Direct Diagnosis in Radiology

Breast ImagingUwe Fischer, MDAssociate ProfessorWomen's Health Care CenterGottingen, Germany

Friedemann Baum, MDWomen's Health Care CenterGottingen, Germany

Susanne Luftner-Nagel, MDWomen's Health Care CenterGottingen, Germany

379 Illustrations

ThiemeStuttgart, New York

Library of Congress Cataloging-in-PublicationDara is available from the publisher.

This book is an authorized and revised trans-lation of the German edition published andcopyrighted 2007 by Georg Thieme Verlag,Stuttgart. Germany. Title of the Germanedition: Pareto-Reihe Radiologie: Mamma.

Translator: Susanne Luftner-Nagel, MD,Gottingen, Germany

Illustrator: EmilWOlfgangHanns,Schriesheim, Germany

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Mammography: Galactography .. 17Digital Mammography 18MR Mammography 21Fine Needle Aspiration Biopsy(FNAB) 24Core Biopsy 26Vacuum Biopsy 28Preoperative LocalizationTechniques 31Sentinel Lymph Node (SLN) 35

J MethodsUltrasonographyRadiation ExposureMammography:Craniocaudal Projection .Mammography:Mediolateral Oblique ProjectionMammography:Spot Compression 12Mammography:Magnification Mammography ...

2 Nomencloture and FindingsDiagnostic Criteria inUltrasonography 37Diagnostic Criteria inMammography 39Diagnostic Criteria inMRMammography 41PGMI (Perfect, Good, Moderate,Inadequate) Criteria 44Breast Composition 48BI-RADS (Breast ImagingReporting And Data System) 52Normal Findings 54Asymmetry 56Architectural Distortion 58

Skin Changes 60Changes in the Nipple 62Non-Sanguineous NippleDischarge 64Bloody Nipple Discharge 66Mass: Shape 68Mass: Margins 70Mass: Density (Attenuation) 72Distribution of Micro calcifications 74Monomorphic Microca1cifications 76Pleomorphic Microca1cifications 79Amorphous Microca1cifications . 82Benign Calcifications 84

3 Benign ChangesAxillary and Intra mammaryLymph Nodes 87Skin Lesions 89Mondor Disease 92Abscess 94Adenoma 96Adenosis 98Atypical Lobular Hyperplasia(ALH) 100Hyalinizing Fibroadenoma 102Myxoid Fibroadenoma 104Giant Fibroadenoma 106Focal Fibrosis 108Hamartoma (Fibroadenolipoma) 110

Hemangioma 112Lipoma 114Mastitis 116Papilloma 119Multiple Peripheral Papillomas .. 122Plasma Cell Mastitis 125Radial Scar 127Tubular Adenoma 129Simple Breast Cyst 132Complex Cyst 134Gynecomastia 136Pseudo gynecomastia 139Breast Changes DuringPregnancy 142

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4 Borderline LesionsAtypical Ductal Hyperplasia(ADH) 145

5 Breast CarcinomaRisk Facrors 150Surrogate Factors for Screening. 152Early Detection 154Breast Cancer Genes (BRCA) 156Ductal Carcinoma In Situ(DCIS, Low Grade) 158Ductal Carcinoma In Situ(DCIS, Intermediate Grade) 160Ductal Carcinoma In Situ(DCIS, High Grade) 162Invasive Ductal Carcinoma(lDC) 164Invasive Lobular Carcinoma.Nodular Form 166

Lobular Carcinoma In Situ(lCIS) 148

Invasive lobular Carcinoma,Diffuse Form 168Invasive Papillary Carcinoma." .. 170Medullary Carcinoma 173MucinousCarcinoma 176Tubular Carcinoma 179Inflammatory Breast Cancer ", .. 182Male Breast Cancer 185Paget Disease of the Nipple 187local Recurrence 191Extensive IntraductalComponent(EIC) 194Multifocality 196Multicentricity 198

6 Other Potentially Malignant and Malignant LesionsPhyllodes Tumor 200 lymphoma 206CUP Syndrome 202 Intramammaty Metastases , 208Sarcoma 204

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7 Post-Traumatic ChangesSeroma 210Early Fat Necrosis 212late Fat Necrosis 214Oil Cyst 216

8 ProsthesisBreast Prosthesis 227Gel Bleeding 230Capsular Contracture .. , 232

Index 241

Postoperative Changes , 220Post-Radiation Changes 222Reduction Mammaplasty 224

Intracapsular Rupture 234Extracapsular Rupture 237

ACR American College IDC invasive ductal carcinomaof Radiology ILC Invasive lobular carcinoma

ADH Atypical ductal IR Inversion recoveryhyperplasia LCIS Lobular carcinoma in situ

ALH Atypical lobular MIP Maximum intensityhyperplasia projection

BI-RADS Breast imaging and MLO Mediolateralobliquereporting data system projection

BRCA Breast cancer gene MRI Magnetic resonanceCR Computed radiography imagingCUP Cancer of unknown PGMI Perfect, good, moderate,

primary inadequate. QualityDCIS Ductal carcinoma in situ assurance categorizationDO Differential diagnosis of mammograms usedEIC Extensive intraductal in the British screening

component system.FNAB Fine needle aspiration PNL Posterior nipple line

biopsy ROI Region of interestFOV Field of view SE Spin echoGE Gradient echo SLN Sentinel lymph nodeHRT Hormone replacement TSE Turbo spin echo

therapy WHO World Health Organization

VII

Brief Description............................................................................................Imaging modality using sound waves. Tissue-specific wave renection.

Indlcotlons

Evaluation of palpable breast nodules. Evaluation of clinically occult mammo-graphic findings. Complementary assessment of dense breast tissue. Assessmentof breast tissue after reconstruction surgery or augmentation with silicone im-plants. Supplementary examination of women with a high risk for breast cancer.Guidance during interventional techniques.

Devlce-reloted Prerequisites............................................................................................Calibration to 1540 m/s sound velocity. B-mode with automatic scanning. Matrixmemory with more than 16 gray scales. Adjustable transmitting power. Mea-surement error < 3% • Image documentation with measurement scale. Display ofrated frequency. Display of signal processing.

Technlcol Requirements

Digital or hard-copy documentation. Transducer frequency of> 5 MHzor multifre-quency transducer. Image rate> 12 images/s • 128 gray scales. Field of viewwidth of at least 5 em at 1.5em depth. Variable focus. Monitor screen must dis-play-patient name. date of examination, transducer identifier. measurement scale,body marker. capacity, depth adjustment, preset, depth scale. Symmetric imaging(right/left) • Depiction of wall irregularities in tumors. Depiction of cysts ~4 mmdiameter (better: 2 mm) • Penetration depth ~4 em.

Evoluotlon Crlterlo

- Echogenicity of lesion compared with surrounding tissue.- Presence of hyper echogenic lesion wall.- Shape (round, oval, lobular, irregular).- Margins (circumscribed, microlobulated, obscured, ill-defined, spiculated).- Surrounding tissue (disruption of continuous structures, e.g..Cooper ligaments).- Transmission of ultrasound waves (i.e., posterior acoustic enhancement or shad-

owing).- Compressibility.- Internal structure (homogeneous/inhomogeneous).- Lesion axis in relation to the skin.- Mobility.- Architectural distortion.

Ultrasonography

~ Fig. J.Ja-d Ultrasound.:;. a Complicated cyst with intraluminalo hyperechoic mass at the upper margin.~

b Fibroadenoma. Well-circumscribed,hypoechoic lesion. Slight posterioracoustic enhancement and bilateral edgerefraction.

Conclusion

Ultrasonography can be selectively performed in the diagnostic workup of palpablebreast findings. In addition, ultrasonography is an important supplementary pro-cedure in the diagnostic workup of ambiguous mammographic lesions, as well as inthe assessment of dense breast tissue, where the detection of breast cancer onmammography is limited (ACR3 and 4).

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Ultrasonography

c Papilloma. Well-circumscribed.hypoechoic lesion. Posterior acousticenhancement.

d Carcinoma. III-defined hypoechoiclesion. Posterior acoustic shadowing.Irregular echogenic rim.

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;::: Brief DescriptionI'() ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

S-o Terminology in mammography:s;. - Skin dose (with backscatter): 110%

- Entrance surface dose (without backscatter): 100%- Average glandular dose: 20%- Image receptor dose: 1%

Guidelines for Rodiation Protection and Quality Assurance............................................................................................- Justification requirement: The indication for mammography must be declared by

a physician (except when performed in the context of a quality-assured mam-mography screening program).

- Optimization requirement: The applied patient radiation dose must be the low-est possible with which the required image quality can be achieved.Breast compression: Maximized within safety limits.Radiation quality: (orrect anode and filter materials.Correct exposure: Automatic exposure control.Correct screen-film combination.(orrect film processing: Verified by phantom imaging and analysis.Regular system testing by a radiation protection officer: Dosimetry. image quali-ty. and consistency.

Radiation Exposure............................................................................................Average glandular dose: 2 mGy per exposure • Reduced in digital mammography by30% • Bilateral mammography (two views) increases the risk for breast cancer in a45-year-old woman by 0.0055 %• One additional radiation-induced breast cancer isexpected to occur in 100 000 women undergoing regular screening mammogra-phy • Lifetime risk of breast cancer is increased from 10%to 10.06% after 20 yearsof biennial screening mammography beginning at 40 years of age. For 1 breastcancer induced by screening mammography. 300 breast cancers are detectedthrough screening.The risk of developing radiation-induced breast cancer decreases with age. Risk co-efficient;- 10-19 years: 2.95% Sv-I- 20-29 years: 0.52% Sv-1

- 30-39 years: 0.43% Sv-I- 40-49 years: 0.20% Sv-1

- 50-59 years: 0.06% Sv-1

- 60-69 years: 0.00% Sv-I

Conclusion

The benefits of mammography are realized immediately. the potential side effectsafter 20-30 years.

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.::.Skin dose 110%(with backscatter)

Entrance surface dose100%(without backscatter)

Average glandulardose 20 %

Image receptor dose 1 %

Radiation Exposure

Fig.l.2 Terminologyfor radiation dose inmammography.

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3!: Brief Description~ .S-o Standard mammographic view positioning the breast in the craniocaudal x-ray~ beam path. Best method to visualize the medial aspect of breast tissue.

Indications

- Screening.- Diagnostic workup.- Follow-up.

Positioning Technique............................................................................................C-arm in neutral position. Patient position: Feet forward, 5 cm back from position-ing platform, leaning forward from the waist (pendent position), rotate patientslightly medially. Image receptor adjusted to meet elevated inframammary fold.Breast positioning: Lift and pull breast forward with nat hands onto image recep-tor. Apply compression while smoothing skin wrinkles toward the nipple. Con-tinue compression until firm. Place AECdetector under glandular tissue. Expo-sure in breath-hold technique.

Quality Assessment Criteria

- Adequate visualization of glandular tissue: Pectoral muscle presents at the pos-terior medial aspect of the craniocaudal projection. Nipple visualized in pro-file. Visualization of a maximum amount of lateral breast tissue without com-promising medial tissue visualization.

- Correct labeling: Patient data. Specification of side and examination date.- Correct exposure: Optical density 0.4-2.5.- Firm compression.- No motion blurring.- Correct film processing.- No developing or handling artifacts.- No skin folds.- Symmetry of right and left mammograms.

Radiatian Exposure............................................................................................The average glandular dose is 2 mGy per exposure. The increased risk for develop-ing breast cancer due to bilateral mammography (two views) in a 45-year-old wom-an is 0.0055% • Potential side effects do not occur before 20-30 years.

Selected ReferencesRoth-Gander G. Mammographie-Handbuch fUr die tagliche Praxis. Stuttgart: Thieme;2002

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Mammography: Craniocauda/ Projection

F1g.l.3a-dCraniocaudalmammography.a lean thoracic wallagainst positioningplatform.

b lift and pullbreast forward withflat hands.

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• _M_Om_m_o_9_ro_p_h_Y_: _C_ra_n_iO_C_o_ud_o_I_P_ro_~_ect_io_n _I

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c Right craniocaudal mammogram. Nippleis not visualized in profile and is slantinglaterally. PGMIcategory: Inadequate.

d Right craniocaudal mammogram.PGMIcategory: Perfect.

Brief Description............................................................................................Standard mammographic view positioning the breast in the mediolateral oblique x-ray beam path (MLO projection) • Maximum visualization of breast tissue in itsentirety, including the axillaty tail. Limited visualization of the inner breast quad-rants.

Indications............................................................................................

- Screening,- Diagnostic workup.- Follow-up.

Positioning Technique............................................................................................X-ray projection plane: Varies depending on patient habitus. Adjust (-arm angle toobliquity of pectoral muscle (45-60·) • Patient position: Patient should first standwith her hips sideways and slightly anterior to the lower end of image receptor,then turn toward the unit approximately 45· • Rest the relaxed upper portion ofthe ipsilateral humerus on the image receptor at right angles to the body. Liftand pull breast upward and forward, bringing the lateral aspect of the breast ontoimage receptor and placing the upper corner of the image receptor slightly posteriorto the axilla. Pull breast upward and outward with a nat hand bringing the infra-mammary fold into the open position with the thumb. Apply compression, keep-ing paddleedge as close to the chest wall as possible. (ompression paddle shouldrest against the middle of the clavicle and sternum.

Quality Assessment Criteria............................................................................................_ Adequate visualization of glandular tissue: Pectoral muscle visualization to the

posterior nipple line. Pectoral muscle angle> 20· to the vertical film edge. Nip-ple visualized in profile. Open inframammary fold.

- (orrect labeling: Patient data. Specification of side and examination date.- (orrect exposure: Optical density 0.4-2.5.- Firm compression.- No motion blurring.- (orrect film processing.- No developing or handling artifacts.- No skin folds.- Symmetry of right and left mammograms.

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Mammography: Media!atera! Oblique Prajection

F1g.1.4a-dMediolateraloblique (MLO)mammography.a Position ofthe right axilla.

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b Position of theright infra mammaryfold.

Mammography: Medio/ateral Oblique Projection

c Right MlO mammogram. Nipple is notvisualized in profile, abdominal skin fold.PGMI category: Moderate.

d Right MlO mammogram. PGMI catego-ry: Perfect.

Radiation Exposure............................................................................................The average glandular dose is 2 mGy per exposure. The increased risk for develop-ing breast cancer due to bilateral mammography (two views) in a 45-year-old wom-an is 0.0055% • The benefits of mammography are seen immediately. the potentialside effects after 20-30 years.

Selected ReferencesRoth-Gander G. Mammographie-Handbuch fUr die tagliche Praxis. Stuttgart: Thieme;

2002

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s: Brief Description~ ....•5' Localized compression over an area of interest (spot compression) using a small5l- compression paddle. In techniques with structural overlap, such as mammogra-

phy, superimposition can result in pseudo lesions. Increased compression allowsmore effective and even spreading of glandular tissues. thus reducing structuraloverlap • Spot compression can resolve dubious mammographic densities byspreading apart the superimposed areas.

Positioning Technique............................................................................................Use spot compression paddle and collimator. Calculate position of the area ofinterest in relation to the nipple. Position spot compression paddle on the area ofinterest and in the central ray.

Indications

- Differentiation between a true abnormality and superimposition of normalbreast structures-increased focal compression reduces the summation effect ofnormal structures.

- More precise assessment of questionable findings-lesion border definition is im-proved by reducing superimposition, geometric blurring. and radiation scatter.

- Diagnostic workup of densities seen only in one projection.

Examinotion Results

A spot compression study can have the following effects:- The finding is no longer identifiable; Summation, benign,- The finding appears changed and can be assessed more easily; Benign/malignant.- The finding appears unchanged but can be better assessed (less overlap and blur-

ring); Benign/malignant.

Tips and Pitfalls

Missed lesion (spot compression paddle is misplaced).

Conclusion

A spot compression view can be useful in the diagnostic workup of questionablelesions (masses. densities, or architectural distortions).

Selected ReferencesRoth-Gander G. Mammographie-Handbuch fOr die t~gliche Praxis. Stungart; Thieme;2002

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Mammography: Spat Compression

Flg.l.50-d Spot compression study.a left MlO mammogram. Architectural distortion in the central aspect of the left breast.b Spot compression study. left MLO projection. Architectural distortion is seen more

clearly than in a.c leftcraniocaudal mammogram. Questionable mass in the lateral aspect of the left breast.d Spot compression study, left craniocaudal projection. The spiculated mass is seen more

clearly than in c.

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Brief Description............................................................................................Geometric magnification achieved by increasing object-film. i.e.. object-detectordistance. Visualization of the finding of interest is optimized by its magnification.

Positioning Technique............................................................................................Mammography unit must be adapted for magnification view by adding positioningtable that increases object-film distance. Use spot compression paddle and colli-mation blade. Calculate position of the area of interest in relation to the nipple.Position spot compression paddle on the area of interest and in the central ray.Magnification factor: 1.8.

Indications

To characterize microcalcifications by improving visualization of their:- Morphology.- Number.- Distribution.To better assess a mass or density with regard to:- Reproducibility.- Form alteration.- Better delineation of mass borders.

Technical Requirements

Mammography units with a high frequency/constant potential generator to allowshort exposure times. Focal spot size of 0.1 mm to reduce geometric blurring re-sulting from the increased object-film distance. High intensifying film-screencombinations [0 reduce exposure time. No grid is used to maintain acceptabledoses and exposure times.

Tips and Pitfalls............................................................................................Magnification mammography with its increased radiation dose can often be avoid-ed with digital mammography. Use of the zoom function during monitor evaluationoften allows adequate visualization and analysis of detected microcalcifications.

Selected ReferencesRoth-Gander G. Mammographie-Handbuch fUr die tagliche Praxis. Stuttgart: Thieme;2002

Mammography: Magnification Mammography

b Magnification mammography of a.Better visualization of microcalcifications(invasive lobular carcinoma).

Flg.l.60-d Digital mammography.a Right craniocaudal mammogram. Fine.linear branching microcalcifications at theposterior glandular border.

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Mammography: Magnification Mammography

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c Clustered pleomorphic microcalcifica·tions in left upper outer quadrant.Enlarged detail view (MLO).

d Magnification mammography of c.Better visualization of microcalcifications(sclerosing adenosis).

~'!.~r~~~~~~.t!?~ .Contrast-assisted depiction of ductal structures after selective cannulation of one ormore discharging ducts. Synonym: Ductography.Indication: Bloody duct nipple discharge (positive hemo-test or cytologic proof).Histology: Papilloma (approximately 97%). intraductal carcinoma (approximately3%).

Examination Technique............................................................................................Cleanse and disinfect nipple' Elicit nipple discharge using gentle pressure to iden-tify discharging duct orifice (magnifying glasses) • Cannulate discharging duct withblunt-tipped sialography needle attached to contrast-filled flexible tubing. Slowlyinject 0.1-0.5 mL iodinated. water soluble contrast material. being careful to avoidair bubbles. Spray nipple with liquid bandage' Mammography in craniocaudaland medio-Iateral views. Carefully manually express contrast material from mam-mary duct.

Findings............................................................................................Nonnalfindings: Smooth-walled mammary duct with increasing branching and de-creasing caliber toward the base of the breast.Pathologic findings: Filling defect (caution: air bubbles?) • Abrupt termination ofdilated. contrast-filled duct.

Consequences............................................................................................When a lesion is detected within a duct. surgery is usually recommended (ductec-tomy).

Conclusion

Galactography allows the detection and localization of intraductal lesions.It does not. however. permit differentiating between benign and malignant lesions.

Selected ReferencesGreglA.Atlasder Galaktographie.Stuttgart: Schattauer; 1985

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Fig.1.70-d Galactography.a Normal findings.b Galactography depicting dilated ducts.c Galactography depicting microcystic changes in duct segment.d Galactography depicting abrupt termination of contrast filled duct

and filling defect (carcinoma).

Digital Mammography

Brief Description............................................................................................X-ray mammography using a digital detector to form an image. There are twoways of digital acquisition:- Computed radiography (indirect technique. "off-line"): Primary exposure of a

photostimulable phosphor plate in the CRcassette using a conventional mam-mography machine. Secondary digital image formation in a CRreader.

- Digital full-field mammography (direct technique. "on-line"): Primary exposureof large-format detectors. Direct digital image production.

Advantages............................................................................................Radiation exposure is 25-30% less than in conventional mammography. Consis-tent optimal exposure. Improved diagnostic potential in younger women. Im-proved diagnostic potential in women with dense breast tissue. ·Soft-copy" imagereading and post-processing on a computer workstation. Digital archiving. Tele-radiology.

Post-processing............................................................................................

Alteration of image brightness and contrast. Zooming. Image inversion. Tumormeasurement. CADsystem: Computer-aided diagnosis. analyzes digital mammo-grams for evidence of suspicious findings. can act as second reader.

Future Possibilities

Fusion systems (combination of digital mammography and ultrasonography) •Contrast-assisted tomosynthesis • Contrast-assisted dual-energy technique.

Conclusion

Digital full-field mammography is the method of choice for radiographic examina-tion of the breast. Conventional screen-film mammography is increasingly losingimportance.

Selected ReferencesFischerUet al. Oigitalmammography: current state and future aspects. Eur Radial2006;

16:38-44Pisano ED et .11.Diagnostic performance of digital versus film mammography for breast-

cancer screening. N EnglJ Med 2005; 353: 1773-1783

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Fig. 1.8 a-d Digital mammography.a Digital full-field mammography system.b Computer workstation for "soft·copy"

image reading.c Digital mammogram.d CAD markings on digital mammogram.

~.

,

( ,

~~.•

•

~~~~U?~~~~~~.t!~~ .Contrast-enhanced MRI of the breast. High sensitivity and specificity for invasivebreast cancer due to its neoangiogenesis • Goal sensitivity for in situ carcinomas.

Indications

- Preoperative local staging- Differentiation between postoperative scar and recurrence or carcinoma- CUP syndrome- High-risk constellation, BRCA- Prosthesis- Problem cases

Examination: Requirements. Technique. and External Influences............................................................................................- Technique: Field strength: 1-3 (usually 1.5) Tesla • Bilateral breast surface coil.

Immobilization of breasts to reduce motion artifacts (compression device, pads),- Optimal time of examination: Second (or third) week of the menstrual cycle,- Influence of HRT: If the evaluation of the examination is limited, a repeat exami-

nation should be carried out after 4-6 weeks without HRT- Time interval between open surgery and MRI of the breast: ~ 6 months,- Time interval between radiation therapy and MRI of the breast: ~ 12 months.- Slice orientation: Transverse, coronal, sagittal.- Sequences: T1-weighted GE sequence, T2-weighted SE,TSE,or IR sequence.- Spatial resolution: S4 mm per slice,- Temporal resolution: < 2.5 min per sequence,- FOV: 300-350 mm- Matrix: At least 256 x 256, bener 512 x 512- Paramagnetic contrast material: 0,1 mmol/kg body weight for two-dimensional

technique. 0,1-0,2 mmol/kg body weight for three-dimensional technique- Contrast material injection in the cubital vein, followed by at least 20 mL NaCI

(2-3 mL/s),- Dynamic measurement: One precontrast measurement. Further measurements

over at least 6 min after contrast injection- Documentation: Complete T1-weighted precontrast examination (obligatory).

complete T1-weighted early postcontrast examination. complete Tl-weightedearly subtraction. T2-weighted examination and curve analysis based on find-ings.

- Post-processing: Subtraction (obligatory: early postcontrast - precontrast). Sig-nal-time curve (obligatory for hypervascularized findings) • Largest possible ROIshould be placed within maximally enhancing part of lesion. MIP (facultative,recommended),

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•MR Mammography

----Fig. 1.90-<1MRmammography.a MRmammography(T2-weighted. fatsuppressed).

b MRmammography(Tl-weighted precon-trast).

Evaluation............................................................................................

- Morphologic criteria.- Dynamic criteria.- Multimodal evaluation concepts.- Consideration of the T2-weighted images._ Synoptic consideration: Correlation between mammography and other imaging

results.- Specification of location and size of pathologic findings.- Categorization of findings according to the BI-RADScriteria.

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MR Mammography

c Subtraction image. ~

'"-".o~

d Maximum intensityprojection (MIP).

Tips and Pitfalls............................................................................................Incorrect injection of contrast material. Out-of-phase (opposed phase) imaging.Transmitter/receiver problems. Inadequate patient positioning (incomplete visu-alization) • Motion artifacts.

Selected References

Fischer U. Practical MR-Mammography. Stuttgart: Thieme; 2000

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s: Brief Description/'t) ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

S-o Definition: Tissue puncture with aspiration of cells from the breast or axilla, or~ puncture of breast cysts,

Equipment: Holding device (handheld) • Cameco-System • Syringe, usually 20 mL •Needle, usually 20-24 G.Indication: Limited. Cyst puncture (if painful or ambiguous) • Palpable lesionwithout image correlation. Axillary lymph node. Cutaneous nodule (e.g., aftermastectomy).Goal: Pain relief. Acquisition of cell material from centrifuged cyst liquid. Cyto-pathologic examination of cells after HEstaining.Procedure:- Cyst: Antegrade puncture using ultrasound guidance' Application of suction.

Optional cytologic examination of cyst fluid.- Palpable nodule or lymph node: Antegrade puncture using ultrasound guidance

throughout procedure' Application of suction. Oscillating, shearing motions ofthe needle with fanning out to sample different areas. Suction release beforeneedle is removed from lesion. Air-dried slides for cytologic examination.

Cytology............................................................................................Classification of cytologic results into five categories:- C1: insufficient for diagnosis- C2: clearly benign- 0: benign with cellular atypia- C4: suspicious cellular atypia without clear signs of malignancy- (5: clearly malignant

Tips and Pitfalls............................................................................................In the diagnostic workup of solid intramammary tumors, a histologic sampleshould be acquired by percutaneous biopsy' FNABis not sufficient in these cases .•FNABrequires an excellent, experienced cytopathologist.

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Fine Needle Aspiration Biopsy (FNAB)

fig.l.lOa-d Fine needle aspiration biopsy (FNAB).a Holding device.b Sonographic documentation of FNAB.c Glass slides with aspirated material.d Microscopic view of cytologic material.

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;:: Brief Description~ .S-o Minimally invasive percutaneous procedure for acquiring a histologic sample.~ Needle size: 14-19 G.

Examination Technique............................................................................................o Measures perfonned before intervention

Laboratory coagulation tests.o Ultrasound-guided biopsy

Visualize lesion. Local anesthesia. Insert needle parallel to the long axis of thetransducer. Real-time visual monitoring of needle progress to pre-fire posi-tion. Fire needle into lesion. Document needle position in two planes. Ac-quisition of five histologic samples is recommended.

o Stereotactic biopsyRarely indicated for the diagnostic workup of microcalcifications and nonpalpa-ble mammographic findings seen only in one plane (vacuum biopsy is prefer-red). Full imaging workup in craniocaudal and mediolateral planes is requiredprior to carrying out the procedure. Determine preferred biopsy plane and vis-ualize finding within biopsy window. Acquire stereotactic images by incliningthe x-ray tube ± 15' to calculate lesion coordinates. Local anesthesia and nickincision. Insert 14 G needle. Acquire pre-fire stereotactic images. Fire needleto fully extended position • Take biopsy samples (recommended number isfive). X-ray core biopsies to verify calcification retrieval.

o MR mammography-guided biopsyNo standard procedure is yet defined for MR-guided biopsy. Vacuum biopsy isrecommended.

o Measures perfonned after interventionRemove needle. Cool and compress biopsy region for at least 15 min. Dressbiopsy region with adhesive or compression bandage.

Conclusion

Core biopsy is the standard method for minimally invasive acquisition of histologicsamples in the diagnostic workup of suspicious breast lesions seen on ultrasound.Core biopsy is rarely indicated in stereotactic or MR-guided biopsies.

Selected ReferencesSchulz KD. Albert US. Stufe-3-Leitlinie. Brustkrebs-Friiherkennung in Deutschland.

Munich.Vienna. NewYork:Zuckschwerdt: 2003

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Core Biopsy

Fig.l.lla-d Core biopsy.a Ultrasound-guided core biopsy. pre-fire. Lesion 5 mm in diameter.b Ultrasound core biopsy, post-fire.c Stereotactic image. Lesion 8 mm in diameter.d Stereotactic image. post-fire.

27

s: Brief Descriptionn:l ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••....g- Minimally invasive. vacuum-assisted percutaneous procedure to acquire a histolog-sr ic sample. Needle size: 8 G-11 G.

Exominotion Technique............................................................................................~ Measures performed before intervention

Laboratory coagulation tests.~ Ultrasound-guided biopsy

Rarely indicated. Local anesthesia. Insert 8-11 G needle parallel to the longaxis of the transducer. Real-time visual monitoring of needle progress to pre-fire position • Fire needle into lesion • Document needle position in twoplanes. Rotate biopsy notch for acquisition of each tissue specimen. Acquisi-tion of 20 histologic samples is recommended. Perform post-procedural ultra-sound with documentation ofbiopsied area.

~ Stereotactic biopsyPreferred method is the diagnostic workup of microcalcifications • Full imagingworkup in craniocaudal and mediolateral planes is required prior to carrying outprocedure. Determine preferred biopsy plane and visualize finding within bi-opsy window. Acquire stereotactic images by inclining the x-ray tube ± 1S' tocalculate lesion coordinates. Local anesthesia and nick incision. Insert 8-11 Gneedle. Acquire pre-fire stereotactic images. Fire needle to fully extended po-sition • Acquire post-fire stereotactic images to verify correct position. Makeappropriate corrections if necessary. Rotate biopsy notch for acquisition of eachtissue specimen. Acquisition of 20 histologic samples is recommended. X-raycore biopsies to verify calcification retrieval. Continue biopsy acquisition if re-quired • Separate and label core biopsies with and without calcifications forpathologist. Optional placement of clip marker. Acquire post-procedural im-age of biopsied area. Perform post-procedural mammogram in craniocaudaland mediolaterai planes.

~ MR mammography-guided biopsyVisualize contrast-enhancing lesion. Use marker to determine appropriate bi-opsy plane and position of lesion. Measure depth of lesion in acquired image.Local anesthesia and a nick incision. Insert 8-11 G needle. Fire needle to fullyextended position. Rotate biopsy notch for acquisition of each tissue cylinder.Acquisition of 20 histologic samples is recommended. Undertake post-proce-dural MR mammography, if necessary with contrast. Continue biopsy acquisi-tion after correction of needle position if required. Optional placement of clipmarker. Post-procedural documentation of biopsy area .

•.. Measures performed after interventionRemove needle. Cool and compress biopsy region for at least 30 min. Dressbiopsy region with adhesive or compression bandage.

28

Vacuum Biopsy

Fig.l.12a-d Vacuum biopsy.a Stereotactic vacuum biopsy. pre·fire. Microcalcifications.b Stereotactic vacuum biopsy. post-procedural documentation.c MR mammography·guided vacuum biopsy. pre-fire documentation.d MR mammography-guided vacuum biopsy. post-procedural documentation.

29

30

Conclusion

Vacuum biopsy is the standard method for minimally invasive acquisition of histo-logic samples in the diagnostic workup of suspicious mammographic (especiallymicrocalcifications) and MR mammographic breast lesions • Vacuum biopsy israrely indicated for ultrasound-guided biopsies. In special cases the minimally in-vasive extirpation of a papilloma (benign lesion with increased risk of malignanttransformation) by means of vacuum biopsy may be considered.

Selected ReferencesSchulz KD. Albert US. Stufe-3-Leitlinie. Brustkrebs-FrGherkennung in Deutschland.

Munich.Vienna.NewYork:Zuckschwerdt; 2003

Brief Description............................................................................................Image-guided procedure used to localize nonpalpable breast lesions prior to sur-gery.

Localization Technique............................................................................................• Ultrasound-guided free-hand technique

- Visualize lesion.- Insert 20 G needle parallel to the long axis of the transducer.- Real-time visual monitoring of needle progress.- Penetrate through and 1 em beyond the lesion.- Document needle position in two perpendicular planes.- Release hookwire.- Document hookwire position in two perpendicular planes.- Mammographic documentation of wire position in the craniocaudal

and mediolateral projections.• Mammography-guided free-hand technique

- Visualize lesion in craniocaudal and mediolateral projections.- Calculate lesion depth and angle in relation to the nipple.- Insert 20 G localization needle to penetrate through and 1cm past the lesion.- Perform mammographic documentation of needle position in the

craniocaudal and mediolateral projections.- Perform corrections if necessary.- Release hookwire.- Mammographic documentation of wire position in the craniocaudal

and mediolateral projections.- Alternative: Calculation of coordinares by the Berger method.

• Stereotactic technique for x-ray guided localization- Full imaging workup prior to localization.- Visualize finding within biopsy window.- Acquire stereotactic images.- System directs needle entry to X- and V-coordinates.- Z-axis is calculated from parallax shift on stereo images.- Inject anesthesia.- Insert 20 G localization needle to penetrate through lesion.- Acquire stereotactic images to verify correct position.- Release hookwire.- Mammographic documentation of wire position in the craniocaudal

and mediolateral projections.• MR Mammography-guided technique

- Visualization of contrast-enhancing lesion in appropriate plane.- Use external marker to determine plane and position of lesion.- Measure depth of lesion in acquired image.- Insert 20 G localization needle.- Penetrate through and 1 cm past the lesion.

31

Preoperative Localizotion Techniques

3: Flg.l.13o-g Preoperative hookwirerc localization.S.o a Ultrasound guided. Wire penetrates~ and protrudes 1 em past the lesion.

- Post-procedural MRmammography documentation.- Communication with surgeon, post-operative measures.

Surgery: To demonstrate the pre-operative localization status to the surgeon it isideal to provide a drawing of the breast showing the course of the localization wirein relation to the localized lesion. The localization wire issurgically removed withan appropriate safety margin.Post-operative measures: In the case of mammographic lesions or microcalcifica-tions. take a radiograph of the specimen to verify the complete excision.

Quality Assessment Criteria............................................................................................

According to international guidelines. the distance between the localization wireand the localized lesion should be less than 1em in over 90% of cases. In addition.more than 95 % of localized lesions should be completely excised after surgery.

Canclusian

Hookwire localization is the current standard method for the preoperative localiza-tion of nonpalpable breast lesions.

TIps and Pitfalls............................................................................................

Quick-frozen sections of tissue containing microcalcifications should not be taken.The resistance of the calcifications to the mechanical forces encountered during mi-crotome sectioning disrupts the deep-frozen tissue sample.

32

Preoperative Localization Techniques

b-d Mammography. Hookwire protrudes1 em past the lesion.

b Mediolateral projection.c Craniocaudal projection.d Specimen radiography.

33

34

Preoperative Locolizotion Techniques

e-g MR mammography.e Subtraction image.f Tl-weighted image showing contrast-

enhancing lesion.g Tl-weighted image showing hookwire

penetrating localized lesion.

~~~~(~~~~~!~.t!?~ .• Definition

First lymph node to receive lymphatic drainage from the site of a primary tumor.• General information

Axillary lymph nodes are the main filters of the flow of lymph passing from thebreast: Levell (peripheral)-2 (proximal)-3 (deep axillary). Lymph from someareas of the inner breast quadrants drains to the internal mammary lymphnodes. Rarely. lymph may drain from some areas of the upper breast quadrantsdirectly to the infraclavicular lymph nodes. The status of lymph node involve-ment is the most important prognostic factor in patients with breast cancer·Full axillary dissection causes lymphedema in the arm in 10%of women. 20-25%of women who undergo radiation therapy of the axillary region suffer fromlymphedema.

• IndicationThe sentinel node technique is appropriate for invasive breast cancers < 2-3 cmin diameter without suspicious lymph nodes on imaging.

Imaging............................................................................................• Nuclear imaging

SLNmapping in two perpendicular views shows the SLN3 hours after radiocol-loid injection.

Technique............................................................................................Preoperative injection of 0.1-5 mL of 99mTcradiocolloid or isosulfan blue dye intotumor or near tumor location (3.5-111 MBq) • Intraoperative identification of SLN(visually: isosulfan blue dye or using handheld gamma probe) • Quick-frozen sec-tion of surgical specimen. Identification of carcinoma cells within the SLNin thehistologic evaluation is proof of lymphatic metastatic spread requiring a full axil-lary dissection.

Contralndicatlons

Pregnancy. Allergy against tracer or dye. Multicentricity. Inflammatory breastcancer. Recurrent breast cancer. Prior breast or axillary surgery with extensivescarring. Suspected advanced lymphatic metastasis.

Conclusion

Standard full axillary dissection with the risk of lymphedema of the arm may beavoided when the sentinel node technique shows no lymphatic metastasis.Major drainage is to the axilla. Some areas of the inner breast quadrants drain intothe internal mammary lymph nodes. Rarely. some of the areas of the upper breastquadrants drain into the infraclavicular lymph nodes.

35

Fig. 1.14 Lymphatic drainage of thebreast. Major drainage to the axilla. Someareas of the inner breast quadrants drainto the internal mammary lymph nodes.Rarely, some areas of the upper breastquadrants drain into the infraclavicularlymph nodes.

36

Selected References

Kuhn T et al. Sentinel-Node Biopsie beim Mammakarzinoffi. Geburtsh Frauenheilk 63:835-840:2003

Major Findings............................................................................................

- Cystic lesions.- Solid lesions.- Architectural distortion.

Evaluation Criteria

Shape: Round. oval. lobular. irregular.- Margins: Circumscribed (well-defined). indistinct (ill-defined).- Internal echoes: Anechoic. hypoechoic. isoechoic, hyperechoic (compared with

normal parenchyma).- Internal structure: Homogeneous. inhomogeneous.- Mobility: Good. immobile.- Surrounding structures: Intact, displaced, interrupted.- Posterior acoustic changes: Enhancement. indifferent. shadowing,- Main lesion axis (orientation): Parallel to the skin. perpendicular to the skin,- Compressibility: Good. none.

Selected ReferencesAmerican College of Radiology. BI-RADS Breast Imaging Reporting and Data System.

Breast Imaging Atlas: Mammography. Breast Ultrasound. Breast MR Imaging. Virginia:Reston: 2003

Fischer U. Helbich T. ACR BI-RAOS. IIlustrierre Anleitung zur einheitlichen Befunderstel-lung von Mammographie. Mamrnasonographie. MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

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37

Diagnostic Criteria in Ultrasonography

Combination

Surrounding tissue• Duct changes• Disruption or displaced Cooper ligaments• Edema• Architectural distortion• Skin thickening• Skin retraction

Caldflcatlons• Macrocalcifkations• Microcalcifications• Microcalcifications inside a mass

Special cases• Clustered microcalcifications• Complicated cyst• Cutaneous or subcutaneous lesion• Foreign matter• lymph node-intramammary• lymph node-aXillary

Vascularization• Detectable/not detectable• In direct proximity to a lesion• Diffuse

Posterior acoustic changes

None Enhancement Shadowing-

Isoechoic

Anechoic

Hyperechoic

Hypoechoic

Complex

••Perpendicularto skin line

MargIns

Parallel toskin line

Well-defined III-defined

Internal echoes

ShapeOObd

Round Oval lobular Irregular

Orientation

Fig. 2.1 Diagnostic criteria in ultrasonography.

38

Density............................................................................................Detected only in one projection: Pseudo lesion caused by structural overlap. Truemass masked by adjacent or superimposed glandular tissues in the second projec-tion • Some true lesions are seen in one projection only (e.g.. radial scar).

Mass

Space-occupying lesions detected in two projections:- Shape: Round. oval. lobular. partially obscured. irregular.- Margins: Circumscribed (well-defined), microlobulated, obscured by structural

overlap, ill-defined (indistinct), spiculated._ Density: Fat equivalent, hypodense (but not fat equivalent), isodense to parenchy-

ma, hyperdense,

Calcifications

Macrocalcifications (usually benign) • Microcalcifications (0,05-0.1 mm diameter).- Morphology: Monomorphic, pleomorphic/heterogeneous,- Distribution: Diffuse, regional, segmental, linear. clustered « 2 cm').

Architectural Distortion............................................................................................Focal distortion of the normal parenchymal architecture without visible mass·Usually seen as spicules radiating from a point, as a focal retraction, or distortionof the edge of the parenchyma.Classicdifferential diagnosis:- Postoperative scar (history I)- Radial scar- Breast carcinoma (e.g" tubular carcinoma)

Selected ReferencesAmerican College of Radiology.BI-RADSBreast Imaging Reporting and Data System.

Breast Imaging Atlas: Mammography, Breast Ultrasound. Breast MR Imaging. Virginia:Reston:2003

Fischer U. Helbich T. ACR 81-RADS. lIIustrierte Anleitung zur einheitlichen Befunderstel-lung von Mammographie. Mammasonographie. MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

39

Diagnostic Criteria in Mammography

Mass

o

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Spiculated

ooMicro- 111-

lobulated definedDensity

Finding in two projections

Form

ooC:)dIrregular

•Round Oval Lobular

Margins

••••••••••Well-

defined

Finding in one projection only

Fat equival. Hypodense Isodense Hyperdense

CalcificationsMorphologyw·····. :....

. " ..Monomorphic

Distribution

[i]

Architectural distortion

Flg.2.2 Diagnostic criteria in mammography.

40

o,

o,

o,2

o,2

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o,2

~1~~/P*~~_~.,~••••~tIH~~••••..•!!~a~.~a~••~J~•••~••!:I~.~.I~.~•••!.....__ ~••~III~••~m~_~~_~~¥~_~•.!p~L~"!.....~.JShape• Round. oval. lobular• Irregular

Margins• Well-defined• III-defined. spiculated

Contrast medium distribution• Homogeneous• Inhomogeneous• Ring enhancement

Initial contrast medium enhancement(1-3 min after administration of contrast medium)

• Weak• Moderate• Strong

Post-initial contrast medium enhancement(3-8 min after administration of contrast medium)• Continuous increase• Plateau• Washout

Table 1 Goettingen method: diagnostic criteria for distinguishing masses in MR mammography(contrast-assisted Tl-weighted GEsequences)

Mass (Space-occupying Lesion)............................................................................................

Evaluation (Goellingen score)Total scoreo1-234-56-8

BI·RADS categoryMR mammography BI-RADS 1MR mammography BI-RADS 2MR mammography BI-RADS 3MR mammography BI-RADS 4MR mammography BI-RADS S

Further Diagnostic Criteria: f2-weighted Sequence............................................................................................High water content usually indicates a benign lesion. Low water content usuallyindicates a malignant lesion. Septa within a mass indicate a benign lesion (e,g.,fibroadenoma).

Non-mass Lesion

Definition: Hypetvasculatized lesion which tespects, i.e., does not displace at de-stroy. the normal anatomic structures of the breast (distribution pattern of fat andparenchymal tissue) • Morphology is more important than dynamic criteria.

41

MMMHomogeneous Inhomo- Ring

geneous enhancement

Spiculated

lobular Irregular

MassForm

Margins

III-defined

Enhancement

Round Oval

~Well-defined

Focus/foci

Enhancing area < 5 mm diameter

Diagnastic Criteria in MR Mammography

MMMDarksepta light septa Central

enhancement

Non-mass enhancement Kinetic curves

MMACJSegmental Regional Diffuse

MM Continuous

Time

DuctallinearFocal

Multiple

Flg.2.3 Diagnostic criteria in MR-mammography.

42

Diagnostic Criteria in MR Mammagraphy

~~lf.~~~.~~~~~.'?!?~~~~;~.?r.~~.~.N.~n.-.~~~~.~.~~~~~ .

Intraductal carcinoma (DClS) • Invasive lobular carcinoma (ILC) • Radial scar·Other benign changes.

Selected ReferencesAmerican College or Radiology. BI-RADS Breast Imaging Reporting and Data System.

Breast Imaging Atlas: Mammography. Breast Ultrasound. Breast MR Imaging. Virginia:Reston; 2003

Fischer U. Helbich T. ACRBI-RADS.llIustrierte Anleitung zur einheitlichen Berunderstel-lung von Mammographie. Mammasonographie. MR Marnmographie. 2nd ed. Stutt-gart; Thieme; 2006

43

44

Definition............................................................................................Mammographic quality assurance standards used in the British screening system.Defined criteria for the documentation and evaluation of mammograms • Major re-quirements are the complete visualization of breast parenchyma. good ability to as-sess image material. and the clear allocation of images to a certain individual.Mammograms are classified into four categories:- P: Perfect.- G: Good.- M: Moderate.- I: Inadequate.

Positioning technique............................................................................................

MLOprojection (Fig.2.4a):- Visualization of the pectoral muscle at least down to the level of the PNL.- Posterior nipple line (PNL): Line drawn from the nipple at right angles to the pec-

toral muscle.- Pectoral muscle at correct angle (> 20° to vertical).- Nipple in profile.- Clear visualization of the open inframammary fold.- Complete visualization of craniolateral breast tissue.Craniocaudal projection (Fig.2.4b):- Posterior nipple line (PNL): Line drawn from the nipple at right angles to the pec-

toral muscle.- PNLon craniocaudal projection must be within 15 mm of that on MLO.- Nipple in profile.- Nipple position in the center or slanted slightly medially.- Complete visualization of medial breast tissue. maximal visualization of lateral

breast tissue.

Other Quality Assessment Criteria

- Correct image labeling (patient data. specification of side. projection. and exami-nation date).

- Correct exposure and contrast (optical density 0.8-2.5).- Firm compression.- No motion blurring.- Correct film processing.- No or minimal developing or handling artifacts.- No or minimal skin folds (not overlapping parenchyma).- Symmetry or minimal asymmetry of right and left mammograms.- Concordance of indication. imaging. and findings.

PGMI (Perfect. Good. Moderate. Inadequate) Criteria

MLO projectionRfL

Craniocaudal projection.sideR/l

Fig.2.40-d PGMI criteria.a PGMI criteria for the optimalpositioning for MLO projection.

b PGMIcriteria for the optimalpositioning for craniocaudal projection.

45

PGMI (Perfect. Good. Moderate. Inadequate) Criteria

is= c Perfect MLO projection.

3",""Q2'~Q

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d Perfect craniocaudal projection.

46

PGMI (Perfect, Good, Moderate, Inadequate) Criteria

Quality Standards............................................................................................Deficiencies in image labeling, exposure, and compression. as well as motion blur-ring and artifacts reduce an otherwise perfect mammographic image to an inade-quate image.- 275% of mammographic images must be classified as perfect or good.- 297% of mammographic images must be classified as perfect, good, or moderate.- A maximum of3% of mammographic images may be inadequate.- Alternative classification: class I (P + G), class 11(M), and class 111(I) • Of 10 mam-

mographic studies (40 mammograms): one mammogram may be in class 111.12 mammograms in class 11.

Tips and Pitfalls

Only visualized structures can be evaluated.

Selected References

Perry N et al. European guidelines for quality assurance in mammography screening.EUREF,European Commission: 2006

47

48

Definition............................................................................................Overall assessment of the attenuating tissues in the breast. Helps indicate the rel-ative possibility that a lesion may be hidden by the normal breast tissue and is ameasure of the diagnostic reliability of mammography' This term is also used inMR mammography. where it refers to the physiologic enhancement of normalbreast parenchyma after injection of contrast.

Mommogrophic Composition, i.e., Density Potterns According to ACR............................................................................................- Type I: Almost entirely fat. Less than 25%of the breast is composed ofparenchy-

ma • Vety high diagnostic reliability. Sensitivity for carcinoma detection ap-proximately 98%.

- Type II: Contains scattered fibroglandular densities. 25-50% of the breast iscomposed of parenchyma' High diagnostic reliability. Sensitivity for carcino-ma detection approximately 90%.

- Type III: Heterogeneously dense breast tissue. 50-75% of the breast is composedof parenchyma. Limited diagnostic reliability. Sensitivity for carcinoma detec-tion approximately 70% • Additional diagnostic procedures are recommended(ultrasonography. MRmammography).

- Type IV: Extremely dense breast tissue. 75-100% of the breast is composed ofparenchyma. Very limited diagnostic reliability. Sensitivity for carcinoma de-tection approximately 40-50% • Additional diagnostic procedures are stronglyrecommended (ultrasonography. MRmammography).

Alternotive Clossificotion of Mommographic Breast Composition............................................................................................In the opinion of the authors. because parenchyma is not always homogeneouslydistributed. it is advantageous and more expedient to classify breast compositionpatterns according to estimated size of a tumor that could be missed instead of thepercentage of breast parenchyma as described above. For example:- Type I: Reliable detection of tumors over 2 mm diameter.- Type II: Reliable detection of tumors over 5 mm diameter.- Type III: Reliable detection of tumors over 10 mm diameter.- Type IV: Limited detection of tumors under 20 mm diameter.

MR Mammographic Composition Patterns............................................................................................- MR mammography density type I: No enhancement of normal breast parenchyma

within the first 3 min after contrast administration. Very high diagnostic relia-bility.

- MR mammography density type II: Minor. fine nodular enhancement of normalbreast parenchyma within the first 3 min after contrast administration. High di-agnostic reliability.

Flg.2.5o-d Mammographiccomposition patterns.a ACRI.

b ACR II.

Breast Composition

49

Breast Composition

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50

- MR mammagraphy density type III: Fine nodular, merging enhancement patternof normal breast parenchyma within the first 3 min after contrast administra-tion. Limited diagnostic reliability (earliest possible subtraction image recom-mended),MR mammography density type IV: Widespread strong enhancement of normalbreast parenchyma within the first 3 min after contrast administration. Verylimited diagnostic reliability (earliest possible subtraction image recommended),

Composition Patterns in Ultrasonography

In principle it is conceivable to create an analogous categorization system for 50no-graphic breast tissue patterns for the purpose of communicating the diagnostic re-liability of the individual examination. At present such a categorization does notexist. Factors known to limit the reliability of a breast ultrasound examination are,e,g" echo alterations due to mastopathy and/or breast cysts.

51

52

Definition

A system developed by the ACR to standardize the language used in breast imaging,and the assessment categories for breast findings (mammography, ultrasonogra-phy, and MR mammography) • The current edition was published in 2003 and hassix assessment categories.

Selected References

American College of Radiology. 81-RADS Breast Imaging Reporting and Data System.Breast Imaging Atlas: Mammography. Breast Ultrasound, Breast MR Imaging. Virginia:Reston: 2003

Fischer U, Helbich T. ACRBI-RADS. lIIustrierte Anleitung zur einheitlichen Befunderstel-lung von Mammographie. Mammasonographie, MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

BI-RADS (Breast Imaging Reporting And Data System)

Table 2.2 BI·RAOSevaluation ~o3'"""Q-c:~o"Q..":;'Q.:i'

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• Imaging is complete• No findings to comment on• Probability of breast cancer 0%• Course of action: Patient returns for routine

mammogram

• Further diagnostic procedures necessary (recall)• Category usually used in screening situation• Course of action: completion of diagnostic workup

(e.g., spot compression view)

Inconspicuous

Incompleteo

2 Benign finding • Imaging is complete• Described finding is definitely benign (e.g., fat ne-

crosis on mammography, macrocyst on ultrasound.hamartoma on MR mammography)

• probability of breast cancer 0%• Course of action: patient returns for routine

mammogram

3

4

5

Probably benignfinding

Suspicious abnor-mality

Highly suggestiveof malignancy

• Imaging is complete• Described finding is probably benign• Probability of breast cancer < 2%• Course of action: short interval follow-up

(usually 6 months)

• Imaging is complete• Described finding is worrisome, but has no typical

characteristics of malignancy• Probability of breast cancer approximately 30%

(between 2% and 90%)• Subcategories: 4A: low probability; 48: moderate

probability; 4C: high probability of malignancy• Course of action: percutaneous biopsy

• Imaging is complete• Described finding has typical characteristics

of malignancy• Probability of breast cancer> 90%• Initiate appropriate action: Therapeutic proce-

dures/percutaneous biopsy

6 Histologicallyverified cancer

• Histological report is obtained before treatmentis initiated

• Course of action: Initiate therapeutic procedures

S3

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54

Definition

Appearance of the normal breast. Relative proportion of parenchyma to fany tis-sue and its distribution varies among individuals-hence the variable appearance ofthe individual breast in diagnostic imaging. Normally breast density decreases af-ter menopause (involution).

Imaging 51gns

• Ultrasound findingsParenchyma is hyperechoic • Milk ducts are present throughout the parenchy-ma, and their diameter increases toward the nipple. Fat tissue is hypoechoic •Cooper ligaments appear as linear hyperechoic structures,

• Mammographic findingsTransparency of parenchyma is variable. Hence the diagnostic reliability is alsovariable. Overall breast composition. Le.,density is categorized according to theACRtypes:- Most favorable diagnostic situation: Very transparent. predominantly fatty

breast tissues with high diagnostic reliability (ACRtype I).- Least favorable diagnostic situation: Extremely dense parenchyma with very

limited diagnostic reliability in the detection of breast masses (ACRtype IV).• MR mammographic findings

Parenchyma has a low signal in T1-weighted images and intense signal in T2-weighted images. Fany tissues have an intense signal in Tl-weighted images.Contrast enhancement of parenchyma depends on the phase of the menstrualcycle. Parenchyma shows no or little contrast enhancement in the second (andthird) week of the menstrual cycle (optimal phase for performing examina-tion) • Nipple usually shows conspicuous enhancement after contrast adminis-tration.

Clinical Aspects............................................................................................

• l)'pical presentationUsually symmetric. No skin retraction. No nipple retraction. Histology: regu-lar arrangement of acini surrounded by fat tissue. Uniform arrangement of lac-tiferous ducts lined by a single layer of epithelial cells without proliferation oratypia.

• Course and prognosisThe estimated lifetime risk of developing breast cancer for women in industrial-ized nations is approximately 10%.

Tips and Pitfalls............................................................................................

The individual appearance of the breast on diagnostic imaging is highly variable.To rule out breast cancer with the highest possible certitude. an individualized di-agnostic approach is necessary.

Normol Findings

Fig.2.6a-d Normal findings.a Right MlO projection mammogram.b Left MLO projection mammogram.c Right craniocaudal mammogram.d left craniocaudal mammogram.

55

56

Definition

Difference in volume between the right and left breast (size asymmetry) • Unilat-eral, localized area of parenchyma (focal asymmetry) • Difference in the amount ofparenchyma between the right and left breast (global asymmetry),

Imaging Signs............................................................................................

• Ultrasound findingsFocal or global asymmetry in the distribution of parenchyma-equivalent echoge-nicity,

• Mammographic findingsFocal or global asymmetry in the distribution of parenchymal densities,

• MR mammographic findingsFocal or global asymmetry in the distribution of parenchyma (Tl-weighted pre-contrast image), Occasional asymmetric enhancement pattern after contrast ad-ministration.

Clinlcol Aspects............................................................................................

• Typical presentationVisible difference in right and left breast size (size asymmetry) • Occasional pal-pable asymmetric increase in consistency (most often for global asymmetry) •Focal asymmetries are usually inconspicuous. Occasional palpable glandularfinding. Histological examination reveals normal breast tissue.

• Treatment optionsNone. Percutaneous biopsy is indicated if findings are not clearly benign. Oth-erwise continue screening at usual intervals.

• Course and prognosisIf asymmetry is due to normal parenchyma, prognosis is excellent (no increasedrisk of developing breast cancer) • If asymmetry is due to malignancy, prognosisdepends on tumor histology and stage,

Dlfferentlol Diagnosis

Constitutional anisomastia • Accessory parenchyma. Hamartoma. Malignancy.

Tips and Pitfalls............................................................................................Asymmetries in breast size and parenchymal distribution are common and usuallyharmless,

Asymmetry

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57

58

Definition............................................................................................Focal interruption of the normal mammographic pattern of lines (converging at thenipple). usually presenting as a star-shaped distortion.

Imaging Signs

~ Ultrasound findingsUsually no characteristic changes. May present as architectural distortion indense parenchymal structures.

~ Mammographic findingsStar-shaped distortion of the normal parenchymal structure. Center may be ra-diolucent • Occasionally associated with microcalcifications • One projectionfinding in approximately 30% of cases. Spot compression view is recommend-ed.

~ MR mammographic findingsStructural distortion occasionally seen in Tl-weighted image (especially whenparenchyma is permeated by fatty tissue) • Contrast enhancement depends onetiology (e.g.. postoperative scar shows no enhancement. carcinoma showsstrong enhancement) • Most often one sees no space-occupying lesion ("non-mass") • No specific changes in T2-weighted image.

Clinical Aspects............................................................................................~ 'JYpical presentation

Depending on etiology. either no pathologic finding (frequent) or palpable mass(rare).

~ Treatment optionsA postoperative scar requires no further diagnostic or therapeutic measures.Usually a radial scar is excised by open surgery (borderline lesion. concurrent in-cidence of cancer is approximately 30%) • There are insufficient data pertainingto the role of vacuum biopsy in the treatment of radial scars. Breast carcinomasrequire the initiation of adequate therapeutic procedures (e.g .. breast-conservingtreatment).

Differential Diagnosis............................................................................................Postoperative or post-inflammatory scar (history) • Radial scar. Malignancy (dis-proportionately high rate of tubular and lobular breast cancers).

Tips and Pitfalls............................................................................................The slightest evidence of architectural distortion should prompt the performance ofa spot compression view of the area of interest to confirm or rule-out the presenceof a radial scar.

Architectural Distortion

Fig.2.8a-d Architectural distortion.a Histologic section.b Mammography.c Ultrasonography.d MR mammography (Tl-weighted precontrast image).

59

60

Definition

Changes of the skin which must be differentiated between those that might indicatemalignancy (secondary sign of malignancy) and those which result from benigncauses.

Skin Changes of Benign Origin............................................................................................Calcifications of the sebaceous glands: Round calcifications in skin plane.

- Deodorants containing zinc: Radiopaque particles mimicking calcifications areusually seen in the axillary tail on MLO.

- Powder particles containing cadmium and/or aluminum may be seen in the in-framammary crease.

- Skin thickening: May be constitutional. seen after radiotherapy or in acute mas-titis.

- Skin retraction: Seen postoperatively and in Mondor disease.- Nipple retraction: May be constitutional or may be seen postoperatively.- Skin changes appearing as masses: E.g.,moles, warts, sebaceous cysts, neurofi-

bromatosis.

Skin Changes Indicating Malignancy

- Skin thickening: E.g" inflammatory breast cancer, tumor infiltration.- Skin retraction: E.g.,caused by pulling in of skin by Cooper ligaments associated

with malignancy,- Nipple retraction: E.g"caused by pulling in of skin by Cooper ligaments associat-

ed with malignancy.- Nipple flattening: E.g" in Paget disease of the nipple.- Enlarged skin pores (digital mammography): May be seen in lymphedema or in-

flammatory breast cancer.

Skin Changes

Fig.2.9a-d Skin changes in mammography.a Skin retraction.b Skin thickening.c Skin calcifications.d Nipple retraction.

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Definition............................................................................................Deviation from the normal nipple appearance.~ Etiology, pathophysiology, pathogenesis

Physiologic variations. Variations due to benign causes. Changes due to malig-nancy.

Clinical Aspects............................................................................................Normal findings include numerous variations in form, size, and position of the nip-ple, among others:- Periodic retraction.- Inverted nipple.- Split nipple.- Accessory nipple (polythelia) occurring along the milk streakNipple changes associated with benign disorders: Eczema' Secretion.Nipple changes associated with malignant disorders: Flattening (carcinoma) • In-version (carcinoma) • Eczema and/or ulceration (Paget disease of the nipple) •Bloody nipple discharge (intraductal carcinoma) • Pigmented lesion (melanoma) •Vascular changes (sarcoma).

Tips and Pitfalls............................................................................................If the nipple appearance deviates from the normal, inquire for how long this statehas been noticed by the patient. The slightest suspicion of malignancy shouldprompt a complete diagnostic workup (imaging. skin biopsy, open biopsy).

Selected ReferencesBork K. Haut und Brust. Dermatologische Aspekte der Brustkrankheiten. Stuttgart:

Fischer: 1995

Changes in the Nipple

Flg.2.100-<1 Nipple changes.a Eczema.b Bloody nipple discharge.c Paget disease of the nipple,d Nipple inversion due to carcinoma.

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Definition............................................................................................Discharge of non-sanguineous fluid from the nipple. Usually bilateral from multi-ple ducts. Physiologic build-up of breast secretions outside the lactation period.Can often be provoked by massage of the breast. Increased secretions may be dueto hormonal imbalance. or be a physiologic response to endogenous hormones.Character: Serous. milky. or dark (green co black: due to milk decomposition).

Imoging Signs

o Ultrasound findingsRetroareolar duct dilation is seen often. No characteristic mass.

o Mammographic findingsUsually no characteristic findings.

o MR mammographic findingsNo characteristic findings on Tl-weighted image. Often signal-intense retro-areolar duct ectasia in T2-weighted image • Rare: Concrast enhancement afterapplication of contrast material.

Clinical Aspects

o Typical presentationNon-sanguineous fluid wetting from the nipple. Cytology:High protein contentwithout detection of erythrocytes. Character: Serous. milky. or green. occasion-ally black. When secretion is macroscopically green or black. blood should beruled out (e.g.. dipstick or microscopy) • If blood is confirmed. galactographyand cytologic examination are indicated.

o Treatment optionsNone. Ifdischarge is voluminous. prolactin level and thyroid function should beevaluated (pituitary tumor?).

o Course and prognosisEven excessive non-sanguineous discharge usually stops sponcaneously after ashort time. There in no increased risk of developing breast cancer.

Tips and Pitfalls............................................................................................The breast produces minimal secretion throughout life from the menarche onward.even outside the lactation period. Non-sanguineous discharge is not usually asso-ciated with malignancy.

Non-Songuineous Nipple Dischorge

Fig.2.11 a-d Non-sanguineous discharge.a Non·sanguineous discharge.b Ultrasonography. Tubular, hypoechoic, dilated ductal structures (duct ectasia).c MR mammography (T2-weighted image). Signal-intense, tubular duct showing little

branching (duct ectasia).d MR mammography (subtraction image). Linear contrast enhancement of terminal

duct wall in a woman with non·sanguineous nipple discharge.

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Imaging Signs............................................................................................

Discharge of blood or blood-tinged fluid from the nipple. Discharge may appeardark. almost black • Black discharge may be a result of milk decomposition innon-sanguineous nipple discharge.

o Ultrasound findingsDilated retroareolar duct may be seen. Occasionally an intraductal. hypoechoic.smooth-bordered mass is seen (papilloma).

o Mammographic findingsUsually no characteristic finding. Galactography: Usually polyplike. intralumi-nal filling defect. Occasionally complete obliteration of the duct with abruptcontrast termination.

o MR mammographic findingsDucts with increased signal intensity in Tl-weighted image (blood) • Occasionalduct visualization with signal-intense contents in T2-weighted image (duct ecta-sia) • Rare: Contrast-enhancing lesion after application of contrast material(papilloma) • Spatial mapping of discharging duct is difficult.

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o Typical presentationSpontaneous bloody or blood-tinged discharge from the nipple. Usually there isno palpable abnormality. Blood is verified either by microscopic examination ofthe smear. or by dipstick (hemoglobin) • When bloody discharge is confirmed.galactography and cytologic examination are indicated.

o TreatmentoptionsGalactography is indicated to identify the discharging duct and the location of thesecreting lesion (usually a papilloma). Papillomas should be excised because oftheir malignant potential. Papillomas under 1 em in diameter may be resected byultrasound- or MR-guided vacuum biopsy. Important: Good cooperation withthe pathologist is necessary to ensure that complete excision has been achieved.

o Course and prognosisBloody discharge is associated with breast cancer in 5% of cases.

Differential Diagnosis............................................................................................Milk decomposition products can produce the macroscopic appearance of bloodydischarge (no confirmation of blood).

TIpsand Pitfalls............................................................................................Radial scars and papillomas are the only benign lesions of the breast that should beexcised because of their increased malignant potential.

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Bloody Nipple Discharge

fig.2.12a-d Bloody discharge.a Bloody discharge from single duct.b Enlarged detail view of galactogram. Intraductal lobulated papilloma.c MR mammography corresponding to b (subtraction image). Hypervascularized.

lobulated lesion.d Histologic specimen of papilloma.

Selected ReferencesFrancis A, England D. Rowlands D. Bradley S. Breast papilloma: Mammogram. ultrasound

and MRI appearance. Breast 2002: J 1: 394-397

67

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Definition............................................................................................A mass is a space-occupying lesion seen in two different projections (three dimen-sional) • Descriptive criteria are:- Shape.- Margins.- Density.

Evo/uation of Lesion Shape According to the BI-RADS Lexiconof the American College of Radiology............................................................................................The shape of a lesion alone is not a useful criterion in estimating the probability ofmalignancy. It is an important characteristic. however, in conjunction with otherevaluation criteria. Round or oval masses are often benign. Irregular-shaped massesare more suspicious for malignancy.~ Round

A mass that is spherical. circular or ball-shaped. The size is indicated by the di-ameter • Typical examples-cyst. hamartoma.

~ OValElliptical or egg-shaped mass. The size is indicated by the longitudinal andtransverse axis. Typical example-fibroadenoma.

~ lobulatedA mass with undulated contours. Up to three undulations are typical for andcompatible with benign lesions (e.g.. fibroadenoma) • More than three undula-tions are compatible with suspicious lesions and require further diagnosticworkup. Typical example-fibroadenoma.

~ IrregularThe lesion's shape cannot be characterized and is not round. oval. or lobulated.Typical examples-breast carcinoma. scar.

Selected ReferencesAmerican College of Radiology.BI-RADSBreast Imaging Reporting and Data System.

Breast ImagingAtlas: Mammography.Breast Ultrasound. Breast MRImaging.Virginia:Reston: 2003

Fischer U. Helbich T. ACR BI-RADS. Illustrierte Anleitung zur einheitlichen Befunderstel-lung van Mammographie. Mammasonographie. MRMammographie. 2nd ed. Stutt-gart: Thieme; 2006

Mass: Shape

Flg.2.13o-d Mass shapes in mammography.a Round.b Oval.c Lobulated.d Irregular.

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Definition............................................................................................A mass is a space-occupying lesion seen in two different projections (three-dimen-sional).

Descriptive criteria............................................................................................- Shape,- Margins.- Density,

Evoluation of Lesion Margins According to the BI-RADS Lexiconof the American College of Rodiology............................................................................................

The lesion margin alone is not a useful criterion in estimating the probability ofma-lignancy. It is an important characteristic. however, in conjunction with other eval-uation criteria. Indistinct and spiculated margins are more suspicious for malignan-cy than well-defined margins.~ Circumscribed (well defined or sharply defined)

Lesion margins are sharply demarcated. Abrupt transition between lesion andsurrounding tissues. Occasional halo sign (hypodense, peritumoral zone) •Typical examples-cyst, fibroadenoma. hamartoma,

~ MicrolobulatedLesion margins undulate within a short distance of a few millimeters. Typicalexample-medullary breast cancer.

~ ObscuredMore that 25%of a lesion's margins are hidden by superimposed or adjacent nor-mal tissue and cannot be further assessed. Additional imaging can often allowbetter evaluation of lesion margins. e.g., spot compression view.

~ Indistinct (ill defined)Lesion margins are poorly defined. Transition between lesion and surroundingtissues is gradual and not sharp' Typical example-ductal breast cancer.

~ SpiculatedLesion is characterized by lines radiating from the margins of a mass. Typicalexamples-tubular breast cancer, postoperative scar.

Selected ReferencesAmerican COllege of Radiology. BI-RAOS Breast Imaging Reporting and Data System.

Breast Imaging Atlas: Mammography. Breast Ultrasound. Breast MR Imaging. Virginia:Reston: 2003

Fischer U. Helbich T. ACR BI-RAOS. Illustrierte Anleitung zur einheitlichen Befunderstel-lung von Mammographie. Mammasonographie. MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

Mass: Margins

F1g.2.14o-d Mass margins in mammography.a Well defined.b Microlobulated.c Indistinct.d Spiculated.

71

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Definition............................................................................................A mass is a space-occupying lesion seen in two different projections (three dimen-sional).

Descriptive Criterio............................................................................................- Shape.- Margins.- Density.

Evoluation of Lesion Density According to the BI-RADS Lexiconof the American College of Radiology............................................................................................The density of a lesion alone is not a useful criterion in estimating the probability ofmalignancy. It can be an important characteristic. however. in conjunction withother evaluation criteria. Increasing lesion density correlates with an increasingprobability of malignancy.~ Fat-containing (radiolucent)

Lesion density is identical with that offat (compare with subcutaneous fat) • le-sions can be completely or partially fat-containing. The inclusion offat within alesion is a sure indication of a benign finding. Typical examples-lipoma. oilcyst, hamartoma.

~ Hypodense (but not fat-containing)The lesion x-ray attenuation is lower than that expected of an equal volume offibroglandular breast tissue. Typical example-adenoma.

~ Isodense (equal density)The lesion x-ray attenuation is equal to that expected of an equal volume of fibro-glandular breast tissue. Typical example-fibroadenoma, carcinoma.

~ Hyperdense (high density)The lesion x-ray attenuation is higher than that expected of an equal volume offibroglandular breast tissue • Typical example-breast cancer with high celldensity.

Selected ReferencesAmerican College of Radiology.BI-RADSBreast Imaging Reporting and Data System.

Breast ImagingAtlas: Mammography.Breast Ultrasound, BreastMRImaging.Virginia:Reston: 2003

Fischer U, Helbich T. ACR BI-RAOS. lIJustrierte Anleitung zur einheitlichen Befunderstel-lung von Mammographie. Mammasonographie. MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

Moss: Density (Attenuation)

fig.2.150-<1 Massdensity in mammography (compared with that expected of an equalvolume of fibroglandular breast tissue).a Hyperdense.b Isodense.c Hypodense.d Fat-containing.

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Definition............................................................................................The pattern of arrangement of microcalcifications • Due to the intraductal origin ofbreast cancer, microcalcifications showing a ductal arrangement pattern are suspi-cious of malignancy.The arrangement pattern of microcalcifications alone is not a useful criterion in es-timating the probability of malignancy. It can be an important characteristic, how-ever, in conjunction with other evaluation criteria.

Distribution pottern............................................................................................• Grouped (clustered)

Multiple calcifications occupy a small volume of tissue (less than 2 mL)..•. Unear

Calcifications are arranged in a line that may have branch points and are usuallyoriented along a duct.

• SegmentalTriangular distribution of calcifications suggesting deposits in a duct and itsbranches.

• RegionalScattered calcifications in a large volume of breast tissue, not necessarily con-forming to a duct distribution, and not found throughout the entire breast.

• Diffuse (scattered)Scattered calcifications distributed randomly throughout the breast.

nps and Pitfalls............................................................................................The pattern of arrangement of microcalcifications correlates with their root cause:- Regional and diffuse: Often adenosis or sclerosing adenosis- Clustered, linear, and segmental: More likely DClS

Fig.2.16a-d Distribution of microcalcifications.a Grouped.b Segmental.c Regional.d Diffuse.

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Definition............................................................................................Microcalcifications with uniform shapes' Often form in the acini of lobules due tothe accumulation of products of organic decomposition and ensuing precipitationof salts. Ductules are occluded as a physiologic phenomenon during the menstrualcycle. often associated with microcystic changes.

Imaging Signs............................................................................................~ Ultrasound findings

Occasionally visualization of microcysts • Usually no characteristic finding.~ Mammographic findings

Uniform. usually round calcifications' Often scattered or grouped randomly inthe breast.

~ MR mammographic findingsTl-weighted image: Normal findings. calcifications with low signal intensity can-not be distinguished from surrounding normal tissue. 12-weighted image: Nor-mal findings. No contrast enhancement.

Clinical Aspects............................................................................................~ Typical presentation

Women with microcystic breast tissue often have cyclic breast tenderness. His-talogy: Sedimented calcifications in the acini oflobules • No intraductal prolifer-ations .

•.. Course and prognosisMonomorphic microcalcifications are usually associated with benign findings.They may be difficult to assess when seen on the first mammogram or early intheir development • If distribution is grouped. follow-up mammography in6 months may be indicated. Constant findings over 2 years confirms benigni-ty. If findings are ambiguous. stereotactic vacuum biopsy is indicated.

Differentiol Diagnosis

Adenosis, fibrosis. other benign lesions, rarely DClS or invasive carcinoma.

TIps and Pitfalls............................................................................................The mammographic morphology of benign and malignant microcalcifications over-laps markedly. If findings are ambiguous. stereotactic vacuum biopsy allows defin-itive clarification of histology.

Selected References

Guhan-Bilgen et al. Sclerosing adenosis: Mammographic and ultrasound findings withclinical and histopathological correlation. EurJ Radiol2002; 44: 232-238

Fig. 2.17a-d Monomorphicmicrocalcifications.a Adenosis.

Monomorphic Microcolcificotions

b Fibrosis mammae.

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c Sclerosing adenosis. d Granulomatous mastitis.

~!!~I.t!?~ .Microcalcitications of varying shapes. Calcitications associated with necrosis orpostinnammatory processes • Usually develop following intraductal prolifera-tion • Orientation corresponds to anatomy and course of ducts.

Imaging Signs............................................................................................~ Ultrasound findings

In contrast with macrocakifications, microcalcifications are rarely visualized.DClSis occasionally associated with duct ectasia. Advanced breast cancer asso-ciated with microcalcitications is often easily visualized.

~ Mammographic findingsPleomorphic (punctate, linear, branching) calcitications arranged along milkducts. Distribution usually linear, grouped « 2 mL),or segmental (DClS)• Pleo-morphic microcalcitications can also be found in invasive, usually ductal breastcancer. Distribution is then not restricted to following the course of the milkducts.

~ MR mammographic findingsCalcitications have a low signal intensity in T1-weighted and T2-weighted im-ages and cannot be distinguished from normal parenchyma. 15%of noncalcify-ing, intraductal carcinomas, however. are diagnosed by their linear, dendritic orsegmental contrast enhancement in MRmammography.

Clinical Aspects............................................................................................~ Typical presentation

No symptoms in the early, intraductal growth phase of breast cancer. Intraduc-tal microcalcitications can be seen 3-5 years before a palpable abnormality be-comes apparent. Histology: Proliferation of malignant epithelial cells within themilk duct.

~ rreahoent optionsMinimally invasive stereotactic vacuum biopsy. If malignancy is veri tied, fol-low-up resection is recommended.

~ Course and prognosisWell-differentiated (low-grade) DCISdoes not necessarily progress to invasivebreast cancer. Approximately 30% of DClSnever become invasive. It is notpossible to prospectively identify DCISlesions that will progress to invasive can-cer by its imaging characteristics.

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b Grouped, pleomorphic microcalcifica-tions (invasive ductal carcinoma). Secon-dary finding: Benign calcified cysts.

Differential Diagnosis............................................................................................Sclerosing adenosis (benign finding without malignant potential) • Early stages ofcalcifying fibroadenoma. DCIS • Invasive breast cancer. Fat necrosis.

Tips and Pitfalls............................................................................................Quick-frozen section is not indicated when specimens containing calcifications areexamined. The quick-frozen specimens are destroyed by the mechanical resistanceof calcifications during microtome sectioning.

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Pleomorphic Microcolcifications

c Multifocal, pleomorphic micro-calcifications DClS).

d Segmental. pleomorphic micro·calcifications (invasive ductal carcinoma).

Selected References

American College of Radiology. BI-RADS Breast Imaging Reporting and Data System.Breast Imaging Atlas: Mammography. Breast Ultrasound. Breast MR Imaging. Virginia:Reston: 2003

Fischer U. Helbich T. ACR BI-RADS. IIlustrierte Anleitung lUT einheitlichen Befunderstel-lung von Mammographie. Mammasonographie. MR Mammographie. 2nd ed. Stutt-gart: Thieme: 2006

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Definition

Indistinct microcalcifications • Calcifications cannot be assigned a more specificmorphologic classification. The continuous, low-level milk production with occa-sional congestion can lead to development of calcifications in acini.

Imoging Signs............................................................................................• Ultrasound findings

No characteristic findings.• Mammographic findings

Indistinct, hazy calcifications.• MR mammographic findings

Normal findings in Tl- and T2-weighted images. Microcalcifications cannot bedistinguished from surrounding normal tissue. No enhancement after contrastadministration.

Clinical Aspects............................................................................................• Typical presentation

No symptoms. Histology: Calcium sedimentations (milk-of-calcium) are oftenfound in dilated acini. No proliferations.

• Course and prognosisAmorphous appearance is usually indicative of benignity. Often difficult toevaluate after initial detection. In ambiguous cases, short-term follow-up is in-dicated • In more suspicious cases. stereotactic vacuum biopsy is indicated.

Differential Diagnosis............................................................................................Adenasis, fibrosis, ADH,DClS• Rare: Ductal or lobular carcinoma.

Tips and Pitfalls............................................................................................The mammographic morphology of benign and malignant microcalcifications over-laps markedly. If findings are ambiguous, stereotactic vacuum biopsy allows defin-itive clarification of histology.

Amorphous Microcalcifications

Flg.2.190-d Amorphous microcalcifications.a Adenosis.b Focal fibrosis.c Atypical ductal hyperplasia.d Invasive lobular breast cancer.

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Definition............................................................................................Microcalcifications associated with benign histology • Etiology: Inflammatoryprocesses. poor circulation, sedimentation. Usually large enough to be seen with-out magnifying glass. Solitary macrocalcifications are almost always benign.

Imaging Signs

• Ultrasound findingsMicrocalcifications usually not perceptible. Macrocalcifications have a highecho signal, reflect ultrasound waves, and cause complete posterior shadowing.

• Mammographic findings- Coarse, "popcorn" calcifications: Fibrous. involuting fibroadenoma.- "Eggshell" calcifications: Fat necrosis.- Rim, lucent-centered calcifications: Breast cysts.- Milk-of-calcium: Particulate calcium sediment in microcysts • "Teacups" in

horizontal beam views. Rounded, indistinct calcific densities on craniocau-dal projection.

- Dermal calcifications: Usually multiple, grouped or scattered. polygonal orspherical. lucent-centered, 1-2 mm (skin sweat glands) • Coarse and planarin dermal scars (e.g" burn).

- Parallel continuous or discontinuous calcifications: Vascular.- Rodlike calcifications, following ductal distribution: Plasma cell mastiris or

duct ectasia.- Dystrophic calcifications: Found in irradiated or traumatized breast.

• MR mammographic findingsBecause calcifications have a low signal intensity inT1- and T2-weighted images,only large calcifications can be detected. No enhancement.

Clinical Aspects............................................................................................

• Typical presentationCalcifying fibroadenomas are sometimes palpable. Fat necroses in post-surgicalscars and calcifying cysts are usually not palpable.

• Treatment optionsNo treatment is necessary fortypically benign calcifications. lffindings are am-biguous. further workup is required. e.g., stereotactic vacuum biopsy.

• Course and prognosisNo increased malignant potential.

Differential Diagnosis

Talc in skin pores: The morphologic appearance of macrocalcifications is usuallycharacteristic. May be difficult to evaluate in early development phase. Compar-ison with previous mammograms may be helpful.

Fig.2.20a-d Benign calcifications.a Dermal calcifications in burn scar.

Benign Calcifications

b Involuting. calcifying fibroadenoma("popcorn").

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Benign Calcifications

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Tips and Pitfalls............................................................................................The mammographic morphology of macrocalcifications is usually characteristicand pathognomonic for benign lesions. In the early formation phase (microcalcifi-cations). however. it may be difficult to reach a definitive diagnosis without furtherdiagnostic workup. Comparison with previous mammograms may be helpful.

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Definition............................................................................................Oval. smoothly marginated. fat-containing masses with lymphocytes in a reticularstroma· Normally there are 20-30 lymph nodes in the axilla (levels 1-3). Occa-sionally one can find intramammary lymph nodes.

Imaging Signs............................................................................................• Ultrasound findings

Hypoechoic mass. Oval or kidney shaped. Well-circumscribed borders. Oftenechogenic (fatty) hilum and central areas. Noalterations of the surrounding pa-renchyma.

• Mammographic findingsHyper- or isodense mass. Oval or kidney shaped. Well-circumscribed bor-ders. Often radiolucent (fat equivalent) hilum and central areas. Prepectorallymph node is seen in the MLOprojection.

• MR mammographic findingsMass with low signal intensity on Tl-weighted images. Oval or kidney shaped.Well- circumscribed borders. Fat equivalent signal in hilum and central areas.Usually no enhancement in Tl-weighted postcontrast image. Homogeneouscontrast enhancement of reactive or metastatic lymph nodes • Note: When alymph node has central fat or reactive changes. ring enhancement may be seen.Intermediary or high signal intensity in T2-weighted images.

Clinical Aspects............................................................................................May present as mobile. palpable mass in subcutaneous fat. Usually in the lateralaspect of the breast. Usually < 20 mm diameter.

Differential Diagnosis............................................................................................Classic appearance is usually diagnostic. When enlarged or without visible fat-breast cancer. lymphoma. metastasis.

Tips and Pitfalls............................................................................................Intramammary lymph node involvement in a patient with breast cancer is includedin the pathologic N (pN) grade.

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Fig.3.1o-d Axillary and intramammary lymph nodes.a Histologic specimen of a normal lymph node.b Mammography. Kidney-shaped lymph node.c Ultrasonography. Typical axillary lymph node.d MR mammography (Tl-weighted precontrast image). Fat-containing lymph node.

Definition............................................................................................

Lesions lying in the skin plane' Physiologic: Benign lesions which increase in num-ber with increasing age. Pathologic: Skin changes acquired as a result of disease.

Clinical Aspects............................................................................................- Seborrheic keratosis (verruca senilis): Benign, light to dark brown, elevated le-

sion • Hard consistency. Spherical shape' Rough, prickly surface' DD: Mela-noma.

- Atheroma (epidermal inclusion cyst, sebaceous cyst): Cyst filled with sebaceousmatter. Formed by distension of a sebaceous gland as a result of obstruction ofits excretory duct. Usually associated with hair follicles. Etiology varies.

- Furuncle: Localized swelling and purulent inflammation of the skin resultingfrom infection of a hair follicle and adjacent tissue.

- Angiomatous processes: Tumor composed chiefly of blood vessels. Benign andmalignant etiology possible (hemangioma, hemangiosarcoma) • Arteriovenousmalformations. Angiokeratoma.

- Malignant melanoma: Malignant tumor that starts in melanocytes of normalskin or moles.

Imaging Signs

Lesion is imaged in skin plane (tangential view) • Usually benign impression(round, well circumscribed) • Seborrheic keratosis lesions often have a classicmammographic appearance due to air in crevices ("reptile skin") and between theedges of the mass and surrounding skin (halo).

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Skin Lesions

~ Fig. 3.2 a-d::. Mammographic~. appearance of9 certain skin lesions.Q a Seborrheic

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b Sebaceous cyst.

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Skin Lesions

c Epidermalinclusion cyst.

d Furuncle.

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Definition............................................................................................Superficial thrombophlebitis of the breast. Benign process with painless superfi-cial cord or skin retraction. Usually affects middle-aged women between 40 and60 years of age. Causes: Trauma. infection, pregnancy. rarely breast cancer.

Imaging SIgns

• Ultrasound findingsSuperficial, dilated, hypoechoic tubular structure. May have beaded appear-ance • Hyperechoic when thrombosis is present.

• Mammographic findingsMay be visible as tubular. isodense structure • Vascular calcifications may bepresent in chronic cases.

• MR mammographic findingsTubular structure with low signal intensity on Tl-weighted images. Often can-not be distinguished from surrounding normal tissue. Tubular structure withhigh signal intensity on T2-weighted images. No contrast enhancement.

Clinical Aspects............................................................................................

• Typical presentationThickening of superficial vein in lateral breast quadrants. May be palpable aslinear cord. Visible linear skin retraction. May reach medial aspect of lower,inner breast quadrant. Usually painless .

•.. Treatment optionsSymptomatic treatment.

• Course and prognosisUsually resolves spontaneously.

Differential Diagnos;s............................................................................................IDCwith skin retraction. Dermatomyositis.

Tips and Pitfalls............................................................................................Most cases with skin retraction are due to malignancy. Careful evaluation and di-agnostic workup is required.

Selected ReferencesShetty MK et al. Mondor's disease of the breast. sonographic and mammographic find-

ings. AJR2001: 177:893-896

Fig. 3.3 a, b Mondordisease.a Skin retraction inMondor disease.

b Ultrasound. lineararrangement of hypo·echoic structures alongthe course of an affect-ed subcutaneous vein(thrombophlebitis).

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Definition............................................................................................Localized pus collection within a cavity in the breast. Most common infecriousagents: Staphylococcus. Streptococcus. Typically occurs in lactating women (puer-peral mastitis) • Otherwise rare.

Imoging Signs............................................................................................• Ulb'asound findings

Hypoechoic mass with variable margin characteristics. Circumscribed. ill-de-fined. irregular. Central areas may contain fluid structures. Peripheral echo-genic wall. Posterior acoustic enhancement.

• Mammographic findingsRound to oval. hyperdense mass with variable margin characteristics. Circum-scribed. ill-defined. irregular. No calcifications. Unspecific changes.

• MR mammographic findingsRound to oval mass with variable margin characteristics. Circumscribed. ill-de-fined, irregular. Low signal intensity on Tl-weighted images. High signal in-tensity on T2-weighted images • Contrast enhancement in abscess wall oftendisplays continuous increase. Nate: Ring-shaped contrast enhancement in ab-scess wall may be difficult to distinguish from the "rim-sign" found in malignantlesions. Peripheral enhancement is caused by surrounding inflammation.

Clinicol Aspects

• Typical presentationPainful focal or diffuse skin thickening and edema. When extent is greater. focalabscess may present as localized, palpable mass. Signs of inflammation (skinreddening, local hyperthermia. pain) • Taut skin. Possibly fever. Cytology:Signs of inflammation, pus, bacteria. Histology: Signs of inflammation, pus, ab-scess wall • Bacteriology: Specific causative organisms (usually Staphylococcus,Streptococcus ).

• Treab'nentoptionsAspiration of abscess cavity (fine-needle aspiration, indwelling catheter) • De-pending on extent: Cooling, rest, systemic antibiotics. surgical excision.

• Course and prognosisGood prognosis with adequate treatment.

Differential Diagnosis............................................................................................Complicated cyst. Carcinoma with central necrosis. Inflammatory breast cancer.

nps and Pitfalls............................................................................................Identification of infectious agent and antibiotic resistance should be done at an ear-ly clinical stage.

Fig.3.4a-d Breast abscess.a Clinical presentation.b Mammography.c Ultrasonography.d MR mammography (Tl-weighted postcontrast image).

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Imaging Signs............................................................................................

Benign, fibroadenoma-like. glandular tumor with a minimal stromal component.The following types are differentiated:Ductal adenoma. Lactating adenoma. Tubular adenoma. Apocrine adenoma.

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Round or oval mass • Circumscribed • Hypoechoic • Homogeneous internalechoes. Frequent posterior acoustic enhancement. Lesion axis parallel to theskin. No disruption of surrounding tissues.

• Mammographic findingsRound or oval mass. Circumscribed. Often isodense. sometimes hypodense incomparison with normal parenchyma. Usually homogeneous. Rarelyassociat-ed with calcifications.

• MR mammographic findingsWhen located within the parenchyma, it cannot be distinguished from surround-ing tissues in Tl-weighted image. When located in the fatty tissue. it is seen asan isointense, round or oval mass in Tl-weighted image. Lowor absent contrastenhancement in Tl-weighted postcontrast image. Slight or absent initial con-trast enhancement « 50%) • Continuous post-initial contrast enhancement orpost-initial plateau. Usually isointense. sometimes hyperintense mass in T2-weighted images.

Clinical Aspects............................................................................................

• Typical presentationSmall adenomas are usually inconspicuous • Larger adenomas present as asmooth bordered. soft, mobile mass.

• Course and prognosisWhen findings are typical. no further diagnostic workup or treatment is neces-sary • If appearance is atypical or ambiguous, percutaneous biopsy is recom-mended (e.g.. ultrasound guided) • Prognosis is excellent. No increased risk ofmalignancy.

Differential Diagnosis............................................................................................Fibroadenoma. Papilloma. Phyllodes tumor. Carcinoma (medullary. mucin-ous). Other benign, tumor-building entities.

Tips and Pitfalls............................................................................................Adenomas of the breast have a variable histologic appearance and share featureswith papillomas and sclerosing lesions. Clear differentiation from a fibroadenomais often impossible. and indeed unnecessary because it is of no clinical importance.

96

Fig.3.5 a-d Adenomas of the breast.a Ultrasonography. Lactating adenoma.b Mammography. Tubular adenoma.c Ultrasonography. Tubular adenoma.d MR mammography (subtraction image). Tubular adenoma.

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98

Definition

Proliferation of glandular tissue (small ductal segments and acini) with increase inperiductal and perilobular tissue .• Typesof adenosis:- Sclerosing adenosis: Periductal sclerosis and constriction of lobular lumina.- Microglandular adenosis: Increase in the number and size (approximately 1 mm)

of lobuli.- "Blunt-duct" adenosis: Dilation of lobuli (up to approximately 2 mm).- Microcystic adenosis: Development of small cysts (up to approximately 5 mm).

Imaging Signs

• Ultrasound findingsOccasional microcystic changes.

• Mammographic findingsMicrocalcifications are associated with blunt-duct adenosis (amorphous. dis-tributed in small. round groups). and sclerosing adenosis (monomorphic. oftendistributed diffusely and bilaterally) • Teacups (milk-of-calcium) are associatedwith microcystic changes.

• MRmammographic findingsNo specific characteristics in T1-weighted and T2-weighted images. Suspicious.ill-defined areas of contrast enhancement may be seen in focal adenosis (espe-cially sclerosing adenosis) • Occasionally contrast enhancement may demon-strate suspicious dynamics (strong initial signal increase and post-initial wash-out phenomenon).

dinical Aspects............................................................................................• Typical presentation

No specific symptoms.• Course and prognosis

In ambiguous cases with microca1cifications in categories BI-RADS4 or 5 stereo-tactic vacuum biopsy is indicated. If contrast-enhancing lesion is seen on MRmammography (MR-BIRADS4 or 5) MR-guided vacuum biopsy is indicated. Ex-cellent prognosis' No increased risk of malignancy.

Differential Diagnosis

Intraductal changes (DClS) • Invasive carcinoma.

Tips and Pitfalls............................................................................................Sclerosing adenosis is the most common false-positive finding in MR mammogra-phy • Typically an incidental finding in tissue excised for other reasons (microcal-cifications).

Adenosis

Flg.3.6a-d Adenosis.a Histologic specimen. Sclerosing adenosis.b Mammography. Microcystic adenosis with "teacups" (calcium sedimentation).c Mammography. "Blunt-duct" adenosis with lobular distribution of microcalcifications.d Mammography. Microglandular adenosis with pleomorphic microcalcifications.

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100

Definition............................................................................................Epithelial proliferation within terminal lobular units with atypical cells close to butnot fulfilling all of the characteristic appearances of LCiS.

Imaging Signs............................................................................................• Ultrasound findings

No specific characteristics.• Mammographic findings

No specific characteristics. Usually no microcalcifications.• MR mammographic findings

No specific characteristics.

Clinical Aspects............................................................................................• Typical presentation

No specific symptoms. Typically an incidental finding. Cytology is unsuitablefor diagnostic workup. Histology: Epithelial proliferation within terminallobu-lar units.

• Treatment optionsNo treatment is recommended when the diagnosis of ALHis made following anexcisional biopsy. Following percutaneous core biopsy, treatment is controver-sial (imaging follow-up in 6 months, excisional biopsy).

• Course and prognosisBenign lesion. Good prognosis (relative risk for developing cancer is four to fivetimes that of the normal population).

Differential Diagnosis............................................................................................None.

Tips and Pitfalls............................................................................................ALHis typically is an incidental finding in tissue excised for other reasons.

Atypical Lobular Hyperplasia (ALH)

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Fig.3.7o-d Atypical lobular hyperplasia.a AlH without mammographic correlation.b Mammography. AlH presenting as mammographic density.c Ultrasonography. ALH presenting as hypoechoic lesion.d MR mammography (subtraction image). AlH with slight focal enhancement.

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Definition............................................................................................Benign fibroepithelial tumor with regressive changes (hyalinization, calcification) •Develops over decades by involution from a myxoid fibroadenoma. Found in post-menopausal women.

Imaging Signs............................................................................................• Ultrasound findings

Round or oval mass. Circumscribed. Hypoechoic • Occasional internal calcifi-cations • Tendency towards increasing posterior acoustic shadowing. Lesionaxis parallel to the skin. No disruption of surrounding tissues.

• Mammographic findingsRound or oval mass. Circumscribed. Often isodense, sometimes hyperdense incomparison with normal parenchyma. Internal composition may be homoge-neous or inhomogeneous. Increasing tendency to calcify ("popcorn").

• MR mammographic findingsWhen located within the parenchyma, itcannot be distinguished from surround-ing tissues in T1-weighted image. When located in the fatty tissue, it is seen asan isointense, round or oval mass in Tl-weighted image. Low or absent contrastenhancement in T1-weighted postcontrast image. Endotumoral septa may beseen • Slight or absent initial contrast enhancement « 50%) • Continuouspost-initial contrast enhancement or post-initial plateau. Usually hypointensein T2-weighted images.

Clinical Aspects............................................................................................• Typical presentation

Small fibroadenomas are usually inconspicuous. Larger fibroadenomas presentas a smooth bordered, firm, mobile mass.

• TreatrnentoptionsWhen findings are typical, no further diagnostic workup or treatment is neces-sary • If appearance is atypical or ambiguous, percutaneous biopsy is recom-mended (e.g., ultrasound guided).

• Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis............................................................................................Papilloma. Phyllodes tumor. Carcinoma (medullary, mucinous) • Other benign,tumor-building entities.

Fig.3.8a-d Hyalinized fibroadenoma.a Mammography. Early calcifications in a fibroadenoma.b Mammography. Advanced calcifications in a fibroadenoma ("popcorn").c Ultrasonography. Circumscribed, hypoechoic fibroadenoma.d MR mammography (Tl-weighted precontrast image). Circumscribed fibroadenoma

with endotumoral calcifications.

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104

Definition

Benign fibroepithelial tumor with a typically high water content. Develops gradu-ally through regressive changes over decades to the hyalinized form of fibroadeno-ma • Most common benign solid tumor in young women.

Imoging Signs

~ Ultrasound findingsRound, oval or lobulated mass. Circumscribed. Homogeneous, intermediateechogenicity • Occasional internal septa. Slight posterior acoustic enhance-ment • Lesion axis parallel to the skin. No disruption of surrounding tissues.

~ Mammographic findingsRound, oval or lobulated mass. Circumscribed. Often isodense in comparisonwith normal parenchyma. Homogeneous internal composition. Calcificationsdevelop with increasing involution.

~ MR mammographic findingsWhen located within the parenchyma, it is hypointense or not distinguishablefrom surrounding tissues in Tl-weighted precontrast image. When located infatty tissue, it is seen as an isointense, round, oval or lobulated mass in Tl-weighted image. Homogeneous or inhomogeneous contrast enhancement inTl-weighted postcontrast image. Endotumoral septa are seen often. Oftenstrong initial contrast enhancement (> 100%) • Continuous post-initial contrastenhancement or post-initial plateau. Often hyperintense in T2-weighted im-ages.

Clinicol Aspects............................................................................................~ Typical presentation

Small fibroadenomas are usually inconspicuous. Larger fibroadenomas presentas a smooth bordered, sometimes soft, mobile mass.

~ Course and prognosisIn young women « 35 years) without high-risk profile and with typical findings,sonographic follow-up may be appropriate. In women> 35 years of age, or if ap-pearance is atypical or ambiguous, percutaneous biopsy is recommended (e.g.,ultrasound guided) • Prognosis is excellent. No increased risk of malignancy.

Differential Diagnosis

Papilloma. Phyllodes tumor. Carcinoma (medullary, mucinous) • Other benign,tumor-building entities.

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Fig.3.90-d Myxoid fibroadenoma.a Mammography. Oval fibroadenoma.b Mammography. Lobulated fibroadenoma.e Ultrasonography. Lobulated fibroadenoma.d MR mammography (Tl-weighted posteontrast image). Lobulated myxoid

fibroadenoma.

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Rapidly growing benign fibroepithelial tumor. Rare. Especially affects youngwomen.

Imaging Signs............................................................................................~ Ultrasound findings

Often lobulated mass that fills the entire viewing screen. Circumscribed. Ho-mogeneous. intermediate echogeniciry • Occasional internal septa. Slight pos-terior acoustic enhancement. No disruption of surrounding tissues.

~ Mammographic findingsLarge.often lobulated mass. Circumscribed. Iso- or hyperdense in comparisonwith normal parenchyma. Internal composition may be homogeneous or inho-mogeneous • No calcifications. Displacement of surrounding tissues.

~ MRmammographic findingsLarge. isointense mass in Tl-weighted precontrast image • Circumscribed •lobulated • Homogeneous or inhomogeneous contrast enhancement in Tl-weighted postcontrast image. Endotumoral septa are seen often. Often stronginitial contrast enhancement (> 100%) • Continuous post-initial contrast en-hancement or post-initial plateau. Often hyperintense in T2-weighted images.

Clinical Aspects

~ Typical presentationOften extremely large tumor causing enlargement of one breast • Pronouncedvascular skin markings occasionally seen. Histology: Fibroadenoma.

~ TreattnentoptionsExcision usually for psychosocial reasons. Medical indication for excision is lesscommon (e.g.. back pain).

~ Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis............................................................................................Phyllodes tumor (endotumoral cysts!) • Sarcoma (very rare) • Carcinoma (veryrare).

Giant Fibroadenoma

Fig.3.100-<l Fibroadenoma ("giant fibroadenoma").a Clinical presentation with breast enlargement.b Mammography.c Ultrasonography. Internal structure of a giant fibroadenoma.d MR mammography (subtraction image).

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Definition............................................................................................Benign stromal proliferation with obliteration of milk ducts and acini.

Imaging Signs............................................................................................

• Ultrasound findingsNo specific characteristics.

• Mammographic findingsMicrocalcifications seen rarely (amorphous, monomorphic) • Rare mammo-graphic densities. No characteristic findings.

• MR mammographic findingsNo specific characteristics.

Clinicol Aspects............................................................................................

• Typical presentationNo characteristic findings.

• Treatment optionsNone.

Differential Diagnosis............................................................................................When microcalcifications are present: DClS(e.g., low grade) or benign calcifyinglesions.

Tips and Pitfalls............................................................................................Focal fibrosis is a common histologic finding in tissue acquired by percutaneousbiopsy of microcalcifications.

Focol Fibrosis

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fig. 3.11a-d Focalfibrosis.a Mammography. Fibrosispresenting as a mammographic density.b Mammography. Fibrosiswith diffuse monomorphic microcalcifications.c Ultrasonography. Fibrosis as a focal lesion with small calcification.d MR mammography (subtraction image). Fibrosiswith focal hypervascularization.

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Definition............................................................................................Encapsulated breast tissue with varying amounts of different tissue components(glandular, fat, and connective tissue) • Typically surrounded by a pseudocapsule'Often referred to as a "breast within a breast".

Imoglng Signs............................................................................................• Ultrasound findings

Circumscribed mass containing a heterogeneous mixture of fat and fibroglandu-lar tissue echo patterns' May contain cysts. Occasionally the tissue composi-tion will be very different from that of the surrounding breast tissue.

• Mammographic findingsCircumscribed, heterogeneous mass with pseudocapsule • Composed of a mix-ture of parenchymal structures (fat and fibroglandular tissue elements, as wellas cysts) • Occasionally the tissue composition will be very different from thatof the surrounding breast tissue.

• MR mammographic findingsMixed tumor with pseudocapsule in Tl-weighted precontrast image. Com-posed of a mixture of parenchymal structures (fat and fibroglandular tissue ele-ments, as well as cysts) • Occasionally the tissue composition will be very differ-ent from that of the surrounding breast tissue. Variable contrast enhancementpattern in Tl-weighted postcontrast image, often differing greatly from that ofthe surrounding breast tissue. Parenchymal pattern in T2-weighted images.

Clinical Aspects............................................................................................• Typical presentation

Small hamartomas are usually inconspicuous' Larger hamartomas may presentas an asymmetry or palpable mass.

• Treatment optionsWhen findings are rypical, no further diagnostic workup or treatment is neces-sary • If appearance is arypical or ambiguous, percutaneous biopsy is recom-mended (e.g.. ultrasound guided).

• Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis............................................................................................Ectopic breast tissue. Phyllodes tumor.

Tips and Pitfalls............................................................................................When the pathologist reports normal breast tissue on core biopsy, this confirms thepresence of a hamartoma if the imaging characteristics are rypical.

Hamartoma (Fibroadenolipoma)

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Flg.3.12a-d Hamartoma.a Mammography. Hamartoma.b Mammography. Hamartoma in the axillary tail.c Ultrasonography. Hamartoma.d MR mammography (T2"weighted image). Hamartoma containing cysts.

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Definition............................................................................................Benign. circumscribed vascular neoplasm. Synonyms: Cavernous hemangioma.subcutaneous hemangioma. Very rare. Affects all age groups.

Imaging Signs............................................................................................~ Ultrasound findings

Indistinct. hyper- or isoechoic mass. Inhomogeneous internal echoes. No dis-ruption of surrounding tissues. No characteristic posterior acoustic changes.Increased flow on color Doppler ultrasound.

~ Mammographic findingsRound or lobulated mass. May be indistinct or circumscribed. Endotumoral,round macrocalcifications are uncommon, but the most specific indicator whenpresent.

~ MR mammographic findingsWhen located in fatty tissue, seen as spotty. hypointense areas in Tl-weightedprecontrast image. When located within parenchyma. usually not distinguish-able from surrounding tissues in Tl-weighted precontrast image. Areas withsignal 1055are seen when macrocalcifications are present. Unspecific initialcontrast enhancement. Post-initial contrast enhancement exhibits plateau orwashout phenomenon. Hypo- or isointense in T2-weighted images.

Clinical Aspects............................................................................................~ Typical presentation

Small hemangiomas are usually inconspicuous • Larger hemangiomas maypresent as a soft palpable mass.

~ Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis............................................................................................Venous malformations. Angiosarcoma.

Hemangioma

fig.3.l3a-d Hemangioma.a Macroscopic specimen. Hemangioma with macrocalcifications.b Mammography. Hemangioma.c Specimen radiography.d MR mammography (Tl-weighted precontrast image). Hemangioma.

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Definition

Encapsulated tumor with mature adipose tissue. Incidence: < 1% • Affects all agegroups.

Imaging Signs............................................................................................~ Ultrasound findings

Homogeneous, circumscribed. oval mass • Often hyperechoic in comparisonwith the surrounding fat tissue. No disruption of surrounding tissues. No pos-terior acoustic changes.

~ Mammographic findingsCircumscribed. oval mass. Radiolucent (fat) • Fine capsule. May displace sur-rounding tissues. No microca1cifications.

~ MR mammographic findingsHyperintense (fat equivalent) mass in T1-weighted precontrast image. Oval.Circumscribed. Suppressed signal when using fat saturation techniques. Nocontrast enhancement. Fat equivalent signal in T2-weighted images.

Clinical Aspects

~ Typical presentationSmall lipomas are usually inconspicuous. Larger lipomas may present as a softpalpable mass.

~ Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis............................................................................................None.

Tips and Pitfalls............................................................................................Lipomas are lesions containing only fat.

Lipoma

fig.3.14a-<1 Lipoma.a Mammography. Typical lipoma.b Mammography. Lipoma in the axillary tail.c Ultrasonography. lipoma located in subcutaneous fat.d MR mammography (Tl-weighted precontrast image). Giant lipoma.

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Definition

Bacterial infection of the breast. Infectious agent is usually Staphylococcus (focalmastitis) or Streptococcus (diffuse mastitis).- Puerperal (lactational) mastitis: Usually focal breast infection occurring in lactat-

ingwomen.- Non-puerperal mastitis: Often diffuse breast infection not related to lactation.

Imaging Signs

• Ultrasound findingsDiffuse or focal increase in echogenicity of parenchyma • Skin thickening. easilyrecognized in comparison with the healthy side. No mass. No architecturaldistortion.

• Mammographic findingsDiffuse or focal increase in parenchymal density. Often concomitant skin thick-ening.

• MRmammographic findingsNo characteristics changes in Tl-weighted images. Skin thickening may beseen. Diffuse signal increase of affected areas in TI-weighted images. Markedcontrast enhancement in the postcontrast image. often with suspicious contrastdynamics.

Clinical Aspects............................................................................................• Typical presentation

Erythema. Edema. Increased breast firmness. warmth. and pain.- Puerperal mastitis: Very painful. focal erythema in a lactating woman.- Non-puerperal mastitis: Painful swelling and redness usually affecting the en-

tire breast. sometimes restricted to one or two breast quadrants. Skin is oftenshiny and taut.

- Complication: Abscess.- Histology: Diffuse infiltration of breast tissue with bacteria, lymphocytes. and

macrophages.• Treatment options

- Puerperal mastitis: Coaling. and massage of affected areas towards the nipple.- Nan-puerperal mastitis: Agent-specific antibiotics for 7 days (penicillin) •

Erythromycin for patients with penicillin allergy' When symptoms continueover 10 days. core biopsy is indicated to rule out innammatory breast cancer.Open biopsy is indicated if uncertainty remains.

• Course and prognosisAfter innammation has abated. relapse is rare.

Differential Diagnosis............................................................................................Mastitis: Abscess. Innammatory breast cancer. Infected galactocele.

Mastitis

Fig. 3.15o-d Mastitis.a Clinical presentation with erythemaand shiny skin.

b Mammography. left MLO projection.Regional increase in density and skinthickening due to edema.

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c MRmammog-raphy. Tl-weightedprecontrast. Skinthickening aroundnipple.

d MRmammog-raphy (subtractionimage). Contrastenhancementaround nipple.

Tips and Pitfalls

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Breast imaging alone does not usually allow differentiation between non-puerperalmastitis and inflammatory breast cancer. Diagnosis can only be made after an anti-biotic trial or biopsy.

~(!?f.t!~~ .Benign intraductal tumor (or intracystic) • Hypervascularized proliferation of ductepithelium with papillary growth pattern' Most common cause of bloody nippledischarge' Usually central. retroareolar location.

Imaging Signs............................................................................................~ Ultrasound findings

Usually circumscribed. lobulated. hypoechoic. intraductal mass. May have in-termediate echogenicity • May appear as solid component within a cyst.

~ Mammographic findingsUsually not visible. May present as circumscribed. isodense mass. May havemicrocalcifications • Galactogrophy: Focal. intraductal. lobulated filling defect.Occasionally shows complete obliteration of the milk duct with truncation of thecontrast-filled duct on galactography.

~ MR mammographic findingsHypointense mass on Tl-weighted precontrast image. Usually difficult to dif-ferentiate from normal parenchyma' Often hyperintense on the T2-weightedimage. sometimes hypointense • Usually strong contrast enhancement in Tl-weighted postcontrast image. Often shows pathologic contrast dynamics'15% of papillomas show no contrast enhancement.

Clinical Aspects

~ Typical presentationMost frequent clinical manifestation is a bloody or clear. amber-colored dis-charge from the nipple. Rarely presents as a clinically palpable mass. Histolo-gy: Intraductal proliferation of duct epithelium .

•.. Treatment optionsCore biopsy is indicated to differentiate between papilloma and fibroadenoma.Surgical excision is indicated because of increased risk of developing breast can-cer • Papillomas under 1.5em may be excised by vacuum biopsy' Due to thelimited visualization of papillomas on mammography. percutaneous excision iscarried out under ultrasound or MR guidance. Important: Good cooperationwith the pathologist is necessary to ensure that complete excision has been ach-ieved.

~ Course and prognosisPapillomas are associated with an increased risk of between 3%and 7%of devel-oping breast cancer. If completely excised. excellent prognosis.

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Fig.3.16o-d Papilloma.a Ultrasonography. Circumscribed, hypoechoic mass.b Mammography. Circumscribed, hyperdense mass.e MR mammography (T2-weighted image). Lobulated mass with high signal intensity.d MR mammography (subtraction image). Lobulated mass with inhomogeneous

contrast enhancement.

Papilloma

Differential Diagnosis............................................................................................Fibroadenoma. Papillary carcinoma. Adenoma.

Tips and Pitfalls............................................................................................Papillomas and radial scars are the only benign lesions of the breast that should beexcised because of their increased malignant potential.

Selected ReferencesFrancis A. et .11.Breast papilloma: Mammogram, ultrasound and MRI appearance. Breast

2002; 11: 394-397Kramer SC. et .11.Diagnosis of papillomas of the breast: value of magnetic resonance

mammography in comparison with galactography. Eur Radio12000; 10: 1733-1736

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J22

Definition

Multiple benign intraductal tumors. Hypervascularized proliferation of duct epi-thelium. Common cause of bloody discharge from the nipple. Usually locatedperipherally.

Imaging Signs............................................................................................~ Ultrasound findings

Multiple circumscribed, hypoechoic intraductal masses. May have intermedi-ate echogenicity • Commonly associated with duct ectasia.

~ Mammographic findingsMay present as circumscribed, isodense masses. Galactagrophy: Multiple, focal,intraductal, lobulated filling defects. Occasionally shows complete obliterationof milk ducts with truncation of the contrast-filled ducts on galactography.

~ MR mammographic findingsHypointense masses on T1-weighted precontrast image. Often hyperintense onT2-weighted images, sometimes hypointense • Usually strong contrast en-hancement in Tl-weighted postcontrast image • Often shows pathologic con-trast dynamics. 15% of papillomas show no contrast enhancement.

Clinlcol Aspects

~ Typical presentationMost common clinical manifestation is a bloody or amber-colored dischargefrom the nipple. Rarely presents as a clinically palpable mass. Histolagy: Intra-ductal proliferation of duct epithelium.

~ Treatment optionsCore biopsy is indicated. Surgical excision is indicated because of increased riskof developing breast cancer.

~ Course and prognosisPeripheral papillomas have a higher malignant potential than solitary, centrallylocated papillomas. Associated with an increased risk of between 10%and 33 %of developing breast cancer.

Differentiol Diagnosis............................................................................................Intraductal accumulation of secretions. Papillary carcinoma.

Multiple Peripheral Papillomas

Fig. 3.17 a-d Multiple peripheralpapillomas. a Ultrasonography. Ductectasia with intraluminal, hypoechoicmasses.

b Mammography. Multiple. isodense.circumscribed masses within one breastsegment.

Tips and Pitfalls............................................................................................Papillomas and radial scars are the only benign lesions of the breast that should beexcised because of their increased malignant potential.

Selected References

Francis A. et al. Breast papilloma: Mammogram, ultrasound and MRI appearance. Breast2002; 11: 394-397

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Multiple Peripheral Papillomas

c MR mammography(T2-weighted MIP).Multiple, hyperintensemasses, and duct ectasiawithin one breast quad-rant.

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d MR mammography(subtraction MIP). Multi-ple masses with inho-mogeneous contrastenhancement withinone breast quadrant.

Definition

Extraductal calcifications of the periductal myoepithelium cells. Infiltration ofperiductal stroma with plasma cells and proliferation of the cells lining the ducts(hyperplasia). Regular. rodlike calcifications (> 0.5 mm diameter) orten distributedin a ductal or linear pattern. Occasional branching. Despite suspicious distribu-tion pattern. morphology of calcifications is characteristic and allows a definitivediagnosis.

Imaging Signs............................................................................................• Ultrasound findings

No specific characteristics.• Mammographic findings

Regular. rodlike calcifications ("cigar-shaped") • Distributed in a ductal or linearpattern. Uni- or bilateral. Calcifications may be up to 10mm long.

• MR mammographic findingsNo specific characteristics.

Clinical Aspects

• lYPical presentationNo characteristic symptoms. Histology: Periductal calcifications of myoepitheli-urn.

• TreatrnentoptionsNone. Observation. If uncertainty is present, short-term follow-up mammog-raphy in 6 months is recommended. If appearance is ambiguous. percutaneousbiopsy is recommended (e.g.. stereotactic vacuum biopsy).

• Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis

DClS.

Tips and Pitfalls............................................................................................Calcifications seen in the early development of plasma cell mastitis may be difficultto differentiate from intraductal processes.

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Flg.3.18a-d Plasma cell mastitis.a Mammography MLO projection. Diffuse plasma cell mastitis.b Mammography craniocaudal projection. Early, segmental plasma cell mastitis.c Mammography craniocaudal projection. Segmental plasma cell mastitis.d Mammography MLO projection. Segmental plasma cell mastitis.

Definition............................................................................................Synonyms: "Black star", complex sclerosing lesion, radial sclerosing lesion. Benignproliferative lesion with hypertrophic fibroelastic core surrounded by radially ex-tending ducts with epithelial hyperplasia. Contains trapped glandular elements.Possibly caused by chronic inflammation or impaired circulation. Detected in ap-proximately 50%of histologic survey specimens (approximately 5 mm diameter) •Spiculated architectural distortion of breast parenchyma not associated with sur-gery or prior trauma. Often displays a radiolucent center ("black star" phenome-non) • Calcifications seen in approximately 50% • Approximately 33% are seen inonly one projection (disk shaped).

Imaging Signs............................................................................................• Ultrasound findings

50%are seen as a hypoechoic mass with radial spicules. May display prominentposterior acoustic shadowing.

• Mammographic findingsArchitectural distortion. Long spicules (up to 5 cm diameter) • Radiolucentcenter. Detection possible starting from 1cm diameter.

• MR mammographic findingsArchitectural distortion in Tl-weighted precontrast image if aligned in imagingplane. Inconspicuous signal in T2-weighted image. 50% show contrast en-hancement • May show suspicious contrast dynamics.

Clinical Aspects............................................................................................• "JYpicalpresentation

Usually nonpalpable architectural distortion of breast parenchyma without his-tory of trauma. Histology: Fibroelastic core surrounded by stellate projections ofducts, occasionally with fat inclusion ("black star").

• Treatment optionsExcision. Reports of percutaneous vacuum biopsy of radial scars suggest that ifno atypia (DClS,ADH,or LCIS)found on histological examination, surgical exci-sion is not indicated (preliminary results; controversial).

• Course and prognosisIncreased risk of developing breast cancer is approximately 8% • Tubular carci-nomas are most often found in the periphery of radial scars.

Differential Diagnosis............................................................................................DCIS• Tubular carcinoma. lOCo Surgical scar.

Tips and Pitfalls............................................................................................Papillomas and radial scars are the only benign lesions of the breast that should beexcised because of their increased malignant potential.

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128

fig.3.190-<1 Radial scar.a Macroscopic specimen: radial scar.b Mammography left CC: lateral architectural distortion.c MR-Mammography (Tl-weighted precontrast image): lateral architectural distortion

in the left breast.d MR-Mammography (subtraction image): architectural distortion with intermediate

contrast enhancement.

Selected ReferencesJacobs TW et al. Radial scars in benign breast biopsy specimens and the risk of breast can-

cer. N Engl J Med 1999; 340: 430-436

Definition............................................................................................Benign tumor of a glandular structure whose cells are arranged in tubules. Mostoften affecting young women (20-30 years of age) • Usually presents as painless.mobile. palpable mass • Related to fibroadenoma • Not distinguishable from fi-broadenoma on mammography or ultrasonography.

Imoging Signs............................................................................................~ Ultrasound findings

Round or oval, hypoechoic mass. Circumscribed. Posterior acoustic enhance-ment • Lesion axis parallel to the skin. Often displays increased vascularizationon color Doppler ultrasound.

~ Mammographic findingsRound or oval mass. Circumscribed. Iso- or hyperdense • Halo occasionallypresent.

~ MR mammographic findingsHypointense. round or oval. circumscribed mass in Tl-weighted images • Hy-perintense mass in T2-weighted images • Homogeneous contrast enhance-ment. Rarely exhibits internal septa • Often has strong initial contrast en-hancement (> 100%) • Occasionally post-initial washout.

Clinical Aspects

~ Typical presentationSmooth bordered. mobile mass. Histology: Glandular structures with a singlelayer epithelium arranged in tubules.

II> Treatment optionsFollow-up or percutaneous core biopsy.

~ Course and prognosisPrognosis is excellent. No increased risk of malignancy.

Differential Diagnosis

Fibroadenoma. Papilloma. Other adenoma. Carcinoma (medullary. mucinous).

Tips and Pitfalls

Tubular adenomas are rare benign lesions.

Selected References

Soo MS et al. Tubular adenomas of the breast: Imaging findings with histologic correla-tion. AJRAmJ Roentgenol2000; 174:757-761

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129

130

Fig.3.200-<l Tubular adenoma.a Ultrasonography. Circumscribed,hypoechoic mass with posterior acousticenhancement.

b Mammography. Circumscribed.isodense mass with halo-sign.

Tubular Adenoma

c MR mammography (ll-weightedimage). Circumscribed mass with inter·mediate signal intensity and MR halo.

d MR mammography (subtractionimage). Circumscribed. hypervascular-ized mass.

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132

Definition

Fluid-filled breast cavity. Imbalance between secretion and absorption with con-gestion and dilation of terminal ducts. Clear fluid remains after decomposition ofcongested milk.

Imoging Signs............................................................................................

• Ultrasound findingsRound or oval. anechoic mass. Circumscribed. Occasionally septated. Poste-rior acoustic enhancement.

• Mammographic findingsRound or oval mass. Circumscribed. Iso- or hyperdense • Halo occasionallypresent.

• MRmammographic findingsHypointense, round or oval, circumscribed mass in Tl-weighted images. Hy-perintense mass in T2-weighted images. No contrast enhancement.

Clinicol Aspects............................................................................................

• Typical presentationSmooth bordered. mobile mass. May reach several centimeters in diameter.Often multiple. May be tender. Aspiration cyralogy: Apocrine metaplasia with-out detection of malignant cells (not routinely indicated for non-bloody fluid).

• Treatment optionsNone. Aspiration if painful.

•.. Course and prognosisMay resolve spontaneously. May develop rapidly. Approximately 50% recurafter aspiration. No increased risk of malignancy.

Differential Diagnosis............................................................................................Postoperative seroma • Complicated cyst (cyst with low-level homogeneous ech-oes) • Complex cyst.

TIps and Pitfalls............................................................................................Cysts are the most common benign lesions of the female breast.

Simple Breast Cyst

fig. 3.21 a-d Simple breast cyst.a Ultrasonography. Circumscribed, anechoic mass with posterior acoustic

enhancement.b Mammography. Circumscribed. isodense mass with halo-sign.c MR mammography (T2-weighted image). Oval. circumscribed mass with high signal

intensity.d MR mammography (subtraction image). Cyst with no contrast enhancement.

133

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Definition

Fluid-filled breast cavity which displays an intracystic mass or wall irregularities.Tumor in cyst wall or in direct proximity.

Imaging Signs

• Ultrasound findingsRound or oval, anechoic mass with wall irregularity or internal polypoid echoes.

• Mammographic findingsRound or oval mass. Wall abnormality rarely visible. Iso- or hyperdense • Wallmay calcify (rim or eggshell calcification).

• MR mammographic findingsHypointense, round or oval mass in Tl-weighted images. Wall abnormality notvisible in Tl-weighted images. In the T2-weighted image mass may be visiblein the lumen of the hyperintense cyst. Variable contrast enhancement of cystwall or intracystic mass.

Clinical Aspects

• Typical presentationSame as for simple cyst (smooth bordered, mobile mass) • May reach severalcentimeters in diameter,

• Treatment optionsIf cyst wall displays contrast enhancement in MR mammography. follow-up in6 months is recommended. If intracystic mass is present. open biopsy is recom-mended.

• Course and prognosisWall enhancement of cysts with inflammatory changes on MR mammographyusually resolves within 6 months.

Differential Diagnosis

Carcinoma with central necrosis (ring enhancement on MRmammography) • Pap-illoma, papillary carcinoma. fibroadenoma. DCIS(focal wall enhancement on MRmammography).

Tips and Pitfalls............................................................................................Malignant tumors within cysts are very rare.

Complex Cyst

Fig.3.220-d Complex cyst.a Ultrasonography. Anechoic mass with posterior acoustic enhancement

and intraluminal mass on superficial border.b Ultrasonography. Anechoic mass with wall irregularity on superficial border.c MR mammography (T2-weighted image). Circumscribed. lobulated mass with

high signal intensity.d MR mammography (subtraction image). Circumscribed. lobulated cyst

with asymmetric contrast enhancement in deep portion of cyst wall.

135

136

Definition............................................................................................Uni- or bilateral enlargement of the male breast.~ Etiology, pathophysiology, pathogenesis

- In newborns: Physiologic' No imaging indicated.- In puberty: Physiologic. Increased estradiol. Note: Some tumors produce

hormones.- In elderly: Acquired. Medication I

Imaging Signs............................................................................................~ Ultrasound findings

Hyper- or isoechoic structure (parenchyma) • Irregular shape reflecting mam-mographic appearance. Indistinct borders. Rarely displays posterior acousticchanges' No disruption of surrounding tissues.

~ Mammographic findingsRetroareolar parenchymal mass. Irregular shape' Indistinct borders. No as-sociated calcifications • Note: Bilateral mammography in MLO projection isstrongly recommended.

~ MR mammographic findingsHypointense, irregular, indistinct mass in Tl-weighted images. Variable con-trast enhancement (none to strong) in Tl-weighted postcontrast image. Usual-ly unspecific signal dynamics' Intermediate or high signal intensity in 12-weighted images.

Clinical Aspects............................................................................................~ lYPical presentation

Uni- or bilateral volume increase of the male breast. Uni- or bilateral, palpable,subareolar mass. May present as hard lump.

~ TreatmentoptionsPronounced gynecomastia in puberty may create psychosocial problems' Sur-gical excision may be considered.

~ Course and prognosisNo increased risk of malignancy. Hormone-producing tumors should be ruledout (hormone studies, urologic examination) • Ifappearance is atypical or ambig-uous, percutaneous biopsy is recommended (e.g..ultrasound-guided core biopsy).

Differential Diagnosis............................................................................................Pseudogynecomastia (fat) • Male breast cancer.

Tips and Pitfalls

Male breast cancer is very rare « 1% of all breast cancers) • The presence of a suspi-cious, palpable mass should prompt percutaneous biopsy to rule out malignancy.

Gynecomastia

F1g.3.23o-d Gynecomastia. a,b Mammography. Unilateral gynecomastia.

137

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Gynecomastia

c,d Mammography. Bilateral gynecomastia.

Definition............................................................................................Visible. fatty enlargement of the male breast. No glandular tissue. Occurs fre-quently in puberty and in adipositas per magna.

Imaging Signs............................................................................................

~ Ultrasound findingsVery small parenchymal bud. Enlargement is caused by an increased amountoffal.

~ Mammographic findingsRadiolucent fatty tissue.

~ MRmammographic fmdingsHigh signal fat in Tl-weighted images. High signal fat in TI-weighted images.low signal intensity in IR sequence. No contrast enhancement and no mass inTl-weighted postcontrast image.

Clinical Aspects

~ Typical presentationEnlargement of the male breast. No histological examination is required.

~ Treatment optionsNone required. Pseudogynecomastia in puberty may disappear spontaneously.

~ Course and prognosisBenign. No increased risk of malignancy.

Tips and Pitfalls............................................................................................Obese men are more likely to have pseudogynecomastia than gynecomastia.

139

Fig.3.24a-d Pseudogynecomastia.a Mammography. right craniocaudalprojection. Enlarged male breast dueto an increase in breast fat.b Ultrasonography. Hypoechoicfat tissue.

140

PseudogynecornosHo

( MR mammography(Tl-weighted image,right breast). Enlargedmale breast due to anincrease in breast fat.No glandular tissue.

d MR mammography(subtraction image.right breast). Enlargedmale breast due to anincrease in breast fat.Contrast enhancementof the nipple.

141

142

Definition

Lobular hyperplasia and edema of the breast due to the innuence of gestagens andprolactin in pregnancy' Breast preparation for lactation.

Imaging Signs

• Ultrasound findingsDiffuse increase in parenchymal echogenicity.

• Mammographic findingsDiffuse increase in radiographic density of parenchyma.

• MR mammographic findingsNormal findings in Tl-weighted image. Usually diffuse signal increase in 12-weighted image due to edema. Marked contrast enhancement of entire breastparenchyma in Tl-weighted postcontrast image.

Clinical Aspects............................................................................................• Typical presentation

Enlargement and increased breast firmness. Dilated cutaneous veins. Hyper-pigmentation of areola and nipple. Histology: Proliferation of terminal ductulesand lobules.Breast lesions in pregnancy:- Fibroadenoma.- Papilloma.- Galactocele.- Lactating adenoma.- Breast carcinoma (most frequent malignancy in pregnancy).

• Course and prognosisThe prognosis of breast cancer is worse in pregnancy • Tumor size is usuallygreater. Vascular invasion is more frequent.

Radiation Risks in Pregnancy............................................................................................Mammography should be avoided unless there is an extremely high index of suspi-cion or ultrasound findings are equivocal. Radiation risk for the embryo is theoret-ical (low-energy radiation is absorbed by the mother) • Interruption of pregnancyis recommended for exposures over 50 mGy (mammography: 2 mGy).Radiation risks for the pregnancy:- Implantation (all or nothing): Conception to approximately 14 days in utero.- Congenital malfonTIations: Organogenesis from second to eighth week in utero.- Intrauterine growth retardation: From eighth week in utero to term.

Fig. 3.250-<1 Breast changes duringpregnancy.a Ultrasonography. Increased echogenicitydue to edema.

b Mammography, left MLO projection.Diffuse increase in radiographic density.

143

Breast Changes During Pregnancy

~ c MR mammography" (T2-weighted image) ..g' Marked, diffuse signal9 increase due to edema.Q

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d MR mammography(subtraction MIP).Marked contrast en-hancement of entirebreast parenchyma.

144

~~f?f~~?~ .Synonym: DIN 1B (DIN z ductal intraepithelial neoplasia. WHO classification2003). Histologically defined lesion within milk ducts. Proliferative lesion thatpossesses some. but not all of the features of DCIS • DDnot always straightforward.

Imaging Signs............................................................................................• Ultrasound findings

No specific characteristics.• Mammographic findings

No specific characteristics. Rarely there are microcalcifications (amorphous.monomorphic. pleomorphic).

• MRmammographic findingsNo specific characteristics.

Clinical Aspects

• Typical presentationNo characteristic findings. Cytologic examination is unsuitable • Histology:Proliferation of intraductal epithelial cells (more than four cell layers) in only aportion of the affected duct. Rarely extends over more than 2-3 mm .

•. Treatment optionsWhen diagnosed in tissue obtained by open biopsy. follow-up is recommended.When diagnosed in percutaneous core biopsy. surgical excision should be con-sidered (may reflect sampling error in the vicinity of a malignant lesion).

• Course and prognosisBorderline lesion. which may develop into DCIS• Increased risk of developingbreast cancer-four to five times that of the general population.

Differential Diagnosis............................................................................................Low-grade DCIS• Benign. calcifying lesions.

Tips and Pitfalls............................................................................................ADHis a benign but borderline lesion. When ADHis diagnosed in tissue obtainedby percutaneous core biopsy. surgical excision is usually advised to rule out adja-cent OCIS or invasive breast cancer. ADH is usually an incidental finding in tissueexcised for other reasons (e.g.. microcalcifications).

145

Atypical Ductal Hyperplasia (ADH)

F1g.4.1a-dAtypical ductalhyperplasia (ADH).a Histologicspecimen.

146

b Mammography.ADH presentingwith amorphousmicrocalcifications.

Atypical Ductal Hyperplasia (ADH)

( Mammography.ADH presentingwith few monomor·phic microcalcjfica-tions .

d Mammography.ADH presentingwith diffuse micro·calcifications.

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148

Definition............................................................................................Synonym: Lobular neoplasia. Histologically defined proliferative lesion in the ter-minal duct-lobular unit. Proliferation of atypical epithelial cells. Incidental mi-croscopic finding in breast tissue removed for other reasons.

Imaging Signs............................................................................................• Ultrasound findings

No specific characteristics.• Mammographic findings

No specific characteristics. Rarely there are microcalcifications (amorphous,monomorphic).

• MR mammographic findingsNo specific characteristics.

Clinical Aspects............................................................................................• Typical presentation

No characteristic findings. Cytologic examination is unsuitable. Histology:Proliferation of atypical epithelial cells in the terminal duct-lobular unit.

• Treatment optionsWhen diagnosed in tissue obtained by open biopsy, short-term follow-up is rec-ommended • When diagnosed on percutaneous core biopsy, surgical excisionshould be considered.

• Course and prognosisBenign, high-risk marker for the development of subsequent breast cancer in ei-ther breast. Location of the subsequent breast cancer is not closely associatedwith the location of LCiS• Most subsequent invasive breast cancers are IDC •Approximately 25% of subsequent invasive breast cancers are invasive lobular(more common than in general population). Increased risk of developing breastcancer-six times that of the general population.

Differential Diagnosis............................................................................................None.

Tips and Pitfalls............................................................................................LCISis a benign but borderline lesion. High-risk marker for the subsequent devel-opment of invasive breast cancer. LeiS is usually an incidental finding in tissue ex-cised for other reasons.

Lobular Carcinoma In Situ (LOS)

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Flg.4.2o-d Lobular carcinoma in situ (LClS).a Histologic specimen.b Mammography. LOS presenting with amorphous microcalcifications.c Mammography. LOS presenting with amorphous microcalcifications.d Mammography. LOS presenting with round, monomorphic microcakifications.

149

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Definition............................................................................................Factors increasing the probability of developing breast cancer .

Most Important Risk Factors............................................................................................Estrogens: Breast cancer risk increases with the increasing lifetime estrogen influ-ence • Increased in women with early menarche and/or late menopause. De-creased in women with early ovariectomy. The influence of hormonal contracep-tives is unknown. Increased with hormone replacement therapy.Age: Breast cancer risk increases with increasing age.Benign breast lesions: Breast cancer risk is increased in women with certain benignproliferative lesions.Lifestyle: Breast cancer risk is increased in women with high alcohol consumption,high-fat diet, and sedentary lifestyle.Radiation exposure: Radiation exposure increases the risk of breast cancer (e.g..mantle radiation to the thorax for Hodgkin disease).Geneticfacrors: Several genetic factors increase the risk of developing breast cancer• BRCAgene mutations greatly increase the risk of developing breast cancer. BRCAgene mutations result in the production of defective proteins involved in the repairof damaged DNA. As a consequence, other gene defects accumulate and may resultin tumor growth. BRCA1 and 2 genes have been identified thus far. BRCA-3and-4 genes will probably be identified soon.Indications of an increased familial risk of developing breast cancer (BRCAgene de-fect) are:- Two or more related women with breast and/or ovarian cancer under SOyears of

age at time of diagnosis.- One woman with unilateral breast cancer under 30 years of age at time of diag-

nosis.

Table 5.1 Riskfactors for the development of breast cancer

BRCA-' mutation 7

Personal history of prior breast cancer 5

Family history of breast cancer (mother, sister) 4

Biopsyshowingatypicalductal/lobularhyperplasia 3Personal history of cancer of the ovary, endometrium, or colon 3

Obesity 2Nulliparous, or first pregnancy after the age of 30 years 2

Earlymenarche (before 12years),late menopause(alter 52years) 2Olderage (over50years) 2Hormonereplacementtherapy(longerthan 5 years) 1.5Nonnalrisk 1

Risk Factors

- One woman with bilateral breast cancer under 40 years of age at time of diagno-sis.

- One woman with ovarian cancer under 40 years of age at time of diagnosis,

Tips and Pitfalls............................................................................................Women with a high risk of developing breast cancer are especially sensitive to theefTects of radiation • Hence low-dose diagnostic investigations should be per-formed. MR mammography is the most sensitive and most specific diagnosticprocedure,

Selected ReferencesKriege M et al. Efficacy of MRI and mammography for breast-cancer screening in women

with a familial or genetic predisposition, N Engl J Med 2004: 351: 427-437Kuhl CKet aJ. Die EVA-Studie: Evaluierung der leistungsfahigkeit diagnostischer Verfah-

ren (Mammographie. Sonographie. MRT) zur sekundaren und tertiaren Pravention desfamiliaren Mammakarzinoms-Zwischenergebnisse nach der ersten Halfte der Forde-rungsperiode, Rdfo 2005; 177; 818-827

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Definition............................................................................................Indicators used to appraise the effectiveness of mammography screening pro-grams. Screening reduces mortality associated with breast cancer by 20-30% •In spite of this. more than a third of breast cancers are missed (interval carcinomas).

Screening Procedure............................................................................................Women between the ages of 50 and 69 years receive a written invitation to take partin screening. A specialized mammographic technologist performs the bilateral.two-view mammography examination. No primary clinical examination. No ul-trasound examination • Double reading is carried out by two specially trainedphysicians. Women who need to be recalled are informed within 5 working daysof the primary examination.

Table 5.2 Early surrogate indicators used to assess the impact of breast cancer screening

Intervalcancer rate/backgroundIR(%)• 0-11 months after screening• 12-23 months after screening

Breast cancer detection rate• In initial screening• In subsequent regular screening examinations

Stage II+/totalscreen-detected cancers (%)• In initial screening• In subsequent-regular screening examinations

Invasive cancers s: 10 mm/total screen-detected cancers(%)• In initial screening• In subsequent-regular screening examinations

Invasive cancers/total screen·detected cancers (%)

Node-negative cancers/total screen-detected cancers (%)• In initial screening• In subsequent-regular screening examinations

IR - Incidence rate

30%50%

3 x IR1.5 x IR

25%20%

~20%~2S%

90%

70%75%

<30%<50%

>3)( IR> 1.5)( IR

<25%<20%

~2S%~30%

80-90%

>70%>75%

152

Tips and Pitfalls............................................................................................Mammography screening can reliably rule out breast cancer for women with lowparenchymal density (ACRtypes I+ II) • In mammograms with dense parenchyma(ACRtypes III+ IV)up to 50% of breast cancer may be missed. Additional imagingis highly recommended.

Surrogate Fadors for Screening

Fig. 5.1 a-d Screening for carcinoma.a Screening mammography. right MlO projection. No pathologic findings.b Screening mammography, left MlO projection. Centrally located carcinoma.c Screening mammography. right craniocaudal projection. No pathologic findings.d Screening mammography. left craniocaudal projection. Centrally located carcinoma.

153

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Definition............................................................................................Detection of breast cancer at an early pathologic stage with a cure rate over 90% •Tumor size < 1 em.- Primory prevention: Avoidance of the development of breast cancer.- Secondory prevention: Early detection of breast cancer.- Tertiary prevention: Limitation of the negative consequences of breast cancer.

Prerequisites for Effective Early Detection............................................................................................Slow tumor growth: The volume-doubling time of a breast carcinoma averages ap-proximately 1 year (6-24 months. depending on its grade) • Thus. a breast carcino-ma with a diameter of 2 em has been growing for approximately 8-10 years.Curative therapies: Breast cancers with a diameter under 1 em at diagnosis have a5-year survival rate of over 95% • The average size of a breast tumor presenting asa palpable mass is 2.3 em.Favorable constellation: Certain tumor characteristics can be detected early onbreast imaging:- Intraductal microcalcifications (mammography).- lesion location within fatty tissue (mammography. MRmammography).- Non-calcified lesion < 5 mm 0 located within parenchyma (MR mammography).- Non-calcified lesion 5-10 mm 0 located within parenchyma (ultrasound. MR

mammography).

Diagnostic Methods for Early Breast Cancer Detection/Recommendations............................................................................................- Breast self-examination: Begin at 20 years of age.- Annual physical examination: Begin at 30 years of age • In special cases includingultrasound examination.

- Mammography: Begin at 40 years of age. Interval: Every 1-2 years. Modifiedapproach for women with familial or genetic predisposition.

- Ultrasound: Supplementary to mammography for breast composition types ACRII-IV.

- MR mammography: Supplementary to mammography for breast compositiontypes ACRII-IV.

- Optipack concept: Combination of digital. low-dose one-view mammography(MLO) plus MR mammography. Currently the most sensitive diagnostic strat-egy for early breast cancer detection with the lowest radiation exposure.

Tips and Pitfalls............................................................................................Carrying out diagnostic procedures in symptom-free women to detect breast cancerat an early stage is the most important factor in reducing the mortality of this con-dition.

Early Detection

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flg.5.20-d Early detection.a Microcalcifications seen on mammography as the first sign of breast cancer.b Mammography. Small breast cancer (7 mm).c Ultrasonography. Small breast cancer (8 mm).d MR mammography (subtraction image). Small breast cancer (5 mm).

155

156

Definition

~ EpidemiologyApproximately 10%of breast cancers are associated with an inherited suscepti-bility to the disease (50% BRCA1 or 2 defects, 50% other),

~ Etiology, pathogenesisTumor suppressor genes are involved in the repair of damaged DNA(e.g., recog-nition and mending of breaks in DNA)• Defective genes lead to an accumulationof more defects on other genes and uncontrolled cell growth and division. Au-tosomal dominant inheritance • Men can also be carriers of gene defects(healthy fathers pass defective gene to their daughters).

~ Genes associated with an increased risk of developing breast cancer- BRCA1:Tumor suppressor gene associated with an increased susceptibility for

breast and ovarian cancer, often at an early age. Sequenced and identifiable.- BRCA2: Tumor suppressor gene associated with an increased susceptibility for

breast and ovarian cancer, often at an early age. Sequenced and identifiable.- BRCA3: Tumor suppressor gene associated with an increased susceptibility

for breast and ovarian cancer, often at an early age. Not yet completely se-quenced.

- BRCA4: Tumor suppressor gene associated with an increased susceptibilityfor breast and ovarian cancer, often at an early age. Not yet sequenced.

- Ataxia telangiectasia mutated (ATM).- li-Fraumeni syndrome (TP53 gene).

Particular Characteristics of Defective Gene Carriers............................................................................................- Extremely high lifetime risk of developing breast or ovarian cancer (approxi-

mately 80-90%).- Early disease onset (approximately 40 years of age).- Increased risk for multiple breast carcinomas.- Aggressive tumor types occur more commonly than in the general population

(grade 3, negative receptor status).- Increased susceptibility of normal breast tissue to radiation exposure.- Increased risk of developing colon carcinoma.

Indications for Genetic Testing............................................................................................- Blood relatives with breast cancer under 40 years of age at time of diagnosis.- Two or more relatives with breast cancer under 50 years of age at time of diagno-

sis.- One or more relatives with bilateral breast cancer.- One or more relatives with ovarian cancer under 40 years of age at time of diag-

nosis.- Three or more relatives with breast or ovarian cancer.- Male relative with breast cancer.

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Chromosome 17BRCAl

a b

Fig. 5.30, b BRCAgene ("breast cancer gene").a BRCA1.b BRCA2.

Consequences of Positive Results of Gene Defect Tests............................................................................................Regulordiagnastic imaging: E.g.. annual mammograms (preferably digital. low-dose.perhaps single-view mammography). annual MR mammograms. supplementaryultrasonography. Alternative: Prophylactic. bilateral mastectomy.

Selected References

Kriege M et al. Efficacy of MRI and mammography for breast-cancer screening in womenwith a familial or genetic predisposition. N Engl J Med 2004; 351: 427-437

Kuhl CK et al. Die EVA-Studie: Evaluierung der leistungsfahigkeit diagnostischer Verfah-ren (Mammographie. Sonographie. MRT) zur sekundaren und tertiaren Pravention desfamiliaren Mammakarzinoms-Zwischenergebnisse nach der ersten Halfte der Forde-rungsperiode. Riifo 2005; 177: 818-827

157

158

Definition............................................................................................Proliferation of monomorphous malignant epithelial cells of ductal type within themilk ducts. No invasion through the epithelial basement membrane. Lownucleargrade. No necrosis. Noncomedo architecture. Less biologic aggressiveness thanhigh-grade DClS.

Imaging Signs............................................................................................~ Ultrasound findings

Usually no specific characteristics. Rarely dilation of affected duct. Rarely solidintraductal mass.

~ Mammographic findingsOften displays microcalcifications: Usually round. monomorphic. occasionallyamorphous or pleomorphic. Clustered, linear or segmental distribution. Maybe regionally or diffusely distributed if tumor is extensive. May be very fine(punctate. just above spatial resolution limits) • Extent of DClSis often underes-timated.

~ MR mammographic findingsNo characteristics changes in Tl-weighted precontrast image. May display fo-cal, linear. or segmental contrast enhancement in Tl-weighted postcontrast im-age. May appear as a "nonmass lesion" • Signal-to-time relationship is usuallyunspecific. Occasionally norma) postcontrast examination. No characteristicschanges in T2-weighted images.

Clinical Aspects............................................................................................~ Typical presentationNo specific clinical symptoms. In extensive cases, a discrete, increased firmnessof the affected breast in comparison to the other breast may be noticed.

~ Treatment optionsHI-RADS 3: Follow-up imaging in 6 months. Ifunchanged: Fallow-up imaging inanother 6 months .'fagain unchanged: Annual mammography. Bl-RADS4 or S:Percutaneous core biopsy (stereotactic vacuum biopsy + specimen radiography).

~ Course and prognosisExcellent prognosis if completely excised. Survival rate> 98%.

Differential Diagnosis............................................................................................Adenosis • High- and intermediate-grade DClS • Carcinoma (invasive. minimallyinvasive) • ADH • Postoperative calcifications. Calcifying fibroadenoma (earlyphase) • Fat necrosis (early phase).

Ductal Carcinoma In Situ (OCIS. Low Grade)

Flg.5.4o-d DOS (low grade).a Histologic specimen.b Mammography. DOS presenting with predominantly monomorphic calcifications.c Ultrasonography. DOS displaying diffuse shadowing.d MR mammography (subtraction image). DOS displaying diffuse contrast

enhancement.

159

Proliferation of mildly to moderately polymorphous epithelial cells of ductal typewithin the milk ducts. No invasion through the epithelial basement membrane.Intermediate nuclear grade. May display nonpure comedo necrosis. Noncomedoarchitecture. Less biologic aggressiveness than high-grade DClS.

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Imaging Signs............................................................................................• Ultrasound findings

Usually no specific characteristics. Rarely dilation of affected duct. Rarely solidintraductal mass.

• Mammographic findingsOften displays microcalcifications-usually amorphous. occasionally round.monomorphic or pleomorphic. Clustered, linear or segmental distribution.May be regionally or diffusely distributed if tumor is extensive. Extent of DClSis often underestimated.

• MR mammographic findingsNo characteristics changes in Tl-weighted precontrast image. May display fo-cal. linear. or segmental contrast enhancement in Tl-weighted postcontrast im-age without the characteristics ofa mass ("nonmass lesion") • Signal-to-time re-lationship is usually unspecific • Occasionally normal postcontrast examina-tion • No characteristics changes in T2-weighted images.

Clinical Aspects............................................................................................

• Typical presentationNo specific clinical symptoms. In extensive cases,a discrete, increased firmnessof the affected breast in comparison with the other breast may be noticed.

• Treatment optionsBI-RADS3: Follow-up imaging in 6 months .Ifunchanged: Follow-up imaging inanother 6 months. Ifagain unchanged: Annual mammography. BI-RADS 4 or 5:Percutaneous core biopsy (stereotactic vacuum biopsy + specimen radiography).

• Course and prognosisExcellent prognosis if completely excised. Survival rate> 98:t.

Differential Diagnosis............................................................................................Adenosis • High- and low-grade DCIS• Carcinoma (invasive. minimally invasive) •ADH • Postoperative calcifications. Calcifying fibroadenoma (early phase) • Fatnecrosis (early phase).

Tips and Pitfalls............................................................................................DCISof intermediate grade includes only those lesions which cannot be clearly clas-sified as low- or high-grade DCISlesions.

160

Ductal Carcinoma In Situ (DC/S. Intermediate Grade)

Fig.5.5a-d DClS (intermediate grade).a Mammography. DOS presenting with diffuse microcalcifications.b Mammography. DClS presenting with regionally distributed microcalcifications.c Mammography. DOS presenting with clustered microcalcifications.d Mammography. DOS presenting with diffuse microcalcifications.

161

Imaging Signs............................................................................................

Proliferation of overtly malignant epithelial cells of ductal type within the milkducts. No invasion through the epithelial basement membrane. High nucleargrade and extensive necrosis. Comedo architecture. High biologic aggressiveness.

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o Ultrasound findingsUsually no specific characteristics. Rarely dilation of affected duct. Rarely solidintraductal mass.

o Mammographic findingsOften displays pleomorphic. linear and branching microcalcifications • Clus-tered. linear. or segmental distribution. May be regionally or diffusely distrib-uted if tumor is extensive. Mammographic extent of DClSis relatively accuratein estimating lesion size.

o MR mammographic findingsNo characteristics changes in Tl-weighted precontrast or T2-weighted images.May display focal. linear. or segmental contrast enhancement in Tl-weightedpostcontrast image ("nonmass lesion") • Unspecific contrast dynamics. Nor-mal postcontrast examination is rare.

eliniealAspects............................................................................................o lYPical presentation

Usually without specific clinical symptoms. In extensive cases. a discrete. in-creased firmness of the affected breast in comparison with the other breast or apalpable mass may be noticed.

o Treatment optionsHI-RADS 3: Follow-up imaging in Gmonths .'funchanged: Follow-up imaging inanotherG months ./fagain unchanged: Annual mammography. BI-RADS40r5:Percutaneous core biopsy (stereotactic vacuum biopsy + specimen radiography).

o Course and prognosisExcellent prognosis if completely excised. Survival rate> 98%.

Differential Diagnosis............................................................................................Adenosis • l.ow- and intermediate-grade DClS • Carcinoma (invasive. minimallyinvasive) • ADH • Postoperative calcifications. Calcifying fibroadenoma (earlyphase) • Fat necrosis (early phase).

Tips and Pitfalls............................................................................................Notall DCISlesions progress roinvasivecarcinoma • Riskofdevelopinginvasivecarci-noma increases with increasing tumor grade • The probability that a DCISlesion willprogress to invasive carcinoma is not predicta ble from its mammographic appearance.

162

Ductal Carcinoma In Situ (DC/S. High Grade)

Flg.5.6o-d DClS(high grade).a Histologic specimen.b Mammography. DOS presenting with clustered. pleomorphic microcalcifications.c Ultrasonography. DClSdisplaying intraductal tumor.d MR mammography (subtraction image). DClSdisplaying ductal contrast

enhancement.

J63

164

Definition

Synonyms: Infiltrating ductal carcinoma not otherwise specified - NOS(no or limit-ed cell differentiation, do not constitute a specific histologic tumor type) • Morpho-logically diverse group of tumors that do not fit into any of the other defined cate-gories of invasive breast cancer (e.g., scirrhous carcinoma) • Invasive breast canceroriginating in the terminal milk ducts • Continuous or discontinuous invasionthrough the epithelial basement membrane. Single largest group of malignantmammaty tumors. Accounts for approximately 75% of all breast cancers. Peokage: 50-60 years. Multifocal in 15%of cases. Bilateral in 5%of cases,

Imaging Signs

• Ultrasound findingsIrregular, indistinct mass. Hypo- or isoechoic • Very rarely hyperechoic • Inho-mogeneous echatexture • Echogenic rim • Posterior acoustic shadowing. Le-sion axis usually perpendicular to the skin. Disruption of surrounding tissuestructures (e,g" ligaments).

• Mammographic findingsIrregular mass. Rarely round, oval, or lobulated. Indistinct or spiculated bor-ders • Hyper- or isodense in comparison with normal parenchyma. Microcalci-fications within 30% of tumors. Peritumoral microcalcifications may be an in-dication of accompanying EIC.

• MR mammographic findingsIrregular mass in T1-weighted precontrast image. Rarely round, oval, or lobu-lated • Indistinct or spiculated borders. Inhomogeneous or peripheral (ring)contrast enhancement in T1-weighted postcontrast image. Often strong initialcontrast enhancement (> 100%signal increase) • Post-initial plateau or washoutphenomenon. Hypo- or isointense in T2-weighted images.

Clinical Aspects............................................................................................• Typical presentation

Small carcinomas are usually clinically inconspicuous. Larger carcinomas maypresent as a hard, irregular palpable mass. May cause nipple or skin retraction.

• Treatment optionsUsually surgery (breast-conserving therapy, mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy. Neoadjuvant therapy.

• Course and prognosisPrognosis depends on tumor size (T stage), grading (GI-3), and especially thelymph node status (N stage).

Differential Diagnosis............................................................................................Carcinomas of other histology. Benign. solid tumors.

Invasive Ductal Carcinoma (lDC)

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Fig. 5.7 a-d Invasive ductal carcinoma.a Histologic specimen.b Mammography.c Ultrasonography.d MR mammography (subtraction image).

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Definition............................................................................................Breast carcinoma with a linear arrangement of tumor cells ("Indian file pattern")and a tendency to grow circumferentially around ducts and lobules ("targetoid"growth pattern) • Small tumor cell size. May contain signet ring cells (cells withcentral mucoid globule) • May affect all age groups. Peak age: 50-60 years. Mul-tifocal in 15% of cases. Multicentric in 5% of cases. Bilateral in 5% of cases.

Imoging Signs............................................................................................• Ultrasound findings

Irregular, indistinct mass. Hypo- or isoechoic • Very rarely hyperechoic • Inho-mogeneous echotexture • Echogenic rim. Posterior acoustic shadowing. le-sion axis usually perpendicular to the skin. Disruption of surrounding tissuestructures (e.g.. ligaments).

• Mammographic findingsIrregular mass. Rarely round, oval. or lobulated. Indistinct or spiculated bor-ders • Hyper- or isodense in comparison with normal parenchyma • Almostnever displays microca1cifications.

• MR mammographic findingsIrregular mass in Tt-weighted precontrast image. Rarely round, oval, or lobu-lated • Indistinct or spiculated borders • Inhomogeneous or peripheral (ring)contrast enhancement in Tt-weighted postcontrast image. Often strong initialcontrast enhancement (> 100% signal increase) • Post-initial plateau or washoutphenomenon. Hypo- or isointense in T2-weighted images.

Clinicol Aspects............................................................................................• TYPical presentation

Small carcinomas are usually clinically inconspicuous. Larger carcinomas oftenpresent as an indistinct palpable mass. May cause nipple or skin retraction.

• Treatment optionsUsually surgery (breast-conserving therapy. mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy. Neoadjuvant therapy.

• Course and prognosisPrognosis depends on tumor size (T stage), grading (GI-3), and especially onlymph node status (N stage).

Differential Diagnosis............................................................................................Carcinomas of other histology, especially IDC• Benign, solid tumors.

Tips and Pitfolls

The nodular form of infiltrating lobular carcinoma cannot be differentiated fromIDCby diagnostic imaging.

Fig.5.8a-d Nodular form of invasive lobular carcinoma.a Histologic specimen.b Mammography.c Ultrasonography.d MR mammography (subtraction image).

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Definition............................................................................................~ Epidemiology

Approximately 10%of all breast cancers. May affect all age groups. Peak age:50-60 years. Multicentric in 5%of cases. Bilateral in 5%of cases.

~ Etiology, pathogenesisBreast carcinoma with a linear arrangement of tumor cells ("'ndian file pattern")and a tendency to grow circumferentially around ducts and lobules ("targetoid"growth pattern) • Small tumor cell size. May contain signet-ring cells (cellswith central mucoid globule).

Imoging Signs............................................................................................~ Ultrasound findings

Architectural distortion with discrete posterior acoustic shadowing. Disruptionof surrounding tissue structures (e.g., ligaments).

~ Mammographic findingsArchitectural distortion. "Shrinking sign" • Rarely irregular mass with indis-tinct or spiculated borders. Almost never displays microcalcifications • Focalor global asymmetry. Change in comparison with previous mammograms.

~ MR mammographic findingsArchitectural distortion in Tl-weighted precontrast image. Asymmetry of non-fatry structures. Diffuse contrast enhancement respecting the fat tissue struc-tures in Tl-weighted postcontrast image ("nonmass lesion") • Contrast dynam-ics usually uncharacteristic. Hypo- or isointense in T2-weighted images.

Clinicol Aspects............................................................................................~ TYPicalpresentation

Small carcinomas are usually inconspicuous. larger carcinomas often presentas an indistinct palpable mass. May cause nipple or skin retraction,

•.. Treatment optionsUsually surgery (breast-conserving therapy, mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy. Neoadjuvant therapy,

~ Course and prognosisPrognosis depends on tumor size (T stage), grading (Gl-3), and especially onlymph node status (N stage),

Differentiol Diognosis............................................................................................Carcinomas of other histology, especially DCIS• Postoperative scar. Radial scar.

Tips ond Pitfolls

The diffuse form of infiltrating lobular carcinoma is the most dimcult tumor to de-tect on diagnostic imaging.

Invasive Lobular Carcinama. Diffuse Farm

Fig.5.9a-d Diffuse form of invasive lobular carcinoma.a Histologic specimen.b Mammography.c Ultrasonography.d MR mammography (subtraction image).

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Definition............................................................................................~ Epidemiology

Approximately 2% of all breast cancers • May affect all age groups • Peak age:65 years.

~ Etiology. pathogenesisBreast carcinoma with a predominantly frond-forming growth pattern • Cystformation is sometimes present. Develops from a benign papilloma. Invasivepapillary carcinoma must be differentiated from intracystic and intraductal pap-illary carcinomas, which may be regarded as a variant of intraductal carcinoma.

Imoging Signs............................................................................................~ Ultrasound findings

Oval, lobulated. or irregular mass. Usually indistinct. sometimes well-definedborders. Hypo- or isoechoic • Echogenic rim. Posterior acoustic shadowing.Disruption of surrounding tissue structures (e.g.. ligaments).

~ Mammographic findingsOval, lobulated. or irregular mass. Usually indistinct, sometimes well-definedborders. Hyper- or isodense in comparison with normal parenchyma. Almostnever displays microcalcifications.

~ MR mammographic findingsOval, lobulated. or irregular. hypointense mass in Tl-weighted precontrast im-age. Usually indistinct, sometimes well-defined borders. Homogeneous, in-homogeneous. or peripheral (ring) contrast enhancement in Tl-weighted post-contrast image. Often strong initial contrast enhancement (> 100% signal in-crease) • Post-initial plateau or washout phenomenon. Usually hypo- or iso-intense, rarely hyperintense mass in T2-weighted images.

Clinical Aspects............................................................................................~ Typical presentation

Small carcinomas are usually clinically inconspicuous. Larger catcinomas maypresent as a firm, irregular, palpable mass. Rarely causes pathologic dischargefrom the nipple,

~ Treatment optionsUsually surgery (breast-conserving therapy, mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy. Neoadjuvant therapy,

~ Course and prognosisPrognosis depends on tumor size (T stage). grading (Gl-3), and especially onlymph node status (N stage).

Differential Diagnosis............................................................................................Carcinomas of other histology. Benign, solid tumors (e.g.. papilloma).

Invasive Papillary Carcinoma

Fig.5.10a-d Invasive papillarycarcinoma.a Macroscopic specimen.

b Mammography.

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Invasive Papillary Carcinoma

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Tips and Pitfalls............................................................................................Papillomas of the breast should be excised because of possibility of malignanttransformation to an invasive papillary carcinoma. Depending on size. this may beperformed as a minimally invasive procedure or open surgery.

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Definition............................................................................................

• EpidemiologyApproximately 5% of all breast cancers. May affect all age groups. Peak age:45-55 years. 10%of patients youngerthan 35 years. Constitutes a greater pro-portion of tumors diagnosed in younger women with BRCAgene defect. Bilat-eral in 5%of cases.

• Etiology, pathogenesisBreast cancer with clearly defined histology (typical form):- Tendency for tumor cells to grow in broad sheets (syncytial pattern). little

stroma.- Large, pleomorphic nuclei with prominent nucleoli. usually with high mitotic

rate.- Grossly and microscopically well circumscribed.- Intense Iymphoplasmacytic reaction around and within the tumor.

Imaging Signs............................................................................................• Ultrasound findings

Round, oval, or lobulated, rarely irregular mass. Usually microlobulated bor-ders. Hypo- or isoechoic • Echogenic rim. Posterior acoustic shadowing. Dis-ruption of surrounding tissue structures (e.g., ligaments).

• Mammographic findingsRound, oval, or lobulated, rarely irregular mass. Usually microlobulated bor-ders. Hyper- or isodense in comparison with normal parenchyma. Rarely dis-plays microcalcifications.

• MR mammographic findingsHypointense. round, oval. or lobulated, rarely irregular mass in Tl-weighted pre-contrast image. Usually microlobulated borders. Inhomogeneous or peripher-al (ring) contrast enhancement in Tl-weighted postcontrast image • Oftenstrong initial contrast enhancement (> 100%signal increase) • Post-initial pla-teau or washout phenomenon. Usually hyper- or isointense, rarely hypointensemass in T2-weighted images.

Clinical Aspects............................................................................................

• Typical presentationSmall carcinomas are usually inconspicuous. Larger carcinomas may presenr asa firm. well-circumscribed palpable mass.

• Treatment optionsUsually surgery (breast-conserving therapy. mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy.

• Course and prognosisPrognosis depends on tumor size (T stage), grading (Gl-3). and especially onlymph node status (N stage). Relatively favorable prognosis in comparison withIDCand ILC.

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Fig. 5.11a-d Medullarycarcinoma.a Macroscopic specimen.

b Mammography.

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Differential Diagnosis............................................................................................

Carcinomas of other histology. Benign. solid tumors (e.g.. fibroadenoma).

Medullary Carcinoma

c Ultrasonography.

d MR mammography(subtraction image).

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Definition............................................................................................~ Epidemiology

Approximately 3%of all breast cancers. May affect all age groups. Wide agerange (20-90 years). Peak age: 65 years. Bilateral in 5%of cases.

~ Etiology, pathogenesisBreast cancer with clearly defined histology (pure form):- Clusters of tumor cells within lakes of abundant extracellular mucinous secre-

tion.- Tumor cells arranged in slender strands or papillary clusters.- Gland formation uncommon.

Imaging Signs

~ Ultrasound findingsRound, oval, or lobulated, rarely irregular mass. May display microlobulatedborders. Usually hypoechoic, but sometimes iso- or hyperechoic • Echogenicrim. Posterior acoustic shadowing. Disruption of surrounding tissue struc-tures (e.g.. ligaments).

~ Mammographic findingsRound, oval. or lobulated, rarely irregular mass. Well-circumscribed, some-times obscured or microlobulated borders. Hyper- or isodense in comparisonwith normal parenchyma. Rarely displays microcaleifications.

~ MR mammographic findingsHypointense, round, oval, or lobulated, rarely irregular mass in Tl-weighted pre-contrast image. Usually well-circumscribed. partly indistinct or microlobulatedmargins. Inhomogeneous or peripheral (ring) contrast enhancement in Tl-weighted postcontrast image • Often strong initial contrast enhancement(> 100%signal increase). Post-initial plateau or washout phenomenon. Usual-ly hyper- or isointense, rarely hypointense mass in T2-weighted images. Somecase reports of mucinous carcinomas show no contrast enhancement.

Clinical Aspects............................................................................................~ Typical presentation

Small carcinomas are usually clinically inconspicuous. Larger carcinomas maypresent as a soft to hard, well-circumscribed palpable mass.

~ Treatment optionsUsually surgery (breast-conserving therapy, mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy.

~ Course and prognosisPrognosis depends on tumor size (T stage). grading (Gl-3), and especially onlymph node status (N stage). Relatively favorable prognosis in comparison withIDCand ILC.

Mucinous Carcinoma

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Fig.5.12a-d Mucinous carcinoma.a Histologic specimen. Extracellular mucin lakes with a few clusters of tumor cells.b Mammography. Microlobulated mucinous carcinoma.c Ultrasonography. Mucinous carcinoma.d MR mammography (subtraction image). Mucinous carcinoma.

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Mucinous Carcinoma

Differential Diagnasis

Carcinomas of other histology (especially medullary carcinoma) • Benign. solid tu-mors (e.g.. fibroadenoma. adenoma. papilloma).

Tips and Pitfalls

The differentiation of a mucinous carcinoma from a fibroadenoma by diagnosticimaging may be very difficult. In case of doubt. core biopsy should be done for his-tological verification.

Definition............................................................................................• Epidemiology

Approximately 2% of all breast cancers. May affect all age groups. Peok age:55 years. Bilateral in 5%of cases.

• Etiology, pathogenesisBreast cancer with clearly defined histology (pure form):- Proliferation of small glands or tubules that closely resemble nonneoplastic

mammary ductules (well differentiated). are haphazardly dispersed. and areoften angular.

- At least 75% of the tumor must display a tubular growth panern.- Tubules are lined by a single layer of cuboid epithelial cells.- Stroma within the tumor is formed of dense collagenous tissue. with variableamounts of elastic tissue.

- Tendency to form a stellate tumor with ill-defined boundaries.

Imaging Signs............................................................................................• Ultrasound findings

Irregular mass with spiculated or indistinct borders. Usually hypo- or isoecho-ic. Echogenic rim. Lesion axis usually perpendicular to the skin. Posterioracoustic shadowing. Disruption of surrounding tissue structures (e.g" liga-ments) • May distort the normal architecture.

• Mammographic findingsStellate or irregular mass. Indistinct or spiculated margins. Hyper- or isodensein comparison with normal parenchyma. Displays microcalcifications in 50%ofcases. May display architectural distortion.

• MR mammographic findingsStellate or irregular. hypointense mass in Tl-weighted precontrast image. In-distinct or spiculated margins. May display architectural distortion. Homoge-neous or inhomogeneous contrast enhancement in Tl-weighted postcontrastimage. Often strong initial contrast enhancement (> 100% signal increase) •Post-initial plateau or washout phenomenon. Usually iso- or hypointense massin T2-weighted images.

Clinical Aspects

• Typical presentationSmall carcinomas are usually clinically inconspicuous. Larger carcinomas maypresent as a hard. irregular. palpable mass. Occasionally increased firmness andretraction of skin or nipple.

• Treatment optionsUsually surgery (breast-conserving therapy. mastectomy) • Depending onstage-adjuvant chemotherapy and/or radiation therapy.

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Tubular Carcinoma

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Flg.S.13a-d Tubular carcinoma.a Mammography. Typical tubular carcinoma.b Mammography. Tubular carcinoma.c Ultrasonography. Tubular carcinoma.d MR mammography (subtraction image). Tubular carcinoma.

Tubular Carcinoma

• Course and prognosisPrognosis depends on tumor size (T stage). grading (G 1-3). and especially onlymph node status (N stage). Relatively favorable prognosis in comparison withIDC and ILC • Usually Gl grade.

Differentiol Diognosis............................................................................................Carcinomas of other histology (especially diffuse form oflLC) • Postoperative scar.Radial scar.

Tips and Pitfalls............................................................................................Tubular breast cancer is the most important DD for an architectural distortion.

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Definition

~ EpidemiologyLess than 1% of all breast cancers. May affect all age groups. Peak age: 50-60years. Rarely bilateral.

~ Etiology, pathogenesisSpecial form of breast cancer with diffuse involvement of the breast. Poorly dif-ferentiated tumor cells. Skin involvement is common (histology: dilated lym-phatic channels, intra lymphatic tumor emboli, lymphocytic reaction localizedaround dilated vascular spaces) • Clinical signs of inflammation (erythema,swelling, warmth, peau d'orange).

Imaging Signs............................................................................................~ Ultrasound findings

Diffuse or regional skin thickening. Edematous changes of subcutaneous tis-sues (right/left comparison) • Possible identification of a focal mass with typicalsigns of malignancy.

~ Mammographic findingsSkin thickening. Trabecular thickening. Loss of detail sharpness. Diffuse orregional. asymmetric increase in parenchymal density. Possible identificationof a focal mass with typical signs of malignancy.

~ MR mammographic findingsNo specific characteristics. Limited indication. Skin thickening on T1-weight-ed precontrast image. Skin and/or generalized contrast enhancement of affect-ed side in TI-weighted postcontrast image. Possible identification of a focalmass with typical morphologic signs of malignancy and suspicious contrastdynamics. Increased water content of skin and/or intramammary structures inT2-weighted images.

Cllnlco/ Aspects............................................................................................~ l)'pical presentation

Striking clinical cutaneous findings with erythema. swelling, and increasedwarmth of affected breast. Possible increased firmness of affected breast.Rarely associated with pain.

~ Treatment optionsAntibiotics may be tried for 7-10 days. Ifsymptoms persist, core biopsy or openbiopsy must be done. Skin punch biopsy may be diagnostic but is often nega-tive. Treatment should be started without delay (e.g.. neoadjuvant chemo- orradiation therapy, primary mastectomy).

~ Course and prognosisRapidly progressive form of breast cancer with very poor prognosis. Should beconsidered a systemic illness at onset. Axillary lymph node involvement almostuniversal.

Inflammatory Breast Cancer

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Flg.5.J4o-d Inflammatory breast cancer.a Clinical presentation of inflammation.b Mammography. Inflammatory breast cancer of right breast.c Ultrasonography. Inflammatory breast cancer changes on right image

(normal image on left).d MR mammography (subtraction image). Inflammatory breast cancer with increased

enhancement of skin and intra mammary structures.

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Inflammatory Breast Cancer

Differential Diagnosis

Mastitis (nonpuerperal, puerperal) • Advanced breast cancer with secondary lym-phatic invasion. Post-radiation therapy changes,

Tips and Pitfalls............................................................................................Because innammatory breast cancer and non puerperal mastitis cannot be reliablydifTerentiated on the basis of clinical symptoms and breast imaging, early histologicassessment is strongly recommended (core biopsy, open biopsy),

Definition............................................................................................• Epidemiology

Less than 1%of all breast cancers. May affect all age groups. Peak age: 65years. Rarely bilateral.

• Etiology, pathogenesisBreast cancer in the male breast. Histology is identical with that of breast can-cer found in women. BRCA2 gene defect in up to 30% of cases.

Imaging Signs

• Ultrasound findingsRound or irregular, indistinct mass. Hypo- or isoechoic • Echogenic rim. Pos-terior acoustic shadowing. Disruption of surrounding tissue structures (e.g" lig-aments).

• Mammographic findingsRound or irregular mass. Indistinct or spiculated borders. Hyperdense • Maydisplay microcalcifications.

• MR mammographic findingsRound or irregular mass in Tl-weighted precontrast image. Indistinct or spicu-lated borders. Homogeneous, inhomogeneous or peripheral (ring) contrast en-hancement in Tl-weighted postcontrast image • Often strong initial contrastenhancement (> 100% signal increase) • Post-initial plateau or washout phe-nomenon • Hypo- or isointense in T2-weighted images.

Clinical Aspects

• 1)rpical presentationFirm, painless. palpable mass. Usually rerroareolar • Eccentric location moresuspicious for malignancy. In advanced stages tumor can no longer be movedfreely relative to the pectoral muscle. Nipple changes .

•.. Treatment optionsUsually surgery. Depending on stage, adjuvant chemotherapy and/or radiationtherapy. Hormonal treatment if receptor status is positive.

• Course and prognosisPrognosis depends on tumor size (T stage), grading (Gl-3), and especially onlymph node status (N stage),

Differential Diagnosis............................................................................................Gynecomastia. Nonmammary tumors.

TIpsand Pitfalls

Daughters of men with breast cancer have an increased risk of developing breastcancer.

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Male Breast Cancer

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Fig.5.15 a-d Male breast cancer.a Clinical presentation.b Mammography.c Bilateral mammography. Breast cancer on right, gynecomastia on left.d Ultrasonography.

Definition............................................................................................• Epidemiology

Approximately 2% of all breast cancers. May affect all age groups. Peak age:50-60 years. Rarely bilateral.

• Etiology, pathogenesisRare form of DClSinvolving the nipple. Eczematoid changes of the nipple aredue to DCISextending through lactiferous ducts to nipple surface. Often asso-ciated with an invasive breast cancer that may present as a palpable mass.

Imaging Signs............................................................................................• Ultrasound findings

Skin thickening around areola. Possible dilation oflactiferous ducts. Advancedcarcinomas show typical signs of malignancy. Microcalcifications are not usu-ally visualized.

• Mammographic findingsPleomorphic microcalcifications are often the only imaging characteristic ofDCIS• Comma. punctate. linear. and V-forms • Distributed in a segmental or lin-ear pattern. Possible skin thickening around areola.

• MR mammographic findingsNo characteristics changes in Tl-weighted precontrast and T2-weighted im-ages. Often shows no contrast enhancement in Tl-weighted postcontrast im-age. If invasive breast cancer is present, mass with typical morphologic signsof malignancy and suspicious contrast dynamics may be seen.

Clinical Aspects

• Typical presentationEczema of the nipple. usually without pruritus. May show reddening. scaling.crusting, and/or moist erosions or ulcerations. Usually no palpable mass. His-tology: Intraepidermal spread of malignant cells (DClS) without invasionthrough the epithelial basement membrane .

•. Treatment optionsPunch biopsy of the skin. Percutaneous core biopsy. Stereotactic vacuum bi-opsy of microcalcifications.

• Course and prognosisPrognosis depends on underlying tumor histology and stage.

Differential Diagnosis............................................................................................Seborrheic dermatitis. Dermatophytosis. Contact dermatitis. Protruding intra-ductal papilloma.

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Paget Disease af the Nipple

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Flg.5.160-<l Paget disease of thenipple.a Histologic specimen. large, intra-epidermal round and oval tumor cells(DOS).

b Clinical presentation with eClemaof the nipple.

Paget Disease of the Nipple

c Mammography. Microcalcifications inretromammillary region.d Enlarged detail view of c. Pleomorphicmicrocalcifications.

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Paget Disease of the Nipple

Tips and Pitfalls............................................................................................The cutaneous manifestation of a retromammillary carcinoma, i.e., Paget the dis-ease of the nipple, should always be included in the DD of nipple eczema, especiallyif not responding to treatment.

Selected ReferencesBjiker N, Breast conserving therapy for Paget's disease of the nipple: a prospective Euro-

pean organization for research and treatment of cancer study. Cancer 2001 : 91: 472-477

Definition

• EpidemiologyRate of recurrence: 1-2 % per year. Local recurrence usually associated with in-complete excision of primary breast cancer.

• Etiology. pathogenesisRecurrent breast carcinoma after treatment of primary breast cancer is complet-ed • Riskfactors: Young age, DCIS> 4 em, EIC,lymphatic invasion. RJ resection ofprimary tumor, negative receptor status.

Imoging Signs

• Ultrasound findingsMass at lumpectomy site may be difficult to identify due to scar shadowing andpoor compressibility. Color Doppler ultrasound may be helpful.

• Mammographic findingsArchitectural distortion at lumpectomy site may make detection of a mass ordensity difficult. New microcaJcifications are the easiest identifiable imagingcharacteristic (DO:scar calcifications. fat necrosis).

• MR mammographic findingsNot visible in hypointense, postoperative architectural distortion in T1-weightedprecontrast or T2-weighted images. High sensitivity of TJ-weighted postcon-trast image due to contrast enhancement of recurrent carcinoma. Scar tissuedisplays no contrast enhancement.

Clinicol Aspects

• Typical presentationLocal recurrences most often at lumpectomy site. Often presents as a palpablemass, microcalcifications on mammography, or contrast enhancement on MRmammography • Histology: Infiltrating carcinoma in approximately 50% ofcases.

• Treatment optionsMastectomy if patient has already had a lumpectomy with radiation treatment(second radiation treatment is not an option) • Recurrence within 6 years of pri-mary treatment usually due to incomplete primary resection (local failure. oftenat lumpectomy site) • Recurrence after 6 years is usually a new primary (oftenelsewhere in breast).

• Course and prognosisPrognosis depends on recurrent tumor size, multifocality. the time interval fromprimary tumor to recurrence, and the primary treatment ()umpectomy betterthat primary mastectomy) • Metastatic disease present in 30%.

Differential Diagnosis

Surgical scar. Fat necrosis.

191

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Fig. 5.170-<1 Local recurrence. a Mammography, right MLO projection. Inconspicuousfindings after laterallumpectomy. b MR mammography of patient in a (subtractionimage). Triangular contrast enhancement at surgery site. c MR mammography (T1-weighted precontrast image). Postoperative scar located centrally in the left breast(mammogram showed inhomogeneous dense breast tissue without suspicious find-ings). d MR mammography (subtraction image). Local recurrence, 8 mm in diameter.

Local Recurrence

Tips and Pitfalls............................................................................................MR mammography has the greatest sensitivity and specificity in the detection oflocal recurrences after breast cancer. Postoperative scars show no contrast en-hancement.

Selected ReferencesFischer U et al. The influence of preoperative MRI of the breast on recurrence rate in

patients with breast cancer. EurRadio12004; 14: 1725-1731

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Definition............................................................................................Intraductal tumor in addition to an invasive breast carcinoma (index tumor) • In-traductal carcinoma (DCls) in the periphery of an index tumor.Intraductal component forms:- Predominantly intraductal component (PIC): Proportion of intraductal tumor

>80% • Proportion of invasive tumor < 20%.- Extensive intraductal component (fIC): Proportion of intraductal tumor 25-80%.- Slight intraductal component (SIC)• Proportion of intraductal tumor < 25 % • Pro-

portion of invasive tumor> 75%.

Imaging Signs............................................................................................o Ultrasound findings

Dilation of lactiferous ducts in proximity to the index tumor. Possible detectionof intraductal solid tumor matter.

o Mammographic findingsMicrocalcifications in proximity of the index tumor. Linear densities extendingfrom the index tumor into the surrounding tissues. Additional densities oftendistributed following the course of the milk ducts toward the nipple.

o MR mammographic findingsLinear or dendritic contrast enhancement in proximity of the index tumor. Es-pecially suspicious when distributed following the course of the milk ducts.

Clinical Aspects............................................................................................o lYPical presentationNo characteristic clinical symptoms. Microcalcifications on mammography.Dendritic or linear contrast enhancement on MR mammography.

to> Treatment optionsEICmust be completely excised along with index tumor. Important: If an intra-ductal component is suspected. this should be communicated the surgeons en-sure complete excision. Preoperative localization of borders may be advisable.

o Course and prognosisThe local rate of recurrence is much higher when EICis present (approximately25% vs. 2%).

nps and Pitfalls............................................................................................Incomplete excision of EICin breast-conserving therapy is the most common causeof intramammary recurrences.

Extensive Intraductal Component (fie)

Flg.5.180-<1 Extensive intraductal component (Ele).a Mammography. Suspicious hyperdense area extending toward the nipple.b Mammography. Peritumoral microcalcifications.c Ultrasonography. Oblong. hypoechoic extension of an index tumor into the

surrounding tissues.d MR mammography (MIP). Spiculated. hypervasculanzed mass in the lateral aspect of

the right breast. Dendritic contrast enhancement between index tumor and nipple(EIC).

195

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Definition............................................................................................No single, clear definition is universally accepted. Most commonly used to meantwo or more carcinomas within one breast quadrant (- V.of the breast) • Maximumseparating distance - 2 em • Breast-conserving therapy is still a therapeutic option(quadrantectomy).

Imaging Signs

• Ultrasound findingsMultiple hypoechoic masses within one quadrant • Often display posterioracoustic shadowing.

• Mammographic findingsMultiple masses. Possibly associated with suspicious microca\cifications.

• MR mammographic findingsUsually difficult to detect in Tl-weighted precontrast image. Masses usuallyhypointense in the T2-weighted image and difficult to detect. Tl-weightedpostcontrast image have the highest sensitivity and specificity for invasivebreast carcinomas. MR mammography in the preoperative setting allows thedetection of additional, otherwise occult, contrast-enhancing carcinomas in10%of cases (therapeutic consequences!).

Clinical Aspects............................................................................................• lYPical presentation

Multiple masses on breast imaging. Sometimes palpable.• Treatment options

Usually surgety (quadrantectomy, mastectomy) • Adjuvant chemotherapy and/or radiation therapy.

• Course and prognosisPrognosis is relatively unfavorable due to increased rate of local recurrence (ap-proximately 60%) • Second radiation treatment is not an option.

Tips and Pitfalls

MR mammography is the imaging method of choice to rule out multifocality inwomen with a BI-RAOS5/6 lesion and dense parenchyma on mammography.

Selected ReferencesFischer U et a!. The influence of preoperative MRJ of the breast on recurrence rate in pa-

tients with breast cancer. EurRadioI2004; 14: 1725-1731Lagios et a!. The concept and implications of multicentricity in breast carcinoma. Pathol

Annu 1981; 16:83-102

Muftifocafity

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Fig.5.190-d Multifocality.a Mammography (enlarged detail view). Multifocal groups of pleomorphic

microcalcifications.b Mammography, left craniocaudal projection. Multifocal breast carcinomas.c Ultrasonography (panoramic view). Multifocal breast carcinomas.d MR mammography (subtraction image). Spiculated mass in the lateral aspect of

the left breast. Additional lesion 1.5 em posterior to the index tumor.

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Definition

No single. clear definition is universally accepted. Most commonly used to meantwo or more carcinomas in different breast quadrants or separated by distance ofmore than 3-5 cm from each other (varying definitions found in the literature) •Breast-conserving therapy is not a therapeutic option. 15-30% of all breast carci-nomas are multicentric.

Imaging Signs

~ Ultrasound findingsMultiple hypoechoic masses in different breast quadrants or separated by a dis-tance of more than 3-5 cm • Often display posterior acoustic shadowing.

~ Mammographic findingsMultiple masses or suspicious microcalcifications in different breast quadrantsor with a separating distance of more than 3-5 cm.

~ MR mammographic findingsUsually difficult to detect in Tl-weighted precontrast image. Masses usuallyhypointense in T2-weighted images and difficult to detect. Tl-weighted post-contrast image have the highest sensitivity and specificity for invasive breastcarcinomas. MR mammography in the preoperative setting allows the detec-tion of additional, otherwise occult. contrast-enhancing carcinomas in differentbreast quadrants or separated by a distance of more than 3-5 cm (approximately30% of cases-therapeutic consequences I).

Clinical Aspects

~ Typical presentationMultiple masses in different breast quadrants or separated by a distance of morethan 3-5 cm on breast imaging. Sometimes palpable.

~ Treatment optionsUsually mastectomy. Adjuvant chemotherapy andlor radiation therapy.

~ Course and prognosisPrognosis is unfavorable in comparison with that of a solitary breast carcinoma.

TIps and Pitfalls............................................................................................MR mammography is the imaging method of choice to rule out multicentricity inwomen with a BI-RADS5/6 lesion and dense parenchyma on mammography.

Selected ReferencesFischer U et al. The influence of preoperative MRI of the breast on recurrence rate in pa-

tients with breast cancer. EurRadio12004; 14: 1725-1731Lagios et al. The concept and implications of multicentricity in breast carcinoma. Pathol

Annu 1981; 16:83-102

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Definition............................................................................................Synonyms: Cystosarcoma phyllodes (obsolete). periductal stromal tumor. Fibroepi-thelial tumor originating from periductal stroma. Found only in the breast. Rapidgrowth over a few weeks is pathognomonic' Peak age: 50-60 years. Usually benign(40-80%), sometimes borderline (10-40%) or malignant (approximately 20%) • Di-agnosis of malignancy is based on the stromal component. High rate oflocal recur-rence for both benign and malignant lesions (negative surgical margins I).

Imaging Signs

• Ultrasound findingsRound or oval, often lobulated. hypoechoic mass • Well circumscribed • Maydisplay inhomogeneous echogenicity • Characteristic cystic inclusions are com-monly seen. Posterior acoustic characteristics vary (shadowing, indifferent, orenhancement may be seen) • lesion axis may be perpendicular to the skin. Nodisruption of surrounding tissue structures (e.g., ligaments).

• Mammographic findingsRound or oval, often lobulated mass. Hyper- or isodense • Well circumscribed.Microcalcifications rare.

• MRmammographic findingsRound or oval, usually lobulated, hypointense mass in the Tl-weighted precon-trast image. Well-circumscribed borders. Hypointense mass with variable hy-perintense cystic component in T2-weighted images. Pathologic contrast en-hancement in solid tumor component in Tl-weighted postcontrast image.

~/!?I~~~~~~ ,.,.,.." .." ..,', .• Typical presentation

Rapidlygrowing. palpable tumor. Histology: Benign epithelial component with orwithout arypia. leanike proliferation into cystic spaces. fibroblastic spindle cellswithin the stroma. The diagnosis of malignancy is based solely on the stromalcomponent (marked cellularity. atypical nuclei. and increased mitotic activiry).

• TreahnentoptionsComplete surgical excision (wide local excision. mastectomy) • Axillary nodedissection for malignant phyllodes tumor unnecessary. Radiation therapy.No chemotherapy.

• Course and prognosisIfbenign phyllodes tumor is completely excised. local recurrence is uncommon.Higher rate of recurrence for malignant phyllodes tumors without radiationtreatment (approximately 35%).

Differential Diagnosis............................................................................................Necrotic ductal or lobular carcinomas. Fibroadenoma in proximity to a cyst.

Phylfodes Tumor

FIg.6.1o-d Phyllodes tumor.a Ultrasonography. Well-circumscribed. hypoechoic mass.b Mammography (enlarged detail view). Well-circumscribed. isodense mass.c MR mammography (T2-weighted image). Lobulated. partially cystic mass.d MR mammography (subtraction image). Lobulated mass with inhomogeneous

contrast enhancement.

Selected References

Yiimaz E et al. Differentiation of phyllodes tumor vs. fibroadenomas. Acta Radiol 2002:43:34-39

201

202

Definition............................................................................................CUP- "Carcinoma of unknown primary" • Proved metastasis of an unknown pri-marytumor.

Clinicol Aspects............................................................................................• Typical presentation

Enlarged axillary lymph node as a manifestation of lymphatic tumor spread.Hematogenic tumor spread may become apparent by the organ-related clinicalsymptoms it causes.

• Treatment optionsFine-needle or core biopsy may be used in the diagnostic workup of enlarged ax-illary lymph nodes. Organ manifestations require cytologic or histologic clarifi-cation by percutaneous biopsy (e.g., liver, lung, or bone biopsy) • Histologicworkup should provide information on tumor malignancy, cell-type, and recep-tor status. Immunohistochemical studies provide additional information. Ap-propriate therapeutic measures should be initiated when primary tumor is veri-fied • When metastasis is histologically verified and the primary tumor is (still)occult, diagnostic workup including a clinical examination, mammography (bi-lateral in two projections), and breast ultrasound are indicated. If these exami-nations remain inconclusive, MR mammography should be done. If a primarytumor is not found in the breast, histologic evidence, however, strongly suggestsan intramammary origin, then mastectomy and/or treatment according to theguidelines for metastatic breast cancer should be considered.

• Course and prognosisIn spite of the fact that some small and/or inconspicuous breast carcinomas pre-sent with the clinical symptoms of distant metastases, there is a strong inversecorrelation between the initial tumor stage and the time lapse to the appearanceof distant metastases.

Tips ond Pitfalls............................................................................................In the diagnostic workup of a patient with CUP syndrome, there should be a lowthreshold for proceeding to a biopsy, even when there are only slightly suspiciousfindings on mammography, ultrasonography, and/or MRmammography.

a

Axillary lymph nodesInfraclavicular lymph nodes

3 Supraclavicular lymph nodes4 Internal mammary lymph nodes

CUP Syndrome

Flg.6.2o-d CUPsyndrome.a Lymphatic drainage of the breast.b Typical sites of hematogenic metastatic spread.c Mammography. Detection of primary tumor.d MR mammography. Detection of primary tumor.

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204

Definition

~ EpidemiologyMalignant stromal tumor. Very rare breast lesion « 1%).

~ Etiology, pathogenesisUsually an angiosarcoma. Development sometimes related to prior radiationexposure.

Imaging Signs

~ Ultrasound findingsOften lobulated. hypoechoic mass. Margins may be well circumscribed or indis-tinct. Pronounced echogenic rim. Posterior acoustic shadowing.

~ Mammographic findingsUsually lobulated. hyperdense mass. Usually indistinct. sometimes well-de-fined margins.

~ MR mammographic findingsUsually lobulated. hypointense mass in Tl-weighted precontrast image. Usual-ly hypointense mass in T2-weighted images. sometimes associated with in-creased signal intensity of surrounding tissues. Usually indistinct. sometimeswell-defined borders. Inhomogeneous or peripheral (ring) contrast enhance-ment in Tl-weighted postcontrast image with pronounced. pathologic contrastdynamics. Often displays signs of tumor necrosis.

Clinical Aspects

~ Typical presentationOften large. palpable mass. Occasionally associated with livid skin discoloration(angiosarcoma) • Histology: Angiosarcoma. osteogenic sarcoma. rhabdomyosar-coma, malignant fibrous histiocytoma. leiomyosarcoma. fibrosarcoma. heman-giopericytoma. and liposarcoma .

•. Treatment optionsUsually surgery (mastectomy).

~ Course and prognosisPrognosis is relatively poor. Depends on tissue rype and grade.

Differential Diagnosis............................................................................................Necrotic ductal or lobular carcinoma. Phyllodes tumor.

Tips and Pitfalls............................................................................................Malignant breast tumors are not fat-containing. Even liposarcomas rarely have fatinclusions.

Sarcoma

Fig.6.3 a-d Sarcoma of the breast.a Ultrasonography (panoramic view). Indistinct. hypoechoic mass with echogenic rim.b Mammography. right MLOprojection. lobulated. partially indistinct.

hyperdense mass.e MR mammography (MIP). Lobulated mass with inhomogeneous contrast

enhancement.d Macroscopic specimen. Lobulated mass with central necrosis.

205

206

Definition

- Primary breast lymphama is a rare tumor in patients without previous or concur-rent lymphoma at another site. Incidence: <0.5%. Usually presents as a soli-tary mass.

- More commonly, a lymphoma in the breast is an extralymphatic metastasis from ahematopoietic primary tumor (lymphomas or leukemias) • Usually multiple andbilateral. AHodgkin or non-Hodgkin lymphoma with an extralymphatic manifes-tation has a poorer prognosis than those with an intralymphatic manifestation.

- Both primary and secondary lymphomas develop in the periductal lymphatic tis-sue with periductal or perilobular distribution of cancer cells (no intraductal car-cinoma or LCIS!),

Imoging Signs

o Ultrasound findingsRound, well circumscribed mass. Hypoechoic • Slight posterior acoustic shad-owing. May be associated with skin thickening.

o Mammographic findingsRound, well-circumscribed mass. Hyper- or isodense • No microcalcificarions •May be associated with skin thickening.

o MR mammographic findingsHypointense, round, usually well-circumscribed mass(es) in T1-weighted pre-contrast image. May display microlobulated borders. Hypointense mass(es)in T2-weighted images. Homogeneous contrast enhancement in T1-weightedpostcontrast image. Usually display(s) pathologic contrast dynamics.

Clinical Aspects............................................................................................o Typical presentation

- Primary breast lymphoma may not be differentiated from a primary breastcarcinoma clinically or by imaging. Often presents as a palpable mass.

- Secondary breast lymphomas rarely present with multiple palpable findings.Possible skin thickening and edema. Occasionally associated B-symptoms •Histology: Usually uniform, large lymphatic cells.

o TreatrnentoptionsCore biopsy or excisional biopsy is indicated for histologic examination (frozensection often misleading) • Systemic therapies. Primary lymphoma may betreated by mastectomy or breast-conserving therapy and radiation treatment.

o Course and prognosis5-year survival rate: 45-80%.

Differential Diagnosis............................................................................................Carcinomas of other histology. Fibroadenoma. Papilloma.

Lymphoma

Fig.6.40-</ Lymphoma of the breast. a Mammography. right craniocaudalc projec-tion. Inconspicuous. b Mammography, left craniocaudal projection. Medially locatedmass. c MR mammography (Tl-weighted precontrast image). Skin thickening and hy-pointense mass in lateral aspect of left breast. d MR mammography (subtraction im-age). Homogeneous contrast enhancement of lesion and skin.

Selected References

Liberman Let al. Non-Hodgkin lymphoma of the breast: imaging characteristics and COf-

relation with histopathologic findings. Radiology 1994; 192; 157-160Wong WW et al. Primary non-Hodgkin lymphoma of the breast; The Mayo Clinic experi-

ence.j Surg Onco12002; 80; 19-25

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208

Definition

Metastases to the breast from primary malignancies of other organs. Spread maybe Iymphogeneous or hematogeneous • Cross-lymphatic spread from contralateralbreast is most common. Probability of hematogeneous spread increases with in-creasing size and decreasing differentiation of the primary tumor. Metastases tothe breast are very rare. Most common primaries metastasizing to the breast arethe contralateral breast, lymphomas and leukemias, melanoma, lung (oat cell carci-noma), and stomach. Less frequent are ovary, thyroid, kidney, prostate, and carci-noid lesions.

Imaging Signs............................................................................................~ Ultrasound findings

Round or oval, well-circumscribed mass. Usually hypoechoic. Posterior acous-tic shadowing. Echogenic rim. Often multiple. May distort the normal archi-tecture,

~ Mammographic findingsRound, indistinct mass. Hyper- or isodense in comparison with normal paren-chyma • No microcalcilications • Often multiple.

~ MR mammographic findingsHypointense, round, usually well-circumscribed massees) in Tl-weighted pre-contrast image. Hypointense massees) in T2-weighted images. Homogeneouscontrast enhancement in Tl-weighted postcontrast image. Peripheral (ring)enhancement is seen if central necrosis is present. Usually display(s) patholog-ic contrast dynamics.

Clinical Aspects............................................................................................~ Typical presentation

In advanced cases, painless mass(es) may be palpable. Histology: Low differen-tiation of tumor cells with enlarged nuclei and an increased mitotic activity. Peri-ductal and perilobular distribution of malignant cells. Other cell characteristicsdepend on primary tumor and cell differentiation,

•. Treatment optionsUsually palliative. Treatment is directed at the primary tumor. Breast involve-ment from a distant primary neoplasm indicates widespread dissemination,

~ Course and prognosisPrognosis is usually very poor.

Differential Diagnosis............................................................................................

Primary breast carcinoma. Fibroadenoma. Papilloma,

Intra mammary Metastases

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Fig. 6.5 a-d Intra mammary metastases.a Ultrasonography. Melanoma metastasis.b Mammography. Melanoma metastases.c MR mammography (Tl-weighted precontrast image). Plasmocytoma metastases.d MRmammography (Tl-welghted postcontrast image). Plasmocytoma metastases.

209

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Definition

Serous fluid collection in a postoperative cavity. Caused by postoperative accumu-lation of fluid in the dead space.

Imaging Signs

• Ultrasound findingsWell-circumscribed, fluid-filled cavity. Usually extensive. Anechoic. Maydisplay internal or peripheral echoes. Posterior acoustic enhancement.

• Mammographic findingsNot usually done post operatively. Well-circumscribed or indistinct mass. Iso-or hyperdense.

• MR mammographic findingsNot usually done post operatively • Round, well-circumscribed, hypointensemass in Tl-weighted precontrast image. Round, well-circumscribed, hypoin-tense mass in T2-weighted images. No contrast enhancement in Tl-weightedpostcontrast image. Initial strong postoperative enhancement of surroundingtissues (wound healing).

Clinical Aspects

• Typical presentationRound palpable mass. Sometimes quite large. Occasionally painful. Histolo-gy: Fluid collection without typical wall structure.

• Treatment optionsFrequent aspiration of the wound is required for extensive seroma formation(twice weekly).

• Course and prognosisBenign complication of surgery.

Differential Diagnosis

Lymphocele • Cyst.

Tips and Pitfalls

Seroma is a common postoperative complication that often heals spontaneously.

Seroma

Fig.7.1o-d Seroma.a Ultrasonography. Well·circumscribed. hypoechoic mass.b Mammography.leftcraniocaudal projection. Lateral. well-circumscribed. hypodense mass.c MR mammography (T2-weighted image). Well-circumscribed seroma with high

signal intensity.d MR mammography (subtraction image). Well-circumscribed seroma with low signal

intensity. no contrast enhancement.

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212

Definition............................................................................................Circumscribed area of necrotic fat tissue. In the early stage (up to 6 months aftertrauma. e.g.. surgery) there is infiltration by leukocytes and foamy histiocytes •With time there is an increasing development of well-perfused granulation tissue.Nearly always present post operatively.

Imaging Signs............................................................................................~ Ultrasound findings

Irregular. hypoechoic mass. Indistinct margins' Posterior acoustic shadowing• Disruption of surrounding normal structures.

~ Mammographic findingsIrregular. hyper- or isodense mass. Indistinct margins' Occasionally displaysspicules. No calcifications.

~ MR mammographic findingsIrregular. hypointense mass in Tl-weighted precontrast image. Indistinct mar-gins' Postoperatively often associated with susceptibility artifacts from electro-cauterization • Homogeneous or ring contrast enhancement in Tl-weightedpostcontrast image • Unspecific contrast dynamics • Irregular mass in T2-weighted images with variable signal intensity depending on age (hypo-. iso-.or hyperintense).

Clinical Aspects............................................................................................~ Typical presentation

Usually inconspicuous' Rarely presents as palpable mass or skin thickening.~ Course and prognosis

Benign finding' No treatment necessary.

Differential Diagnosis............................................................................................Breast carcinoma.

Tips and Pitfalls............................................................................................Fresh fat necrosis may display typically malignant characteristics. especially on MRmammography' After 3-6 months hyperemia regresses and findings normalize.

Early Fat Necrosis

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214

Definition

Circumscribed area with residual necrotic fat tissue. After wound healing is com-pleted, histological examination shows scar tissue with signs of liquefied fat. Oilcysts develop frequently' Tend to calcify (coarse, pleomorphic. dystrophic calcifi-cations) • Often seen post operatively.

Imaging Signs............................................................................................

• Ultrasound findingsIrregular or round (oil cyst), hypoechoic mass. Well-defined or indistinct mar-gins' Posterior acoustic shadowing' Disruption of surrounding normal struc-tures.

• Mammographic findingsIrregular, hyper- or isodense mass. Indistinct margins' Occasionally has spi-cules • Oil cysts are round masses with fat equivalent density. Often developbizarre. dystrophic calcifications (early manifestation as pleomorphic calcifica-tions, DD: DClS),

• MRmammographic findingsIrregular. hypointense mass in Tl-weighted precontrast image. Indistinct mar-gins' Oilcysts have fat equivalent signal. Postoperatively often associated withsusceptibility artifacts from electrocauterization' Signal loss from macrocalcifi-cations. Normally no contrast enhancement in Tl-weighted postcontrast im-age. Exception: Associated reactive inflammatory enhancement (may presentas ring enhancement) • Fat equivalent mass in T2-weighted image,

Clinical Aspects............................................................................................

• Typical presentationUsually inconspicuous' Rarely presents as palpable mass or skin thickening.

• Course and prognosisBenign finding' No treatment necessary.

Differential Diagnosis............................................................................................Oil cysts and/or macrocalcifications are clear findings without differential diagno-sis. In the early development of calcifications. pleomorphic microcalcificationsmay be confused with DCIS• When associated with inflammation (focal mastitis),findings on MRmammography may be difficult to distinguish from carcinoma.

Tips and Pitfalls............................................................................................During the transition from the early to late phase of fat necrosis development, theslow evolution of pleomorphic (micro)calcifications may make DDdifficult. This isespecially true for patients who have undergone breast-conserving therapy,

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and oil cyst.

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216

Definition

Fat necrosis with development of oil-filled cavity. Usually post-traumatic (e.g..surgery). sometimes without history of prior trauma (e.g.. diabetes. collagen vascu-lar disease. radiation therapy) • Most commonly develops 1-2 years after trauma.sometimes as early as 6 months after trauma.

Imaging Signs............................................................................................• Ultrasound findings

Round. well-circumscribed mass. Hypoechoic • May display inhomogeneousinternal echoes. Posterior acoustic shadowing.

• Mammographic findingsRound or oval. well-circumscribed mass • Approximately 1 em diameter. Hy-podense • Displays subtle wall structure. In advanced stages usually displaycharacteristic eggshell calcifications.

• MR mammographic findingsHyperintense. round. usually well-circumscribed mass(es) in Tl-weighted pre-contrast and T2-weighted images • Hypointense in fat-suppressed IR se-quence • Occasional peripheral contrast enhancement due to innammation inTl-weighted postcontrast image. Older oil cysts do not show contrast enhance-ment.

Clinical Aspects............................................................................................• Typical presentation

Usually inconspicuous' Rarely presents as palpable mass. Location in scar tis-sue after surgery makes palpation difficult to interpret.

• Treatment optionsNo treatment is necessary when appearance is characteristic. If microcalcifica-tions are seen on mammography. and MR mammography shows a correlatingarea of contrast enhancement at the surgical site. then stereotactic or MR-guidedvacuum core biopsy is indicated for histological examination. Differentiationfrom recurrent breast cancer is difficult. especially 1-2 years after breast-con-serving therapy' Histology: Confluent fat with connective tissue pseudocapsule(may calcify).

• Course and prognosisBenign finding. No malignant potential.

Differential Diagnosis............................................................................................The classic appearance of an oil cyst with eggshell calcifications is unambiguousand without a DD • In the early development of calcifications. pleomorphic micro-calcifications may be confused with DClSor recurrent breast carcinoma. especiallyafter breast-conserving therapy for intraductal carcinoma.

Flg.7.4a-dOileyst.a Mammography(enlarged detailview). Oil cyst witheggshell calcifica·tions.

b Ultrasonography. Oil cyst.

217

Oil Cyst

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Oil Cyst

Tips and Pitfalls............................................................................................In the early phase of oil cyst development. findings on mammography and MRmammography may be ambiguous and difficult to differentiate from local breastcancer recurrence. Core biopsy may be indicated for histological examination.

Selected References

Bilgen IG et al. Fat necrosis of the breast: clinical. mammographic and sonographic fea-tures. Eur J Radiol 2001: 39: 92-99

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220

Definition............................................................................................Dense fibrous connective tissue developing after trauma (usually surgical). Imagefindings are changed. Scar tissue rarely develops after core- or vacuum biopsy.

Imoging Signs............................................................................................• Ultrasound findings

Hypoechoic. irregular lesion that often extends to the skin. Posterior acousticshadowing. Lackof elasticity on compression. May distort the normal archi-tecture.

• Mammographic findingsPostoperative architectural distortion. May appear as a spiculated mass.

• MR mammographic findingsHypointense architectural distortion in Tl-weighted precontrast image. Mayappear as spiculated mass. Often susceptibility artifacts. Hypointense archi-tectural distortion in T2-weighted images. Displays a high signal intensity inthe first 6 months after surgery due to edema. Edema may be seen up to 3 yearsafter radiation treatment. Contrast enhancement is seen in the early postoper-ative phase due to reactive hyperemia. Older scar tissue displays no contrastenhancement.

Clinical Aspects

• Typical presentationVariable. palpable scar tissue formation along surgical incision. Correlates withextent of surgical procedure. Histology: Collagen-rich connective tissue withfew fibroblasts.

to- Treatment optionsShort-term image follow-up increases diagnostic confidence. In ambiguouscases, contrast-assisted MR mammography allows a reliable clarification (DO:carcinoma).

• Course and prognosisSize and density of postoperative architectural distortions may decrease, butthey never increase, over time.

Differential Diognosis............................................................................................

Primary breast carcinoma.

Tips and Pitfalls............................................................................................Scars which appear suspicious on mammography and ultrasonography can be reli-ably clarified by MRmammography. Contrast enhancement within a scar is highlysuspicious of malignancy. Le., local carcinoma recurrence.

Postoperative Changes

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intensity.d MR mammography (subtraction image). No contrast enhancement.

221

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Definition............................................................................................Changes seen on breast imaging after radiation treatment. Due to interstitial ede-ma. Innammation of the entire breast.

Imoging Signs............................................................................................• Ultrasound findings

Skin thickening. Diffuse, edematous increase in echogenicity (up to 3 years af-ter radiation therapy).

• Mammographic findingsDiffuse, edematous increase in density of the affected breast (up to 3 years afterradiation therapy) • Skin thickening (may be irreversible, decreases partiallyovertime).

• MR mammographic findingsSkin thickening in Tl-weighted precontrast image. Hyperintense edema of theskin and parenchyma up to 3 years after radiation treatment in T2-weighted im-ages. Contrast enhancement is seen due to reactive hyperemia (usually for 1year after radiation treatment, rarely up to 18 months).

Clinicol Aspects............................................................................................• Typical presentation

Persisting skin reddening and edema of the skin and parenchyma (up to 3 yearsafter radiotherapy) • As a consequence, increase in breast consistency.

• Course and prognosisRadiotherapy-induced contrast enhancement on MR mammography usuallysubsides within 1 year. Radiotherapy-induced edema may last up to 3 yearsafter radiotherapy has been completed.

Differentiol Diognosis............................................................................................Inflammatory breast carcinoma. Mastitis.

Tips and Pitfalls............................................................................................Changes of the breast after radiotherapy correspond to an innammatory irritationthat subsides over time. MRmammographic examinations should not usually bedone before 1 year after radiotherapy is completed,

Post-Radiation Changes

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edema.c MR mammography (T2-weighted image), Linear, spotty increase of signal intensity

due to edema.d MR mammography (subtraction image). No contrast enhancement.

223

~ Ultrasound findingsNo characteristic findings.

~ Mammographic findingsRedistribution of parenchyma from upper to lower quadrants. Possible archi-tectural distortion, fat necrosis, and/or calcifications associated with the surgicalscars.

~ MRmammographic findingsOccasionally postoperative architectural distortion and susceptibility artifacts inTl-weighted precontrast image. T2-weighted images usually inconspicuous.No contrast enhancement.

............................................................................................Imaging Signs

Surgical removal of breast tissue to reduce the breast size. Indications: Medical(macromastia with back pain. to match contralateral breast after breast carcinomasurgery, anisomastia), psychosocial. or cosmetic.

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Clinical Aspects............................................................................................

~ Typical presentationTypical surgical scars around the areola, in the midline between the lower breastquadrants (nipple repositioned cranially), and along the inframammary fold.

Tips and Pitfalls............................................................................................A thorough breast examination. including imaging, should be carried out prior tosurgery to rule out breast cancer. Ambiguous findings may be excised as part ofthe breast-reduction surgery.

224

Reduction Mammaplasty

Flg.7.7a-d Reduction mammaplasty.a Mammography, right MLO projection.Scar calcifications after reduction mam-maplasty.

b Mammography, enlarged detail view of a.

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226

c MR mammography(Tl-weighted precon-trast image). Redistrib-uted parenchymatoward thoracic wall.

d MR mammography(MIP). No contrastenhancement.

Definition............................................................................................Surgically placed implanr for breasr reconstruction or augmentation.Design:- Silicone gel lies within a silicone shell (envelope) in the center.- In modern implants the silicone sac lies within an outer shell filled with saline

solution (double lumen prostheses).Implantation:- In general, prostheses are implanted in a subpectoral position.- The cranial two-thirds of the prosthesis lies between the thorax and the pectoral

muscles.- The caudal one-third of the prosthesis lies in contact with the breast parenchy-

ma.- The body forms a reactive fibrous capsule around the entire prosthesis.

Imoging Signs............................................................................................• Ultrasound findings

Prosthesis is well circumscribed and anechoic. Reverberation echo along ante-rior margin is commonly seen.

• Mammographic findingsProsthesis is hyperdense and limits sensitivity of mammography. Implant-dis-placed views for better visualization of breast tissue. Better visualization possi-ble in digital mammography (post processing).

• MR mammographic findingsProsthesis protocol includes the following sequences:- Silicone-sensitive sequence (2 mm slice thickness)-sagittal and axial orienta-

tion.- T2-weighted, water-sensitive sequence (silicone-suppressed)-axial orienta-

tion • Radial folds of prosthesis shell are commonly seen (normal finding).- T1-weighted, without contrast material-axial orientation. Usually no visu-

alization of fibrous capsule.

Cllnlcol Aspects

• Course and prognosisCurrent durability approximately 20 years. Potential for complications increas-es with time (gel bleeding, capsular contracture. intra- and extracapsular rup-ture).

Selected ReferencesFischerU.PracticalMRmammography. Stuttgart: Thieme: 2004.

227

228

Breast Prosthesis

FIg.8.1a-d Breastprostheses.a MR mammography(silicone-sensitive. axialsequence). Prosthesisexamination.

b MR mammography(water-sensitive. axialsequence). Prosthesisexamination.

Breast Prosthesis

c MR mammography (silicone-sensitive.sagittal sequence. left breast). Prosthesisexamination.

d MR mammography (silicone-sensitive.sagittal sequence. right breast). Prosthe-sisexamination.

229

230

Definition............................................................................................Leakage of silicone through the prosthesis shell due to changes in the shell perme-ability. Shell does not collapse. Is an indication of increasing material fatigue 1S-20 years after implantation. Considered a precursor to an intracapsular rupture(shell is torn and separated from fibrous capsule. Iinguine sign on MRmammogra-phy).

Imaging Signs............................................................................................• Ultrasound findings

Unremarkable.• Mammographic findings

Inconspicuous.• MR mammographic findings

No characteristic findings in Tl-weighted precontrast image. Tl-weightedpostcontrast images are not required in the diagnostic workup for complicationsrelating to prostheses. T2-weighted images are usually not helpful becausethey cannot differentiate reliably between silicone and water in the radial foldsof the prosthesis. Silicone-sensitive sequence: Detection of silicone in the radialfolds and/or between the shell of the prosthesis and the fibrous capsule. Sili-cone-suppressed sequence (12-weighted): No nuids (water. serous nuids) in theradial folds and/or between the shell of the prosthesis and the fibrous capsule.

Clinical Aspects............................................................................................... Typical presentation

Inspection and palpation unremarkable.

Differential Diagnosis............................................................................................"Chemical shift" artifacts on MRmammography.

Tips and Pitfalls............................................................................................MR mammography is the only examination technique that can reliably detect gelbleeding. Evidence of gel bleeding alone. however. is not a mandatory indicationfor prosthesis explantation.

Gel Bleeding

Fig.8.20-<1 Gel bleeding.a MR mammography (Tl·weighted image without contrast). Prosthesis examination.b MR mammography (T2-weighted image).c MR mammography (silicone-sensitive. axial sequence). Silicone signal is seen in

the radial folds.d MR mammography (silicone-suppressed. axial sequence). No water signal in the

radial folds.

231

232

Definition............................................................................................Tough fibrous capsule develops around the breast prosthesis as a reactive inflam-matory process • Encapsulation increases pressure on prosthesis and decreaseselasticity. Consequently. increasing firmness and deformation may be seen.

Imoging Signs............................................................................................

• Ultrasound findingsFibrous capsule is difficult to distinguish from prosthesis. Echogenic bands maybe seen if capsule shows extensive calcifications.

• Mammographic findingsRounded prosthesis shape due to encapsulation with increased pressure. Opti-mal windowing in digital mammography allows the depiction of capsule calcifi-cations in spite of the hyperdense silicone prosthesis.

• MR mammographic findingsImaging technique: Axial Tl-weighted. without contrast medium. Silicone-sen-sitive/water-suppressed sequence (thin slice thickness): Sagittal (two slicepacks) and axial orientation. Water sensitive/suppressed silicone sequence:Axial orientation.findings: Rare capsule thickening. Fibrous capsule is often not distinguishablefrom prosthesis shell. Spherical deformation of prosthesis.

Clinical Aspects............................................................................................• Typical presentation

Firm. immobile prosthesis with reduced elasticity. Elevation of the arm oftenresults in considerable deformation of the breast. Histology: Collagen-rich cap-sule due to granulomatous foreign body reaction to the prosthesis.

• TreatmentoptionsExplantation of prosthesis with or without replacement.

Differentiol Diognosls............................................................................................

None.

Tips ond Pitfalls............................................................................................Capsular contracture is primarily a cosmetic complication.

Selected ReferencesBaldt M et al. The long-term changes after the implantation of silicone breast prostheses.

Raro 1994; 160: 441-447Fischer U. Practical MR mammography. Stuttgan: Thieme; 2000

Capsular Contracture

Fig. 8.3 a. b Capsular contracture.a Mammography. left MLO projection.Prosthesis with spherical shape andcapsule calcifications.

b MR mammography (Tl-weightedimage). Medial and posterior thickeningof prosthesis capsule.

233

234

Definition

Rupture of the prosthesis silicone shell. Outer fibrous capsule remains intact.

Imaging Signs

• Ultrasound findingsUsually unremarkable. Rare visualization of linguine sign.

• Mammographic findingsUsually inconspicuous. Saline component is not distinguishable.

• MR mammographic findingsGel bleeding: Silicone drops seen in saline compartment (shell intact).Salad oil sign: Saline drops seen in silicone compartment (shell intact).Linguine sign: Ruptured, collapsed inner and/or outer prosthesis shell(s} withinthe silicone-filled fibrous capsule boundaries.

Clinical Aspects............................................................................................• Typical presentation

Ilsa/ine shell is ruptured: Decrease in volume. Histology: Normal prosthesis cap-sule and surrounding parenchyma.

• Treatment optionsAn intracapsular rupture is not a mandatory indication for prosthesis explanta-tion.

• Course and prognosisCapsular ruptures are due to material fatigue and usually occur approximately20 years after implantation.

Tips and Pitfalls

An intracapsular rupture is not a mandatory indication for prosthesis explantation.

Intracapsular Rupture

Flg.8.4a-e Intracapsular prosthesis rupture.a, b Mammography. bilateral MlO projection. Intracapsular rupture of left outer saline

compartment.c MR mammography (silicone sensitive). Salad oil sign; water drop with low signal

intensity in silicone with high signal intensity.d MR mammography (water sensitive). Salad oil sign; water drop with high signal

intensity in silicone with low signal intensity.

235

236

Intracapsular Rupture

e MR mammography (silicone-sensitive). Unguine sign; curvilineardepiction of the ruptured envelope insidethe silicone-filled fibrous cavity.

•

Definition............................................................................................Rupture of the prosthesis silicone shell and outer fibrous capsule. Possible devel-opment of siliconoma • Modern implants are double-lumen prostheses: The sili-cone gel lies inside a central silicone shell surrounded by an outer shell filled withsaline solution. The body builds a tough fibrous capsule around the breast pros-thesis. Prostheses are usually implanted in a subpectoral position.

Imaging Signs

• Ultrasound findingsRare linguine sign. Round. hypoechoic lesion extending from and usually lyingabove the prothesis. Often echogenic rim.

• Mammographic findingsHyperdense. satellite-like mass.

• MR mammographic findingsRare Iinguine sign: Ruptured. collapsed. inner and/or outer prosthesis shell(s)within the silicone filled fibrous capsule boundaries • Satellite-like. usuallywell-circumscribed extension of prosthesis material into parenchyma (usuallyat upper. outer aspect) • Here peripheral contrast enhancement may be seen.

Clinical Aspects............................................................................................• Typical presentation

Reduced volume. especially for prostheses with a large saline compartment.Often inflammatory reaction with increased firmness. Macroscopic impression:Hyperemia in the periphery. around central silicone deposits. Histology: Gran-ulomatous reaction in areas in contact with the silicone.

• Treatment optionsAn extracapsular rupture is an indication for prosthesis explantation because ofthe likelihood of siliconoma formation .

... Course and prognosisCapsular ruptures usually occur approximately 20 years after implantation.

Tips and Pitfalls

An extracapsular rupture is an indication for prosthesis explantation.

237

238

Extracapsular Rupture

Fig.8.50-d Extracapsular prosthesisrupture.a Mammography. Depiction of siliconeoutside prosthesis. at cranial and ventralaspect. In addition: Capsule calcifications.

b MR mammog-raphy (Tl-weightedimage). Prosthesisand extracapsularsilicone mediallyand laterally.

c MRmammog-raphy (silicone-sen-sitive). Prosthesisand extracapsularsilicone mediallyand laterally.

239

240

d MR mammography (Tl-weightedimage): Silicone satellite with high signalintensity at cranial aspect. Note increasedthickness of fibrous capsule.

A

abscess 94.95accessory nipple 62adenoma 72. 96. 97

apocrine 96ductal 96lactating 97.142tubular 97.129.130-/31seealso fibroadenoma

adenosis 77,83. 98. 99'blunt-duct' 98.99microcystic 98. 99microglandular 98.99sclerosing 16.78.98.99

angiokeratoma 89angiomatous processes 89angiosarcoma 204apocrine adenoma 96architectural distortion 39.40.58.59

postoperative 220arteriovenous malformations 89asymmetry 56.57

focal 56.57global 56. 57

atheroma 89atypical ductal hyperplasia

(ADH) 145.146-/47atypical lobular hyperplasia

(ALH) 100.10/axillary lymph nodes 35.36.87.88

enlarged 202

B

81-RADS(Breast Imaging ReportingAnd Data System) 52-53

biopsycore 26.27fine needle aspiration (FNAB) 24.25MR mammography-guided

26.28.29stereotactic 26. 27. 28.29ultrasound-guided 26.27.28vacuum 28-30

'black star' 127bloody nipple discharge

62.63.66.67.119.122

'blunt-duct' adenosis 98.99breast cancer 70.72

early detection 154.155inflammatory 182-184local recurrence 191-193male 185. 186risk factors 150-151surrogate factors for screening

152.153see also specific forms of cancer

breast cancer genes (BRCA)150.156-157consequences of positive test

results 157indications for genetic testing 156

breast composition 48-51breast prosthesis see prosthesisburn scar 84.85

ccalcifications 39.40

benign 84-86capsular 232.233.238dermal 84'eggshell' 84.86.2/7fat necrosis 214.2/5fibroadenoma 84.85.102. 103focal fibrosis 109hemangioma 113plasma cell mastitis 125'popcorn' 84.85. 102. 103scar 127skin 60.6/vascular 86see also microcalcifications

capsular contracture 232.233carcinoma 3. 18.62.68.72

CUP(carcinoma of unknown pri-mary) syndrome 202.203

ductal 80.8/in situ (DCIS) 80.81.158-163. /88invasive (IDC) 164.165

Pagenumbers in italics refer toillustrations.

241

Index

carcinoma. extensive intraductalcomponent(EIC) 194,195invasive papillary 170,171-172lobular

in situ (LCIS) 148,149invasive 166,167,168,169

local recurrence 191-193medullary 173-17Smucinous 176-178multicentricity 198, 199multifocality 196, 197nipple inversion 63predominantly intraductal

component (PIC) 194pregnancy and 142screening 152,153slight intraductal component

(SIC) 194tubular 179-181see also breast cancer

complex cyst 2, 134, 135composition of breast 48-51core biopsy 26,27craniocaudal projection 6, 7-8,46

PGMI criteria 44,45CUP (carcinoma of unknown primary)

syndrome 202,203cyst 84

calcified 80complex 2, 134, 135epidermal inclusion 89,91fine needle aspiration biopsy

(FNAB) 24in hamartoma 111oil 72,86,214,216-219sebaceous 89,90simple 132, 133

cystosarcoma phyllodes 200cytology 24

PGMI (perfect, good, moderate,inadequate) criteria 44-47

ultrasonography 37,38digital mammography 19,20DIN (ductal intraepithelial

neoplasia) 145discharge see nipple dischargeduct ectasia 65,84

multiple peripheral papillomas123,124

ductal adenoma 96ductal carcinoma 80,81

invasive (IDC) 164, 165ductal carcinoma in situ (DClS)

80,81,188high grade 162,163intermediate grade 160,161low grade 158,159see also Paget disease of the nipple

E

eczema 62, 63Paget disease of the nipple 187, 188

edemaduring pregnancy 143, 143, 144inflammatory breast cancer 182mastitis 116, 117postoperative 220postradiation 222,223

'eggshell' calcifications 84,86,217epidermal inclusion cyst 89,91erythema

inflammatory breast cancer 182mastitis 116,117

estrogens 150extensive intraductal component

(EIC) 194, 195

F

242

D

density 39,40, 63, 72patterns 48

deodorants 60diagnostic criteria

mammography 39,40MR mammography 41-43

fat necrosiscalcified 215early 212,213late 214,215oil cyst 216

fibroadenolipoma 110,111fibroadenoma 2,68,70,72. 84

calcifying 84.85giant 106. 107hyalinizing 102. 103myxoid 104. 105pregnancy 142

fibrosarcoma 204fibrosis 109

focal 83. 108. 109fibrosis mammae 77fine needle aspiration biopsy

(FNAB) 24.25focal asymmetry 56. 57furuncle 89.91

G

galactocele 142galactography 17.18giant fibroadenoma 106. 107giant lipoma 116global asymmetry 56. 57gynecomastia 136. 137-138

bilateral 138pseudogynecomastia 139.140-141unilateral 137

H

halo sign 70.130.131.133hamartoma 68. 70. 72. 110.110hemangioma 89.112.113hemangiopericytoma 204hemangiosarcoma 89histiocytoma. malignant fibrous 204Hodgkin lymphoma 206hyalinizing fibroadenoma 102. 103hyperemia

postoperative 220postradiation 222

hyperplasiaatypical lobular (ALH) 100. 101ductal 83

atypical (ADH) 145. 146-147

index tumor 194. 195Indian file pattern 166.168

Index

inflammation 182postradiation 222prosthesis encapsulation 232

inflammatory breast cancer 182-184intramammary lymph nodes 87.88intramammary metastases 208.209invasive ductal carcinoma (IDC)

164.165invasive lobular carcinoma

diffuse form 168. 169nodular form 166.167

invasive papillary carcinoma170.171-172

K

keratosis. seborrheic 89.90

L

lactating adenoma 97.142lactational mastitis 116leiomyosarcoma 204linguine sign 234.236.237lipoma 72.114. 115

giant 115liposarcoma 204lobular carcinoma

in situ (LCI5) 148.149invasive 166-169

diffuse form 168. 169nodular form 166. 167

local recurrence. carcinoma 191-193lumpectomy site. cancer recurrence

191.192lymph nodes 88

axillary 35.36.87.88enlarged 202

fine needle aspiration biopsy(FNAB) 24

intramammary 87.88sentinel (SLN) 35.36

lymphatic drainage 35.36.203lymphoma 206.207

Hodgkin 206metastatic 206non-Hodgkin 206primary 206

243

244

M

magnetic resonance imaging(MRI) 21-23diagnostic criteria 41-43MRmammography-guided biopsy

26,28,29normal findings 54preoperative localization

31-32,34magnification mammography

14,15-/6male breast cancer 185,/86male breast enlargement

see gynecomastiamalignant fibrous histiocytoma 204malignant melanoma 89mammography

breast composition patterns 48-51craniocaudal projection

6, 7-8,44,45,46diagnostic criteria 39,40digital mammography 19,20galacrography 17, 18magnification mammography

14,/5-/6mediolateral oblique projection

(MLO) 9-11,44,45,46MRmammography see magnetic

resonance imaging (MRI)normal findings 54,55preoperative localization

31-32,33,34spot compression 12, /3

mass 39,40, 41, 68density 72,73margins 70,71shape 68,69see also specific masses

mastitis 116,117-118granulomatous 78non-puerperal 116plasma cell 84,125, /26puerperal (lactational) 116

mediolateral oblique (MLO)projection9-11,46PGMIcriteria 44,45

medullary carcinoma 173-175

melanoma 62malignant 89metastasis 209

metastasis 203intramammary 208,209lymphoma 206melanoma 209plasmocytoma 209

microcalcifications /5-/6,29,39adenosis and 98, 99amorphous 82, 83atypical ductal hyperplasia

(ADH) /46, /47benign 84-86distribution of 74, 75ductal carcinoma in situ 158, /59,

160,/6/, 162,163,187,/89early breast cancer detection

152,/55focal fibrosis 109index tumor 194, /95lobular carcinoma in situ (LeiS) /49monomorphic 76,77-78pleomorphic 79-81,99,187,/89, /99

multifocal /97see also calcifications

microcystic adenosis 98,99microglandular adenosis 98,99milk-of-calcium 82,84,98Mondor disease 60, 92, 93monomorphic microcalcifications

76,77-78mucinous carcinoma 176-178multicentricity 198,199multifocality 196, 197multiple peripheral papillomas

122-123,124myxoid fibroadenoma 104,105

N

neoplasiaductal intraepithelial (DIN) 145lobular 148

nipple changes 62,63eczema 62, 63inversion 62,63mastitis 118

Pagetdisease 60,62,63, 187-190retraction 60,61,62

nipple dischargebloody 62,63,66,67,119,122non-sanguineous 64,65

non-Hodgkin lymphoma 206non-mass lesions 41-43non-puerperal mastitis 116normal findings 54,55

ooil cyst 72,86,216-219

fat necrosis and 214

p

Pagetdisease of the nipple 60,62,63,187-190

papilloma 3,119-121multiple peripheral 122-123,124nipple discharge 66,67pregnancy and 142

periductal stromal tumor 200PGMI (perfect, good, moderate,

inadequate) criteria 44-47phyllodes tumor 200,201plasma cell mastitis 84,125,126plasmocytoma metastases 209pleomorphic microcalcifications

79-81adenosis 99multicentric 199multifocal 197Pagetdisease of the nipple 187,189

polythelia 62'popcorn' calcifications

84,85,102, 103posterior nipple line (PNL) 44,45postoperative changes 220,221postradiation changes 222,223pregnancy 142,143-144

radiation risks 142preoperative localization techniques

31-34prosthesis 227,228-229

capsular contracture 232,233extracapsular rupture 237,238-240

gel bleeding 230,231,234intracapsular rupture 234,235-236

pseudogynecomastia 139, 140-141puerperal mastitis 116

Q

quality standards 44-47

R

radial scar 58, 127,128radiation exposure 4,5

breast cancerrisk 150craniocaudal projection 6guidelines 4mediolateral oblique projection 11postradiation changes 222,223risks during pregnancy 142

reduction mammoplasty224,225-226

reporting system 52-53'reptile skin' 89rhabdomyosarcoma 204risk factors 150-151

ssalad oil sign 234sarcoma 62,204,205

osteogenic 204scar 58,68,70,84,220,221

burn 84,85radial 58,127,128

sclerosing adenosis 16,78,98,99screening 152,153sebaceouscyst 89, 90sebaceousgland calcifications 60seborrheic keratosis 89,90sentinel lymph node (5LN) 35,36seroma 210,211'shrinking'sign 168silicone implants 227

examination 227,228-229extracapsular rupture 237,238-240gel bleeding 230,231,234intracapsular rupture 234,235-236

size asymmetry 56

245

246

Index

skin changes 60,61lesions 89, 90-91mastitis 116,117-118retraction 60,61thickening 60,61,117-118,182,187

postradiation 222,223space-occupying lesions 41spot compression 12, 13standards 44-47stereotactic techniques

biopsy 26,27, 28, 29preoperative localization 31

susceptibility artifact 218,220

T

'targetoid' growth pattern 166,168'teacups' 84,98,99thrombophlebitis 92,93tubular adenoma 97,129, 130-131tubular carcinoma 179-181

uultrasonography 1-2,3

breast composition patterns 51diagnostic criteria 37,38normal findings 54preoperative localization 31,32ultrasound-guided biopsy 26,27,28

vvacuum biopsy 28-30verruca senilis 89

Breast Imaging

HIGHLIGHTS

• Presentation of a systematic method for evaluatingmammograms, based on anatomic architecture. sub·structures, and patterns

• Photomicrographs of large. thin-section pathologyslides and subgross 3D pathology section which arecorrelated with mammographic images to explain whymammograms appear as they do

Breast CancerThe Art and Science of EarlyDetection with MammographyPerception. Interpretation.HistopathologyLaszlo Tabar, MO. Tibor Tot, MD, and Peter B. Dean. MO

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Sectional Anatomy

Torsten Bert Moeller, MO. and Emil Reif, MD

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