carcinoma in situ. Recognize that the ability to detect and characterize calcifications and small masses is significantly compromised (and may be eliminated) on images with blurring.

How would you describe these calcifications in this patient, and what is your differential diagnosis?

What is indicated?

Round, punctate, and linear calcifications demonstrating linear orientation are confirmed on the double spot compression magnification views. The differential is limited but includes fibrocystic changes including columnar alteration with prominent apical snouts (CAPPS), ductal hyperplasia and atypical ductal hyperplasia, fibrosis, and ductal carcinoma in situ. In the absence of any other change related to trauma (e.g., mixed-density mass, oil cyst), or a specific history of trauma or surgery to the site of the calcifications, these calcifications are unlikely to represent an early stage of fat necrosis. Given the linear orientation of the calcifications, biopsy is indicated.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

Ductal carcinoma in situ is reported on the stereotactically guided biopsy and confirmed on the lumpectomy [Tis(DCIS), pNX, pMX; Stage 0].

 

Patient 5

Figure 3.5. Screening study, 65-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) spot compression view confirms the presence of a mass with indistinct and spiculated margins in the right breast. On a 90-degree lateromedial (LM) view (not shown), the lesion moves up with respect to its position on the mediolateral oblique view, consistent with a medial location for the lesion. Further review of the craniocaudal (D) views demonstrates a possible mass at the edge of the right craniocaudal view medially (box). Spot compression (E) view of the medial aspect of the right breast in the craniocaudal projection demonstrates a mass with indistinct and spiculated margins. Some punctate calcifications may be present. Pectoral muscle is now also seen at the edge of the spot compression view posteriorly. The spot compression paddle often enables visualization of otherwise hard-to-reach areas such as the upper inner quadrants posteriorly Ultrasound images, upper inner quadrant, right breast, in radial (RAD) (F)and antiradial (ARAD) (G) projections. Ultrasound image (H) in the antiradial (ARAD) projection at the 1 o'clock position of the right breast, posteriorly, demonstrating gentle mass effect on the deep pectoral fascia (arrowheads).

What do you think, and what is your recommendation at this point?

Arterial calcifications are present bilaterally. A possible mass is present on the right mediolateral oblique (MLO) view superimposed on the pectoral muscle inferiorly. This should be distinguished from several well-circumscribed, mixed-density masses (i.e., lymph nodes) superimposed on the pectoral muscles, bilaterally. No definite corresponding abnormality is apparent on the right craniocaudal (CC) view. Comparison with prior studies is the starting point. If no prior films are available, or if this potential mass represents a change, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

How would you approach the diagnostic evaluation of this patient?

Be specific in describing the steps you would follow

When a potential abnormality is seen in only one of the two standard views, we start by determining if the finding is real in the view in which it is initially perceived. In this patient, a spot compression view in the MLO projection is obtained. If no abnormality persists on the spot compression view, no additional views are done; if a question remains, rolled spot compression views can be done. In this patient, a 1.2-cm mass with indistinct margins is confirmed on the MLO spot compression view (Fig. 3.5C). We must now establish the location of this abnormality in the CC projection using a logical approach. We make no assumptions as to the lateral, central, or medial location of the lesion on the CC view. Rather, a 90-degree lateral view (usually a lateromedial view) is done to determine how this lesion moves with respect to its location on the MLO view. If the lesion moves up, it is located medially and a spot cleavage view is done; if the lesion moves down, it is located laterally such that a spot craniocaudal view exaggerated laterally is done; and if it does not move significantly, the lesion is central in location and a spot compression view directly behind the nipple is obtained. In this patient the lesion moves up (image not shown), consistent with a medial location. Upon further review of the C view, a density is partially noted on the craniocaudal view at the edge of the film medially (box, Fig. 3.5D). A follow-up image with the spot compression paddle enables visualization of more tissue so that the lesion is imaged in its entirety (Fig. 3.5E) in the CC projection.

How would you describe the ultrasound findings?

An irregular, 1.2-cm mass with indistinct, angular, and spiculated margins is imaged at the 1 o'clock position posteriorly (Z3), abutting the deep pectoral fascia (arrowheads, Fig. 3.5H). Straightening, thickening, and disruption of Cooper ligaments are noted. This mass corresponds to the mass seen mammographically.

 

 

What is your differential diagnosis, and what recommendation do you make to the patient?

Differential considerations include invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, or lymphoma. Rarely, ductal carcinoma in situ can present as a mass, asymmetric density, or distortion in the absence of microcalcifications. Benign considerations include an inflammatory process or posttraumatic changes, focal fibrosis, a papilloma, sclerosing adenosis, pseudoangiomatous stromal hyperplasia, granular cell tumor, or an extra-abdominal desmoid. Given the imaging features of this lesion, a biopsy is indicated.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

An ultrasound-guided biopsy is done. An invasive ductal carcinoma with associated ductal carcinoma in situ is diagnosed on the core biopsy.

A 1.5-cm, grade I invasive mammary carcinoma, with apocrine differentiation and an associated extensive, intermediate-grade (solid, cribriform patterns) ductal carcinoma in situ is reported on the lumpectomy specimen. Malignant cells are reported on a touch imprint of the sentinel lymph node done intraoperatively. Twenty additional nodes removed at the time of the lumpectomy are negative for metastatic disease (pT1c, pN1a, pMX; Stage IIA).

What are touch imprints, and how are they used at the time of the lumpectomy and sentinel lymph node biopsy?

Touch imprints of the excised sentinel lymph node(s) are commonly done intraoperatively at the time of the lumpectomy and sentinel lymph node biopsy. The lymph node is sectioned and the cut edge is blotted on slides. The cytologic material on the slides is fixed, stained, and reviewed by the pathologist. If malignant cells are identified on the touch imprints, a complete axillary lymph node dissection is done at the time of the lumpectomy. However, metastatic disease is not excluded if the imprints are reported as benign; false-negative touch imprints are commonly associated with invasive lobular carcinoma. In patients in whom the imprint is negative but metastatic disease is identified in the permanent, hematoxylin and eosin–stained sections of the sentinel lymph node, a full axillary dissection is usually undertaken as a second operative procedure.

How is an extensive intraductal component defined, and what is its significance?

An extensive intraductal component (EIC) is described when an invasive ductal carcinoma has a prominent intraductal component within it or intraductal carcinoma is present in sections of otherwise normal adjacent tissue. This term also applies to lesions that are predominantly intraductal but have foci of invasion. An EIC may indicate the presence of residual disease 2 cm beyond the primary lesion in as many as 30% of patients and is associated with an increased incidence of local recurrence following breast-conserving surgery and radiation therapy. Patients with tumors characterized by an extensive intraductal component may benefit from a wider resection. Tumors with EIC are reportedly more common in younger women.

 

Patient 6

Figure 3.6. Diagnostic evaluation, 49-year-old patient presenting with two “lumps” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views, right breast; metallic BBs used to mark “lumps.” Spot compression (C) view (orthogonal view not shown), right breast. Ultrasound image (D) of anterior mass, antiradial (ARAD) projection, and ultrasound image (E) of posterior mass, ARAD projection. Frontal diagram (F) of the right breast, illustrating the course of the x-ray beam for craniocaudal, lateral, and mediolateral oblique views. On craniocaudal views, the location of lesions is anatomic: those projecting laterally or medially are in the lateral and medial aspects of the breast, respectively. Similarly, on true lateral views, lesions projecting superiorly or inferiorly are located in the upper or lower quadrants, respectively. On mediolateral oblique views, however, some of the tissue that projects above the level of the nipple is inferior to the nipple (G), and some tissue projecting below the level of the nipple is superior to the nipple (H). Frontal diagram (F) of the right breast, illustrating the course of the x-ray beam for craniocaudal, lateral, and mediolateral oblique views. On craniocaudal views, the location of lesions is anatomic: those projecting laterally or medially are in the lateral and medial aspects of the breast, respectively. Similarly, on true lateral views, lesions projecting superiorly or inferiorly are located in the upper or lower quadrants, respectively. On mediolateral oblique views, however, some of the tissue that projects above the level of the nipple is inferior to the nipple (G), and some tissue projecting below the level of the nipple is superior to the nipple (H). Consequently, on a mediolateral oblique (I) view, some lesions projecting above the level of the nipple (gray triangle, “A”) are anatomically in the lower outer quadrant, and some lesions projecting below the level of the nipple (black triangle,! “B”) are anatomically in the upper inner quadrant of the right breast. Diagrams illustrating (Eklund, p.c.) how to determine the approximate clock position of the lesions based on the craniocaudal and mediolateral oblique views of the current patient. On the mediolateral oblique view (J), determine the location of the lesion relative to the posterior nipple line (i.e., how far above or below the posterior nipple line the lesion is located). The location of the lesions relative to the posterior nipple line is transposed to the frontal diagram (K). Now use the craniocaudal view (L) to determine whether the lesion is medial, lateral, or central in location.

How would you describe the two masses?

What would you do next?

Two masses are present in the right breast, corresponding to the “lumps” described by the patient. The margins of the anterior mass are well circumscribed on the spot compression views (only one shown). In comparison, the margins of the larger, posterior mass are not as sharp and, for a portion of the mass, are indistinct. In entertaining a differential, you need to consider that these may reflect the same or, possibly, different processes. Cyst(s), fibroadenoma(s), tubular adenoma(s), phyllodes tumor(s) papilloma(s), pseudoangiomatous stromal hyperplasia (PASH), focal fibrosis, abscess(es), posttraumatic or postsurgical fluid collections, invasive ductal carcinoma(s), medullary carcinoma(s), mucinous carcinoma(s), papillary carcinoma(s), and metastatic lesion(s) are included in the differential. Correlative physical examination and an ultrasound are indicated for further characterization of these lesions.

 

Although these masses are palpable, based on their location on the mammogram, at what clock position do you expect to find these lesions?

Be specific

The anterior mass is located at the 12:30 o'clock position, 4 cm from the right nipple. It is a 1.2-cm oval, well-circumscribed mass characterized by areas of enhancement and shadowing. Although projecting below the level of the nipple on the mediolateral oblique view, the posterior mass is located in the upper inner quadrant of the right breast at the 2 o'clock position, 8 cm from the nipple, and measures 3 cm. It is vertically oriented, markedly hypoechoic, with indistinct margins and some spiculation. Some posterior acoustic enhancement is present. The imaging features of the anterior mass suggest a benign process and those of the posterior mass suggest a malignancy. Biopsies are recommended for both lesions.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

A complex fibroadenoma is reported histologically for the anterior mass. An invasive mammary carcinoma is diagnosed for the posterior lesion. A 4-cm, metaplastic carcinoma with no heterologous elements and a normal sentinel lymph node biopsy are reported following surgery [pT2, pN0(sn) (i—), pMX, Stage IIB].

As you progress from the mammogram to doing the ultrasound, consider carefully and focus your attention on the anatomic location of the lesion being evaluated. Obviously, it is critically important to assure that the lesion seen on the mammogram correlates with what you find on the ultrasound study. To this end, review the mammographic images before scanning the patient, so that when you walk in to evaluate the patient you have the expected clock position and approximate distance from the nipple for the lesion being evaluated as your starting point.

On craniocaudal and 90-degree lateral views (LM and ML), the location of a lesion is anatomic with respect to the nipple. Medial, lateral, and central findings on craniocaudal views are located medially, laterally, and centrally (i.e., behind the nipple) in the breast. Superior and inferior findings with respect to the nipple are located in the upper and lower quadrants, respectively, on the 90-degree lateral view (Fig. 3.6F). On mediolateral oblique views, however, it is important to recognize that some lesions projecting below the level of the nipple are in an upper quadrant of the breast and some that project above the level of the nipple are in a lower quadrant (Fig. 3.6G–I).

Based on the CC and MLO views, the anatomic location of the lesion needs to be determined, to assure accurate correlation between what is seen on the mammogram and anything that may be found on the ultrasound study. The information on the CC and MLO views (taken with the patient upright and tissue pulled out away from the body) needs to be transposed to a patient who is now supine, or in a slight oblique position, for the ultrasound study. Approximating the clock position of a lesion in the breast can be facilitated (and learned) by using frontal diagrams of the breast, in conjunction with the location of the lesion on the CC and MLO views.

On a frontal diagram of the breast, the posterior nipple line (PNL) is drawn as extending from the upper inner quadrant to the lower outer quadrant of the breast, transecting the nipple (this defines the course of the x-ray beam when an MLO view is done). Next, reference the location of the lesion on the MLO view (Fig. 3.6J) with respect to the PNL. The lesions are how far above or below the posterior nipple line on the MLO view? The lines describing the location of the lesion, with respect to the PNL on the MLO view, are drawn on the frontal diagram (Fig. 3.6K). Using the location of the lesions on the CC view (Fig. 3.6L), you can now narrow down the clock location of the lesion along the course of the lines drawn on the frontal view (Fig. 3.6J). You can now walk into the ultrasound room and place the transducer at the expected clock position for each lesion and find them easily with the assurance that what you are imaging on ultrasound correlates with what is being seen mammographically.

 

 

Patient 7

Figure 3.7. Diagnostic evaluation, 82-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views photographically coned to the area of concern in the left breast. Metallic BB (arrows) indicate the location of the palpable mass. Spot tangential (C) view of palpable finding in the lower inner quadrant of the left breast. Ultrasound image (D) of the palpable finding in the lower inner quadrant of the left breast, in the antiradial (ARAD) projection.

At this point, what can you say and with what degree of certainty?

What else would you tell the technologist to do?

Scattered and some clustered round and punctate calcifications, as well as more dense, coarse, and some lucent-centered calcifications, are present. However, no definite abnormality is apparent on the craniocaudal and mediolateral oblique views that corresponds to the site of concern to the patient. At this point, we have insufficient information to say anything definitive. A spot tangential view of the palpable finding may be helpful; if it is not, correlative physical examination and an ultrasound are indicated.

When women who are over the age of 30 years present with a “lump” or other focal symptom (focal pain, skin change etc.), a metallic BB is placed at the site of focal concern. This is followed by craniocaudal and mediolateral oblique views, bilaterally, as well as a spot tangential view of the focal abnormality (a unilateral study of the symptomatic breast is done if the patient has had a mammogram within the last 6 months). Based on these initial images, additional spot compression or double spot compression magnification views may be done. Depending on the location of the focal finding, and the appearance of this area on the spot tangential view, correlative physical examination and an ultrasound are usually indicated.

 

How helpful is the tangential view of this patient?

At this point, what can you say and with what degree of certainty?

What BI-RADS® assessment category would you assign?

For this patient, the tangential view is helpful. A spiculated mass is now readily apparent, corresponding to the palpable finding. Unless the patient has had trauma, or surgery localized specifically to this area, or there are symptoms related to an inflammatory process, a biopsy is indicated and the likelihood of malignancy in an 82-year-old patient is high. The patient has no history of breast-related surgery or trauma.

Is an ultrasound indicated in this patient for the purposes of evaluating the lesion?

If not, why do an ultrasound?

Given a spiculated mass and no history of surgery or trauma, or symptoms related to an inflammatory process, corresponding to the site of concern to the patient, a biopsy is indicated regardless of the ultrasound findings. An ultrasound is done to determine if the lesion can be imaged so that the biopsy can be done expeditiously using ultrasound guidance. Ultrasound-guided core biopsies are better tolerated by patients, particularly elderly patients, because the patient is supine as opposed to prone (with her neck turned all the way over to one side) on the dedicated stereotactic table, or sitting, if an add-on device is used. No breast compression or radiation is required when the biopsy is done using ultrasound guidance. Additionally, because orthogonal images of the needle can be obtained following firing of the needle during the biopsy, it is easier to verify that the needle has gone through the mass. This is in contrast to the unidimensional postfire images of needle positioning during a stereotactically guided biopsy.

How would you describe the ultrasound findings?

What is your leading diagnosis, and what is your recommendation?

On physical examination, a discrete, hard mass is palpated in the lower inner quadrant of the left breast. There are no findings to suggest an ongoing inflammatory process (e.g., no erythema, tenderness, or warmth over the palpable finding). An irregular, 1.5-cm hypoechoic mass with indistinct and angular margins and shadowing is imaged on ultrasound at the 8 o'clock position, 6 cm from the left nipple, corresponding to the palpable finding. The clinical, mammographic, and ultrasound findings are highly suggestive of a malignancy. Differential considerations include invasive ductal carcinoma not otherwise specified (NOS), tubular carcinoma, or invasive lobular carcinoma. Although it is uncommon, ductal carcinoma in situ can present as a mass, asymmetry density, or distortion in the absence of microcalcifications. If there were a history of trauma or surgery localized specifically to this spot, this could represent an area of fat necrosis. Rarely, in the appropriate clinical setting, this could represent an inflammatory process.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

Rather than just consider a biopsy, one is done using ultrasound guidance. An invasive ductal carcinoma (NOS) is diagnosed on the core biopsy. A 1.5-cm grade II invasive ductal carcinoma NOS is confirmed on the lumpectomy specimen. No metastatic disease is diagnosed on the sentinel lymph node [pT1c, pN0(sn) (i—), pMX; Stage I].

What are the clinical and imaging features related to invasive ductal carcinoma NOS?

Invasive ductal carcinoma NOS is the most common breast malignancy diagnosed in approximately 65% of all patients with breast cancer. Depending on tumor size, location, and breast size, the lesion may be palpable, or skin thickening or dimpling may be noted clinically. Subareolar lesions may be associated with nipple retraction, inversion, or displacement. A spiculated mass is the most common mammographic finding in patients with invasive ductal carcinoma NOS. Associated pleomorphic calcifications, reflecting the presence of ductal carcinoma in situ, are sometimes seen in the mass or extending away from it for variable distances. If there are associated calcifications, it is important to characterize them and describe their extent.

A round or oval mass with obscured, indistinct, or ill-defined margins is a less common mammographic presentation for invasive ductal carcinoma NOS. On ultrasound, these lesions are round or oval, solid, hypoechoic masses with well-circumscribed or partially indistinct margins; many have posterior acoustic enhancement. Some may be markedly hypoechoic. Alternatively, a complex cystic mass may be seen. When they present as a round or oval mass, invasive ductal carcinomas NOS are often rapidly growing, poorly differentiated lesions, particularly if the lesion is solid and associated with posterior acoustic enhancement on ultrasound. In lesions with cystic changes on ultrasound, necrosis is commonly present histologically.

What are the more common subtypes of invasive ductal carcinomas, and what are their clinical and imaging features?

Tubular, medullary, mucinous, and papillary carcinomas are some of the more common subtypes of invasive ductal carcinoma. Of these four subtypes, tubular carcinoma is the only one that presents as a small spiculated mass; in some patients, multiple small spiculated masses may be identified. Medullary carcinoma usually presents in premenopausal woman as a round or oval mass and is characterized by rapid growth; many of these patients present with interval cancers (within a year of a normal screening mammogram). Medullary carcinoma can be markedly hypoechoic on ultrasound (simulating a cyst). Mucinous and papillary carcinomas usually present as round or oval masses in older, postmenopausal women and are usually characterized by slower growth patterns. Ultrasound can be helpful in distinguishing among some of the mucinous and papillary carcinomas. Mucinous lesions are commonly iso- to slightly hypo- or hyperechoic and may have posterior acoustic enhancement. Papillary carcinomas, particularly those arising in the subareolar area, are often complex cystic masses with posterior acoustic enhancement.

 

Patient 8

Figure 3.8. Screening study, 67-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) views with a box helping to focus attention on the lower thirds of breasts. Craniocaudal (D) views with a box to help focus attention on the medial quadrants of the breasts. Spot compression views, craniocaudal (E) and mediolateral oblique (F) projections. Ultrasound images in the radial (RAD) (G) and antiradial (ARAD) (H)projections at the 3 o'clock position, 3 cm from the right nipple. On the right mediolateral oblique (I) view, the lesion is “X” cm below the posterior nipple line (PNL). On the craniocaudal (J) view, the lesion is medial in location. On the frontal diagram of the right breast (K), a line is drawn “X” cm below the PNL so that, in combination with the location of the lesion on the CC view, you can approximate the location of the lesion at the 3 o'clock position.

Is this a normal screening mammogram, or do you perceive a potential abnormality?

Remember to focus your attention by splitting the images into thirds. On the oblique views, focus your attention on the lower third of the breasts (Fig. 3.8C); now do you see something? Do you see a corresponding asymmetric area, medially in the right breast (Fig. 3.8D), on the craniocaudal view? What would you do next?

BI-RADS® category 0: need additional imaging evaluation. Spot compression views, correlative physical examination and an ultrasound are indicated.

 

 

What do you think now?

A 1-cm, irregular, spiculated mass is confirmed on the spot compression views. A small focus of pleomorphic calcifications is also noted in the tissue adjacent to the mass. In the absence of symptoms suggesting an ongoing infection, or a history of surgery or trauma localized to this specific area, this finding requires biopsy. Although a biopsy is indicated on the mammographic findings alone, an ultrasound is done because if the lesion is identified on ultrasound, a core biopsy can be done easily and expeditiously using ultrasound guidance.

 

Is this the correct location for the mammographic finding?

What is your differential?

A hypoechoic mass with irregular, spiculated, and angular margins, associated shadowing, and disruption of Cooper ligaments is imaged, corresponding to the area of mammographic concern. Although the lesion projects below the level of the nipple on the mediolateral oblique view, the lesion imaged on ultrasound corresponds to the lesion seen mammographically (Fig. 3.8I–K). Differential considerations include fat necrosis if the patient has had surgery or trauma localized specifically to this area, papilloma, sclerosing adenosis, mastitis, granular cell tumor (rare), extra-abdominal desmoid (rare), invasive ductal carcinoma not otherwise specified, tubular carcinoma, or invasive lobular carcinoma. Rarely, ductal carcinoma in situ can present as a mass, asymmetrical density, or distortion in the absence of microcalcifications. Given the imaging features of this lesion (i.e., a spiculated mass with adjacent calcifications), the working diagnosis for this patient is an invasive ductal carcinoma with associated ductal carcinoma in situ.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

 

An ultrasound-guided biopsy is undertaken, and an invasive ductal carcinoma is reported on the cores. A 0.9-cm, grade I invasive ductal carcinoma with associated cribriform-type ductal carcinoma in situ is diagnosed on the lumpectomy specimen. Two excised sentinel lymph nodes are normal [pT1b, pN0(sn) (i—), pMX; Stage I].

What is the basic concept underlying sentinel lymph node biopsies?

Traditionally, most patients diagnosed with invasive breast cancer had axillary lymph node dissections (ALND) for staging and as part of the surgical treatment of their breast cancer (i.e., local-regional control). More recently, sentinel lymph node biopsy (SLNB) has been suggested as an alternative to assess the status of the axilla and is being used increasingly to replace ALND for most women diagnosed with breast cancer. It is postulated that the sentinel lymph node(s) is the first node draining a tumor, and that the histologic status of this lymph node accurately predict the status of the regional (axilla) lymphatic basin.

Given some of the complications associated with ALND, sentinel lymph node biopsies are now used routinely at many institutions as an alternative to ALND for patients with clinically normal axillary exams. Axillary lymph node dissections are undertaken if the sentinel lymph node(s) is not identified, metastatic disease is known to be present following fine needle aspiration (FNA), or core biopsy, of ultrasound-detected, abnormal lymph nodes in the axilla, or when abnormal lymph nodes are suspected clinically. Axillary lymph node dissection may also be performed in patients with metastatic disease in the sentinel lymph node(s), to establish the number of axillary lymph nodes involved by tumor.

The methods used to identify the sentinel lymph node are still evolving, undergoing investigation, and vary among institutions. In general, a radioisotope is used alone or in combination with a blue dye (e.g., lymphazurin blue) for lymphatic mapping; these are injected in a peritumoral, intradermal, periareolar, or intratumoral location. The volume used and the interval between injection and surgery vary. If a radioisotope is used, preoperative lymphoscintigraphy can be used to assess the pattern of lymphatic drainage before surgery; this also provides information regarding the internal mammary lymph nodes. Alternatively, a gamma probe is used intraoperatively to identify the “hot spots” in the axillary tail without preoperative lymphoscintigraphy. It has been suggested by many researchers that optimal results are obtained when blue dye and isotope are used in combination. In a review of the literature correlating SLNB with ALND in more than 3,000 patients with breast cancer, Liberman reported technical success rate, sensitivity, and accuracy of 88%, 93%, and 97%, respectively, for SLNB.

The use of SLNB in patients with ductal carcinoma in situ (DCIS) remains controversial. It is probably indicated for women with DCIS and known microinvasion and for patients in whom invasive disease is suspected preoperatively based on the size or imaging features of the DCIS. The alternative approach that can be taken is to excise the DCIS and, if invasive disease is identified on the lumpectomy specimen, have the SLNB done as a second operative procedure.

What is the prognostic significance of isolated tumor cells or micrometastatic disease described following a sentinel lymph node biopsy?

The advent and now widespread use of sentinel lymph node biopsy has resulted in a more meticulous evaluation of excised lymph node(s). This includes serial sectioning of the entire lymph node (as opposed to sample sections from multiple lymph nodes) and a more focused histologic and immunohistochemical (IHC) evaluation of the excised lymph node. Some of the consequences include the observation of isolated tumor cells and micrometastatic disease. Consequently, the significance of these findings (e.g., isolated tumor cells and micrometastases) involving excised sentinel lymph nodes is not yet clear, and there is no consensus on their prognostic significance. Currently, the use of IHC evaluation of sentinel lymph nodes is not encouraged; however, it is done at many institutions. The determination of micrometastatic disease should be based on routine hematoxylin and eosin–stained histologic sections.

 

Patient 9

Figure 3.9. Diagnostic evaluation, 79-year-old patient presenting with a “lump” in the mid-axillary region inferior to the left axilla. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) view photographically coned, left breast. A spot tangential view of the palpable area could not be obtained. Ultrasound images (D, E) of the palpable finding in the left breast. Ultrasound image (F) of tissue surrounding the palpable finding. Patient is on coumadin.

How would you describe the findings?

Scattered dystrophic and large rodlike calcifications are present bilaterally. A mixed-density (fat containing) mass is imaged on the left mediolateral oblique view, superimposed on the left pectoral muscle, corresponding to the area of clinical concern. The trabecular markings surrounding the mass are more dense and numerous compared to those in the corresponding area on the right. Given the far lateral and posterior location of the lesion, it is not imaged on the craniocaudal view and a spot tangential view could not be obtained.

What diagnostic considerations would you entertain?

Based on the mammographic findings, what BI-RADS® assessment category would you assign, and what would you do next?

The main differential considerations for a mixed-density lesion include lymph node, fibroadenolipoma (hamartoma), fat necrosis, oil cyst, galactocele, postoperative or posttraumatic fluid collection, and abscess. Although malignant lesions may rarely entrap fat, fat-containing lesions should be considered benign; consequently, no malignant lesions are usually included in the differential for a mixed-density lesion. Prior studies in this patient are normal. Specifically, no lymph node or fibroadenolipoma is seen in the upper outer quadrant of the left breast. A galactocele is not a consideration in a 79-year-old patient. Primary considerations at this point include an abscess or a hematoma (particularly because the patient is on coumadin), both of which also help explain the associated prominence of the trabecular markings. Physical findings and additional history may be helpful in sorting through these possibilities.

On physical examination, there is a hard mass just inferior to the left axilla at the mid-axillary line; no associated skin changes or discoloration are noted at this time. The mass is superficial, readily mobile, and nontender. An oval, well-circumscribed mass with a heterogeneous echotexture is imaged on ultrasound at the site of the palpable abnormality. Areas of posterior acoustic enhancement are associated with the cystic areas in the mass, and shadowing is noted with the more solid components. The surrounding tissue is echogenic, consistent with hyperemia, there is disruption of the normal tissue architecture, and lymphatic channels or interstitial fluid collections are seen as thin hypoechoic linear channels subcutaneously. In the absence of significant tenderness or erythema, an abscess is unlikely. On questioning the patient at the time of the ultrasound, she has not had any surgery to either breast, but she does describe having had trauma to this site several weeks before while being lifted from her bed on a Hoyer lift. She states that although at this time there is no skin discoloration, there was a large ecchymotic area at this site immediately following the trauma. The currently palpable mass developed as the ecchymosis resolved.

As hematomas evolve clinically, so do their imaging features. Acutely, there may be a water-density mass. As the hematoma ages, a mixed-density mass is often seen mammographically. This may resolve completely, or an oil cyst may develop eventually, as can dystrophic calcifications. On ultrasound, a complex cystic mass or a solid mass with a heterogeneous echotexture that may include hyperechoic, hypoechoic, and cystic areas can be seen. Increased echogenicity (e.g., reflecting hyperemia) and disruption of the normal tissue architecture is often found in the surrounding tissue.

BI-RADS® category 2: benign finding. Follow-up physical examination and ultrasound in 3 to 4 months is recommended for this patient, to assure resolution. Note that the BI-RADS® assessment categories should be considered independent of the recommendation. For this patient, the finding is benign, yet a short-interval follow-up is recommended. For patients in whom I suspect an inflammatory condition or posttraumatic/surgical changes, I recommend a 3- to 4-month follow-up. Under these circumstances, a rapid change (evolution) is expected in the findings. Six months is the usual recommendation for other patients for whom a short-interval follow-up is recommended (e.g., those with assessment category 3—probably benign lesion, such as a well-circumscribed mass in a patient with no prior studies).

 

Patient 10

Figure 3.10. Diagnostic evaluation, 24-year-old patient presenting during the third trimester of pregnancy with a “lump” in the left breast. Ultrasound images, radial (RAD) (A, B) and antiradial (ARAD) (C) projections of the palpable (PALP) mass, laterally in the left breast.

What is your approach to adolescent, pregnant or lactating women, or those under the age of 30 years who present with breast-related symptoms?

Under what circumstances would you do a mammogram in this patient population?

Physical examination and an ultrasound are the initial tools used in evaluating adolescent, pregnant or lactating women, or those under the age of 30 years who present with breast-related symptoms. If breast cancer is suspected after the initial evaluation, or diagnosed following a core biopsy, a complete bilateral mammogram is done.

How would you describe the ultrasound findings, and what is the most likely diagnosis?

On physical examination a discrete, readily mobile, nontender mass is palpated at the 9 o'clock position, 1 cm from the left nipple. This corresponds to the site of concern to the patient. A well-circumscribed, 3.7-cm, oval mass with internal septations and some posterior acoustic enhancement is imaged corresponding to the palpable mass. Given the clinical and imaging findings, a lactational adenoma is the most likely diagnosis. An ultrasound-guided core biopsy can be done to confirm this impression; clinical and sonographic follow-up is also discussed with the patient as an acceptable alternative.

 

What is the typical clinical presentation and course for lactational adenomas, and what are the ultrasound features associated with these lesions?

Although they are termed lactational adenomas, many of these lesions present during the third trimester of pregnancy as a well-circumscribed, mobile mass. Rarely, when these grow rapidly during the second and third trimesters of pregnancy, they outstrip their vascular supply, resulting in areas of infarction so that patients present acutely, describing a rapidly enlarging, tender mass. In most patients, lactational adenomas decrease in size significantly or resolve completely after delivery or following the cessation of lactation. They may recur with subsequent pregnancies. Patients with these lesions can be managed conservatively unless they are anxious or symptomatic (e.g., tenderness) relief is indicated.

The ultrasound features of these lesions suggest a benign etiology in many patients and include oval shape, well-circumscribed margins that may have smooth lobulations, homogenous internal echotexture, and posterior acoustic enhancement. Fibrous bands traversing the lesion and cystic changes may also be noted on ultrasound. However, in some patients, the lesions may demonstrate features more suggestive of malignancy, including irregular, angulated, and ill-defined margins and shadowing, requiring biopsy.

What histologic features characterize lactational adenomas?

It is unclear whether these tumors arise de novo during pregnancy, or whether they reflect the presence of a pre-existing fibroadenoma or tubular adenoma, stimulated by the hormonal changes that occur during pregnancy. Histologically, the features of lactational adenomas vary, depending on the stage of the pregnancy at the time of the diagnosis. Tubules are distended with secretory material and the lining epithelial cells show cytoplasmic vacuoles and variable mitotic activity. Fibrotic bands and areas of infarction can be seen in a small number of the lesions.

Pregnancy and breast cancer

Pregnancy-associated breast carcinoma (PABC) is defined as breast cancer that is diagnosed during pregnancy or in the year following delivery. It is estimated to affect between 1 in 1,500 to 1 in 3,000 pregnant women, and some suggest that this incidence will increase as women delay their child-bearing years. The tumors that occur during pregnancy are similar to those diagnosed in nonpregnant patients. Although some patients have advanced disease at the time of diagnosis, this is attributed to delays in seeking medical attention or masses being followed clinically rather than any inherent aggressive biologic attribute of the tumors developing during gestation or to any pregnancy-related hormonal stimulation of the tumors.

Diagnosis and staging, termination of pregnancy, timing of local and systemic adjuvant therapy and the potential effects of this therapy to the fetus are some of the concerns facing patients diagnosed during pregnancy and the interdisciplinary team of physicians taking care of the patient. If treatment is modified, consideration has to be given to the potential adverse effects to the mother. Even small doses of radiation during the first trimester of pregnancy are associated with significant adverse effects to the developing fetus, such that termination of pregnancy is a serious consideration if radiation therapy is deemed critical during the first trimester. Given the potential adverse effect of radiation to the fetus, some advocate mastectomy for patients diagnosed with breast cancer during the first two trimesters of pregnancy. When patients are diagnosed later in pregnancy, they may be treated conservatively with surgery and radiation therapy can be deferred until after delivery. Alternatively, patients can be induced after 34 weeks with small risk to the fetus, and radiation therapy can then be given following the delivery. Unlike the effects of radiation on a developing fetus, less is known concerning the effects of chemotherapy on pregnancy and the developing fetus; some suggest it can be used safely after the first trimester.

 

Patient 11

Figure 3.11. Diagnostic evaluation, 50-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views photographically coned to the area of concern in the left breast. Spot compression (C) view and ultrasound image (D) of the palpable finding. Metallic BB used by the technologist to mark the area of concern to the patient.

How would you describe the finding?

What are your differential considerations, and what is your recommendation?

A round, spiculated, 1.5-cm mass is imaged in the upper outer quadrant of the left breast, corresponding to the site of concern to the patient. A solid mass with associated shadowing is seen on ultrasound at the 1 o'clock position, 10 cm from the left nipple. Differential considerations for which history and physical examination may be helpful include fat necrosis if there is a history of recent trauma or surgery localized to this site; an abscess, particularly if there is associated tenderness, erythema, and increased temperature localized to the palpable site; or a galactocele if there is a history of pregnancy within the last several years. A papilloma, focal fibrosis, pseudoangiomatous stromal hyperplasia, phyllodes tumor, sclerosing adenosis, granular cell tumor, or an extra-abdominal desmoid (fibromatosis) are additional benign considerations. Invasive ductal carcinoma not otherwise specified, medullary, mucinous, and papillary carcinomas, lymphoma, or metastatic disease are all malignant considerations. A biopsy is indicated.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered.

 

A granular cell tumor is reported histologically, and a wide surgical excision is done.

What are the clinical manifestations of granular cell tumors in the breast, and what is the treatment of choice?

Granular cell tumors can occur anywhere in the body but have some predilection for the head and neck, including the oral cavity. Approximately 5% of these tumors occur in the breast, including in male patients. Wide excision is the treatment of choice because less than 1% of these lesions are malignant, but local recurrences have been reported following incomplete excision. Clinically, patients describe a firm, hard, nontender mass. Superficial or subareolar lesions may cause skin retraction or nipple inversion, respectively. Rarely, patients with one granular cell tumor of the breast can be found to have multiple or bilateral breast lesions or granular cell tumors in locations outside the breast. The age of presentation is variable, ranging from 17 to 75 years.

What are the described imaging findings associated with granular cell tumors?

Mammographically, granular cell tumors may be round masses with well-circumscribed to spiculated margins, or they can present as spiculated masses. A solid mass with shadowing is the most common ultrasound appearance of these lesions. Although reports in the literature are scant, it may be that benign granular cell tumors lack the features of malignancy on dynamic sequences with magnetic resonance imaging (e.g., no significant contrast uptake).

What are some of the histologic features associated with granular cell tumors in the breast?

Although the lesions appear well circumscribed grossly, an infiltrative pattern is commonly noted histologically. Nests, or solid sheets, of cells with eosinophilic granules in abundant cytoplasm are characteristic of this tumor. These cells, in contrast to those seen in apocrine carcinomas, which they can resemble, contain glycogen and have a positive immunoreaction for S-100 protein. These tumors may also be positive for carcinoembryonic antigen (CEA), however, they are negative for estrogen and progesterone receptors. Given their positive immunoreaction for S-100 protein, these tumors are thought to have a neural origin (possibly Schwann cells).

 

Patient 12

Figure 3.12. Screening study, 78-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Comparison mammogram from 2 years previously (not shown) is normal. The patient is not on hormone replacement therapy. Spot compression views, craniocaudal (C) and mediolateral oblique (D) projections, left breast mass. Ultrasound image, radial (RAD) (E) projection correlating to the area of mammographic concern, left breast. Core samples (F, G) demonstrating the typical appearance of a mucinous lesion. The core is gelatinous, with a glassy, glistening appearance. This is in contrast with the stiff, usually white cores obtained through nonmucinous, malignant lesions. Magnetic resonance imaging, T2-weighted sagittal image (H), right breast. T1-weighted sagittal image (I), right breast, precontrast. T1-weighted sagittal image (J), right breast, 1 minute following an intravenous bolus of contrast, same tabletop position as shown in (I). Subtraction image (K), same tabletop position as (I). Mucinous carcinoma in two different patients (L, M). Clusters of low-grade malignant cells floating in pools of mucin separated by fibrous septa. The cellularity of the aggregates is variable within and among lesions.

What is the primary observation and, specifically, what would you do next?

A mass is present in the left breast.

BI-RADS® category 0: additional imaging evaluation is indicated. The patient is called back for additional evaluation. Spot compression views for confirmation and marginal analysis, correlative physical examination and an ultrasound are indicated.

 

 

How would you describe the mass, and what is your differential at this point?

What is the next step?

A round 1.5-cm mass with partially indistinct margins is imaged mammographically. Also noted are benign-type calcifications in the adjacent tissue. Differential considerations for a benign water-density mass developing in a 78-year-old woman are limited but include cyst, focal fibrosis, papilloma, abscess, and phyllodes tumor. Although cysts more commonly develop in the perimenopausal years (heralding the beginning of menopausal signs, with symptoms in some women), there is a second, smaller peak of occurrence in older, postmenopausal women. Considerations for malignancy include invasive ductal carcinoma not otherwise specified, mucinous carcinoma, papillary carcinoma, lymphoma, or metastatic disease. A fibroadenoma or focal fibrosis is unlikely to develop in a 78-year-old woman, particularly if she is not on hormone replacement therapy. Although they are more common in older women, invasive lobular carcinomas do not usually present as a round mass.

Next, an ultrasound study is done to evaluate the internal characteristics of this mass. Also, if it is seen on ultrasound and it is solid, a core biopsy can be done. In planning the ultrasound, at what clock position would you expect to find this mass?

 

How would you describe the ultrasound findings?

What do you think is the most likely diagnosis, and what is your recommendation?

A nearly isoechoic, round mass with partially circumscribed and indistinct margins is imaged at the 1 o'clock position, 4 cm from the left nipple. There is some posterior acoustic enhancement. The mass is not palpable, there is no associated skin discoloration, and no tenderness is elicited as gentle pressure is applied directly over the mass. The ultrasound excludes the possibility of a cyst. An abscess is unlikely in the absence of any associated skin change or tenderness, and the ultrasound features are not suggestive of an abscess. A solid mass developing in a 78-year-old woman requires biopsy; given the patient's age, and the imaging features of this lesion (i.e., round, 1.5-cm mass, nearly isoechoic with posterior acoustic enhancement), a mucinous carcinoma is a primary consideration. When doing the core biopsy, evaluate the cores carefully: Cores from mucinous carcinomas have a distinctive gelatinous (Fig. 3.12F, G), almost clear appearance (i.e., not stiff, solid white), and tiny air droplets will develop along the edge of the cores when they are placed in 10% formalin.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered. An ultrasound guided core biopsy is done.

On MR, a small component of the mass centrally demonstrates a high signal on T2-weighted images (Fig. 3.12H). On the T1-weighted dynamic sequence (Fig. 3.12I, K), there is rapid wash-in and wash-out of contrast, with rim enhancement. No additional lesions are identified in either breast.

An invasive mammary carcinoma with mucinous features is reported following the ultrasound-guided core biopsy. A 1.5-cm mucinous carcinoma is diagnosed on the lumpectomy specimen, with no associated ductal carcinoma in situ. No metastatic disease is identified in two sentinel lymph nodes [pT1c, pN0(sn) (i—), pMX; Stage I]. By definition, pure mucinous carcinomas are grade I lesions.

What are the clinical and imaging features associated with mucinous carcinomas?

The imaging features of mucinous carcinomas are well demonstrated in this patient. Characteristically, they develop in older women as round water-density masses with a range of well circumscribed to indistinct margins; some may demonstrate macro- or microlobulation. On ultrasound, the lesions are often iso- to slightly hyperechoic with associated posterior acoustic enhancement; rarely, a complex cystic mass may be seen on ultrasound. Depending on the amount of mucin present, a bright T2-weighted signal can be seen on magnetic resonance imaging. Enhancement following contrast is variable and may be limited to the edge of the lesion (irregular rim enhancement).

What are the histologic findings associated with mucinous carcinomas?

Mucinous carcinomas, also called colloid carcinomas, are a subtype of invasive ductal carcinoma characterized by aggregates of low-grade malignant cells floating in pools of mucin (Fig. 3.12L, M). The mucin-to-cell ratio varies from lesion to lesion, and this may explain some of the imaging variability seen with these lesions. Associated ductal carcinoma in situ may be seen in as many as 75% of patients, usually at the periphery of the lesion. These are usually diploid tumors with estrogen and progesterone receptors. Mucinous carcinomas represent 1% to 2% of all breast cancers.

 

 

Patient 13

Figure 3.13. Diagnostic evaluation, 52-year-old patient presenting with a “lump” in the upper outer quadrant of the left breast (metallic BB marking “lump”). Craniocaudal (A), mediolateral oblique (B) views. Right craniocaudal and left craniocaudal view exaggerated laterally (C) views. Metallic BB is used by the technologist to mark the area of clinical concern. Ultrasound images in radial (D) and antiradial (E) projections corresponding to the palpable mass in the upper outer quadrant of the left breast. Magnetic resonance imaging, T2-weighted sagittal images (F, G) at two different tabletop positions. T1-weighted sagittal image (H), left breast, precontrast. T1-weighted sagittal image (I), left breast, at the same tabletop position as (H), 1 minute following bolus intravenous administration of contrast.

What is your differential for the mammographic finding, and what would you do next?

An oval, well-circumscribed, 2.5-cm mass is imaged on the mediolateral oblique view, corresponding to the palpable abnormality. This is partially imaged on the routine left craniocaudal view but imaged in its entirety on the craniocaudal view exaggerated laterally. Diagnostic considerations for an oval-round mass in a 52-year-old woman include cyst, fibroadenoma (complex fibroadenoma, tubular adenoma), phyllodes tumor, focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), papilloma, abscess, postoperative/posttraumatic fluid collection, invasive ductal carcinoma not otherwise specified (NOS), mucinous carcinoma, medullary carcinoma, papillary carcinoma, apocrine carcinoma, adenoid cystic carcinoma, lymphoma, and metastatic carcinoma. A galactocele is unlikely in a 52-year-old woman. Physical examination and an ultrasound are done next to further characterize the mass.

 

 

How would you describe the ultrasound findings in this patient?

What are your primary considerations now, and what is your recommendation for this patient?

On physical examination, a discrete, readily mobile, hard mass is palpated in the upper outer quadrant of the left breast. There is no skin discoloration. On ultrasound, a well-circumscribed complex cystic mass with posterior acoustic enhancement is imaged at the 1- to 2-o'clock position in the left breast. No history of surgery or trauma is elicited from the patient, and there is no associated tenderness when this area is palpated. The ultrasound eliminates the possibility of a simple cyst. With no history of surgery or trauma, this is unlikely to represent postoperative or posttraumatic fluid collection and, in the absence of significant tenderness or erythema, it is unlikely to represent an abscess. Given the age of the patient, the size of the lesion, and its complex appearance on ultrasound, mucinous carcinoma is unlikely. An invasive ductal carcinoma NOS with necrosis (given the complex cystic appearance sonographically) or a papillary lesion is the primary consideration at the time of the ultrasound-guided core biopsy.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered. An invasive papillary carcinoma is diagnosed following the ultrasound-guided needle biopsy.

On MR, variable signal intensities are noted on the T2-weighted images (Fig. 3.13F, G). Following contrast administration, rapid nonuniform enhancement of the mass is noted on the T1-weighted images (Fig. 3.13 H, I).

What are the imaging features that may distinguish central from peripheral papillary carcinomas?

As with papillomas, papillary carcinomas are considered either central (i.e., subareolar) or peripheral. Patients with central papillary carcinomas usually present with a well-circumscribed mass in the subareolar area. The mass may be large enough to cause nipple displacement and overlying skin stretching. Some patients may have associated nipple discharge. A complex cystic mass is commonly seen on ultrasound. Bloody fluid is often obtained on aspiration. Patients with peripheral papillary carcinomas can present with one or multiple masses with well-circumscribed to ill-defined but not usually spiculated margins. Solid, hypoechoic or complex cystic masses are imaged on ultrasound. Papillary carcinomas represent approximately 1% to 2% of all breast cancers and are characterized by in-situ and invasive variants.

Patient 14

Figure 3.14. Diagnostic evaluation, 51-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views with a metallic BB at the site of concern to the patient. Mediolateral oblique (C), photographically coned view, inferiorly. Spot tangential (D) view, palpable mass, left breast. Ultrasound images in transverse (TRS) (E) and longitudinal (LON) (F) projections at the site of concern to the patient, left breast, medially.

 

 

How would you describe the finding, and what is your differential?

What will you ask the patient, and what will you be looking for when you examine her and do the ultrasound?

A mass with indistinct and ill-defined margins is imaged, corresponding to the area of concern to the patient. Prominence of the surrounding trabecular margins is also noted. A well-circumscribed, dense lymph node is present inferiorly in the left axilla. It retains a fatty hilar region, and comparison with prior studies would be helpful in assessing any change in size and overall density. On the mammographic findings alone, differential considerations include inflamed cyst, abscess, posttraumatic/postoperative fluid collection, invasive ductal carcinoma not otherwise specified, mucinous carcinoma, medullary carcinoma, papillary carcinoma, lymphoma, and metastatic disease. Given its proximity to the skin on the spot tangential view, an inflamed sebaceous cyst is also included in the differential. A galactocele is unlikely in a 51-year-old woman unless there has been a pregnancy with lactation within the last several preceding years. The patient should be asked questions relative to associated symptoms (e.g., “heat” overlying the area, tenderness, general malaise, or recent trauma to this site). Before starting the ultrasound, examine the skin for erythema, ecchymosis, or a prominent skin pore possibly associated with a sebaceous cyst. Compare the skin temperature overlying this area with the corresponding area on the contralateral breast.

 

How would you describe the ultrasound findings?

What is your working diagnosis, and what would you recommend?

On physical examination, there is a small patch of erythema overlying the mass, and this area is warmer than the comparable area on the contralateral breast. The mass is not associated with skin because it can be moved independently of the skin (i.e., it is not a sebaceous cyst). Some tenderness is elicited on deep palpation. There is no history of trauma or surgery. On ultrasound, the tissue is hyperechoic with associated irregular fluid collections at the 9 o'clock position, 6 cm from the left nipple. Normal tissue architecture is disrupted. Given the clinical, mammographic, and ultrasound findings, an abscess with an associated ongoing inflammatory process is the primary consideration. The patient is prescribed a course of antibiotics, with a follow-up ultrasound scheduled after completion of the antibiotic course.

The need for an aspiration for fluid evaluation (i.e., gram stain and culture) and to remove as much of the infected fluid as possible is something to consider in women in whom you suspect an ongoing inflammatory process. Acutely, in some of these patients, aspirations can be quite painful and often yield little fluid (even with an 18G or 16G needle). Nevertheless, depending on the size of individual fluid collections, an aspiration can be done; presumably, removing as much of the fluid as possible will improve the effectiveness of the antibiotics. In this patient, given the relatively small size of the mass and the presence of small fluid locules on ultrasound (as opposed to one single fluid collection), aspiration is not done.

With respect to inflammatory lesions in the breast, what are the two groups of nonlactating patients to consider and how do their clinical courses differ?

Traditionally, mastitis and abscesses are associated with lactating patients. Obstetricians manage this group of patients clinically, and imaging is not usually indicated. It is important to recognize, however, that nonlactating women of all ages can present with mastitis or a breast abscess. For women who are not lactating, consider two groups of patients with different presentations and clinical courses: those with peripheral mastitis or abscess and those with subareolar mastitis or abscess. Peripheral mastitis or abscess is seen in women of all ages and, although some patients may have an underlying condition such as diabetes that may predispose them to the infection, most are otherwise healthy individuals. Patients usually respond well, with complete resolution of symptoms and findings, following one or two courses of antibiotics. Recurrence following treatment is uncommon in these patients. In contrast, patients with subareolar mastitis or abscess are usually young (in their 30s) and heavy smokers. Acutely, some of these patients develop periareolar fistulas (Zuska's disease) that drain purulent material. Patients with subareolar abscesses can be difficult to treat effectively and recurrences following treatment, requiring surgical incision and drainage, are common, as is the development of contralateral subareolar abscess.

BI-RADS® category 2: benign finding. A follow-up ultrasound is scheduled in 3 weeks to confirm complete resolution of symptoms and findings. If symptoms persist and there are residual findings on the ultrasound, a second course of antibiotics is prescribed for some patients. Alternatively, if a larger fluid collection is identified sonographically at the time of the follow-up ultrasound, an aspiration may be done.

 

Patient 15

Figure 3.15. Diagnostic evaluation, 59-year-old woman presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views; metallic BB placed at the site of the palpable finding. Spot compression views, right breast, craniocaudal (C) and mediolateral oblique (D)projections. Ultrasound image (E) of palpable finding, 9 o'clock position, zone 2/3 (Z2/3), right breast.

 

 

How would you describe the findings, and what is your differential?

An irregular mass with spiculation, associated distortion, and scattered punctate calcifications is present in the right breast, corresponding to the area of clinical concern. It is more prominent on the craniocaudal view. On physical examination, no definite mass is palpated; however, the tissue at the 9 o'clock position, 5 to 6 cm from the right nipple, is hard and thickened. On ultrasound, an irregular mass with an echogenic rim and significant shadowing measuring at least 4 cm is imaged, corresponding to the area of clinical concern. Given the lack of a discrete mass on physical examination, a more prominent appearance on the craniocaudal view, and the amount of shadowing seen on ultrasound, an invasive lobular carcinoma is a more likely diagnosis; however, invasive ductal carcinoma can present with similar findings. Possible benign considerations are limited but include an inflammatory process or diabetic fibrous mastopathy if the patient has a history of long-standing, insulin-dependent diabetes.

A biopsy is indicated. In planning for the biopsy, consider needle placement carefully. In my experience, these types of lesions with significant shadowing can be hard and often yield little or no tissue on one or more of the passes. Sometimes the inner portion of the needle advances into the mass but the outer sheath does not follow because it cannot cut through the tissue adequately. In targeting these lesions, I aim for the edges of the lesion as opposed to trying to advance the needle into the area of shadowing and, depending on the appearance of the tissue obtained, I will make extra passes as needed to obtain one or two solid tissue cores.

So, are we done with this patient?

Do you have any additional observations?

How about the left breast?

Remember, when presented with obvious clinical and mammographic findings, focus away from them and evaluate the remainder of the mammogram. Did you notice the irregular mass with associated spiculation and distortion in the left breast (comparable location to that on the right)? The patient has bilateral lesions, requiring biopsy (this information is also factored in when considering invasive lobular carcinoma as the likely diagnosis).

Following ultrasound-guided core biopsies, invasive lobular carcinomas are diagnosed bilaterally. Multicentric (5.5-cm and 3-cm foci) invasive lobular carcinoma with associated lymphovascular space involvement is diagnosed following a right simple mastectomy. Metastatic disease is identified in one excised right axillary lymph node [pT3, pN1, pMX; Stage IIIA]. A 4.5-cm invasive lobular carcinoma with associated lymphovascular space involvement is diagnosed in the left breast following a simple mastectomy. Metastatic disease is diagnosed in 8 of 14 excised left axillary lymph nodes [pT2, pN2, pMX; Stage IIIA].

What are the clinical, mammographic, and sonographic findings associated with invasive lobular carcinoma?

Invasive lobular carcinoma is the second most common type of breast cancer, with a reported incidence of 5% to 15%. The incidence of this tumor type varies with patient age: It is uncommon in premenopausal women and increases in frequency with advancing age. Multifocality and bilaterality (synchronous or metachronous) should be considered in patients diagnosed with invasive lobular carcinoma. Clinically, a discrete mass may be palpated; however, it is more common to palpate an area of thickening (described by some as “induration”), which in some patients can be subtle.

A spiculated mass is the most common mammographic finding in women with invasive lobular carcinoma, occurring in close to 40% of patients. Parenchymal asymmetry and distortion are the next most common mammographic findings. These changes may be more apparent in one projection, commonly the craniocaudal view. Diffuse changes include a progressive shrinkage of the involved breast or, alternatively, diffuse enlargement and reduced compressibility of the involved breast may be seen. Invasive lobular carcinoma rarely presents as a round or oval mass. Likewise, when an invasive lobular carcinoma is diagnosed following biopsies done for microcalcifications, the calcifications are usually not found in association with the invasive lesion. The calcifications are found in benign changes such as fibrocystic changes, fibroadenoma, and sclerosing adenosis, and the invasive lobular carcinoma is an incidental finding.

Solid masses with irregular, spiculated, and angular margins are seen on ultrasound. Subtle distortion may be the only finding on ultrasound. In some lesions (such as the one presented here), significant shadowing is seen associated with the lesion. In our experience, some of the most striking shadowing seen is associated with invasive lobular carcinomas.

How accurately does mammography predict tumor extent in patients with invasive lobular carcinoma?

Having described the imaging presentation of invasive lobular carcinoma, it is important to emphasize that invasive lobular carcinoma can be subtle clinically, mammographically, sonographically, and pathologically (I refer to it as the “sleaze disease”). The extent of disease is often underestimated clinically, mammographically, and sonographically. In our own patients, metastatic disease to the axilla is seen in as many as 60% of patients at the time of presentation.

What are the distinguishing histologic features of these lesions?

Histologically, small monomorphic cells infiltrating the stroma in single files characterize these lesions. The cells infiltrate the tissue insidiously, invoking little or no desmoplastic reaction (this likely reflects the subtle imaging changes associated with some of these lesions). In a significant number of patients, lobular neoplasia (i.e., lobular carcinoma in situ), although not considered as a precursor or premalignant lesion, is seen in the tissue surrounding invasive lobular carcinoma. Invasive lobular carcinomas often express estrogen and progesterone receptors; rarely, the HER-2/neu oncoprotein is expressed.

 

Patient 16

Figure 3.16. Diagnostic evaluation, 53-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views, metallic BB at site of “lump,” left craniocaudal view. Spot tangential (C) view, left breast mass. Axillary (D) view, left axilla. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections of the mass in the left breast. Ultrasound image (G) of the mass in the left axilla.

 

 

How would you describe the findings, and what is your differential?

A round 1.5-cm mass with partially circumscribed and indistinct margins is imaged in the left breast, corresponding to the area of concern to the patient. An additional mass measuring at least 3 cm is partially imaged in the left axilla. Given this constellation of findings, the differential is limited. Malignant possibilities include an invasive ductal carcinoma not otherwise specified, with metastatic disease to the axilla. Given the margins and shape of the breast mass and the presence of axillary adenopathy, this is likely to be poorly differentiated. In premenopausal women with a round mass, medullary carcinoma is the primary subtype of invasive ductal carcinoma to consider. Papillary and mucinous carcinomas also present as round masses, but they are more common in older, postmenopausal women. Alternatively, this could represent lymphoma. An inflammatory process with abscess formation in the breast and reactive adenopathy in the axilla is a possible benign diagnostic consideration. Physical examination and an ultrasound are indicated.

How would you describe the findings?

Do you think this could be a cyst?

On physical examination, a hard mass is palpated at the 2 o'clock position, 7 cm from the left nipple; a hard, fixed mass is also palpated in the left axilla. No skin changes are noted, and no tenderness is elicited on palpation. A round, well-circumscribed, markedly hypoechoic mass with some posterior acoustic enhancement is imaged corresponding to the palpable finding in the breast, and a 4-cm, well-circumscribed, markedly hypoechoic (nearly anechoic) mass is imaged in the left axilla. Although you might be tempted to say that the mass in the axilla could be a cyst, it is important to recognize that abnormal, enlarged axillary lymph nodes can be nearly anechoic in some patients.

 

What is your recommendation?

A malignant process has to be the leading consideration in this patient, so biopsies of the left breast and axillary masses are indicated.

BI-RADS® category 5: highly suggestive of malignancy—appropriate action should be taken.

Appropriate action is taken, and a medullary carcinoma with metastatic disease to the left axilla is diagnosed following core biopsies of the breast and axillary masses. The patient is treated with neoadjuvant therapy.

What are the clinical and imaging findings associated with medullary carcinoma?

Medullary carcinomas are a described subtype of invasive ductal carcinoma. When strict histologic criteria are used to classify these lesions, they represent >,2% of all breast cancers. Clinically, they present most commonly as a palpable mass that is often described by the patient as developing rapidly. Mammographically, these are commonly round or oval masses with margins that can range from well circumscribed to ill-defined; however, they are not usually spiculated. On ultrasound, they are moderately to markedly hypoechoic (they may simulate a cyst) and may demonstrate some posterior acoustic enhancement. Because these tumors may have areas of necrosis, you may obtain bloody material if you attempt an aspiration; however, a residual solid component will remain, so a core biopsy can be also be done.

What histologic findings are described for medullary carcinoma?

These tumors are described as having nests of large, high-nuclear-grade epithelial cells forming a syncytial pattern and lacking a significant amount of surrounding stroma. The nuclei are pleomorphic, and a high number of mitotic figures are present. The tumors are surrounded by a significant infiltrate of lymphocytes and plasma cells. Ductal carcinoma in situ is not usually an associated finding. Given the locally aggressive nature of these lesions, areas of necrotic tumor may be present histologically. Presumably, the vascular supply is outstripped by the rapid growth of the tumor. Many of these tumors are estrogen and progesterone receptor negative.

Patient 17

Figure 3.17. Diagnostic evaluation, 51-year-old patient presenting with a “lump” and thickening of the left breast. Craniocaudal (A) and mediolateral oblique (B) views with a metallic BB (arrow on CC view) used at the site of concern to the patient. Technical factors used for the exposures are as follows: Ultrasound images, radial (RAD) (C) and antiradial (ARAD) (D) projections, left breast laterally.

Factor

RTCC

LTCC

RTMLO

LTMLO

kV

26

31

26

27

mAs

296

293

269

439

Comp (mm)

63

76

60

68

           

What do you think, and how would you describe the findings?

The overall density of the left breast is increased and the breast appears larger than the right. As evidenced by the millimeters of compression used, the left breast is less compressible than the right. These observations are confirmed and supported by the technical factors used for adequate exposures. Although the kilovoltage used for the left mediolateral oblique (MLO) view is increased by one compared to that used for the right breast, the resulting milliamperage is much higher on the left MLO. In comparison, when the kilovoltage is increased to 31 kV for the left craniocaudal (CC) view, the resulting milliamperage is comparable to that noted for the CC and MLO views of the right breast. Also noted are slightly more prominent axillary lymph nodes in the left axilla compared to those in the right axilla.

What diagnostic possibilities are you considering at this point?

What would you recommend?

Differential considerations for usually unilateral, although rarely bilateral, diffuse changes include radiation therapy effect, inflammatory changes (e.g., mastitis), trauma, ipsilateral axillary adenopathy with lymphatic obstruction, dialysis shunt in the ipsilateral arm with fluid overload, invasive ductal carcinoma not otherwise specified, inflammatory carcinoma, invasive lobular carcinoma, or lymphoma. Invasive lobular carcinoma can lead to increases in breast density and size or a decrease in breast size (the shrinking breast). Differential considerations for usually bilateral, although sometimes unilateral, diffuse changes include hormone replacement therapy (e.g., estrogen), weight changes, congestive heart failure, renal failure with fluid overload, and superior vena cava syndrome. Additional rare benign causes include granulomatous mastitis, coumadin necrosis, arteritis, and autoimmune disorders (e.g., scleroderma). Obtaining a thorough history, examining the patient, and doing an ultrasound are often helpful in sorting through the differential considerations.

 

 

How would you describe the ultrasound findings?

An irregular area of hypoechogenicity, with associated areas of enhancement and shadowing, is imaged at the 3:30 o'clock position 4 cm from the left nipple. Some tenderness is elicited during the ultrasound study, but there is no erythema, increased warmth, orpeau d'orange change. No other relevant clinical history is elicited (no history of trauma, radiation therapy, or other known medical problems). The clinical and imaging findings do not provide a definite benign etiology; rather they are of concern for a possible malignancy.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

An ultrasound-guided core biopsy is done. A severe mastitis with features suggestive of abscess formation is diagnosed on the core biopsy. Surgical incision and drainage is undertaken following incomplete resolution of symptoms and findings after two courses of antibiotics. No malignancy is diagnosed on excised tissue taken at the time of the surgical drainage, and the patient had an uncomplicated post-operative course with complete resolution of symptoms.

What diagnosis has to be pursued aggressively in patients with this type of presentation?

Given the clinical and mammographic presentation of this patient, inflammatory carcinoma is the main diagnostic consideration. Inflammatory carcinoma represents >,1% of all breast cancers, and patients usually present acutely with rapidly developing symptoms that simulate those of an inflammatory process. Inflammatory carcinoma is primarily a clinical diagnosis considered in patients who present describing the rapid development of diffuse breast changes including warmth, heaviness, thickening, skin changes consistent with edema (peau d'orange) and redness of the breast. Although there may be some tenderness, this is not usually a significant component. Axillary adenopathy is present in >.50% of patients with inflammatory carcinoma at the time of presentation. The diagnosis of inflammatory carcinoma can sometimes be delayed as patients are treated repeatedly with antibiotics. If symptoms do not resolve, or worsen, on antibiotics, the diagnosis of an inflammatory carcinoma needs to be pursued aggressively. A skin biopsy is often done to establish the diagnosis. However, if focal findings are identified on ultrasound, an ultrasound-guided biopsy can also be helpful in establishing the diagnosis. Because adenopathy reflecting metastatic disease is common in women with inflammatory carcinoma, the axilla should be scanned, and either a fine-needle aspiration or a core biopsy can be done if a potentially abnormal lymph node is identified.

In patients with inflammatory carcinoma, the compressibility of the breast is significantly decreased, the density of the parenchyma is increased, and associated skin thickening leads to significant difficulties in obtaining an adequate exposure mammographically (two layers of thickened skin now need to be penetrated for adequate exposure of the parenchyma). On ultrasound, skin thickening, disruption of the normal tissue architecture, increased echogenicity of the tissue (consistent with hyperemia), and dilated subcutaneous lymphatic vessels can be seen. In a small number of women, one or more masses may be identified in the involved breast. A poorly differentiated invasive ductal carcinoma, with associated tumor emboli in dilated dermal lymphatics, is the most common finding in women with inflammatory carcinoma. The presence of tumor in dilated lymphatics is identified in approximately 80% of women with clinical signs and symptoms of inflammatory carcinoma.

Patient 18

Figure 3.18. Diagnostic evaluation, 37-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views. Spot tangential (C) view done at the site of the palpable finding in the upper outer quadrant of the left breast. Ultrasound image (D) of the palpable mass in the upper outer quadrant of the left breast.

 

 

At this point, what can you say and with what degree of certainty?

What else would you tell the technologist to do?

No abnormality is apparent on the craniocaudal (CC) and mediolateral oblique (MLO) views. In women over the age of 30 years who present with a “lump” or other focal symptom (focal pain, skin changes, etc.), a metallic BB is placed at the site of focal concern and CC and MLO views, as well as a spot tangential view at the site of the focal abnormality, are done. A unilateral study of the symptomatic breast is done, if the patient has had a mammogram within the last 6 months. Based on these initial images, additional spot compression or double spot compression magnification views may be done. Depending on the location of the focal finding, and the appearance of this area on the spot tangential view, correlative physical examination and an ultrasound are usually indicated. The ultrasound may be deferred in patients in whom there is no chance the lesion has been excluded from the field of view and completely fatty tissue or a benign lesion (e.g., an oil cyst) is imaged, corresponding to the area of concern.

 

At this point, what can you say and what is your differential?

A 1-cm, round mass with well-circumscribed margins is demonstrated on the spot tangential view. A partial halo sign is seen (arrow, Fig. 3.18C). The halo sign, defined as a 1- to 2-mm sharp radiolucency partially or completely outlining a mass, is a good sign that a lesion is benign. The halo sign is as good a sign that a lesion is benign as spiculation is a sign of malignancy. Some lesions demonstrating a halo sign turn out to be malignant, but most are not; some spiculated masses turn out to be benign, but most are not. The halo sign is thought to reflect a rapidly growing lesion, most commonly a cyst or a fibroadenoma (consequently, it can be seen with the more rapidly growing malignant lesions). Other benign considerations in this patient include tubular adenoma, papilloma, pseudoangiomatous stromal hyperplasia (PASH), focal fibrosis, galactocele, phyllodes tumor, posttraumatic fluid collection, or an abscess. Invasive ductal carcinoma not otherwise specified and medullary carcinoma are the primary malignant considerations for a patient this age. Mucinous carcinomas are typically smaller and more common in older, postmenopausal women, as are papillary carcinomas. Invasive lobular carcinomas do not typically present as a round mass and are more common in older, postmenopausal women.

 

What is your diagnosis?

What BI-RAD® category would you assign?

Would you do anything else?

On physical examination, a superficial, discrete, hard, readily mobile mass is palpated at the 1 o'clock position, 1 cm from the left nipple. A well-circumscribed, 1.3-cm, anechoic mass with posterior acoustic enhancement is imaged, corresponding to the palpable finding. This is a simple cyst. Reverberation artifact (arrow, Fig. 3.18D) is present superficially. In this patient, no further intervention is warranted unless there is significant tenderness or the patient requests an aspiration. Part of our job is to educate women. So, it is important to tell women that cysts are common (i.e., most women have them at some point in their life), often multiple, and may fluctuate in size and associated tenderness. But what are these patients waiting specifically to hear from you? They are hanging on your every word, waiting for you to tell them with confidence that what they are feeling isnot breast cancer. So I make it a point of looking them in the eye when I specifically tell them: “The lump you are feeling is not breast cancer, it is a cyst, a fluid pocket in your breast, and it will not turn into cancer.” However, you still have to assess every patient individually for her response to this information. If I sense continued concern, I will discuss doing an aspiration. Included in this discussion is the likelihood of recurrence following aspiration and the small risk of causing bleeding or infection.

Aspirated fluid may be variable in appearance. The fluid may be free-flowing and range from clear or opaque serous to green to almost black. In some women the fluid is thick and gelatinous; in these patients, aspiration may be incomplete even with an 18G needle. I do not routinely submit the fluid for cytology unless I obtain grossly bloody fluid after an atraumatic tap.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended starting at age 40 years unless there are intervening or persistent clinical concerns requiring earlier evaluation.

Patient 19

Figure 3.19. Diagnostic evaluation, 42-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views, with a metallic BB on the palpable abnormality. Spot tangential (C) view of palpable finding. Ultrasound images (D, E), antiradial (ARAD) projections taken through two different areas of the palpable (PALP) mass.

 

 

How would you describe the imaging findings?

Scattered lymph nodes are noted bilaterally, superimposed on the pectoral muscles. Focal parenchymal asymmetry is incompletely imaged at the site of concern to the patient, inferomedially in the left breast. On physical examination, a tender, hard, fixed mass is palpated just above the medial-most extent of the inframammary fold on the left. This is associated with some dimpling of the overlying skin. A vertically oriented mass, with spiculated and angular margins and some shadowing, is imaged corresponding to the palpable finding at the 8 o'clock position, 12 cm from the left nipple.

What is your differential, and what is your recommendation to the patient?

More common diagnostic considerations include an inflammatory process or posttraumatic changes; rare benign lesions to consider include a papilloma, sclerosing adenosis, granular cell tumor, or fibromatosis (particularly with a lesion in close proximity to or associated with the pectoral muscle). Invasive ductal carcinoma not otherwise specified and invasive lobular carcinoma are the primary malignant considerations. Rarely, ductal carcinoma in situ can present as a mass, asymmetric density, or distortion in the absence of microcalcifications. Given the described clinical and imaging findings, a biopsy is indicated.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

Fibromatosis (extra-abdominal desmoid) is reported histologically on the cores. The diagnosis is confirmed following excisional biopsy.

What are the imaging features of fibromatosis?

Mammographically, a spiculated, irregular, noncalcified mass is the most common finding in women with fibromatosis. Less commonly, focal parenchymal asymmetry that may have associated distortion can be seen. On ultrasound, the lesions are usually hypoechoic, round, oval or irregular masses with an echogenic rim, posterior acoustic shadowing, and margins that are not well circumscribed. Less commonly, well-circumscribed margins and posterior acoustic enhancement may be seen. In a limited number of case reports, these lesions described as heterogeneous on MR imaging, with low to high signal intensity on T2-weighted images, isointense on T1-weighted images, with moderate to strong enhancement following contrast administration. In our experience, the enhancement of these lesions is variable, and some may not enhance significantly on MR.

What is fibromatosis (extra-abdominal desmoid), and what is critical in the management of patients diagnosed with fibromatosis?

Fibromatosis is an uncommon tumor accounting for >,0.2% of all primary breast tumors and is indistinguishable from fibromatosis occurring elsewhere in the body. The tumor is composed primarily of spindle cells lacking significant atypia, low to moderate cellularity, rare mitotic figures and collagen. They do not typically metastasize, but they can recur locally and be fairly aggressive, particularly if the lesion is inadequately excised. Wide surgical excision is therefore critical in the management of these patients. Fibromatosis can occur anywhere in the breast, but is often noted in close proximity to the pectoral muscle. Nipple retraction has been reported in lesions close to the nipple. In some patients, this lesion is associated with Gardner syndrome. An association with trauma and silicone implants has also been reported. Although they are typically painless, they can be tender, as in this patient. Histologically, it is important to distinguish these lesions from fibrosarcomas that can metastasize.

Patient 20

Figure 3.20. Diagnostic evaluation, 42-year-old patient with a history of Ewing sarcoma of the spine 15 years ago, previously treated with radiation therapy, and right breast cancer treated with lumpectomy and radiation therapy 3 years prior to this mammogram. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D) spot compression views, left breast. Ultrasound images, in radial (RAD) (E) and antiradial (ARAD) (F) projections of the lesion at 6 o'clock in zone 3 (Z3).

 

 

What do you think?

What recommendations would you make to this patient?

The right breast is smaller compared to the left, and surgical clips are present on the mediolateral oblique view, anterior to the pectoral muscle, consistent with the history of a right breast cancer 3 years that was previously treated conservatively. Do you see a potential abnormality in the left breast? How about additional evaluation before making any recommendations?

 

How would you describe the finding, and what differential considerations would you entertain?

What is your recommendation?

A 1.2-cm irregular mass with areas of lobulation, as well as indistinct and ill-defined margins, is confirmed on the spot compression views. This is a vertically oriented hypoechoic mass with indistinct, partially microlobulated, spiculated, and angular margins on ultrasound. The mammographic and sonographic findings are suggestive of an ongoing malignant process, particularly in a patient with a personal history of breast cancer. Differential considerations include a metachronous invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, lymphoma, or a metastatic lesion. Rarely, ductal carcinoma in situ can present as a mass, asymmetric density, or distortion in the absence of microcalcifications. Benign considerations include an inflammatory process or posttraumatic changes, focal fibrosis, a papilloma, sclerosing adenosis, granular cell tumor, and an extra-abdominal desmoid. A biopsy is indicated.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered. An ultrasound-guided biopsy is undertaken. A complex ductal carcinoma in situ (DCIS) is reported on the core samples. A complex DCIS measuring 1.1 cm is confirmed on the lumpectomy specimen. No invasion is reported. Two excised sentinel lymph nodes are normal [pTis(DCIS), pN0(sn) (i—), pMX; Stage 0].

Pleomorphic calcifications, particularly when individual calcifications are linear, or when linear, round, and punctate calcifications demonstrate linear orientation (distribution), are the most common mammographic findings associated with DCIS. Rarely, DCIS can be detected mammographically as a mass (well circumscribed to spiculated, and in some patients macrolobulated), focal parenchymal asymmetry, or distortion in the absence of calcifications. Clinically, some patients diagnosed with DCIS present with a palpable mass, spontaneous nipple discharge (which can be clear or serous, negative for occult blood) or Paget's disease of the nipple.

Patient 21

Figure 3.21. Diagnostic evaluation, 64-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views, metallic BB at site of clinical concern. Spot tangential (C) view, right breast mass. Ultrasound images in radial (RAD) (D) and antiradial (ARAD) (E)projections of the palpable (PALP) finding, right breast.

What is your differential, and what is the next appropriate step in the evaluation of this patient?

A 2.5-cm oval mass with indistinct margins is imaged at the site of concern to the patient, laterally in the right breast. Benign differential considerations based on the mammographic finding include a cyst (a galactocele is unlikely in a 64-year-old woman), fibroadenoma (complex fibroadenoma, tubular adenoma), phyllodes tumor, papilloma, nodular adenosis, pseudoangiomatous stromal hyperplasia (PASH), focal fibrosis, posttraumatic fluid collection, and abscess. Malignant considerations include invasive ductal carcinoma not otherwise specified, mucinous carcinoma, papillary carcinoma, and lymphoma. A metastatic lesion is also a consideration, particularly if there is a history of an underlying malignancy (melanoma, lung, renal, colon, etc.), although, in the differential for a round, well-circumscribed mass, medullary carcinoma is less likely given the patient's age. Invasive lobular carcinomas do not usually present as round or oval masses. Correlative physical examination and an ultrasound are undertaken.

How would you describe the findings and further evaluate this patient?

A hard mass is palpated at the 10 o'clock position, posteriorly (Z3) in the right breast. A complex cystic mass with indistinct, microlobulated, spiculated, and angular margins is imaged corresponding to the palpable mass. Given the mammographic and sonographic findings, a poorly differentiated, invasive ductal carcinoma with necrosis is the leading diagnostic consideration. A stepwise approach is taken in the evaluation of this patient. The first step is to attempt an aspiration. If no fluid is obtained, or there is a residual abnormality after the aspiration, an ultrasound-guided core biopsy is done. Although it is unlikely, if nonbloody fluid is aspirated and no residual abnormality is seen on ultrasound, a pneumocystogram can be done to evaluate for the presence of mural abnormalities. Only a small amount of bloody fluid is aspirated in this patient. A core biopsy is done.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered. An invasive ductal carcinoma with necrosis is reported on the core samples. A 3.2-cm, grade III invasive ductal carcinoma is diagnosed on the lumpectomy specimen. Lymphovascular space involvement is present. Malignant cells are described on the imprints from one of two sentinel lymph nodes; a full axillary dissection is completed at the time of the lumpectomy. Metastatic disease with extracapsular extension is described involving the sentinel lymph node. No metastatic disease is diagnosed in 14 additional excised lymph nodes [pT2, pN1a, pMX; Stage IIB]. The tumor is aneuploid and negative for estrogen and progesterone receptor expression.

Poorly differentiated, necrotic, invasive ductal carcinomas often present as round or oval, circumscribed (as opposed to spiculated), solid masses with posterior acoustic enhancement and associated cystic changes (reflecting the necrotic tumor). A rim of poorly differentiated invasive ductal carcinoma is commonly present. It has been suggested that extensive necrosis may be a poor prognostic factor, particularly because nearly 50% of patients with necrotic tumors have axillary nodal metastases and the tumors are aneuploid and typically lack estrogen and progesterone receptors, as described for this patient. It may be that these tumors are proliferating so rapidly that they are outstripping their vascular (angiogenetic) supply.

Lymphovascular space involvement is described in approximately 15% of patients with invasive ductal carcinoma. It has been described as an unfavorable prognostic finding, particularly in node-negative patients treated with either mastectomy or lumpectomy. The significance in patients with positive axillary lymph nodes (such as our current patient) is not clear. Extracapsular tumor extension in involved lymph nodes has also been described as an unfavorable prognostic factor, and some consider this finding an indication for axillary irradiation, particularly in patients who have not had an axillary dissection. The presence of metastatic disease in axillary lymph nodes, however, is the single most important prognostic factor, and there is a direct correlation between the number of positive lymph nodes and disease-free survival as well as mortality.

 

 

Patient 22

Figure 3.22. Diagnostic evaluation, 76-year-old woman called back for further evaluation of the axillary lymph nodes. Spot compression (A, B) views, left axilla. Similar findings are noted in the right axilla (not shown).

How would you describe the findings, and what is your differential?

Several axillary lymph nodes present with punctate, round, and amorphous forms of a high-density material (lacelike in appearance). Although they are somewhat high in density, these may reflect calcifications. Granulomatous diseases including histoplasmosis, tuberculosis, and sarcoid involving axillary lymph nodes may calcify; however, calcifications reflecting granulomatous changes are usually coarse, dense, and larger that what is seen in this patient. Metastatic disease from ovarian or thyroid papillary-type primaries can present with round, punctate, and amorphous calcifications involving one or several axillary lymph nodes. In these diseases the calcifications usually reflect psammoma body formation in the tumor. Lastly, calcifications may be seen in the lymph nodes involved with metastatic disease from a breast primary. These typically represent calcifications developing in a necrotic tumor. Although there have been reports of ductal carcinoma in situ with associated calcifications in the axillary lymph nodes, this is exceedingly rare (i.e., one would not expect metastatic disease to an axillary lymph node to reflect an intraductal, noninvasive process).

Is there any other possibility to consider?

The alternative possibility is that this material is not calcium and, given the high density of the material, this should be suspected. In the past, patients with rheumatoid arthritis have been treated with systemic gold. Mammographically, the gold can be seen deposited bilaterally in all of the visualized intramammary and axillary lymph nodes. Given the bilateral involvement of all lymph nodes in this patient, the next appropriate step is to talk to the patient and ask her if she has rheumatoid arthritis and if she has been treated with gold. The answer is yes, she has rheumatoid arthritis and she has been treated with systemic gold. No further intervention or follow-up indicated.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended.

 

Patient 23

Figure 3.23. Diagnostic evaluation, 88-year-old patient presenting with tender “lumps” bilaterally. Craniocaudal (A) and mediolateral oblique (B) views.

 

What do you think?

In reviewing films, what information do you look at?

There is a dense fibroglandular pattern. No focal abnormality is apparent. In reviewing films you should routinely review the name of the patient, date of birth, and the technical factors used to obtain the image (e.g., kilovoltage, milliamperage, centimeters of compression, angle of obliquity used for the mediolateral oblique view). Remember: Make no assumptions. Although most patients who present with a breast-related problem are women, not all are. By verifying the name of the patient (and talking with the technologist), you can establish that this is a male patient presenting with tender, bilateral “lumps.” The lumps the patient is describing reflect the presence of breast tissue. He has developed gynecomastia and requires no additional imaging evaluation or follow-up.

BI-RADS® category 2: benign finding.

Male patients who present for breast imaging are usually symptomatic and describe uni- or bilateral breast enlargement, a mass, or focal tenderness. Our role with these patients is to exclude an underlying malignancy. Depending on the underlying process, mammographic findings will vary. In men with gynecomastia, glandular tissue is imaged centered on the subareolar area. The amount of tissue can vary from a few trabecular strands to dense tissue indistinguishable from that seen in some women. The findings may be uni- or bilateral, symmetric or asymmetric in appearance. The diagnosis of gynecomastia is established mammographically; sonography is not usually indicated. On ultrasound, gynecomastia has a variable appearance. It is often an irregular area of hypoechogenicity centered in the subareolar area. Pseudogynecomastia may be seen in obese men as breast enlargement characterized by adipose tissue with no associated glandular tissue.

The mammographic presentation of male breast cancer is similar to that described in women and includes a spiculated or round mass that may have associated pleomorphic microcalcifications. Less commonly, distortion or asymmetry may be seen. The lesions may be subareolar, or more eccentric in location.

What is gynecomastia, and is it considered a risk factor or a precursor for the subsequent development of male breast cancer?

Do these patients require mammographic follow-up?

Gynecomastia reflects the proliferation of ductal and stromal tissue in male patients. It can present as unilateral or bilateral (simultaneously or at different times) diffuse breast enlargement that may be associated with tenderness or as a “mass” centered in the subareolar area. Gynecomastia is not considered to be a risk factor or a precursor lesion for the development of male breast cancer. If the clinical and mammographic findings are consistent with gynecomastia, I do not recommend any additional imaging studies or follow-up.

In what groups of males can gynecomastia be seen as a “physiologic” change?

Physiologic gynecomastia related to hormonal imbalances can occur during three different phases in male patients. In newborn males, rapidly regressing gynecomastia is common and reflects the effect of placental estrogens. As many as 60% to 70% of pubertal boys (ages 12 to 15) present 1 to 2 years after testicular enlargement begins with gynecomastia that typically regresses within 2 years of onset. Lastly, in older males, as testosterone levels decrease, and particularly in those with a body mass index greater than 25 kg/m2, breast enlargement may be seen.

What are some of the conditions that should be considered in a male presenting with gynecomastia who does not fall into one of the three categories of physiologic gynecomastia?

Pathophysiologic causes of gynecomastia can be considered in several major categories, including (1) estrogen excess (tumors including Leydig, Sertoli, and granulosa-theca cell tumors, choriocarcinoma, seminoma, teratoma, embryonal cell, hepatoma, and pituitary and feminizing adrenal tumors), (2) androgen deficiency (primary testicular failure—e.g. Klinefelter's syndrome—secondary testicular failure from trauma, orchitis, cryptorchidism, irradiation, hydrocele, or varicocele), (3) drug related (anabolic steroids, diethylstilbestrol, digitalis, estrogen, heroin, marijuana, cimetidine, diazepam, ketoconazole, phenytoin, spironolactone, amiodarone, bumetanide, busulfan, calcitonin, furosemide, isoniazid, methyldopa, nifedipine, reserpine, theophylline, tricyclic antidepressants, verapamil, finasteride), (4) systemic diseases (hyperparathyroidism, cirrhosis, chronic renal failure, chronic pulmonary disease, acquired immunodeficiency syndrome [AIDS] and human immunodeficiency virus [HIV] infection, and chest wall trauma) and (5) idiopathic.

What histologic features are associated with the two main phases of gynecomastia?

Gynecomastia is characterized histologically by an active, florid proliferative phase of ducts and an inactive fibrous phase. Epithelial proliferation with papillary and cribriform-like patterns, associated myoepithelial cell hyperplasia, and increased cellularity of the periductal stroma with increased vascularity is described in the florid proliferative phase. Within 1 to 2 years of onset, the epithelial proliferation becomes much less prominent and dense fibrous stroma with sparse cellularity and decreased vascularity are present. Pseudogynecomastia is characterized by adipose tissue with no ductal or stromal proliferation.

What component of female breast tissue is not typically seen in men who develop gynecomastia (consequently, what group of pathologic processes is rare in men)?

Lobule formation is not typically seen in otherwise normal men. Consequently, lobular processes such as fibroadenomas, cysts, sclerosing adenosis, and invasive lobular carcinoma are rare in men. Ductal and stromal processes such as papillomas, duct ectasia, pseudoangiomatous stromal hyperplasia, apocrine metaplasia, and squamous metaplasia have been reported in men and in association with gynecomastia. Inflammatory processes, epidermal inclusion cysts, lipomas, intramammary lymph nodes, granular cell tumors, and fat necrosis related to trauma can also affect male patients, with presentations similar to those described in women.

 

What management options are available for men with gynecomastia?

At the time of presentation, it is important to exclude a serious underlying cause of gynecomastia (e.g., an estrogen-secreting tumor). Treating (or removing) the underlying cause is appropriate for those men in whom the cause of the gynecomastia is identified. In considering treatment for those patients in whom no definite cause for the gynecomastia is identified, it is important to recognize that in most men, a conservative approach is appropriate because spontaneous regression is common. Reassurance that the process is benign may be all that is needed. However, several medical treatments have been reported, with variable responses (and associated, sometimes, with significant side effects), including the use of dihydrotestosterone, danazol, and tamoxifen. The surgical option of a simple mastectomy is available; however, cosmetic results may not be optimal. More recently, liposuction has been used to treat some men with gynecomastia.

Patient 24

Figure 3.24. Screening study, 55-year-old woman with implants in a subpectoral location. Implant-displaced, craniocaudal (A) and mediolateral oblique (B) views, left breast. Craniocaudal (C) and mediolateral oblique (D) views of the left breast, photographically coned. A box is used to enclose the potential abnormality. Double spot compression magnification views of the left breast, craniocaudal (E) and mediolateral oblique (F) projections. Ultrasound image (G) demonstrating high specular echoes and subtle shadowing corresponding to the area of mammographic concern in the left breast. Specimen radiograph (H) demonstrating distortion and associated punctate calcifications centrally as well as in the surrounding spicules. A portion of the localization wire is also evident.

Is this a normal mammogram, or is there a potential abnormality?

If there is an area of concern, where is it?

Review the images systematically. Split the images into thirds such that on the craniocaudal (CC) views you focus your attention on lateral, mid, and medial tissue, and on the mediolateral oblique (MLO) views you review the superior, mid, and inferior aspects of the breasts. Do you see anything? If not, look specifically for possible masses, asymmetry, distortion, or calcifications. Now do you see anything? If you still do not, look in specific places: fat–glandular interfaces, the strip of tissue between the pectoral muscle and glandular tissue on the MLO views, subareolar areas and medial tissue on CC views. In evaluating the medial quadrants on the CC views, do you perceive a subtle asymmetry with possible distortion on the left, anteriorly? In reviewing the left MLO at the approximate distance back from the nipple, there is also a possible area of asymmetry with distortion. The significance of this potential finding on these views is unknown. Additional evaluation will be helpful.

BI-RADS® category 0: need additional imaging evaluation.

 

 

Now how would you describe the findings, and with what degree of certainty can you say that a lesion is present?

The additional views are invaluable in helping us establish the presence of a lesion. An area of distortion with long, curvilinear spicules, central lucency, and associated punctate and round calcifications is confirmed on the additional views. At this point, what are your differential considerations and what would you recommend next? Differential considerations include fat necrosis, particularly if the patient has had a biopsy or trauma that is localized to this site, complex sclerosing lesion (radial scar when less than 1 cm in size), focal fibrosis, sclerosing adenosis, papilloma, an inflammatory process, invasive ductal carcinoma not otherwise specified, and invasive lobular carcinoma. Although it is somewhat larger than most, this could also be a tubular carcinoma.

How can you sort through this differential and narrow the diagnosis?

As a starting point, a good history is helpful. Does the patient have a scar that corresponds to this site? Does she recall any trauma to this site? If there is no scar or trauma localized to this site, fat necrosis is unlikely. Does the patient have any signs or symptoms of inflammation at this site (e.g., erythema, increased warmth, tenderness)? Physical examination is also helpful. Are there any palpable findings? Complex sclerosing lesions are usually not palpable, and normal or subtle findings are seen on ultrasound. In contrast, invasive ductal carcinomas of this size are usually palpable, and on palpation the findings with invasive ductal carcinoma often overestimate the size seen on imaging studies (i.e., they feel larger than what is seen on the images). On ultrasound, a mass that may have associated shadowing is likely with an invasive ductal carcinoma. Invasive lobular carcinoma is unpredictable: Physical findings may be normal, but either an area of thickening without a discrete mass or a mass may be palpable. On ultrasound, a mass with associated shadowing may be seen, but the ultrasound may be normal. This patient has had no surgery or trauma to this site, and her physical examination and ultrasound are normal. This is thought to most likely represent a complex sclerosing lesion.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

A complex sclerosing lesion with atypical aprocrine adenosis, columnar alteration with prominent apical snouts and secretions, and florid epithelial hyperplasia without atypia is reported on the excisional biopsy.

Lesions characterized by central sclerosis and surrounding radiating epithelial proliferation are referred to as a radial scar when they are >,1 cm in size and as complex sclerosing lesions when they are >.1 cm in size. Associated foci of sclerosing adenosis, papilloma formation, cystic changes, and epithelial hyperplasia may be seen in these lesions. Atypical hyperplasia, ductal carcinoma in situ (usually low nuclear grade), lobular neoplasia, and invasive carcinoma have also been reported arising within radial scars but, more commonly, in the larger complex sclerosing lesions. Identified as incidental findings on histology, radial scars (>,1 cm in size) are common, multiple, and often bilateral. In contrast, complex sclerosing lesions (>.1 cm in size) identified mammographically are less common, presenting as single, unilateral lesions. It has been suggested that infarction occurring in areas of pre-existing proliferative changes may account for the histologic findings. However, these lesions are considered idiopathic and, although the word “scar” is used for the smaller lesions, these lesions do not reflect biopsy changes (i.e., they do not occur at prior biopsy sites).

The mammographic findings that should suggest a complex sclerosing lesion include an area of distortion better seen in one of the two standard projections (usually the craniocaudal view), long curvilinear spicules that contrast with the short stubby spiculation seen with many invasive ductal carcinomas, and central lucency. Approximately 30% of these lesions may have associated round and punctate calcifications. The findings on ultrasound are variable and can be subtle, limited to a small amount of irregular shadowing. Physical examination is often normal or limited to some minimal thickening.

The management of women with complex sclerosing lesions remains controversial. If this entity is suspected based on the clinical and imaging findings, should an imaging-guided biopsy be done, or is an excisional biopsy the appropriate recommendation? If a complex sclerosing lesion is diagnosed following an imaging-guided core biopsy, is excision required or can the lesion be left in the breast? Based on my experience, approximately 30% of patients with complex sclerosing lesions have associated atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ (usually low nuclear grade), or tubular carcinomas. Consequently, if I suspect a complex sclerosing lesion based on the clinical and imaging features of lesion, I recommend an excisional biopsy. If I do a core biopsy on a lesion and a complex sclerosing lesion is reported histologically, I recommend excisional biopsy. Others advocate imaging-guided biopsy of these lesions with no excision required if the biopsy included at least 12 cores, no atypical ductal hyperplasia is reported, and the mammographic findings are reconciled with the histologic findings. It is unclear why there is such confusion in the literature regarding the appropriate management of these lesions. Could it be that, prognostically, the lesions we identify mammographically are not the same as those seen routinely by pathologists as incidental findings in biopsies done for other reasons? The lesions we identify mammographically are not common and almost always measure >. 1 cm in size; we do not routinely identify the small lesions (i.e., radial scars that measure >,1 cm) reported as common, benign incidental findings by the pathologist.

 

Patient 25

Figure 3.25. Diagnostic evaluation, 33-year-old patient presenting with a “lump” in the upper inner quadrant of the right breast. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal view (C), photographically coned to the medial aspect of the right breast, and 90-degree lateral spot compression view (D) of the upper aspect of the right breast, demonstrating the change in appearance of the calcifications on the orthogonal views. Ultrasound images (E–G), upper inner quadrant of the right breast. Cluster of variably sized cysts with associated echogenic foci (arrows) corresponding to the calcifications seen mammographically.

How would you describe the findings?

There is a dense fibroglandular pattern with a regional area of calcification in the upper inner quadrant of the right breast. Did you notice that the appearance of the calcifications is different between craniocaudal (CC) and mediolateral oblique (MLO) views? On the CC view, the calcifications are variable in size, round and not well defined (amorphous); on the MLO view, they are higher in density, better defined, and some demonstrate a curvilinear appearance. This differential appearance between the two views raises the possibility of milk of calcium and, although the diagnosis is established with the current views, a spot compression 90-degree lateral view can be done. In this patient, do we need to do anything else? How about the “lump” she is feeling? Remember not to be lulled by benign findings and forget to look at the rest of the mammogram and evaluate clinical findings.

 

What is indicated next?

Correlative physical examination and an ultrasound of the palpable finding are indicated. On physical examination, a 2- to 3-cm area of globular tissue is palpated, which occupies almost the entire upper outer quadrant of the right breast. It is readily mobile, and tenderness is elicited when gentle compression is applied at this site. No skin changes are present. On ultrasound, cysts of varying sizes are imaged throughout this area. Foci of echogenicity are identified in the dependent portion of many of the cysts. No solid masses are imaged in this quadrant, and there is no distortion or shadowing. This is a palpable fibrocystic complex with associated milk of calcium and corresponds to what the patient is concerned about. I reassure her that what she is feeling is benign and that there are no mammographic or sonographic findings to suggest breast cancer.

BI-RADS® category 2: benign finding.

 

 

Patient 26

Figure 3.26. Diagnostic evaluation, 73-year-old patient presenting with changes involving her left breast and back pain. Craniocaudal (A) and mediolateral oblique (B) views. Ultrasound images, radial (RAD) (C) and antiradial (ARAD) (D) projections. Photograph (E) of the breasts in this patient.

 

How would you describe the findings?

The left breast is diffusely abnormal. It is smaller and more dense than the right. Although the appearance is subtle, the tissue on the left has a distorted appearance with associated prominence of the trabecular markings. Diffuse breast changes can be difficult to perceive, particularly if they evolve slowly from one year to the next; however, if you prepare yourself by considering this possibility, they become easier to detect. In some patients, it can be hard to decide which of the breasts is normal. This is why reviewing prior studies and going back to much earlier mammograms can be useful in indicating the progressive change. Also, when you suspect diffuse changes, consider the technical factors used (e.g., centimeters used for compression, kilovoltage, and milliamperage) for the exposure.

Diffuse breast changes can be characterized by increased density of the breast parenchyma, prominence of the trabecular pattern (with a “spidery” appearance), and skin thickening that results in either a progressive decrease (shrinking) or increase in the size of the involved breast. Commonly, the affected breast is less compressible and requires higher kilovoltage and milliamperage for adequate exposure.

On physical examination the left breast is smaller than right (Fig. 3.26 E). There is distortion medially, dimpling inferiorly, and nipple retraction. The left breast is firm compared with the right, but no discrete mass is palpated, no tenderness is elicited, and there are no peau d'orange changes. On ultrasound (Fig. 3.26 C, D), the tissue at the 1 o'clock position, 2 cm from the left nipple, is distorted, with significant associated shadowing. Invasive lobular carcinoma is the leading diagnostic consideration in this patient. Less likely considerations include invasive ductal carcinoma, lymphoma, posttraumatic changes, or an ongoing inflammatory process. A biopsy is indicated. An invasive lobular carcinoma is diagnosed following ultrasound-guided core biopsy. The patient is also found to have a positive bone scan with lytic lesions involving the thoracic spine, consistent with metastatic disease.

A spiculated mass is the most common mammographic finding in women with invasive lobular carcinoma, occurring in nearly 40% of patients. Parenchymal asymmetry and distortion are the next most common mammographic findings. These changes may be more apparent in one projection, commonly the craniocaudal view. Diffuse changes include a progressive shrinkage of the involved breast or, alternatively, diffuse enlargement and reduced compressibility of the involved breast may be seen. Invasive lobular carcinoma rarely presents as a round or oval mass. Likewise, when an invasive lobular carcinoma is diagnosed following biopsies done for microcalcifications, the calcifications are usually not found in association with the invasive lesion. The calcifications are found in benign changes such as fibrocystic changes, fibroadenoma, and sclerosing adenosis, and the invasive lobular carcinoma is an incidental finding. It is important to emphasize that invasive lobular carcinoma can be subtle clinically, mammographically, sonographically, and pathologically (I refer to it as the “sleaze disease”). The extent of disease is often underestimated clinically, mammographically, and sonographically. In our own patients, metastatic disease to the axilla is seen in as many as 60% of patients at the time of presentation.

 

Patient 27

Figure 3.27. Diagnostic evaluation, 57-year-old patient with a history of left breast cancer treated with lumpectomy and radiation therapy. Craniocaudal (A) and mediolateral oblique (B) views. Ultrasound image (C), corresponding to the mass seen mammographically in the right breast and on physical examination directly over the location of the port-a-catheter. Follow-up mediolateral oblique (D) view and ultrasound (E), left breast, 6 months following that shown in (B, C). There has been almost complete resolution of the findings noted in (A–C).

 

How would you describe the findings and what would you do next?

The left breast is smaller compared to the right, there is prominence of the trabecular markings, and parenchymal asymmetry with distortion is seen at the lumpectomy site on the left. These findings are consistent with the history of lumpectomy and radiation therapy on the left. Did you notice the mass on the right? A mass with indistinct margins is present in the upper central to inner aspect of the right breast posteriorly. Although it is of concern, given its location (upper central to inner quadrant), the possibility that this is related to a prior port-a-catheter site should be considered.

On physical examination a healed scar is noted at the site previously occupied by the port-a-catheter in the upper inner quadrant of the right breast. An oval, 1-cm mass with a heterogeneous echotexture, indistinct margins, and a thin tract to the skin is seen corresponding to the scar site and the area of mammographic concern at the 1 o'clock position, 12 cm from the right nipple (Fig. 3.27C). This patient can be managed conservatively. The changes often evolve with complete resolution (Fig. 3.27D, E). Alternatively, the changes stabilize, and in some women calcifications can develop at these sites. Given the number of women with breast cancer who are receiving chemotherapy, you need to be aware of the changes that may be seen following removal of these catheters. These catheters are commonly placed in the upper inner quadrant of the contralateral, normal breast and removed following completion of chemotherapy. If you review prior films, the location of the port-a-catheter can be established and correlated with the appearance of this new finding. The changes we have seen following removal of a catheter include a round mass with well-circumscribed to indistinct margins, a spiculated mass, focal parenchymal asymmetry, and calcifications that can range from punctate, round, and pleomorphic to those with a more dystrophic appearance.

 

 

Patient 28

Figure 3.28. Diagnostic evaluation, 39-year-old woman presenting with a tender mass in the left axilla. Axillary view (A), left axilla. Ultrasound images (B–D) of the left axilla.

 

How would you describe the findings, and what is your differential?

An oval, well-circumscribed, macrolobulated mass is imaged on the axillary view, corresponding to the area of concern to the patient; a second mass is partially seen at the edge of the film inferiorly. No associated calcifications are present. On physical examination, several hard, movable, exquisitely tender masses are palpated in the left axilla. On ultrasound, well-circumscribed masses with prominent hypoechoic regions and central or eccentrically located areas of hyperechogenicity are imaged corresponding to the palpable findings and consistent with lymph nodes. The findings are nonspecific and the differential is extensive, ranging from reactive adenopathy to lymphoid hyperplasia, collagen vascular disorders (e.g., scleroderma, dermatomyositis), rheumatoid arthritis, granulomatous diseases (sarcoid, tuberculosis, histoplasmosis), human immunodeficiency virus, human immunodeficiency syndrome, dermatopathic, toxoplasmosis, cat scratch disease, metastatic disease (breast or other primary), and lymphoma.

In patients like this, what else might be very helpful in sorting through the differential?

How about obtaining a more extensive history relative to any other underlying systemic diseases, and also examining the patient? During the ultrasound study, as I am examining the patient, I notice several healing scratch marks on her left arm. On questioning her, she describes having recently acquired a kitten, with the scratches having occurred approximately 2 weeks previously. The suspected diagnosis of cat scratch disease is established following serologic testing.

What is cat scratch disease, how do humans contract the disease, and what are the clinical manifestations?

Cat scratch disease is a bacterial infection caused by Bartonella henselae and is transmitted to humans following a scratch, lick (on broken skin), or bite from an infected kitten or cat. It is not transmitted from human to human. The infection is more common in the fall and winter months. Within a couple of weeks following the exposure, the patient may develop tender, indurated, erythematous lymphadenopathy in close proximity to the inoculation site, lasting 4 to 6 weeks in most patients, although it can persist for up to a year. The most commonly involved lymph nodes groups include axillary, cervical, submandibular, preauricular, epitrochlear, femoral, and inguinal. Although infections are often mild, some patients can develop systemic symptoms including fever, fatigue, loss of appetite, headache, rash, and sore throat. In some patients the infection can involve the eye (Parinaud oculoglandular syndrome), with a sore on the conjunctiva, redness of the eye, and swollen preauricular lymph nodes. Rarely, with involvement of the central nervous system, encephalitis with high fever, coma, and convulsions can develop within 6 weeks following the development of lymphadenopathy. Optic neuritis with transient blindness has also been reported. Other rare manifestations include osteolytic bone lesions, granulomatous hepatitis, erythema multiforme, thrombocytopenia purpura, and mesenteric lymphadenitis. In most patients, however, this is a self-limited process that resolves on its own and requires no treatment. Although antibiotics are used in some patients, appropriate antibiotic coverage is not established.

What are the imaging features of cat scratch disease?

The intramammary and axillary lymph nodes on the side scratched by the cat can enlarge, increase in density, and lose the fatty hilar region; however, they typically remain well circumscribed. On ultrasound, the involved lymph nodes demonstrate prominence, thickening, and bulging of the hypoechoic cortical region and attenuation, mass effect, or loss of the echogenic focus usually seen in normal lymph nodes.

What are the histologic features of cat scratch disease?

Histologically, necrotizing granulomas surrounded by lymphocytes limited to the lymph nodes are the hallmark of this disease. Gram-negative, branching, Warthin-Starr–positive bacilli may be seen rarely in the necrotic centers. Cultures do not usually yield growth of the causative agent.

 

Patient 29

Figure 3.29. Diagnostic evaluation, 64-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B) views of the right breast. Spot tangential view (C) at the site of the palpable finding. The metallic BB is on the palpable finding. Ultrasound images, in longitudinal (LON) (D) and transverse (TRS) (E) projections corresponding to the palpable site at the 12 o'clock position, 5 cm from the right nipple.

 

How would you describe the findings, and what would you do next?

Glandular tissue is imaged in the right breast, with no apparent mass or distortion. Scattered dystrophic and arterial calcifications are noted. Correlative physical examination and an ultrasound are indicated.

 

How would you describe the findings, what is your differential, and what is your recommendation?

On physical examination, a hard mass is palpated at the 12 o'clock position, 5 cm from the right nipple. On ultrasound, a 1.2-cm, irregular mass with a heterogeneous echotexture and some minimal shadowing is imaged corresponding to the palpable finding. Differential considerations include invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, and lymphoma. Benign considerations are limited but include fibrosis or an inflammatory process. In the absence of focal symptoms, an inflammatory process is unlikely. Biopsy is indicated.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered. Diabetic fibrous mastopathy is diagnosed on the core biopsy. In these patients, an adequate amount of tissue may be difficult to obtain because the dense fibrosis may preclude adequate sampling. If inadequate sampling is a concern, excisional biopsy should be recommended.

How do patients with diabetic fibrous mastopathy present, and in what group of patients is this entity typically diagnosed?

Diabetic fibrous mastopathy is a rare entity affecting long-standing, insulin-dependent diabetic patients who present with one or multiple hard, irregular, readily mobile, discrete, painless palpable masses. Characteristically, dense glandular tissue is imaged mammographically, and an irregular mass with dense shadowing is imaged on ultrasound corresponding to the palpable area. Biopsies through these areas are often difficult because of the resistance encountered and the inability of the needle to cut through the tissue adequately. Given the history of diabetes, vascular calcifications are often seen bilaterally. Multiple lesions may be present, occurring simultaneously or at different times. Many of these patients have other complications associated with diabetes, including nephropathy, retinopathy, and neuropathy.

What histologic findings are reported in patients with diabetic fibrous mastopathy?

The lesions are characterized by dense fibrosis and a predominantly B-cell lymphocytic infiltrate surrounding ducts, lobules, and vessels. An autoimmune etiology has been suggested for this entity.

 

Patient 30

Figure 3.30. Diagnostic evaluation, 62-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views. Spot compression (C) view of “lump” in the right breast. Ultrasound image (D) in the radial projection of the palpable finding in the right subareolar area.

 

How would you describe the findings, and what is your differential?

Given the small breast size, prominent pectoral muscles, and the fatty pattern on the left, consider that this may be a male patient. This can be confirmed by looking at the name of the patient on the film. A 2.5-cm round mass, with partially well-circumscribed margins, is present in the right subareolar area. There are no associated calcifications. On physical examination, a hard, nontender mass is palpated in the subareolar area on the right. On ultrasound, a round mass with indistinct and microlobulated margins and associated posterior acoustic enhancement is imaged corresponding to the area of concern to the patient.

The differential in a male patient is limited. The main diagnostic consideration in men presenting with a “lump” is gynecomastia; however, the clinical and imaging findings in this patient are not consistent with gynecomastia. If there is a history of trauma or surgery, this could represent a posttraumatic or surgical fluid collection. An inflammatory process is also in the differential; however, no tenderness is elicited and no skin changes (e.g., erythema, warmth) are noted on exam. Other benign lesions that can be seen in men include pseudoangiomatous stromal hyperplasia, duct ectasia, papilloma, fat necrosis, epidermal inclusion cyst, and granular cell tumor. In the malignant category, an invasive ductal carcinoma not otherwise specified would be the leading consideration. Papillary carcinoma is reportedly more common in men; other subtypes that may be seen include medullary, mucinous, and adenoid cystic carcinoma. If the patient is known to have a malignancy (prostate, hematopoetic, etc.), this could represent a metastatic lesion. Because men do not usually have lobules, lobular processes such as fibroadenomas, cysts, sclerosing adenosis, and invasive lobular carcinomas are rarely seen in men.

What is your recommendation?

A biopsy is indicated and done. An invasive ductal carcinoma is diagnosed following the core biopsy. A grade III, 2.5-cm invasive ductal carcinoma not otherwise specified, with associated vascular/lymphatic invasion, is confirmed on the mastectomy. Four of eight lymph nodes have metastatic disease, and extracapsular extension is described in one of the positive lymph nodes [pT2, pN2, pMx, Stage IIB].

What are some of the risk factors for male breast cancer?

Male breast cancer is uncommon, accounting for >,1% of all breast cancers. Men with breast cancer present at slightly older ages compared to women and often have longer duration of symptoms. Several risk factors have been postulated for male breast cancer, including increased levels of estradiol and other estrogenic hormones; mumps orchitis (after age 20 years); testicular trauma; undescended testis; traumatic injury to the breast; cirrhosis; history of employment in steel works, blast furnaces, and rolling mills; radiation exposure; Klinefelter's syndrome; the BRCA 2 mutation; and less commonly, but reported, BRCA1. Gynecomastia is not considered a risk factor or a precursor for male breast cancer.

How do men with breast cancer typically present, and what forms of breast cancers are typically diagnosed histologically?

Most male patients present with a painless mass that is either subareolar or more eccentric (e.g., upper outer quadrant) in location or describing nipple discharge. Invasive ductal carcinoma not otherwise specified represents nearly 85% of all breast cancers diagnosed in male patients. An associated intraductal component may be seen in as many as 50% of invasive lesions. About 5% to 10% of patients are diagnosed with intraductal disease in the absence of invasion. Given the absence of lobular tissue in most males, invasive lobular carcinoma is rare. Prostate cancer with metastasis to the breast can sometimes be difficult to distinguish from primary breast cancer, particularly because some prostate cancers are estrogen receptor–positive.

 

Patient 31

Figure 3.31. Diagnostic evaluation, 66-year-old patient presents describing changes in her right breast. Craniocaudal (A) and mediolateral oblique (B)views. The technical factors used for the routine views are as follows: Ultrasound images (C, D) taken in the radial projection in the upper outer quadrant of the right breast.

Factor

RTCC

LTCC

RTMLO

LTMLO

kV

35

28

35

28

mAs

201

319

170

341

Comp (mm)

101

79

94

81

           

 

What do you think, and what additional information would you like?

The right breast is diffusely abnormal and appears smaller than the left. The decreased compressibility of the right breast is evidenced by the increased number of millimeters required for compression. Also notable is the 35 kV used to obtain adequate exposure of the right breast.

Differential considerations for diffuse changes that are usually unilateral, although rarely can be bilateral, include radiation therapy effect, inflammatory changes (e.g., mastitis), trauma (e.g., hematoma, edema), ipsilateral axillary adenopathy with lymphatic obstruction, dialysis shunt in the ipsilateral arm with fluid overload, invasive ductal carcinoma not otherwise specified, inflammatory carcinoma, invasive lobular carcinoma, or lymphoma. Invasive lobular carcinoma can lead to increases in breast density and size or a decrease in breast size (the shrinking breast). Differential considerations for diffuse changes that are usually bilateral, although they can be unilateral, include hormone replacement therapy (e.g., estrogen), weight changes, congestive heart failure, renal failure with fluid overload, and superior vena cava syndrome. Additional rare benign causes include granulomatous mastitis, coumadin necrosis, arteritis, and autoimmune disorders (e.g., scleroderma). Obtaining a thorough history, examining the patient, and doing an ultrasound are often helpful in sorting through the differential considerations.

 

Based on the ultrasound images alone, what is the most likely diagnosis?

Sonographically, the tissue is hyperechoic consistent with hyperemia, and the normal tissue architecture/planes are disrupted with associated scattered fluid collections. The sonographic findings are suggestive of posttraumatic or inflammatory changes. During the mammogram and when doing the ultrasound, no significant tenderness is elicited, as would be expected if this were an ongoing bacterial inflammatory process. In scanning the patient, the radiologist is in a unique position to obtain a thorough, accurate history from the patient. Indeed, in this patient, the history of a car accident with airbag deployment is obtained from the patient as the ultrasound is being done. She describes significant ecchymosis, diffusely involving the breast, following the accident that has now resolved completely. The findings in this patient are likely related to the trauma.

Although a BI-RADS® category 2: benign finding is used, the patient is asked to return in 3 to 4 months for follow-up. As this process resolves, mixed-density masses (fat containing) and oil cysts may develop; alternatively dystrophic calcifications may be seen, or the findings may resolve completely with no intermediate stages.

Note that the assessment categories should be considered independent of the recommendation. In this patient the finding is benign, yet a short-interval follow-up is recommended. In patients in whom I suspect an inflammatory condition or posttraumatic/surgical changes, I recommend a 3- to 4-month follow-up. Under these circumstances, a rapid change in the findings is expected. Six months is the usual recommendation for other patients in whom a short-interval follow-up is recommended (e.g., those with assessment category 3—probably benign lesion—well-circumscribed mass in a woman with no prior films).

 

Patient 32

Figure 3.32. Diagnostic evaluation, 42-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views. Metallic BB is seen on the craniocaudal view at the site of concern to the patient. Craniocaudal (C) and mediolateral oblique (D) spot compression views of palpable abnormality, right breast. Ultrasound images, in radial (RAD) (E) and antiradial (ARAD) (F) projections of the palpable finding in the right breast. Magnetic resonance, subtraction image (G) of the lesion in the right breast.

 

How would you describe the findings, and what are the main differential considerations?

The overall density of the breast parenchyma on the right is increased, and a mass with distortion is noted in the right craniocaudal view at the site of concern to the patient (metallic BB). The right craniocaudal spot compression view confirms the presence of a mass with indistinct and obscured margins, associated distortion, and punctate calcifications. Except for some punctate calcifications, the findings on the mediolateral oblique spot compression view are not striking: No definite mass is seen, there is scalloping of the tissue, and fat seems to be present, intermingled with glandular tissue. Although tumors are usually three-dimensional and readily apparent on all views, there may be times when the findings are more striking in one of the two projections obtained. This is particularly true for invasive lobular carcinoma; however, it can also be seen with invasive ductal carcinoma. Rarely, an inflammatory process might present with this constellation of findings.

On physical examination, a hard fixed mass is palpated, involving the right breast centrally. A 2.5-cm round mass with indistinct, angular, and microlobulated margins is imaged at the 12 o'clock position, 2 cm from the right nipple, corresponding to the palpable finding. Shadowing and enhancement are seen as different areas of the mass are scanned (Fig. 3.32E, F). On magnetic resonance imaging (MRI), the mass demonstrates rapid wash-in and wash-out of contrast, consistent with a malignancy (Fig. 3.32G). No additional lesions are identified in either breast on MRI.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

An ultrasound-guided biopsy is done. An invasive ductal carcinoma and ductal carcinoma in situ are diagnosed on the core biopsy. The patient is treated with neoadjuvant chemotherapy followed by lumpectomy and sentinel lymph node biopsy. Residual grade III invasive ductal carcinoma (1.5 cm) and high-grade ductal carcinoma in situ with central necrosis are reported following the lumpectomy. The sentinel lymph node is normal [ypT1c, pN0(sn) (i—), pMX; Stage I].

Traditionally, neoadjuvant therapy (preoperative chemotherapy) has been the treatment of choice in women with inflammatory breast carcinoma. It is being used with increasing frequency, however, in women with locally advanced cancer. Following therapy, as the tumor is downstaged, some of these patients can be treated appropriately with breast-conserving surgery. Patients with a complete histologic remission following neoadjuvant therapy have significantly improved long-term survival compared to those with partial or no response to therapy. Following breast-conserving surgery, radiation therapy is also used to treat these patients.

 

 

Patient 33

Figure 3.33. Diagnostic evaluation, 77-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views, right breast, with a metallic BB placed at the site of the palpable finding. Spot tangential (C) view, palpable finding, right breast. Metallic BB used to indicate location of “lump.” Ultrasound image (D) in the longitudinal projection at the site of concern in the upper outer quadrant of the right breast.

What do you think, and with what degree of certainty can you make any recommendations?

What else might be helpful in evaluating women who present with localized findings?

Coarse dystrophic calcifications are present; however, no significant abnormality is apparent on the craniocaudal and mediolateral oblique views of the right breast. A spot tangential view at the site of the palpable finding is done routinely in patients with localized findings. In some patients, the lesion may be partially or completely outlined by fat on the spot tangential view, facilitating detection and characterization of the palpable finding.

 

Now what can you say, and with what degree of certainty?

What is your differential?

A spiculated mass is imaged on the spot tangential view, corresponding to the palpable finding. Scalloping of sharply defined, thin Cooper ligaments can be seen at the subcutaneous fat–glandular tissue interface in many women. When a ligament is thickened, straightened, or appears irregular and spiculated, as shown here, it is of concern and further evaluation is indicated. Differential considerations include invasive ductal carcinoma not otherwise specified, tubular carcinoma, and invasive lobular carcinoma. Benign considerations include fat necrosis (posttrauma or surgery), sclerosing adenosis, papilloma, complex sclerosing lesion, and inflammatory changes. Rare causes include granular cell tumor or fibromatosis (extra-abdominal desmoid).

 

How would you describe the findings, and what is indicated next?

On ultrasound, an irregular, hypoechoic, 1-cm mass with spiculated and angular margins and associated shadowing is imaged at the 10 o'clock position, 7 cm from the nipple. This corresponds to the area of concern to the patient and the mammographic finding.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

An ultrasound-guided biopsy is done and an invasive mammary carcinoma is reported on the cores. A 1.1-cm grade I invasive mammary carcinoma with tubulolobular features and associated intermediate-nuclear-grade ductal carcinoma in situ is reported on the lumpectomy specimen. Extensive perineural invasion is seen. No metastatic disease is seen in three excised sentinel lymph nodes [pT1c, pN0(sn) (i—), pMX; Stage I].

Tubulolobular carcinomas are classified as a variant of invasive lobular carcinomas, characterized by the presence of small, cohesive cells infiltrating the stroma in single files and the formation of tight tubules (similar to those described for tubular carcinomas but smaller). However, it should be noted that the classification of a lesion with tubules as invasive lobular carcinoma is controversial. Perineural invasion is not a common finding in breast cancers (>, 10% of invasive carcinomas) and reportedly has no prognostic significance.

 

Patient 34

Figure 3.34. Diagnostic evaluation, 31-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views, metallic BB placed at the site of the palpable finding (spot tangential view, not shown). Double spot compression magnification views, craniocaudal (C)and mediolateral oblique (D) projections. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections of the palpable finding, left breast.

 

How would you describe the findings, and what is indicated next?

Given the presence of calcifications on the routine views, double spot compression magnification views are done for further characterization of the calcifications and the extent of disease. A cluster of pleomorphic calcifications is imaged corresponding to the “lump” described by the patient, but no mass is seen mammographically. Correlative physical examination and an ultrasound are undertaken for further evaluation of the palpable findings.

 

How would you describe the findings, and what is your differential?

A hard mass is palpated on physical examination. A 1.2-cm oval hypoechoic mass with indistinct margins and associated calcifications is imaged on ultrasound at the 12 o'clock position, 3 cm from the left nipple. Cooper ligaments are disrupted and there is mass effect on the deep pectoral fascia. Differential considerations include fibroadenoma (complex fibroadenoma with, because of the associated calcifications, associated sclerosing adenosis; tubular adenoma), sclerosing adenosis, papilloma, phyllodes tumor, pseudoangiomatous stromal hyperplasia, and invasive ductal carcinoma not otherwise specified with associated ductal carcinoma in situ. A ductal carcinoma in situ, with no associated invasive component, is also a possibility, although less likely given the presence of a palpable mass that is confirmed on ultrasound. A biopsy is indicated.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

A ductal carcinoma in situ is diagnosed on ultrasound-guided core biopsy. A 1.4-cm, intermediate-nuclear-grade, ductal carcinoma in situ with a cribriform pattern and central necrosis is diagnosed on the lumpectomy specimen. No invasion is reported. No metastatic disease is diagnosed in four excised sentinel lymph nodes [pTis(DCIS), pN0(sn) (i—), pMX; Stage 0].

Patients with ductal carcinoma in situ (DCIS) can present clinically with a palpable mass, spontaneous nipple discharge, or Paget's disease. More commonly, however, DCIS is clinically occult, diagnosed following the mammographic detection of pleomorphic calcifications, particularly when some of these are linear, or when linear, round, and punctate calcifications demonstrate linear orientation. Less commonly, DCIS can be detected mammographically as a mass (well circumscribed to spiculated, in some patients macrolobulated), focal parenchymal asymmetry or distortion in the absence of calcifications.

The use of sentinel lymph node biopsy (SLNB) in patients with DCIS remains controversial. It is probably indicated in women with DCIS and known microinvasion and in those patients in whom invasive disease is suspected preoperatively based on the size or imaging features of the DCIS. An alternative approach that can be taken is to excise the DCIS and, if invasive disease is identified on the lumpectomy specimen, the SLNB is done as a second operative procedure.

 

Patient 35

Figure 3.35. Diagnostic evaluation, 40-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned. Craniocaudal (C) and mediolateral oblique (D) spot compression views of palpable finding. Ultrasound image (E) of the palpable (PALP) finding at the 4 o'clock position, anteriorly (Z1) in the left breast.

 

How would you describe the findings, and what differential considerations do you have at this point?

What would you do next?

A well-circumscribed, round, water-density mass is imaged corresponding to the “lump” described by the patient. Benign differential considerations based on the mammographic finding include a cyst, galactocele (provided the history supports this), fibroadenoma (complex fibroadenoma, tubular adenoma), phyllodes tumor, papilloma, nodular adenosis, pseudoangiomatous stromal hyperplasia (PASH), focal fibrosis, posttraumatic (or surgical) fluid collection, vascular lesions, granular cell tumor, and abscess. Malignant considerations include invasive ductal carcinoma not otherwise specified, medullary carcinoma, adenoid cystic carcinoma, and lymphoma. Although they are included in the differential for round, well-circumscribed masses, mucinous and papillary carcinomas are unlikely given the patient's age. Correlative physical examination and an ultrasound are indicated for further evaluation.

 

Given the ultrasound findings and the additional history provided, how would you manage the patient?

On physical examination, a superficial, discrete, hard, readily mobile mass is palpated at the site of concern to the patient. A 1-cm, round, well-circumscribed, complex cystic mass with posterior acoustic enhancement is imaged corresponding to the palpable mass. As the ultrasound is being done, the history of a recent pregnancy is elicited from the patient so that a galactocele is a realistic possibility. This patient can be managed in one of two ways. If the patient is otherwise asymptomatic, follow-up in 3 to 4 weeks is a possibility. Alternatively, if this mass is tender, or the patient remains concerned after the discussion of possible etiologies, a stepwise approach is taken for further evaluation. The first step is to attempt an aspiration. If no fluid is obtained, or if a residual abnormality is seen after the aspiration, an ultrasound-guided core biopsy is done. In this patient, thick milky fluid is aspirated and no residual abnormality is seen following the aspiration. No further intervention or follow-up is indicated.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

What are the imaging findings associated with galactoceles?

Women with galactoceles can present in the third trimester of pregnancy, during lactation, or even several years following the cessation of lactation with a mass that may be tender. Mammographically, galactoceles are often well-circumscribed, round, water- or mixed-density masses but can be characterized by ill-defined and indistinct margins, particularly if they are inflammed. Rarely, a fat/fluid level may be seen. The ultrasound appearance of these lesions is also quite variable, ranging from well-circumscribed solid or cystic masses to complex cystic masses with posterior acoustic enhancement; however, some may be indistinct and associated with significant shadowing. Fluid/fluid levels may be also seen on ultrasound. If they are tender, or the diagnosis cannot be established based on clinical and imaging findings, an aspiration is indicated. If there is a residual abnormality following the aspiration, or concerns persist regarding the diagnosis, a core biopsy can be done.

 

Patient 36

Figure 3.36. Diagnostic evaluation, 47- year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views, right breast, photographically coned; metallic BB seen on the mediolateral oblique view at the site of the “lump.” Spot tangential (C) view of the palpable finding, right breast. Ultrasound images of palpable finding, in longitudinal (LON) (D) and transverse (TRS) (E) projections, at the 9 o'clock position, 5 cm from the right nipple.

Based on the routine views, what can be said and with what degree of certainty?

What would you do next?

No abnormality is perceived on the routine views. A spot tangential view at the site of the “lump” is helpful in many patients because the lesion may be partially or completely outlined by fat enabling visualization and characterization.

 

Now what can you say, and with what degree of certainty?

The spot tangential view demonstrates a spiculated mass corresponding to the area of clinical concern. The differential considerations at this point include invasive ductal carcinoma not otherwise specified (NOS), tubular carcinoma, and invasive lobular carcinoma. Benign considerations include fat necrosis (posttrauma or surgery), sclerosing adenosis, papilloma, focal fibrosis, complex sclerosing lesion, and inflammatory changes (mastitis). Rare causes include granular cell tumor and fibromatosis (extra-abdominal desmoid). Unless there is a direct correlation of this area to a site of prior trauma or surgery, this finding requires biopsy.

A 1-cm hypoechoic, irregular mass with indistinct and angular margins and shadowing is imaged, embedded and disrupting a thickened Cooper's ligament (Fig. 3.36D, E). The clinical, mammographic, and ultrasound findings indicate a biopsy is required.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

An ultrasound-guided needle biopsy is done, and an invasive mammary carcinoma is diagnosed on the core samples. A 1.3-cm grade I invasive ductal carcinoma with associated intermediate-grade ductal carcinoma in situ is reported on the lumpectomy. Extensive lymphovascular space involvement is also noted; however, four excised sentinel lymph nodes are normal: [pT1c, pN0(sn) (i—), pMX; Stage I].

Shrinkage artifact can simulate lymphovascular space involvement as artifactual spaces are created around tumor cells during processing. Consequently, the diagnosis of lymphovascular space involvement is sometimes difficult and subjective. Lymphovascular space involvement is described in approximately 15% of patients with invasive ductal carcinoma and in 5% to 10% of patients with no metastatic disease to axillary lymph nodes. It has been described as an unfavorable prognostic finding, particularly in node-negative patients treated with either mastectomy or lumpectomy. The presence of extensive lymphovascular space involvement in patients with otherwise favorable tumors seems to identify a subset of patients with higher systemic recurrences and mortality rates from metastatic breast cancer.

 

Patient 37

Figure 3.37. Diagnostic evaluation, 44-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) spot compression views of a “lump” in the left breast. Ultrasound images (C, D) of palpable finding, left breast.

 

How would you describe the findings, and what is your differential?

An oval mass with partially well-circumscribed and obscured margins is imaged corresponding to the palpable finding. Based on the mammographic findings, benign differential considerations include cyst, galactocele, fibroadenoma (tubular adenoma, complex fibroadenoma), phyllodes tumor, focal fibrosis, pseudoangiomatous stromal hyperplasia, abscess, and posttraumatic fluid collection. Malignant considerations include invasive ductal carcinoma not otherwise specified and medullary carcinoma. Mucinous or papillary carcinomas and metastatic lesions usually present as round or oval masses; however, given the patient's age, these are less likely considerations.

A 2.5-cm oval hypoechoic mass with a cystic component is imaged corresponding to the palpable finding at the 9 o'clock position, posteriorly in the left breast (Fig. 3.37C, D). Although the margins are well circumscribed superficially, this is not so for the deep margins.

Would you agree with a BI-RADS® category 3 (probably benign lesion, short-interval follow-up is recommended) designation for this mass?

Why not?

If not, what would you recommend be done next?

This lesion does not fit the definition of a probably benign lesion, so this designation is not appropriate. The margins are not well circumscribed and the lesion is palpable. A biopsy is indicated and is done. A fibroadenoma is diagnosed. The “probably benign” category should be reserved for mammographically detected and fully evaluated lesions that include nonpalpable, noncalcified, well-circumscribed solid masses, clusters of round or oval calcifications, nonpalpable focal asymmetry with concave margins and interspersed fat, an asymptomatic, single dilated duct and multiple (three or more) similar findings distributed randomly (circumscribed masses, round or oval calcifications in tight clusters or scattered individually throughout both breasts).

If prior films are available, they should be reviewed before assigning BI-RADS® assessment category 3 (probably benign lesion, short-interval follow-up is recommended). If a mass is stable or getting smaller, short-interval follow-up is not indicated. If a mass is solid and enlarging or is new, a biopsy is more appropriate than short-interval follow-up. Also, detected lesions should be evaluated with spot compression views and ultrasound (if a well-circumscribed mass is a cyst, short-interval follow-up is not usually indicated) or, in the case of calcifications, magnification views so that the likely benign features of the lesion can be well documented. In patients with probably benign lesions, it is particularly important to discuss the findings, the low likelihood of malignancy, and available options with the patient. Ultimately, it is the patient's decision, and although most opt for 6-month follow-up, some request that a biopsy be done for histologic confirmation. Other patients in whom a biopsy may be appropriate include those in whom compliance with the follow-up recommendation is a concern.

In my opinion, there is inconsistency in the management of solid, well-circumscribed, noncalcified masses (i.e., probably benign lesions). Why, if a probably benign solid mass is close to the skin or develops in a patient with a small breast and is palpable, do we consider it a surgical disease, yet if that same mass is deep in the breast or develops in a woman with a larger breast and it is not palpable, is it acceptable to recommend a 6-month follow-up for the patient? In my practice, if the clinical, mammographic and ultrasound findings of a mass are consistent with a benign process (e.g., fibroadenoma), and the patient is comfortable with the option, I recommend a 6-month clinical and sonographic follow-up even if the lesion is palpable.

 

Patient 38

Figure 3.38. Screening study, 38-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast. Double spot compression magnification views, craniocaudal (C) and mediolateral oblique (D) projections.

What should be the next step?

Double spot compression views in two projections are obtained to evaluate calcifications (arrow) detected in the left breast on the screening mammogram.

 

 

How would you describe the calcifications?

What would you do next?

A cluster of calcifications is confirmed on the double spot compression magnification views. The images are well exposed, high in contrast, and demonstrate the calcifications well, with no motion blur. The calcifications are homogenous in density, with no linear forms; however, they are pleomorphic and therefore a stereotactically guided needle biopsy is done. Differential considerations include fibroadenoma, papilloma, fibrocystic changes including ductal hyperplasia, atypical ductal hyperplasia, sclerosing adenosis and columnar alteration with prominent apical snouts (CAPPS), and ductal carcinoma in situ. Sclerosing adenosis with associated calcifications is diagnosed on the core samples. This is congruent with the imaging findings and therefore no further intervention is warranted. Annual screening mammography is recommended starting at age 40 years.

The mammographic presentation of sclerosing adenosis is variable. When a patient presents with calcifications, two distinct patterns for the calcifications can be described: one or multiple clusters of tightly packed, sharply defined but pleomorphic calcifications, some of which may be linear and uni- or bilateral, focal or regionally distributed, amorphous calcifications in dense glandular tissue. Alternatively, a mass with variable marginal characteristics, including spiculation and distortion, may be seen. Some patients may present with a palpable mass, what has been called an “adenosis tumor.” Patients who present with an adenosis tumor are typically premenopausal.

Adenosis is qualified by terms that include blunt duct adenosis, microglandular adenosis, and sclerosing adenosis. Histologically, adenosis is a lobulocentric proliferative process with hyperplasia of epithelial and myoepithelial cells and the surrounding intralobular stroma. Specifically, in sclerosing adenosis there is usually some atrophy of the epithelial cell component and prominence of myoepithelial cells. As with fibroadenomas, the glandular component of these lesions is more prominent in premenopausal woman, whereas sclerosis predominates in postmenopausal women. Interestingly, a small percentage of these lesions demonstrate perineural and vascular extension of the proliferating acini.

 

Patient 39

Figure 3.39. Screening study, 60-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, right breast, photographically coned. Craniocaudal (C) and mediolateral oblique (D) views, right breast, photographically coned, demonstrate a round, radiolucent mass (arrows) and an adjacent round, water-density mass (arrowheads). Ultrasound images in the radial (RAD) projection (E, F), 2 o'clock position, 4 cm from the right nipple.

What are your observations, and what would you do next?

Several observations can be made. There are round and punctate calcifications diffusely scattered in the breast parenchyma. These are benign and do not warrant additional evaluation or intervention. Do you see the round radiolucent mass at the edge of the glandular tissue (Fig. 3.39C, arrow)? What would you recommend for this? Fat-containing masses are benign and do not warrant any additional evaluation. Anything else? Did you notice the water-density mass medial and posterior to the radiolucent mass (Fig. 3.39D, E, arrowheads)? The margins of this mass are indistinct, particularly on the craniocaudal view.

BI-RADS® category 0: Need additional imaging evaluation. Spot compression views (not shown), correlative physical examination, and an ultrasound are done for further evaluation of the water-density mass.

 

 

What is your diagnosis based on the imaging findings, and what BI-RADS® category would you use in your report?

What recommendation would you make to the patient?

On ultrasound, two adjacent masses are imaged at the 9 o'clock position, 4 cm from the right nipple. The radiolucent mass, seen mammographically, is a 1.2-cm oval, hypoechoic mass with circumscribed margins and is consistent with a lipoma. A 0.9-cm oval, anechoic mass with circumscribed margins is seen adjacent to the lipoma. Although no posterior acoustic enhancement is seen, this is a simple cyst and requires no further intervention. Posterior acoustic enhancement may not be readily apparent with small cysts or those deep in the breast.

Oil cysts and lipomas may not be distinguishable mammographically, because they are both radiolucent masses. On ultrasound, lipomas are hypo-, iso- to slightly hyperechoic solid masses. In contrast, oil cysts are variable in appearance, ranging from anechoic (indistinguishable from cysts) to complex cystic masses, to irregular solid masses with significant shadowing.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

Patient 40

Figure 3.40. Diagnostic evaluation, 42-year-old patient presenting with a “lump” in the right breast. Spot tangential (A) view of the “lump” in the right breast. Dense glandular tissue is imaged on the routine views (not shown). Ultrasound images (B–D) through different areas of the palpable mass, in the right breast.

What would you say, based on the tangential view, and what would you do next?

Dense glandular tissue is imaged on the spot tangential view. In this patient, no abnormality is readily apparent on the tangential view. Given the presence of dense glandular tissue on the spot tangential view, correlative physical examination and ultrasound are indicated for further evaluation.

 

How would you describe the ultrasound findings, and what is your differential?

What is indicated next?

On physical examination, a discrete, superficial, hard, readily mobile mass is palpated at the 8 o'clock position, 4 cm from the nipple corresponding to the area of concern to the patient. A vertically oriented, hypoechoic mass with angular and microlobulated margins is seen corresponding to the palpable finding. Ductal extension is noted (Fig. 3.40D, arrows). The clinical and sonographic features of this lesion suggest malignancy; however, differential considerations include fibroadenoma (complex fibroadenoma, tubular adenoma), papilloma, sclerosing adenosis, pseudoangiomatous stromal hyperplasia, invasive ductal carcinoma not otherwise specified, or a medullary carcinoma. Given the patient's age, mucinous and papillary carcinomas are less likely. In the absence of a known malignancy, metastatic disease is also unlikely.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

A biopsy is done, and an invasive ductal carcinoma is diagnosed on the core biopsy. Two invasive ductal carcinomas (0.8 cm and 0.6 cm) with high-nuclear-grade ductal carcinoma in situ with central necrosis are reported on the lumpectomy specimen. The sentinel lymph node is negative for metastatic disease [pT1b, pN0(sn) (i—), pMX; Stage I].

Why do spot tangential views in patients who present with localized findings?

In patients who present with focal symptoms, the spot tangential view is sometimes helpful because lesions may be partially (or, less commonly, completely) surrounded by subcutaneous fat, enabling visualization and characterization of a portion of their margin. If a mass or distortion is seen or if, as in this patient, glandular tissue is imaged on the spot tangential, correlative physical examination and an ultrasound are indicated for further evaluation. Sonography may be deferred if completely fatty tissue or a benign finding is imaged on the tangential view corresponding to the area of concern to the patient and there is no chance that the lesion has been excluded from the mammographic images.

What are some of the ultrasound features associated with malignant lesions?

Ultrasound features suggesting a malignant process include a vertical orientation (i.e., taller than wide), microlobulation, spiculation, angular margins, shadowing, duct extension, branch pattern, calcifications, thick echogenic rim, marked hypoechogenicity, and a heterogeneous echotexture. Most malignant masses have multiple features suggestive of malignancy. Tubular structures arising from a mass can be characterized as duct extension or branch pattern, depending on their relationship to the nipple; this is determined during the real-time portion of the study. Duct extension refers to the presence of hypoechoic tubular structures extending from the mass and directed toward the nipple. A branch pattern is present if the tubular structures arising from the mass are directed away from the nipple. In this patient, a branch pattern is present (Fig. 3.40D, arrow).

 

Patient 41

Figure 3.41. Diagnostic evaluation, 62-year-old woman called back for calcifications detected on a screening mammogram. Craniocaudal (A) and mediolateral oblique (B) double spot compression magnification views. Core radiographs (C, D), done as part of the stereotactically guided core biopsy.

How would you describe the findings, and what is your recommendation?

A cluster of amorphous (“lacelike”) calcifications is demonstrated on the magnification views. Although the term “amorphous” is used to describe these, they actually represent tightly packed, punctate calcifications that are beyond the resolution of the images that can be obtained on a patient. When more magnification is used on specimen radiographs (because exposure length is not an issue with a specimen, more magnification can be obtained), the calcifications can be resolved into punctate calcifications. Differential considerations include fibroadenoma, papilloma, fibrocystic changes including ductal hyperplasia, atypical ductal hyperplasia, sclerosing adenosis and columnar alteration with prominent apical snouts and secretions (CAPSS), and ductal carcinoma in situ (usually a low- or intermediate-nuclear-grade DCIS with no associated central necrosis).

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

A stereotactically guided core biopsy is done.

 

What is the difference between these two images, and what caused it?

When a biopsy is done for calcifications, a radiograph of the cores is obtained to make sure that calcifications have been excised for histologic evaluation. We use magnification technique to radiograph the cores. On the first radiograph (Fig. 3.41C), the calcifications are indistinct and difficult to recognize and characterize. When you detect blurry images, you need to consider suboptimal compression, patient motion, or an inappropriate focal spot. Obviously, suboptimal compression and patient motion are not considerations on a core radiograph. The most likely cause is the use of the 0.3-mm focal spot on the magnification views. The repeat image (Fig. 3.41D), done using the 0.1-mm focal spot, demonstrates the calcifications as sharp, distinct structures, while others remain faint and more “amorphous” in appearance. With magnification technique, the focal spot is changed from 0.3 to 0.1 mm to overcome the penumbra effect that results as the object-to-film distance is increased.

CAPSS with associated calcifications but no atypia is diagnosed on the core samples. CAPSS is being reported with increasing frequency in biopsies done for round and punctate or amorphous calcifications identified mammographically. CAPSS involves the terminal duct lobular unit and is characterized by findings that include columnar epithelial cells with prominent apical cytoplasmic snouts, intraluminal secretions, and varying degrees of nuclear atypia and architectural complexity. Some CAPSS lesions can present diagnostic dilemmas for the pathologist because the spectrum of CAPSS ranges from columnar alteration of the epithelial cells with or without atypia to findings suggestive of low-nuclear-grade ductal carcinoma in situ (micropapillary). Excisional biopsy is indicated when CAPSS is associated with atypia or there are concerns regarding an underlying DCIS.

 

Patient 42

Figure 3.42. Diagnostic evaluation, 41-year-old patient presenting with a “lump” (metallic BB is seen on mediolateral oblique view) in the left breast. Craniocaudal (A) and mediolateral oblique (B) views. Spot tangential (C) view of the “lump”, left breast. Ultrasound images, transverse (TRS) (D) and longitudinal (LON) (E) projections of the palpable (PALP) mass, 11 o'clock position, 3 cm from the left nipple.

 

How would you describe the findings, and what would you do next?

Dense fibroglandular tissue is present. A round mass with obscured margins is seen in the left breast, corresponding to the “lump” described by the patient. On the tangential view, an oval mass is imaged, with partially well-circumscribed and obscured margins and a “halo” sign associated with a portion of the mass. A hard, readily mobile, nontender mass is palpated in the left breast at the site of concern to the patient.

 

How would you describe the findings, and what is your differential?

A 2.5-cm, oval, hypoechoic, macrolobulated mass with posterior acoustic enhancement is imaged on ultrasound at the 11 o'clock position, 3 cm from the left nipple, corresponding to site of the palpable abnormality. Although most of the margins are well circumscribed, some nodularity of the margins is noted on the transverse projection. Differential considerations include fibroadenoma (complex fibroadenoma, tubular adenoma), phyllodes tumor, nodular adenosis, pseudoangiomatous stroma hyperplasia (PASH), and focal fibrosis. A papilloma is an additional consideration, but the size of the lesion makes this less probable. Malignant lesions include invasive ductal carcinoma not otherwise specified and medullary carcinoma. Given the patient's age, mucinous and papillary carcinomas are less likely, and without a known malignancy, a metastatic lesion is also unlikely.

What would you recommend and why?

Given some of the margins of this lesion on ultrasound, a biopsy is recommended.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

A biopsy is done, and tubular adenoma is diagnosed on the core samples. No further intervention is required unless the patient desires or requests an excisional biopsy. Next screening mammogram is recommended in 1 year.

What are the imaging and histologic features of tubular adenomas?

Tubular adenomas most commonly present as noncalcified, round or oval masses with well-circumscribed or obscured margins mammographically and homogeneously hypoechoic with well-circumscribed margins and possibly posterior acoustic enhancement on ultrasound. The findings are indistinguishable from those associated with some fibroadenomas. In some patients, tightly clustered punctate calcifications, in isolation or with an associated mass, may be seen mammographically.

Tubular adenomas are one of several adenomatous lesion types that include fibroadenomas, complex fibroadenomas, and lactating adenomas. Tightly packed glands (acini), with little surrounding stroma, characterize tubular adenomas histologically. Although they are not common, tightly packed, dense, punctate or irregular calcifications have been reported in tubular adenomas. Histologically, the calcifications reportedly occur within inspissated secretions in dilated glands and not in the stroma.

 

Patient 43

Figure 3.43. Diagnostic evaluation, 84-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views. Spot compression (C) view, left breast mass. Ultrasound image, antiradial (ARAD) (D) projection, palpable (PALP) mass, left breast, 3 o'clock position, 7 cm from the left nipple, and ultrasound image, antiradial (ARAD) (E) projection, left axilla.

 

How would you describe the mammographic findings, and what is your leading diagnostic consideration?

What would you do next?

Vascular calcifications are present bilaterally—not an unusual finding given the patient's age. Although there is a patient-related artifact on the spot compression view, a round mass with indistinct and irregular margins is partially imaged in the left breast, corresponding to the area of concern to the patient. In an 84-year-old patient presenting with a palpable mass characterized by indistinct margins, the likelihood of an invasive ductal carcinoma not otherwise specified is high and has to be the leading diagnostic consideration. Other possibilities include metastatic disease (particularly if the patient is known to have an underlying malignancy), papillary carcinoma, mucinous carcinoma, or lymphoma. Although invasive lobular carcinomas are more common in older postmenopausal woman, the round shape of this tumor decreases the likelihood of this diagnosis. Benign considerations include an inflammatory process, particularly if there is associated tenderness, erythema, or warmth at the site of the mass. Posttraumatic or operative fluid collection should be considered if there is a recent history of breast surgery. Lastly, this could represent an atypical presentation for a cyst or papilloma. Cystic changes are most commonly associated with the perimenopausal period; however, there is a second small peak in older postmenopausal women, possibly related to increased estrogen levels from adipose tissue or decreases in liver function.

An ultrasound is done for further characterization of the finding in the left breast. Our routine for patients suspected of a primary breast malignancy is to evaluate the involved breast in its entirety, looking for additional breast lesions. We also scan the ipsilateral axilla. If potentially abnormal lymph nodes are identified, a fine-needle aspiration or a core biopsy is done to establish the presence of metastatic disease. A full axillary dissection (i.e., bypassing the sentinel lymph node biopsy) to establish the number of involved axillary lymph nodes and neoadjuvant therapy is considered for those patients in whom we establish the presence of metastatic disease in the ipsilateral axilla.

 

How would you describe the ultrasound findings, and what are your impressions and recommendations?

On physical examination, a hard, fixed mass is palpated laterally in the left breast. There is no associated tenderness, erythema, warmth, or bruising at this site. There is no history of a recent surgical procedure. On ultrasound, an oval, hypoechoic mass with macrolobulated margins is imaged corresponding to the palpable finding in the left breast. An oval, hypoechoic mass with a focus of hyperechogenicity is imaged in the left axilla. The findings support the diagnosis of an invasive lesion, which is likely associated with metastatic disease to at least one axillary lymph node.

An invasive mammary carcinoma with focal squamous differentiation (possibly a metaplastic carcinoma) is reported on the ultrasound-guided core biopsy. Metastatic disease is diagnosed in the axillary lymph node on fine-needle aspiration. A 1.9-cm, grade III invasive mammary carcinoma with squamous differentiation consistent with an adenosquamous or metaplastic carcinoma is diagnosed on the lumpectomy specimen. Because of the patient's age, no lymph nodes are sampled at the time of surgery [pT1c, pNX, pMX; Stage I].

What imaging features in a lymph node suggest the possibility of metastatic disease?

As it relates to the imaging appearance of intramammary and axillary lymph nodes, the overlap between normal and abnormal findings can be significant. Changes and fluctuations in size, density, and a loss of the fatty hilum mammographically can be related to benign reactive changes or metastatic disease, and similarly, normal-appearing lymph nodes with a fatty hilum and no appreciable change in size or density can be found to have significant metastatic deposits when excised. However, based on the clinical presentation and imaging features, metastatic disease in intramammary or axillary lymph nodes can be suspected in some patients and fine-needle aspiration or core biopsy can be done to confirm the diagnostic impression. In patients with a known breast primary, increases in size, density, loss of the fatty hilum, and marginal circumscription (indistinct or spiculated margins) should suggest the possibility of metastatic disease. On ultrasound, prominence, bulging, lobulation, and marked hypoechogenicity of the cortical region are all of concern, particularly if an echogenic hilar region is not identified or it appears attenuated. In some patients, there is apparent mass effect of what is seen of the echogenic hilar region.

If we suspect an abnormal intramammary or axillary lymph node, a fine-needle aspiration or core biopsy (if this can be done safely) of the lymph node is done under ultrasound guidance. In targeting, we avoid the echogenic hilar region because of the theoretical possibility that a needle could disrupt the afferent vessels to the lymph node, potentially having a negative effect on the sentinel lymph node biopsy if one is to be done at a later date.

What are the clinical, imaging, and histologic features associated with metaplastic carcinomas?

Metaplastic carcinomas represent <, 2% of all breast cancers. They present as a mass described by the patient as having developed rapidly and as a relatively well-circumscribed mass mammographically. In those lesions with osseous metaplasia, dense calcification may be seen mammographically.

These are heterogeneous tumors characterized by metaplasia of the epithelial cells into either squamous or mesenchymal type cells (spindle cell, chondroid, osseous, or myoid). Histologically, these can be broadly divided into those with squamous differentiation and those with heterologous elements such as cartilage, bone, muscle, adipose tissue, vascular elements, melanocytes, and so on.

 

Patient 44

Figure 3.44. Diagnostic evaluation, 61-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)views. Spot compression (C) view, craniocaudal projection, right breast. Ultrasound image, radial projection (D), palpable finding, right breast, 10 o'clock.

 

How would you describe the findings, what is your differential, and what is your most likely diagnosis?

Why?

Multiple subcentimeter-sized masses are present in the right breast, as is a dilated tubular structure within which there are two areas of dense, coarse calcifications. Clips from a prior surgical procedure with a benign diagnosis are also noted in the right mediolateral oblique view. The left breast is normal. The main benign diagnostic considerations in a patient with multiple masses include cysts, fibroadenomas, and papillomas. Metastatic disease, invasive ductal carcinoma, and lymphoma are the main considerations in the malignant category. In this patient, the additional finding of a prominent tubular structure with associated coarse calcifications makes multiple peripheral papillomas the most likely diagnosis. An ultrasound to evaluate the masses and the “lump” described by the patient is done next.

 

How would you describe the finding corresponding to the area of concern to the patient?

A complex cystic mass is imaged corresponding to the palpable finding in the right breast. This is confirmatory of our initial impression that the mammographic findings represent papillomas. As the remainder of the breast is scanned, additional complex cystic masses and solid hypoechoic masses are seen scattered in the upper outer quadrant of the right breast.

How do solitary and multiple peripheral papillomas contrast, and what is their significance?

Solitary papillomas most commonly occur in the major subareolar ducts and present with spontaneous nipple discharge. They can be identified as a solitary mass or a cluster of round and punctate calcifications (with or without an associated mass) on mammography. Coarse, dense, curvilinear calcifications, noted incidentally within dilated ductal structures, are also likely sclerosed papillomas. Peripheral papillomas are usually multiple and are detected on screening mammograms as multiple masses or multiple clusters of round and punctate calcifications. Their distribution is variable and includes clusters in a small area of tissue, segmental, regional, or diffuse involvement of the breast. In some patients, the findings are bilateral. On ultrasound, the solitary central papillomas may be identified as a solid mass within a dilated duct, a complex cystic mass, or a hypoechoic mass indistinguishable from any other solid mass. Multiple peripheral papillomas are often seen as a combination of complex cystic masses and solid, hypoechoic masses scattered in the breast.

What are the basic histologic features of papillomas?

Papillomas are characterized histologically by the presence of a vascular core and an epithelial lining similar to that seen in the ducts, contiguous epithelial cells, and intermittent basilar myoepithelial cells. Proliferative changes, including hyperplasia, atypical hyperplasia, and ductal carcinoma in situ, have been reported in association with the epithelial lining of papillomas. In contrast to patients with solitary, more centrally occurring papillomas (subareolar), in whom excised surrounding tissue is often bland, patients with multiple peripheral papillomas often have significant proliferative changes in the tissue surrounding the papillomas. The described proliferative changes include areas of atypical ductal hyperplasia, lobular neoplasia, and ductal carcinoma in situ. These changes may be seen in nearly 45% of patients, such that some consider multiple peripheral papillomas as marker lesions. The management of some of these patients can present a dilemma, particularly when the findings are regional or diffuse and bilateral.

Our approach to patients with multiple peripheral papillomas that are localized is to do an excisional biopsy. In women with more regional or diffuse findings, we excise any clinically symptomatic area or any lesion or lesions that change on follow-up mammograms or ultrasounds.

 

Patient 45

Figure 3.45. Diagnostic evaluation, 36- year-old patient presenting with a tender “lump” in the left axilla. Mediolateral oblique (A) views with an arrow denoting position of metallic BB used to mark “lump.” Craniocaudal views (not shown) are normal. Left axillary view (B). Ultrasound image (C), left axilla.

 

How would you describe the findings, what is your differential, and what would you do next?

Predominantly fatty tissue is imaged. Scattered benign-appearing lymph nodes are present on the right. A mass that is at least 3 cm in size is partially imaged on the left axillary view, with associated smaller surrounding masses. As is expected on an axillary view, the humeral head (HH) is also partially seen. The findings in the left axilla most likely represent adenopathy. A detailed history should be elicited from the patient. Specifically, ask about a history of lupus, rheumatoid arthritis, sarcoid, psoriasis, tuberculosis, human immunodeficiency virus (HIV) infection, recent exposure to cats (cat scratch disease), an ongoing infectious process, or known malignancy (lymphoma, breast cancer, melanoma, etc.). Correlative physical examination and an ultrasound are done next.

On physical examination, the patient has significant limitations in the range of motion for her left shoulder and significant tenderness is associated with any movement of the left arm or palpation of the left axilla. A hard mass with satellite nodules is palpated in the left axilla. On ultrasound, a round mass that is markedly hypoechoic is imaged corresponding to the dominant palpable abnormality. During the ultrasound study and following multiple questions, a history of HIV infection is elicited from the patient. Although the findings may be benign and reactive, an ultrasound-guided core biopsy is indicated.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered. A non-Hodgkin B-cell lymphoma is diagnosed on the core biopsy. A CT scan of the chest confirms adenopathy in the left axilla; however, no other adenopathy is identified. Similarly, neck, abdominal, and pelvic CT scans are normal.

How does primary breast lymphoma present?

Breast lymphoma, classified as an extranodal lymphoma, represents >,0.1% of all breast malignancies and is only considered primary when the patient does not have widespread lymphoma or a history of having had lymphoma elsewhere in the body. Patients present with one or multiple masses, more commonly involving one breast, although some present with synchronous (and metachronous) bilateral disease. As many as 20% of patients describe night sweats, fever, and weight loss. Axillary adenopathy is identified in 30% to 40% of patients. Mammographically, one or multiple masses with well- to ill-defined margins are the most common presentation. Rarely, diffuse changes that include increased density, prominence of the trabecular pattern, and skin thickening may be seen. On ultrasound, a solid, hypoechoic mass is the most common finding.

Most patients with primary breast lymphoma have diffuse large-cell lymphoma, B-cell origin, of the immunoglobulin M heavy-chain type. The age of presentation and the course of the disease are variable. Histologic type and stage at the time of diagnosis are the major determinants of prognosis. A second presentation for primary breast lymphoma is that of a Burkitt-type lymphoma with bilateral breast involvement, described in pregnant or lactating patients. This is characterized by a more rapid and aggressive course. Axillary adenopathy is identified in 30% to 40% of patients. Patients are usually treated with lumpectomy followed by radiation therapy.

 

Patient 46

Figure 3.46. Diagnostic evaluation, 74-year-old patient presenting with a “lump” in the left breast. Metallic BB used to mark location of “lump.” Craniocaudal (A) and mediolateral oblique (B) views. Spot tangential (C) view of palpable mass, left breast. Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of palpable mass in the left breast at the 8 o'clock position.

 

How would you describe the findings, and what is your differential?

A round mass with mostly circumscribed margins and associated skin thickening is present corresponding to the site of concern to the patient. An oval mass is also noted superimposed on the left pectoral muscle inferiorly. The differential for the mass in the left breast includes sebaceous cyst, cyst, and papilloma. A hematoma or abscess would be considerations if there is a history of trauma to this site, or if there are signs and symptoms of an ongoing inflammatory process. Malignant considerations include an invasive ductal carcinoma not otherwise specified, papillary or mucinous carcinoma, or metastatic disease. The mass superimposed on the pectoral muscle is most likely a lymph node.

 

How would you describe the findings, and what is your recommendation?

On physical examination, a hard mass that is fixed to the skin is palpated at the 8 o'clock position of the left breast. The skin is erythematous, but there is no associated tenderness with compression. On ultrasound, a round mass with a heterogenous echotexture and posterior acoustic enhancement is imaged corresponding to the palpable finding in the left breast. Given the erythema, this may represent an inflammatory process, or possibly a hematoma, but a biopsy is warranted.

BI-RADS® category 4: suspicious abnormality—biopsy should be considered.

As a starting point, after infiltrating the skin and breast tissue up to the lesion with lidocaine, you can attempt an aspiration. If no fluid (pus or blood) is obtained, or there is a residual abnormality, core biopsies are done. In this patient, an invasive carcinoma with intra- and extracellular mucin is reported histologically. Although a breast primary is in the differential, the pathologist is concerned about a metastatic lesion to the breast. A lung primary is identified on a CT scan of the chest.

Metastatic disease to the breast is not common, however, it typically presents as one or multiple round masses with variable marginal features that range from well-circumscribed to ill-defined but usually not spiculated. The more common primaries to consider include melanoma, lung, colon and renal; prostate cancer is a consideration in male patients.

 

Patient 47

Figure 3.47. Diagnostic evaluation, 55-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned to the area of concern to the patient, left breast. Spot tangential (C) view of palpable finding. Metallic BB used to mark the palpable finding. Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of the palpable finding in the left breast at the 10 o'clock position, 12 cm from the nipple.

 

How would you describe the findings, and what is your differential?

A mixed-density (fat containing) mass is imaged in the upper inner quadrant of the left breast at the site of concern to the patient. Differential considerations include a fibroadenolipoma, fat necrosis related to prior surgery or trauma, oil cyst, galactocele, or an abscess. An intramammary lymph node is also in the differential; however, these are more commonly seen in the lateral quadrants. In establishing an etiology, reviewing prior films and obtaining a history may be helpful. In this patient, a fibroadenolipoma or intramammary lymph node is unlikely because her prior mammogram is normal. In patients with mixed-density lesions, the benign etiology of the finding is established mammographically, and no additional evaluation is indicated.

BI-RADS® category 2: benign finding.

 

How would you describe the findings, and what is your diagnosis?

An ill-defined round area of slight hyperechogenicity with associated areas of cystic change is imaged corresponding to the palpable finding. No tenderness is elicited as this mass is palpated, making an inflammatory process unlikely. Although on questioning the patient does not recall any trauma to this area, the findings are most suggestive of fat necrosis related to trauma. (I include the ultrasound for completeness, not because an ultrasound is needed to establish the benign etiology of the mammographic finding.)

 

 

Patient 48

Figure 3.48. Diagnostic evaluation, 78-year-old patient presenting with a tender “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B)views with a metallic BB used to mark the palpable finding. Spot tangential view (C) of the palpable finding, left breast.

 

How would you describe the findings?

What do you think is the likely diagnosis, and how can you confirm your impression?

A round mass with indistinct margins is imaged in the upper inner quadrant of the left breast, corresponding to the “lump” described by the patient. On the spot tangential view this mass is associated with the skin and likely represents a sebaceous cyst. This can be confirmed by examining the patient. On physical examination, a mass that is fixed to the skin (the mass moves with the skin; it cannot be moved independently of the overlying skin) is palpated in the upper inner quadrant of the left breast. On visual inspection, a prominent pore is seen at the center of the palpable finding. With gentle compression, thick white material can be squeezed out of the visualized pore, confirming the impression that the palpable finding is a sebaceous cyst.

BI-RADS® category 2: benign finding.

Sebaceous and epidermal inclusion cysts are clinically, mammographically, and sonographically indistinguishable. Epidermal inclusion cysts have an epidermal cell lining, in contrast to the epithelial cell lining that characterizes sebaceous cysts. These are usually readily palpable, well-defined, cutaneous or subcutaneous masses that can become quite large and may be visible when they cause a smooth bulging of the overlying skin. The orifice of the sebaceous gland may be visible as a dark spot (“blackhead”). In some patients, a thick white cheesy material can be expressed through the orifice of the obstructed sebaceous gland. Mammographically, they are often well-circumscribed masses, commonly in the medial quadrants of the breasts. In some patients the margins are indistinct, particularly if there is associated inflammation. Calcifications may also be seen associated with some sebaceous cysts. On ultrasound, the most common finding is that of a well-circumscribed mass arising in the skin and commonly extending into the subcutaneous tissue. They can be anechoic, hypoechoic, slightly hyperechoic or heterogeneous, and in some patients, a thin hypoechoic tubular (e.g., a track) structure can be seen extending from the mass to the skin surface. Unless the patient is symptomatic, no intervention is required. If the patient is symptomatic surgical excision may be indicated.

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