Breast Imaging: A Core Review (29 page)

Reference: Sickles EA. Practical solutions to common mammographic problems: Tailoring the examination.
AJR Am J Roentgenol
;151:31–39.

19
 
Answer C.
 Mondor’s disease is a rare benign disorder characterized by thrombophlebitis of the subcutaneous veins of the anterolateral chest wall. A tender palpable cord in the breast corresponding to a superficial tubular density on mammography and a subcutaneous vessel on ultrasound, with or without absent Doppler vascular flow, confirms the diagnosis of Mondor’s disease of the breast. Awareness of clinical presentation, pathophysiology, and radiological findings of Mondor’s disease enables accurate diagnosis and avoids the potential pitfall of mistaking this finding for a dilated duct or inflammatory breast carcinoma.

References: Ikeda DM.
Breast Imaging: The Requisites
. St. Louis, MO: Elsevier Mosby; 2004:305–306.
Shetty MK, Watson AB. Mondor’s disease of the breast: Sonographic and mammographic findings.
AJR Am J Roentgenol
2001;177:893–896.
Soler-Gonzalez J, Ruiz MC. Mondor’s disease.
N Engl J Med
2005;352:1024.
Stavros AT.
Breast Ultrasound
. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:429–435.

20
 
Answer E.
 The sternalis muscle is best seen only on the CC view as a well-defined mass in the posterior medial breast measuring typically 3 to 15 mm with smooth, round, or bulging contours. Depending on the amount of traction placed on the medial breast, it may or may not be seen on prior or subsequent exams. Since the medial breast tissue is a potential blind spot on MLO projection, the sternalis muscle is not identified on the MLO view. It is a thin accessory muscle in the chest that runs in a craniocaudal direction, parallel and adjacent to the sternum. The reported prevalence of the sternalis muscle ranges from 1% to 11% and varies by population. It can be seen bilaterally but more commonly presents unilaterally. The sternalis muscle is a normal variant that can mimic breast pathology and create a diagnostic dilemma. Confirmatory imaging with CT or MRI may corroborate the presence of this muscle.

References: Bradley FM, Hoover HC Jr, Hulka CA, et al. The sternalis muscle: An unusual normal finding seen on mammography.
AJR Am J Roentgenol
1996;166:33–36.
Demirpolat G, Oktay A, Bilgen I, et al. Mammographic features of the sternalis muscle.
Diagn Interv Radiol
2010;16:276–278.

21
 
Answer C.
 There is an area of architectural distortion in the upper outer quadrant of the right breast at middle to posterior depth that requires further evaluation. Spot compression magnification views and targeted ultrasound can further define this finding.

Reference: Cardeñosa G.
Breast Imaging Companion
. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:112–145.

22
 
Answer D.
 The mammogram images show an irregular mass at approximately 3 o’clock middle depth of the left breast corresponding to the area of palpable abnormality, idicated by a triangular skin marker. The most common presentation of breast cancer in men is a painless or tender palpable breast mass, classically eccentric to the nipple. The subareolar region is the most common site of involvement. Invasive ductal carcinoma is the most common type of cancer in men, accounting for 99% of cases. Imaging findings and staging are the same as in women. Breast cancer in males is rare and accounts for ~1% of all breast cancers.

References: Cardeñosa G.
Clinical Breast Imaging: A Patient Focused Teaching File
. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:308–309.
Weiss JR, et al. Epidemiology of male breast cancer.
Cancer Epidemiol Biomarkers Prev
2005;14:20–26.

23
 
Answer A.
 Diabetic fibrous mastopathy is a benign breast disorder found most commonly in patients with type I diabetes mellitus. It can mimic malignancy both clinically and radiographically and typically requires a biopsy. While thought of as being a rare disorder, some studies have shown prevalence as high as 13% in long-standing type I diabetic patients.

References: Feder JM, et al. Unusual breast lesions: Radiology–pathology correlation.
Radiographics
1999;19:S11–S26.
Shaffrey JK, et al. Diabetic fibrous mastopathy: Case reports and radiologic–pathologic correlation.
Breast
J 2000;6:414–417.

24
 
Answer C.
 Melanoma is the most common malignancy to produce metastasis to the breast. Primary breast malignancy is much more common.

Reference: Arora R, Robinson W. Breast metastases from malignant melanoma.
J Surg Oncol
1992;50:27–29.

25
 
Answer D.
 Direct paraffin or silicone injections can result in multiple eggshell-type calcifications that obscure underlying breast tissue. This classic appearance is diagnostic on mammogram for silicone injection granulomata.

Reference: Scaranelo AM, et al. Sonographic and mammographic findings of breast liquid silicone injection.
J Clin Ultrasound
2006;34(6):273–277.

26
 
Answer C.
 This patient’s clinical and mammographic findings are consistent with unilateral gynecomastia. Therefore, no further imaging or intervention is needed at this point. The left mediolateral oblique mammograms demonstrate fan- or flame-shaped densities, emanating from nipples, and blending into surrounding fat. Approximately 70% of the gynecomastia cases are unilateral, and if bilateral, 70% are asymmetric. Broad category of conditions can cause gynecomastia, one of which is drug related. In this patient with multiple comorbidities, obtaining a full past medical and drug history is crucial. This patient was on prednisone, Zoloft, and a tricyclic antidepressant, all of which are listed as causes of drug-induced gynecomastia. Hyper-/hypothyroidism, liver disease, renal failure, COPD, and diabetes are physiologic causes of gynecomastia. Hormonal causes of gynecomastia include estrogen therapy, testicular failure, hypogonadism, and Klinefelter syndrome.

References: Bembo SA, Carlson HE. Gynecomastia: Its features, and when and how to treat it.
Cleve Clin J Med
2004;71(6):511–517.
Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2006;IV:5,50–52.
Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:279–280.

27
 
Answer D.
 The right breast demonstrates skin thickening and increased T2 signal consistent with edema. There is no enhancement of the skin or underlying tissues on postcontrast images to suggest recurrence.

References: Kang BL, Jung JI, Park C, et al. Breast MRI findings after modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer.
J Magn Reson Imaging
2005;21:784–791.
Peng C, Chang CB, Tso HH, et al. MRI appearance of tumor recurrence in myocutaneous flap reconstruction after mastectomy.
AJR Am J Roentgenol
2011;196:W471–W475.

28a
 
Answer B.
 Typical ultrasound features of a fibroadenoma include circumscribed or gently lobulated oval hypoechoic mass, parallel to skin surface.

A.
 A complicated cyst is a cyst containing internal echoes and/or thin internal septations on ultrasound. This mass is a solid mass with no cystic features.

C.
 Invasive ductal carcinoma is a malignant solid lesion which most commonly presents as a shadowing solid mass with angular or spiculated margins, antiparallel to the chest wall.

D.
 Phyllodes tumor is usually a large solid mass with low-level internal echoes and small fluid-filled spaces or cysts which are typically seen in middle-age patients.

E.
 Simple cysts are anechoic with posterior acoustic enhancement.

References: Berg WA, Birdwell RL, et al.
Diagnostic Imaging: Breast
. Amirsys; IV:2-33–IV:2-34.
Kopans D.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:589.

28b
 
Answer A.
 Fibroadenomas are typically oval or macrolobulated smooth enhancing masses with variable enhancement and may contain nonenhancing septations.

B. This choice describes typical MRI appearance of a simple cyst.

C. This choice describes typical MRI appearance of a phyllodes tumor.

D. Type 3 curves with rapid uptake followed by washout correspond with cancer in 87% of lesions.

E. Fat containing lesions such as fat necrosis demonstrate signal loss on fat-saturated sequences.

References: Berg WA, Birdwell RL, et al.
Diagnostic Imaging: Breast
. Amirsys; IV:2–33–IV:2–34.
Hendrik RE. Breast MRI
Fundamentals and Technical Aspects
. New York, NY: Springer; 2010: 119–120.

29
 
Answer B.
 Like invasive ductal carcinomas, fat necrosis can demonstrate rim enhancement. Heterogeneous enhancement on MRI, including rim enhancement, is more characteristic of a malignant finding. Potential pitfalls for evaluation of rim-enhancing masses include benign entities such as an inflammatory cyst and benign fat necrosis. Invasive ductal carcinoma may exhibit other findings suggestive of malignancy such as nonuniform signal intensity with enhancing septations or central enhancement.

Homogeneous enhancement and lack of enhancement are more suggestive of a benign finding. For example, hyalinized fibroadenomas may be nonenhancing. Another classic finding for fibroadenomas is dark internal septations. Simple cysts also do not demonstrate enhancement. Hamartomas are usually diagnostic mammographically, and MRI is generally not necessary for diagnosis. When imaged on MRI, the glandular elements within hamartomas show slight enhancement.

References: Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:520–528.
Morris EA, Liberman L.
Breast MRI Diagnosis and Intervention
. New York, NY: Springer Science + Business Media; 2005:152–153, 472–476.

30a
 
Answer B.
 Ultrasound is the best modality for a pregnant female patient under 30 years old.

30b
 
Answer B.
 Breast abscess, hematoma, and malignancy can all have similar appearances. The internal echoes and irregular thick walls may represent various entities in each process. History helps distinguish an abscess if there is increased redness, tenderness, warmth to the area, and skin thickening. A common presentation is a post- or peripartum female. A malignancy will likely have vascularity in the soft tissue components of a complex mass. Hematomas may present after a history of trauma to the breast.

If an abscess is the likely diagnosis, an attempt at aspiration and drainage is reasonable, although it is not entirely possible to determine whether the hypoechoic material can be aspirated or if it is phlegmonous material that cannot be drained through a needle.

References: Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:588–589, 607, 612–613.
Trop I, et al. Breast abscesses: evidence-based algorithms for diagnosis, management and follow-up.
Radiographics
2011;31:1683–1699.

31
 
Answer D.
 Tubular carcinoma is slow growing and the most likely diagnosis of the given options when a very small (5 mm) spiculated lesion is found by mammography. The majority of tubular carcinomas are <1 cm at diagnosis and have a central mass with ill-defined or spiculated margins. Axillary lymph node metastases are rare. Although not a characteristic feature, some contain microcalcifications.

Reference: Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:860.

32
 
Answer C.
 There are many types of calcifications with the breast, some of which are classically benign. These include skin calcifications, oil cysts or fat necrosis, milk of calcium, and vascular calcifications. Skin calcifications are lucent-centered and usually distributed medially. Oil cysts are rim or eggshell calcifications that may be due to previous trauma. Milk of calcium is a precipitate that layers in cystically dilated acini of lobules. On the CC view, they appear as amorphous, smudgy calcifications, while on the lateral view, the layering of calcifications become more crescentic in shape, sometimes referred to as “teacup” shaped. Vascular calcifications occur along the walls of arterial vessels and have a parallel “train track” appearance. In a young (under 40 years old) woman, vascular calcification is likely an indication of diabetes mellitus.