Beruflich Dokumente
Kultur Dokumente
Shah
Gina M. Fundaro
Sabala R. Mandava
Breast
Imaging Review
A Quick Guide to
Essential Diagnoses
Second Edition
123
Breast Imaging Review
Biren A. Shah Gina M. Fundaro
Sabala R. Mandava
Second Edition
Biren A. Shah, MD, FACR Sabala R. Mandava, MD
Department of Radiology Department of Radiology
Henry Ford Hospital Henry Ford Hospital
Detroit, MI Detroit, MI
USA USA
Gina M. Fundaro, MD
Department of Radiology
Henry Ford Hospital
Detroit, MI
USA
vii
Preface
The second edition of Breast Imaging Review is a new volume with all the pearls of the first
edition combined with updated material and improved images. In this edition, most of the
images are digital, allowing for better visualization of the findings. There is information per-
taining to the recently released BI-RADS, 5th Edition, as well as additional material on many
of the cases and the high-yield facts.
Although written primarily as a review for residents and fellows, we hope it will be a useful
tool for radiologists out in the real world as well. We have kept the easy-to-follow format of
the first edition, with different sections and a case-based approach. Wherever possible, we have
tried to include images in multiple modalities for each diagnosis.
The section on interventional procedures gives a step-by-step approach to the common
breast interventions. The high-yield facts at the end of the book are just that: an organized
review of important points in breast imaging that can serve as a quick reference.
We hope you get as much pleasure in reading through the book as we had writing in it.
Anyone who stops learning is old, whether at twenty or eighty.
Anyone who keeps learning stays young.
The greatest thing in life is to keep your mind young.
Henry Ford
ix
Acknowledgments
It all started at the tail end of a busy clinic day in breast imaging. Biren mentioned to Gina an
idea that he had been mulling over for a while, to write a review book in breast imaging geared
toward the oral boards. After hearing the idea, Gina enthusiastically became a part of the proj-
ect. A few days later, Biren explained the concept to Sabala who also hopped on board the
review book bandwagon. And so a book was born.
From then on, it has been a whirlwind of research, writing, deadlines, emails (hundreds of
emails), early mornings, and late nights. We were all at once elated, frustrated, overwhelmed,
and subdued. As this is a freshman project for all of us, we have learned many things by trial
and error. We also found hidden talents in each other, which emerged along the way:
Birens resourcefulness and quick solutions to roadblocks are belied by his calm and quiet
exterior.
Gina, with her attention to detail and task-oriented lists, helped us meet every deadline.
Sabalas natural loquaciousness translated into a flair for sentence structure and layout.
This book would not have been possible without the help of many people:
Dr. Manuel L. Brown, MD, our chairman, who has given us his unconditional support from
the beginning.
Dr. Kanwal Merchant, MD, and Dr. John Blas, MD, our former residents and now fellows,
who graciously reviewed our initial efforts and gave us valuable feedback.
Rhonda Pate, R.T.(R)(M); Penny Rizzo, R.T.(R)(M); and Carmen Czajka, R.T.(R)(M), for
their help in finding many of our images.
Susie Stephen, radiology support assistant, and Sharnita Powell-Bryson, radiology support
assistant leader, who pulled countless folders and digitized images.
Sadie Gomez, our professional assistant, for her hard work and dedication to this project.
Dr. Safwan Halabi, MD, our colleague and friend, who found images when no one else
could.
Dr. Stamatia Destounis, MD, who graciously agreed to write the Foreword for this book.
Janet Foltin, Senior Editor, and Margaret Burns, our development editor, for their guidance
and support.
Our residents and fellows, who keep our minds sharp and our work environment fun.
To all of you, our heartfelt thanks. We could not have accomplished this without you.
xi
Contents
xiii
xiv Contents
B.A. Shah et al., Breast Imaging Review: A Quick Guide to Essential Diagnoses, 1
DOI 10.1007/978-3-319-07791-8_1, Springer International Publishing Switzerland 2015
2 1 Mammography and Ultrasound Review
CASE 1 DIAGNOSIS
MAMMOGRAPHIC ARTIFACTS
Mammographic artifacts
PATIENT HISTORY
a b
Fig. 1.1
4 1 Mammography and Ultrasound Review
Fig. 1.4
Case 1 Mammographic Artifacts 5
Fig. 1.6
Fig. 1.5
6 1 Mammography and Ultrasound Review
CASE 2 DISCUSSION
SECRETORY CALCIFICATIONS
Secretory calcifications arise from secretions and debris
PATIENT HISTORY within the ducts, which calcify and cause inflammation.
Other names include plasma cell mastitis (typically in
A 60-year-old female for bilateral screening mammogram. premenopausal women) and mammary duct ectasia (typi-
cally in post menopausal women).
The calcifications are large and rodlike. Typically radiate
RADIOLOGY FINDINGS from the nipple in a ductal pattern.
Size of the calcifications is greater than or equal to 1 mm.
Fig. 1.1 Bilateral (a, b) CC and (c, d) MLO views demon- Rarely seen in patients before the age of 60.
strate dense, thick, continuous rodlike calcifications in a duc- Usually bilateral.
tal pattern. Asymptomatic.
No intervention necessary.
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 2. Benign finding.
American College of Radiology (ACR) BI-RADS Atlas. ACR
BI-RADS atlas-mammography. 5th ed. Reston: American College
of Radiology; 2013. p. 446.
DIAGNOSIS Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of diseases of the
breast. 2nd ed. Philadelphia: Elsevier; 2005. p. 4445.
Secretory calcifications Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV 1, p. 745.
Case 2 Secretory Calcifications 7
Fig. 1.1 a b
c d
8 1 Mammography and Ultrasound Review
CASE 3 DIAGNOSIS
INVASIVE DUCTAL CARCINOMA (IDC)
Invasive ductal carcinoma (IDC) (not otherwise specified)
PATIENT HISTORY with axillary lymph node metastasis
BI-RADS ASSESSMENT Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 57781.
Ruhbar G, Sie AC, Hansen GC. Benign versus malignant breast masses:
BI-RADS 5. Highly suggestive of malignancy (following ultrasound differentiation. Radiology. 1999;213:88994.
diagnostic workup, prior to biopsy).
Case 3 Invasive Ductal Carcinoma (IDC) 9
a b
Fig. 1.1
a b
Fig. 1.2
10 1 Mammography and Ultrasound Review
a b
Fig. 1.3
Case 4 Complicated Cyst 11
DISCUSSION
a b
Fig. 1.1
Case 4 Complicated Cyst 13
a b
Fig. 1.2
14 1 Mammography and Ultrasound Review
CASE 5 DISCUSSION
DESMOID TUMOR
Desmoid tumor is an infiltrative, locally aggressive area
PATIENT HISTORY of fibromatosis that may recur locally.
May be related to prior trauma or surgery and has been
An 83-year-old female with a palpable mass in the right reported in women with saline breast implants.
axilla. History of right breast lumpectomy and radiation ther- Can present as a solitary, hard, painless mass.
apy for ductal carcinoma in situ (DCIS). On mammography, a mass with indistinct or spiculated
margins can be seen.
On ultrasound, a hypoechoic mass with posterior acoustic
RADIOLOGY FINDINGS shadowing can be seen.
Treatment is local surgical excision.
Fig. 1.1 MLO view shows an asymmetry in the right axilla
seen only on the MLO view.
Fig. 1.2 (a) Grayscale and (b) color Doppler images show an REFERENCES
irregular spiculated hypoechoic mass that is avascular.
Cardenosa G. Breast imaging companion. 3rd ed. Philadelphia:
Lippincott Williams and Wilkins; 2008. p. 4112.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
BI-RADS ASSESSMENT Mosby; 2011. p. 4012.
DIAGNOSIS
Fig. 1.1
16 1 Mammography and Ultrasound Review
Fig. 1.2
a
b
Case 6 Gynecomastia 17
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 2. Benign finding (following diagnostic workup).
Applebaum AH, Evans GF, Levy KR, Amirkhan RH, Schumpert
TD. Mammographic appearance of male breast disease.
Radiographics. 1999;19:55968.
DIAGNOSIS Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 497, 5012.
Gynecomastia Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
ed. Cambridge: Cambridge University Press; 2013. p. 651.
DISCUSSION
Fig. 1.1
a b
c d
Case 7 Atypical Lobular Hyperplasia (ALH) 19
CASE 7 DISCUSSION
ATYPICAL LOBULAR HYPERPLASIA (ALH)
ALH presents commonly as amorphous calcifications.
PATIENT HISTORY Usually incidentally found at biopsy.
ALH is a high-risk lesion associated with increased risk
A 49-year-old female for a screening mammogram. of malignancy in either breast.
Treatment continues to be controversial following diag-
nosis on core needle biopsy.
RADIOLOGY FINDINGS Excision is generally recommended following diagnosis
of ALH on core needle biopsy.
Fig. 1.1 (a) Spot-magnification CC and (b) spot-magnifica- With excision, upgrade rates to malignancy range from 0
tion LM views demonstrate grouped amorphous and hetero- to 23 %.
geneous calcifications at 12 oclock at anterior depth.
REFERENCES
ASSESSMENT
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsy; 2006. Section IV-2, p. 745.
High-risk lesion. Foster M, Helvie M, Gregory N, Rebner M, Nees A, Paramagul
C. Lobular carcinoma in situ or atypical lobular hyperplasia at core
needle biopsy: is excisional biopsy necessary? Radiology.
DIAGNOSIS 2004;231:8139.
Fig. 1.1 a
b
Case 8 Sternalis Muscle 21
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-3, p. 401.
BI-RADS ASSESSMENT Bradley FM, Hoover HC Jr, Hulka CA, et al. The sternalis muscle: an
unusual normal finding seen on mammography. AJR.
BI-RADS 1. Negative. 1996;166:336.
Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 910.
Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
DIAGNOSIS ed. Cambridge: Cambridge University Press; 2013. p. 638.
Sternalis muscle
DISCUSSION
a b
Fig. 1.1
Case 9 Transverse Rectus Abdominis Myocutaneous (TRAM) Flap 23
BI-RADS 2. Benign finding. Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section V-3, p. 225.
Helvie MA, Bailey JE, Roubidoux MA, et al. Mammographic screen-
ing of TRAM flap breast reconstructions for detection of nonpalpa-
DIAGNOSIS ble recurrent cancer. Radiology. 2002;222:2116.
TRAM flap
DISCUSSION
Fig. 1.3
LEFT
26 1 Mammography and Ultrasound Review
CASE 10 DISCUSSION
GALACTOCELE
A galactocele is a focal collection of breast milk.
PATIENT HISTORY On mammography, a galactocele presents as a low-
density or equal-density mass with a fatfluid level appre-
A 35-year-old female with a palpable mass in the left breast ciated on the lateral mammogram.
who recently stopped breast feeding. On ultrasound, a fluiddebris level in the mass (fat rising to
the top of the galactocele and milk/fluid layering depend-
ently below) can be seen.
RADIOLOGY FINDINGS Typically seen in a lactating or postlactational woman.
Usually resolves spontaneously within a few weeks to
Fig. 1.1 Spot magnification (a) CC and (b) MLO demon- months.
strate an oval, low-density mass with circumscribed margins Aspiration can be performed for symptomatic relief.
in the upper outer left breast at middle depth.
Fig. 1.2 ML view shows a fatfluid level within the mass in
the upper left breast at middle depth. REFERENCES
Fig. 1.3 Grayscale (a) transverse, (b) sagittal, and (c) color
Doppler ultrasound images show an oval mass with a fluid Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-5, p. 69.
debris level. Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 37980.
Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
BI-RADS ASSESSMENT ed. Cambridge: Cambridge University Press; 2013. p. 6234.
DIAGNOSIS
Galactocele
Case 10 Galactocele 27
a b
Fig. 1.1
28 1 Mammography and Ultrasound Review
Fig. 1.3
Fig. 1.2
Case 11 Milk of Calcium 29
CASE 11 DISCUSSION
MILK OF CALCIUM
Milk of calcium is sedimented calcium-oxalate calcifica-
PATIENT HISTORY tions within tiny benign cysts and dilated lobules.
Key diagnostic clue is the different shapes of calcifica-
A 45-year-old female for a screening mammogram. tions between CC and lateral views.
Rounded or amorphous (smudgy) calcifications are
seen on the CC view.
RADIOLOGY FINDINGS Teacup, linear, or crescent calcifications are seen on the
lateral view.
Fig. 1.1 (a) Spot-magnification CC and (b) MLO images Biopsy not warranted.
show a cluster of round calcifications at 3 oclock in the left
breast at middle depth.
Fig. 1.2 Spot-magnification ML image of the left breast REFERENCES
demonstrates the cluster of microcalcifications to have a cur-
vilinear appearance. American College of Radiology (ACR) BI-RADS Atlas. ACR
BI-RADS atlas-mammography. 5th ed. Reston: American College
of Radiology; 2013. p. 557.
Berg WB, Birdwell RB, Gombos EC, et al. Diagnostic imaging: breast.
BI-RADS ASSESSMENT 1st ed. Salt Lake City: Amirsys; 2006. Section IV-1, p. 6870.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 7981.
BI-RADS 2. Benign findings (following diagnostic workup). Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
ed. Cambridge: Cambridge University Press; 2013. p. 608.
DIAGNOSIS
Milk of calcium
30 1 Mammography and Ultrasound Review
a b
Fig. 1.1
Fig. 1.2
Case 12 Lymphoma 31
CASE 12 DISCUSSION
LYMPHOMA
Lymphoma accounts for approximately 0.10.2 % of all
PATIENT HISTORY breast carcinomas.
Diagnosis of primary breast lymphoma is reserved for
A 68-year-old female with an enlarging breast mass. patients with no evidence of systemic lymphoma.
More commonly lymphoma occurs in the breast due to
metastasis of extramammary lymphoma.
RADIOLOGY FINDINGS Mammographically, lymphoma can be seen as a solitary
noncalcified mass, often well marginated and less often
Fig. 1.1 (a) CC and (b) MLO images show an irregular mass irregular.
with spiculated margins at 12 oclock in the right breast at A hypoechoic mass with indistinct margins and vascular
middle depth. flow is commonly seen on ultrasound.
Fig. 1.2 Grayscale (a) transverse and (b) sagittal ultrasound On MRI, lymphoma is often seen as intense heterogeneous
images show an irregular hypoechoic mass surrounded by a enhancement with a washout kinetic curve (type III).
hyperechoic rim.
Fig. 1.3 Color Doppler ultrasound image shows vascular
flow within the mass. REFERENCES
Feder JM, Shaw de Paredes E, Hogge JP, Wilken JJ. Unusual breast
lesions: radiologic-pathologic correlation. Radiographics.
BI-RADS ASSESSMENT 1999;19:S1126.
Yang WT, Lane DL, Le-Petross HT, Abruzzo LV, Macapinlac
BI-RADS 5. Highly suggestive of malignancy (following HA. Breast lymphoma: imaging findings of 32 tumors in 27 patients.
diagnostic workup, prior to biopsy). Radiology. 2007;245:692702.
DIAGNOSIS
Lymphoma
32 1 Mammography and Ultrasound Review
a b
Fig. 1.1
a b
Fig. 1.2
Case 12 Lymphoma 33
Fig. 1.3
34 1 Mammography and Ultrasound Review
REFERENCES
DIAGNOSIS
Berg WA, Birdwell RB, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 327.
Fibroadenoma Cyrlak D, Pahl M, Carpenter SE. Breast imaging case of the day.
Radiographics. 1999;19:54951.
Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
DISCUSSION ed. Cambridge: Cambridge University Press; 2013. p. 625.
Fig. 1.1
a
b
36 1 Mammography and Ultrasound Review
CASE 14 DISCUSSION
PAGETS DISEASE
Pagets disease is an extension of carcinoma to the epider-
PATIENT HISTORY mal layers of the nipple.
Often associated with an underlying DCIS and less com-
A 58-year-old female with nipple erythema and retraction. monly with IDC.
Clinically, Pagets disease presents as scaling, erosions,
erythema, or eczematous reaction of the nipple.
RADIOLOGY FINDINGS Mammogram can often be negative; however, calcifica-
tions or a mass associated with an underlying DCIS or IDC
Fig. 1.1 (a) CC, (b) ML, (c) spot-magnification CC, and (d) can be seen.
spot-magnification MLO images show indistinct calcifica- Skin thickening and heterogeneity of the breast paren-
tions in a linear distribution, extending from the nipple to chyma can be seen on ultrasound; the same nonspecific
middle depth in the right breast. The nipple is inverted. changes can be seen with mastitis.
Fig. 1.2 (a) Axial subtracted T1-weighted and (b) sagittal MRI can be of value when the mammogram is normal,
contrast-enhanced delayed T1-weighted images show often showing abnormal nipple enhancement, thickening
non-mass-like enhancement extending from the nipple to the of the nippleareolar complex, or an enhancing underlying
posterior depth of the right breast. There is abnormal carcinoma.
enhancement of the nippleareolar complex. Diagnosis can be made by a punch biopsy of the nipple
areolar complex, which will demonstrate cancer cells.
Pagets disease can be rarely associated with invasive
BI-RADS ASSESSMENT lobular carcinoma.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 375.
DIAGNOSIS Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 5834.
Pagets disease Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex: normal
anatomy and benign and malignant processes. Radiographics.
2009;29:50923.
Case 14 Pagets Disease 37
a b
c d
Fig. 1.1
38 1 Mammography and Ultrasound Review
a b
Fig. 1.2
Case 15 Mastitis 39
CASE 15 DISCUSSION
MASTITIS
Mastitis can present with pain, skin edema, erythema, and
PATIENT HISTORY a palpable mass.
Mammographically, it can be seen as skin thickening and
A 51-year-old male with swelling and erythema of the left trabecular thickening, with or without an area of asym-
breast following a human bite to the left breast. metry in the breast.
Reactive lymphadenopathy can be present.
Skin thickening, edema, and increased echogenicity of
RADIOLOGY FINDINGS the breast can be seen on ultrasound.
Most common pathogens are Staphylococcus aureus and
Fig. 1.1 (a) CC and (b) MLO images show an asymmetry in Streptococcus.
the central anterior left breast. Puerperal mastitis is most common.
Fig. 1.2 (a, b) Grayscale and (c) color Doppler ultrasound A skin-punch biopsy is needed to differentiate inflamma-
images show skin thickening and edematous tissue. tory breast cancer from mastitis refractory to treatment.
BI-RADS 2. Benign findings (following diagnostic workup). Bassett LW, Feig SA, Hendrick RE, Jackson VP, Sickles EA. Breast
disease (third series) test and syllabus. Reston: American College of
Radiology; 2000. p. 82.
Berg W, Birdwell R, Gombos EC, et al. Diagnostic imaging: breast. 1st
DIAGNOSIS ed. Salt Lake City: Amirsys; 2006. Section IV-6, p. 102.
Mastitis
40 1 Mammography and Ultrasound Review
a b
Fig. 1.1
Case 15 Mastitis 41
a b
Fig. 1.2
42 1 Mammography and Ultrasound Review
CASE 16 DISCUSSION
NEUROFIBROMATOSIS TYPE I (NF I)
NF I, also termed as von Recklinghausens disease, pres-
PATIENT HISTORY ents initially in children and young adults.
Classic features of NF I include neurofibromas and cafe
A 52-year-old female with multiple skin lesions for screen- au lait spots.
ing mammogram. NF I also has vascular, skeletal, and pulmonary manifes-
tations.
Associated neoplasms with NF I include meningiomas, optic
RADIOLOGY FINDINGS gliomas, neurofibrosarcomas, and pheochromocytomas.
Likely associated with an increased risk for breast
Fig. 1.1 (a, b) CC and (c, d) MLO views show multiple cir- cancer.
cumscribed skin masses bilaterally. Neurofibromas can project over the breast and have the
appearance of masses within the breast on mammogram.
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 2. Benign findings.
Brant WE, Helms CA, editors. Fundamentals of diagnostic radiology.
2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1999.
p. 430.
DIAGNOSIS Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 352.
Neurofibromatosis Type I (NF I)
Case 16 Neurofibromatosis Type I (NF I) 43
Fig. 1.1
a b
c d
44 1 Mammography and Ultrasound Review
REFERENCES
DIAGNOSIS
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-5, p. 225.
Multiple, bilateral circumscribed masses Leung JW, Sickles EA. Multiple bilateral masses detected on screening
mammography: assessment of need for recall imaging. AJR.
2000;175:239.
DISCUSSION
a b
Fig. 1.1
46 1 Mammography and Ultrasound Review
a b
c d
Fig. 1.1
48 1 Mammography and Ultrasound Review
CASE 19 DISCUSSION
STROMAL FIBROSIS
Stromal fibrosis may present incidentally on imaging or
PATIENT HISTORY as a palpable mass.
Formed by proliferation of collagenized stroma between
A 60-year-old female for a screening mammogram. terminal ductal lobular units.
On mammography, stromal fibrosis can present as a
benign-appearing mass or lesion that has features sugges-
RADIOLOGY FINDINGS tive of malignancy.
On ultrasound, stromal fibrosis appears hypoechoic or of
Fig. 1.1 (a) CC and (b) MLO views demonstrate an oval mixed echogenicity and is nonvascular.
mass with partly circumscribed and partly ill-defined mar- No malignant potential and no intervention are necessary.
gins in the lower inner left breast at posterior depth. It is important to assess radiology/pathology concordance
Fig. 1.2 Grayscale ultrasound image demonstrates a after a diagnosis of stromal fibrosis on core needle biopsy.
hypoechoic oval mass with ill-defined margins and posterior If concordant, 6-month follow-up may be performed to
acoustic shadowing. assess stability.
Discordance between imaging features and diagnosis of
stromal fibrosis should result in rebiopsy or excision.
BI-RADS ASSESSMENT
Stromal fibrosis
Case 19 Stromal Fibrosis 49
a b
Fig. 1.1
Fig. 1.2
50 1 Mammography and Ultrasound Review
DIAGNOSIS
REFERENCES
Reduction mammoplasty
Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of diseases of the
breast. 2nd ed. Philadelphia: Elsevier; 2005. p. 61721.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
DISCUSSION 1st ed. Salt Lake City: Amirsys; 2006. Section IV-4, p. 324.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
Reduction mammoplasty is a plastic surgery procedure to imaging. Philadelphia: Elsevier; 2013. p. 4702.
decrease the breast size in macromastia, in the setting of
Case 20 Reduction Mammoplasty 51
Fig. 1.1
a b
c d
52 1 Mammography and Ultrasound Review
Avril N, Rose CA, Schelling M, et al. Breast imaging with PET and
fluorine-18 fluorodeoxyglucose: uses and limitations. J Clin Oncol.
DIAGNOSIS 2000;18:3495502.
Breas RF, Ioffe M, Rapelyea JA, et al. ILC: detecting with mammogra-
Invasive lobular carcinoma (ILC) phy, sonography, MRI and breast specific gamma imaging. AJR.
2009;192:37983.
Harvey JA. Unusual breast cancers: useful clues to expanding the dif-
ferential diagnosis. Radiology. 2007;242:63894.
DISCUSSION Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 295.
ILC arises from the lobular epithelium. Lopez JK, Bassett LW. ILC of the breast: spectrum of mammographic,
ultrasound and MRI imaging findings. Radiographics.
It is the second most common breast cancer and accounts 2009;29:16576.
for 1015 % of all invasive breast malignancies. Sickles EA. The subtle and atypical mammographic features of invasive
Malignant cells grow in single file, and therefore, ILC lobular carcinoma. Radiology. 1991;178:256.
does not evoke a desmoplastic reaction.
Case 21 Invasive Lobular Carcinoma (ILC) 53
a b c
Fig. 1.1
54 1 Mammography and Ultrasound Review
Fig. 1.2
b
Case 22 Lactating Adenoma 55
BI-RADS ASSESSMENT Chung EM, Cube R, Hall GJ, Gonzalez C, Stocker JT, Glassman
LM. Breast masses in children and adolescents: radiologic-patho-
logic correlation. Radiographics. 2009;29:90731.
BI-RADS 2. Benign finding (following diagnostic workup Harvey JA, March DE. Making the diagnosis: a practical guide to breast
and biopsy). imaging. Philadelphia: Elsevier; 2013. p. 303.
Sabate JM, Clotet M, Torrubia S. Radiologic evaluation of breast disor-
ders related to lactation and pregnancy. Radiographics.
2007;27:S101124.
DIAGNOSIS
Lactating adenoma
DISCUSSION
a b
Fig. 1.1
Fig. 1.2
Case 23 Silicone Granuloma 57
BI-RADS ASSESSMENT Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section: IV-4, p. 367.
Caskey C, Berg WA, Hamper UM, Sheth S, Chang BW, Anderson
BI-RADS 2. Benign finding (following diagnostic workup). ND. Imaging spectrum of extracapsular silicone: correlation of
ultrasound, MR. imaging, mammographic and histopathologic find-
ings. Radiographics. 1999;19:F3951.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
DIAGNOSIS imaging. Philadelphia: Elsevier; 2013. p. 5112.
Silicone granuloma
DISCUSSION
a b
Fig. 1.1
Fig. 1.2
Case 24 Lipoma 59
CASE 24 DISCUSSION
LIPOMA
A lipoma is a benign fatty mass that presents as a radiolucent
PATIENT HISTORY mass surrounded by a thin pseudocapsule on mammogram.
Clinically, lipomas are soft and mobile.
A 58-year-old male with a palpable left breast mass for May distort the breast architecture on mammogram by
1 month. displacing the adjacent normal breast tissue.
On ultrasound, a lipoma is seen as a hypoechoic, isoechoic,
or hyperechoic oval or round circumscribed mass parallel
RADIOLOGY FINDINGS to the skin, with an echotexture similar to the subcutane-
ous fat.
Fig. 1.1 (a) CC, (b) MLO, and (c) ML images show a radio- The diagnosis usually can be made on mammogram with-
lucent oval circumscribed mass, corresponding to a triangu- out the need for ultrasound.
lar marker indicating a palpable mass.
Fig. 1.2 Grayscale ultrasound image shows a nearly isoechoic
oval circumscribed mass. REFERENCES
DIAGNOSIS
Lipoma
60 1 Mammography and Ultrasound Review
a b c
Fig. 1.1
Fig. 1.2
Case 25 Adenoid Cystic Carcinoma 61
CASE 25 DISCUSSION
ADENOID CYSTIC CARCINOMA
Adenoid cystic carcinoma is a rare malignant breast
PATIENT HISTORY tumor.
Typically, a slow-growing lobular mass is seen clinically.
A 47-year-old female with a history of focal left breast pain. Median size is 2 cm with a range between 0.2 and 12 cm.
Commonly seen in the subareolar or central region but
can occur anywhere in the breast.
RADIOLOGY FINDINGS Excellent prognosis. Recurrence is possible if mass is not
completely excised.
Fig. 1.1 (a) CC, (b) MLO, and spot-compression (c) CC and Imaging characteristics vary and range from a circum-
(d) ML views show an oval mass with partially obscured scribed mass to ill-defined mass or focal asymmetries.
margins in the subareolar region of the left breast.
Fig. 1.2 (a) Grayscale and (b) color Doppler images show an
oval circumscribed avascular mass in the subareolar region REFERENCES
of the left breast.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 1023.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
BI-RADS ASSESSMENT Mosby; 2011. p. 131.
Santamarie G, Velasco M, Zanon G, et al. Adnoid cystic carcinoma of
BI-RADS 4. Suspicious abnormality (following diagnostic the breast: mammographic appearance and pathologic correlation.
AJR. 1998;171:167983.
workup, prior to biopsy).
DIAGNOSIS
Fig. 1.1
a b
c d
Case 25 Adenoid Cystic Carcinoma 63
a b
Fig. 1.2
64 1 Mammography and Ultrasound Review
CASE 26 DISCUSSION
DIABETIC MASTOPATHY
Diabetic mastopathy is a variant of stromal fibrosis occur-
PATIENT HISTORY ring in long-term insulin-dependent diabetics, in pre-
menopausal women with long-standing insulin-dependent
A 31-year-old female with a palpable mass in the retroareo- diabetes, or in rare patients with thyroid disease.
lar right breast. The patient is on dialysis. Diabetic mastopathy results from an autoimmune reaction
to the accumulation of abnormal matrix proteins caused by
hyperglycemia.
RADIOLOGY FINDINGS Clinical symptoms include palpable and firm, nontender
masses, thickening of the breasts, or hard breasts.
Fig. 1.1 Bilateral (a, b) CC and (c, d) MLO, and right spot- On mammography, increased parenchymal density may
compression (e) CC and (f) MLO views show no discrete be seen unilaterally or in both the breasts.
mass. There is a focal asymmetry in the retroareolar right On ultrasound, a hypoechoic mass with indistinct margins
breast when compared with that of the left. There is a perma- can be seen.
catheter incidentally seen in the upper right breast. A biopsy is needed to establish the diagnosis.
Fig. 1.2 (a, b) Grayscale and (c) color Doppler ultrasound Excellent prognosis, self-limited.
images show a hypoechoic avascular mass with indistinct
margins in the retroareolar region of the right breast, corre-
sponding to the patients palpable mass. REFERENCES
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-5, p. 301.
BI-RADS ASSESSMENT Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 4001.
BI-RADS 2. Benign finding (following diagnostic workup Sabate JM, Clotet M, Gomez A, De las Heras P, Torrubia S, Salinas
and biopsy). T. Radiologic evaluation of uncommon inflammatory and reactive
breast disorders. Radiographics. 2005;25:41124.
DIAGNOSIS
Diabetic mastopathy
Case 26 Diabetic Mastopathy 65
a b
c d
e f
Fig. 1.1
66 1 Mammography and Ultrasound Review
Fig. 1.2
a
c
Case 27 Diffuse Bilateral Breast Calcifications 67
CASE 27 DISCUSSION
DIFFUSE BILATERAL BREAST CALCIFICATIONS
Multiple calcifications that are diffusely scattered
PATIENT HISTORY throughout the breast are almost always benign.
Diffuse calcifications must be randomly distributed to be
A 79-year-old female for a bilateral screening mammogram. considered benign.
Round and punctuate calcifications are usually benign
when they are scattered throughout both breasts.
RADIOLOGY FINDINGS Round and punctuate calcifications usually develop within
lobules.
Fig. 1.1 (a, b) CC and (c, d) MLO views of both breasts
show multiple diffuse secretory, vascular, round, and oval
calcifications scattered diffusely bilaterally. REFERENCES
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 159.
BI-RADS ASSESSMENT Kopans D. Breast imaging. 3rd ed. Philadelphia: Lippincott Williams
and Wilkins; 2006. p. 463.
BI-RADS 2. Benign findings.
DIAGNOSIS
Fig. 1.1 a b
c d
Case 28 Superior Vena Cava (SVC) Syndrome 69
CASE 28 DISCUSSION
SUPERIOR VENA CAVA (SVC) SYNDROME
SVC syndrome is caused by obstruction of flow in the
PATIENT HISTORY SVC.
Causes of obstruction include:
Screening mammogram in a 62-year-old female recently External compression
diagnosed with lung cancer. Intravascular mass
Thrombus
Most common cause is bronchogenic carcinoma.
RADIOLOGY FINDINGS Other malignancies causing SVC syndrome:
Metastases (commonly from breast)
Fig. 1.1 (a) CC and (b) MLO views demonstrate trabecular Lymphoma
and skin thickening in the left breast. These findings were Thymoma
also seen in the contralateral breast (not shown). Chest radiograph demonstrates widening of mediastinum
Fig. 1.2 Axial contrast-enhanced CT of the thorax demon- with enlarged azygos vein.
strates an irregular heterogeneously enhancing mass in the Right-sided mass is more common.
anterior mediastinum causing displacement of the great Treatment depends on cause of obstruction.
vessels.
Fig. 1.3 PA view of the chest demonstrates a mass within the
left anterior mediastinum causing deviation of the airway to REFERENCES
the right.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-5, p. 423.
Gurney J, Winer-Muram H, Stern E, et al. Diagnostic imaging chest. 1st
DIAGNOSIS ed. Salt Lake City: Amirsys; 2006. Section II-2, p. 4851.
a b
Fig. 1.1
Fig. 1.2
Case 28 Superior Vena Cava (SVC) Syndrome 71
Fig. 1.3
72 1 Mammography and Ultrasound Review
CASE 29 DISCUSSION
POSTOPERATIVE SEROMA
Seromas are common complications of breast conserva-
PATIENT HISTORY tion surgery.
Some studies have shown that risk factors for seroma for-
A 64-year-old female who recently underwent lumpectomy. mation include:
High body mass index
Increased drainage volume in the first 3 days
RADIOLOGY FINDINGS postoperatively
Arterial hypertension
Fig. 1.1 (a) CC and (b) MLO views of the right breast dem- Seromas are usually self-limited and can resolve on their
onstrate a high-density oval mass with circumscribed mar- own.
gins in the lower inner right breast extending from middle to Aspiration can be performed if the seroma is large enough
posterior depth. to cause discomfort.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound
demonstrate an anechoic avascular mass containing echo-
genic material. REFERENCES
DIAGNOSIS
Postoperative seroma
Case 29 Postoperative Seroma 73
a b
Fig. 1.1
a b
Fig. 1.2
74 1 Mammography and Ultrasound Review
CASE 30 DISCUSSION
MEDULLARY CARCINOMA
Medullary carcinoma accounts for 57 % of all breast
PATIENT HISTORY cancers.
More common in younger women.
A 48-year-old female with a palpable left breast mass. Fast growth rate, locally aggressive.
On mammogram, medullary carcinoma is a uniformly
dense, round, or oval noncalcified mass with indistinct or
RADIOLOGY FINDINGS circumscribed margins.
On ultrasound, a solid homogeneously hypoechoic mass
Fig. 1.1 (a) CC and (b) MLO images show a mass with par- is seen.
tially obscured margins in the upper outer left breast at mid- As medullary cancer can have smooth margins and firm
dle depth. consistency, a fibroadenoma is often considered in the
Fig. 1.2 Color Doppler ultrasound image shows an oval clinical and imaging differential diagnosis.
hypoechoic mass with ill-defined margins and vascular flow. A moderately enhancing mass is seen on MRI.
Fig. 1.3 (a) Axial subtracted T1-weighted, (b) axial contrast-
enhanced T1-weighted, and (c) sagittal contrast-enhanced
delayed T1-weighted images show a rim-enhancing mass REFERENCES
with spiculated margins in the upper outer left breast at mid-
dle depth. Cardenosa G. Breast imaging companion. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2001. p. 258.
Meyer JE, Amin E, Lindfors KK, Lipman JC, Stomper PC, Genest
D. Medullary carcinoma of the breast: mammographic and ultra-
BI-RADS ASSESSMENT sound appearance. Radiology. 1989;170:7982.
Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. New York: Springer; 2005. p. 179.
BI-RADS 5. Highly suggestive of malignancy (following
diagnostic workup, prior to biopsy).
DIAGNOSIS
Medullary carcinoma
Case 30 Medullary Carcinoma 75
a b
Fig. 1.1
Fig. 1.2
76 1 Mammography and Ultrasound Review
Fig. 1.3
Case 31 Lobular Carcinoma In Situ (LCIS) 77
ASSESSMENT Berg WA, Mrose HE, Ioffe OB. ALH or LCIS at core needle breast
biopsy. Radiology. 2001;218:5039.
Foster MC, Helvie MA, Gregory NE, Rebner M, Nees AV, Paramagul
High-risk lesion. C. LCIS or ALH at core needle biopsy: is excisional biopsy neces-
sary? Radiology. 2004;231:81319.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 295.
DIAGNOSIS
DISCUSSION
Fig. 1.1
a
b
Case 32 Juvenile Fibroadenoma 79
CASE 32 DISCUSSION
JUVENILE FIBROADENOMA
The most common breast mass in girls younger than
PATIENT HISTORY 20 years of age is a fibroadenoma.
A juvenile fibroadenoma is an uncommon variant,
An 18-year-old female with a palpable mass at 12 oclock in accounting for 78 % of all fibroadenomas.
the right breast. Most common in African-American girls.
Juvenile fibroadenomas grow quickly and can attain a
very large size.
RADIOLOGY FINDINGS Clinically, can be seen as a rapidly enlarging breast, skin
ulceration, and/or distended superficial veins.
Fig. 1.1 (a, b) Grayscale and (c) color Doppler ultrasound On ultrasound, a hypoechoic circumscribed mass is seen.
images show an oval hypoechoic mass with circumscribed The differential diagnosis includes a fibroadenoma and
margins. There is vascular flow within the mass. phyllodes tumor.
BI-RADS 2. Benign findings (following diagnostic workup Cardenosa G. Breast imaging companion. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2001. p. 291.
and biopsy). Chung EM, Cube R, Hall GJ, Gonzalez C, Stocker JT, Glassman
LM. Breast masses in children and adolescents: radiologic-patho-
logic correlation. Radiographics 2009;29:90731.
DIAGNOSIS
Juvenile fibroadenoma
80 1 Mammography and Ultrasound Review
Fig. 1.1 a
c
Case 33 Simple Cyst 81
CASE 33 DISCUSSION
SIMPLE CYST
Cysts are collections of fluid with an epithelial lining.
PATIENT HISTORY Most common breast mass in women.
More common between 40 and 50 years.
A 41-year-old female with a palpable mass at 1 oclock of Rare in postmenopausal females.
the left breast. Cannot distinguish cysts from circumscribed solid masses
on mammography.
Simple cysts have no malignant potential.
RADIOLOGY FINDINGS May fluctuate in size due to menstrual cycle.
Asymptomatic, nonpalpable simple cysts do not require
Fig. 1.1 (a) Spot-compression CC and (b) spot-compression intervention.
MLO views demonstrate an oval mass with circumscribed Painful or palpable cysts can be aspirated for patients
and partially obscured margins in the upper outer left breast comfort.
at middle depth. Benign cyst fluid is typically cloudy yellow or greenish
Fig. 1.2 (a, b) Grayscale ultrasound images demonstrate an black.
anechoic mass with imperceptible walls and posterior acous-
tic enhancement.
REFERENCES
BI-RADS ASSESSMENT Bassett L, Jackson V, Fu KL, Fu YS. Diagnosis of diseases of the breast.
2nd ed. Philadelphia: Elsevier; 2005. p. 4327.
Berg W, Campassi C, Ioffe O. Cystic lesions of the breast: sono-
BI-RADS 2. Benign finding. (Following diagnostic workup). graphic pathologic correlation. Radiology. 2003;227:18391.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-1, p. 4851.
DIAGNOSIS
Simple cyst
82 1 Mammography and Ultrasound Review
a a
Fig. 1.2
Fig. 1.1
Case 34 Poland Syndrome 83
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section I, p. 11.
DIAGNOSIS Gurney JW, Winer-Muram HT, Stern EJ, et al. Diagnostic imaging
chest. 1st ed. Salt Lake City: Amirsys; 2006. Section III-2, p. 89.
Poland syndrome Jeung MV, Gangi A, Gasser B, et al. Imaging of chest wall disorders.
Radiographics 1999;19(3):61737.
DISCUSSION
a b
Fig. 1.1
Case 35 Intracystic Papillary Carcinoma 85
CASE 35 DISCUSSION
INTRACYSTIC PAPILLARY CARCINOMA
Intracystic papillary carcinoma is rare, representing
PATIENT HISTORY 12 % of all breast cancers.
Occurs most commonly in postmenopausal women.
A 76-year-old female for screening mammogram. Family Slow growth rate; excellent prognosis.
history of mother with breast cancer. Can be asymptomatic or present as a palpable mass and/
or bloody nipple discharge.
Often a round or oval mass is seen in the retroareolar
RADIOLOGY FINDINGS breast on mammogram.
On ultrasound, an intracystic papillary carcinoma pres-
Fig. 1.1 (a) CC, (b) ML, (c) spot-compression CC, and (d) ents as a complex cystic mass which can contain:
spot-compression MLO images show an oval mass with pre- Irregular septations
dominantly circumscribed margins in the upper outer right Hypoechoic mass within the cyst
breast at middle depth (circle markers correspond to skin Thickened cyst wall
moles). Papillary projections
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound MRI shows enhancement of cyst walls, septations, and
images show a hypoechoic mass with predominately circum- mural nodules.
scribed margins and an eccentric solid component with vas-
cular flow.
REFERENCES
BI-RADS ASSESSMENT Dogan BE, Whitman GJ, Middleton LP, Phelps M. Intracystic papillary
carcinoma of the breast. AJR. 2003;181:186.
Liberman L, Feng TL, Susnik B. Case 35: intracystic papillary carci-
BI-RADS 4. Suspicious abnormality (following diagnostic noma with invasion. Radiology. 2001;219:7814.
workup, prior to biopsy).
DIAGNOSIS
Fig. 1.1
a b
c d
Case 35 Intracystic Papillary Carcinoma 87
a b
Fig. 1.2
88 1 Mammography and Ultrasound Review
CASE 36 DISCUSSION
INTRACAPSULAR RUPTURE OF SILICONE BREAST IMPLANT
Intracapsular rupture of a breast implant is defined as a
PATIENT HISTORY disruption or tear of the implant shell, in which silicone
gel moves outside of the implant shell but stays within the
A 35-year-old female for evaluation of implant rupture. fibrous capsule.
Intracapsular rupture occurs more commonly than extra-
capsular rupture.
RADIOLOGY FINDINGS On ultrasound, an intracapsular rupture of a silicone
implant is seen as pairs of hyperechoic lines, often referred
Fig. 1.1 (ac) Grayscale ultrasound images show hyper- to as a stepladder appearance.
echoic lines within the implant, often referred to as a step- A rupture or tear of a saline implant is identified clinically,
ladder appearance. and imaging is not necessary to make the diagnosis.
BI-RADS 2. Benign finding (following diagnostic workup). Berg WA, Caskey CI, Hamper UM, et al. Diagnosing breast implant
rupture with MR imaging, ultrasound and mammography.
Radiographics. 1993;13:132336.
Deangelis GA, Lange EE, Miller LR, Morgan RF. MR imaging of
DIAGNOSIS breast implants. Radiographics. 1994;14:78394.
Everson LI, Parantainen H, Detlie T, et al. Diagnosis of breast implant
rupture: imaging findings and relative efficacies of imaging tech-
Intracapsular rupture of silicone breast implant niques. AJR. 1994;163:5760.
Case 36 Intracapsular Rupture of Silicone Breast Implant 89
Fig. 1.1
a
c
90 1 Mammography and Ultrasound Review
REFERENCES
BI-RADS ASSESSMENT
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 34850.
BI-RADS 2. Benign finding (following diagnostic workup). Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
ed. Cambridge: Cambridge University Press; 2013. p. 6479.
Molleran VM, Mahoney M. Breast MRI. 1st ed. Philadelphia; Saunders;
DIAGNOSIS 2014. p. 14850.
Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. New York; Springer; 2005. p. 23949.
Extracapsular rupture of silicone breast implant on
ultrasound
DISCUSSION
Fig. 1.1
92 1 Mammography and Ultrasound Review
REFERENCES
BI-RADS ASSESSMENT
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-1, p. 447.
BI-RADS 2. Benign finding (following diagnostic workup). Da Costa D, Taddese A, Luz Cure M, Gerson D, Poppiti R Jr, Esserman
LE. Common and unusual diseases of the nipple-areolar complex.
Radiographics. 2007;27:S6577.
DIAGNOSIS
Ductal ectasia
DISCUSSION
a b
Fig. 1.1
94 1 Mammography and Ultrasound Review
Fig. 1.2
a
b
Case 39 Radial Scar 95
REFERENCES
DISCUSSION Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of diseases of the
breast. 2nd ed. Philadelphia: Elsevier; 2005. p. 44951.
Most commonly, radial scar presents as an incidental Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
imaging finding on mammography. 1st ed. Salt Lake City; Amirsys; 2006. Section IV-2, p. 849.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
It appears as architectural distortion or a spiculated mass imaging. Philadelphia: Elsevier; 2013. p. 2956.
with central radiolucency on mammography. Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
It is not a scar; it is not due to trauma or surgery. and Wilkins; 1998. p. 5656.
If sonographically visible, radial scar appears as an irreg-
ular, hypoechoic mass.
96 1 Mammography and Ultrasound Review
a b
c d
Fig. 1.1
Case 39 Radial Scar 97
CASE 40 DISCUSSION
DERMAL CALCIFICATIONS
Dermal calcifications may be single or clustered.
PATIENT HISTORY Often have a calcified rim surrounding a lucent center.
Suspected if calcifications are peripheral in location or
A 40-year-old female for a baseline screening mammogram. close to the skin surface in any view.
Occur most often in lower and inner breast.
Dermal calcification workup:
RADIOLOGY FINDINGS Fenestrated compression paddle is placed on the skin
surface closest to the calcifications.
Fig. 1.1 (a) CC and (b) MLO views demonstrate a cluster of BB is superimposed over the calcifications.
calcifications at the 6 oclock position, which have the same Tangential view is obtained demonstrating calcifica-
appearance on both the views. tions in the skin.
Fig. 1.2 CC view with a fenestrated compression paddle
demonstrates the cluster of calcifications with a superim-
posed BB marker. REFERENCES
Fig. 1.3 Tangential view demonstrates that the cluster of cal-
cifications is within the skin directly under the BB. American College of Radiology (ACR) BI-RADS Atlas. ACR
BI-RADS atlas-mammography. 5th ed. Reston: American College
of Radiology; 2013. p. 389.
Bassett LW, Jackson VP, Fu KL, Fu YS, et al. Diagnosis of diseases of
BI-RADS ASSESSMENT the breast. 2nd ed. Philadelphia: Elsevier; 2005. p. 4024.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 769.
BI-RADS 2. Benign finding (following diagnostic workup).
DIAGNOSIS
Dermal calcifications
Case 40 Dermal Calcifications 99
a b
Fig. 1.1
CASE 41 DISCUSSION
TURNERS SYNDROME
XO karyotype.
PATIENT HISTORY Incidence is 1:3,0005,000 live births.
Associated with:
A 42-year-old female for a baseline screening Horseshoe kidney
mammogram. Coarctation of aorta
Aortic stenosis
Cystic hygroma
RADIOLOGY FINDINGS Primary amenorrhea and absence of secondary sex
characteristics.
Fig. 1.1 Bilateral (a, b) CC and (c, d) MLO views demon- Widely spaced nipples.
strate mostly fatty breast tissue with minimal fibroglandular Annual mammography screening is recommended.
development. Circular markers represent skin moles.
REFERENCES
BI-RADS ASSESSMENT
Brant WE, Helms CA, editors. Fundamentals of diagnostic radiology.
2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1999.
BI-RADS 2. Benign finding. p. 319, 576.
Saenger P. Clinical review 48: the current status of diagnosis and thera-
peutic intervention in Turners syndrome. J Clin Endocrinol
DIAGNOSIS Metable. 1993;77:297301.
Turners syndrome
Case 41 Turners Syndrome 101
Fig. 1.1
a b
c d
102 1 Mammography and Ultrasound Review
DISCUSSION
a b
Fig. 1.1
104 1 Mammography and Ultrasound Review
Fig. 1.3
Fig. 1.2
Case 43 Mondors Disease (Superficial Thrombophlebitis) 105
DISCUSSION
a b
Fig. 1.1
Case 43 Mondors Disease (Superficial Thrombophlebitis) 107
Fig. 1.2
a
b
108 1 Mammography and Ultrasound Review
REFERENCES
ASSESSMENT
Cardenosa G. Breast imaging companion. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2001. p. 224.
High-risk lesion. Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 4016.
Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast
DIAGNOSIS core needle biopsies. Am J Surg Path. 2002;26:1095110.
Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw
DD. Is surgical excision warranted after benign concordant diagno-
Intraductal papilloma sis of papilloma at percutaneous breast biopsy? AJR. 2006;186:
132834.
Mercado Cl, Hamele-Bena D, Oken S, Singer CI, Cangiarella
J. Papillary lesions of the breast at percutaneous core needle biopsy.
DISCUSSION Radiology. 2006;238:8018.
a b
Fig. 1.1
a b
Fig. 1.2
110 1 Mammography and Ultrasound Review
CASE 45 DISCUSSION
FAT NECROSIS (MULTIPLE PRESENTATIONS)
Fat necrosis is a benign, inflammatory process, which usu-
PATIENT HISTORY ally occurs after trauma or injury to the breast.
Radiographic appearance may mimic malignancy and
Screening mammograms in multiple different patients. biopsy may be necessary.
Can have multiple mammographic appearances:
Oil cysts
RADIOLOGY FINDINGS Calcifications
Spiculated opacities
Fig. 1.1 (a, b) Bilateral MLO views demonstrate multiple, Focal masses
bilateral, lucent-centered masses compatible with oil cysts. Fat necrosis may also present as a palpable mass with no
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound mammographic findings.
images demonstrate an irregular hypoechoic mass that is Oil cysts are a pathognomonic finding for fat necrosis.
taller than wide. There is no internal vascular flow. Calcifications may be pleomorphic or coarse.
Fig. 1.3 CC view demonstrates two lucent-centered lesions If fibrosis is a predominant component of fat necrosis,
with peripheral rim calcification in the retroareolar plane at then it may appear as a spiculated mass.
anterior depth. Steatocystoma multiplex:
Multiple sebaceous cysts on the trunk, back, external
genitalia, and proximal extremities
BI-RADS ASSESSMENT Autosomal dominant
Predominantly in males
BI-RADS 2. Benign finding (following possible diagnostic Multiple, bilateral oil cysts seen mammographically
workup and biopsy).
REFERENCE
DIAGNOSIS
Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. The mammo-
graphic spectrum of fat necrosis of the breast. Radiographics.
Fat necrosis (multiple presentations) 1995;15:134756.
Case 45 Fat Necrosis (Multiple Presentations) 111
a b
Fig. 1.1
a b
Fig. 1.2
112 1 Mammography and Ultrasound Review
Fig. 1.3
Case 46 Recurrence at Lumpectomy Site 113
a b
Fig. 1.1
Case 46 Recurrence at Lumpectomy Site 115
Fig. 1.2
Fig. 1.3
116 1 Mammography and Ultrasound Review
a b
Fig. 1.1
a b
Fig. 1.2
118 1 Mammography and Ultrasound Review
Bassett LW, Feig SA, Hendrick RE, Jackson VP, Sickles EA. Breast
disease (third series) test and syllabus. Reston: American College of
DIAGNOSIS Radiology; 2000. p. 76.
Bilgren-Gunhan I, Ustun EE, Memis A. Inflammatory breast carci-
Inflammatory breast carcinoma (IBC) noma: mammographic, sonographic, clinical and pathologic find-
ings in 142 cases. Radiology. 2002;223:82938.
DISCUSSION
Fig. 1.1
a b
c d
120 1 Mammography and Ultrasound Review
CASE 49 DISCUSSION
INTRAMAMMARY LYMPH NODE
Intramammary lymph nodes are seen in approximately
PATIENT HISTORY 50 % of screening patient population.
Most commonly located in the upper outer quadrant of
A 56-year-old female for a screening mammogram. the breast.
On mammogram, a lobular circumscribed mass contain-
ing a radiolucent notch (representing the fat in the hilum
RADIOLOGY FINDINGS of the lymph node) is seen.
On ultrasound, pathognomonic findings include a circum-
Fig. 1.1 (a) CC, (b) MLO, (c) spot-compression CC, and (d) scribed hypoechoic cortex with a round, oval, or lobular
spot-compression MLO images show a circumscribed mass shape, and a hyperechoic central fatty hilum is seen.
in the upper outer right breast at middle depth. Usually, vascular flow to the fatty hilum is present.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound An intramammary lymph node can enlarge, with thicken-
images show a circumscribed mass with a hypoechoic outer ing of the cortex and loss of the fatty hilum as a response
cortex and a hyperechoic central fatty hilum. There is vascu- to hyperplasia, inflammation, or metastatic disease.
lar flow seen within the hilum.
REFERENCES
BI-RADS ASSESSMENT
American College of Radiology (ACR) BI-RADS Atlas. ACR
BI-RADS atlas-mammography. 5th ed. Reston: American College
BI-RADS 2. Benign finding (following possible diagnostic of Radiology; 2013. p. 978.
workup). Meyer JE, Ferraro FA, Frenna TH, DePiro PJ, Denison CM.
Mammographic appearance of normal intramammary lymph nodes
in an atypical location. AJR. 1993;161:77980.
Venta LA, Dudiak LM, Salomon CG, Flisak ME. Sonographic evalua-
DIAGNOSIS tion of the breast. Radiographics. 1994;14:2950.
a b
c d
Fig. 1.1
122 1 Mammography and Ultrasound Review
Fig. 1.2
a
b
Case 50 Oil Cyst 123
Fig. 1.1
a
b
Case 51 Hormone Replacement Therapy (HRT) 125
REFERENCES
BI-RADS ASSESSMENT
Berkowitz JE, Gatewood OM, Goldblum LE, Gayler BW. Hormonal
replacement therapy: mammographic manifestations. Radiology.
BI-RADS 2. Benign findings. 1990;174:199201.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 139.
DIAGNOSIS Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 2412.
Stomper PC, VanVoorhis BJ, Ravniker VA, Meyer JE. Mammographic
HRT changes associated with postmenopausal hormone replacement
therapy: a longitudinal study. Radiology. 1990;174:48790.
DISCUSSION
a b
Fig. 1.1
a b
Fig. 1.2
Case 52 Complex Cystic and Solid Mass 127
CASE 52 DISCUSSION
COMPLEX CYSTIC AND SOLID MASS
Complex cystic and solid mass can contain:
PATIENT HISTORY Both cystic and solid components
Thickened cystic wall
A 48-year-old female with a mass in the upper outer right Irregular thickened septations
breast. Differential diagnosis of a complex cyst includes:
Benign intracystic papilloma
Invasive papillary carcinoma
RADIOLOGY FINDINGS Intracystic (papillary) DCIS
Tumefactive debris within a complicated cyst
Fig. 1.1 (a) Spot-compression CC, (b) spot-compression Postsurgical seroma or hematoma
MLO, and (c) ML views show an oval mass in the upper Biopsy is recommended for definitive diagnosis by either
outer right breast at middle to posterior depth. ultrasound-guided wire localization or ultrasound-guided
Fig. 1.2 (a) Grayscale and (b) color Doppler images show an core needle biopsy of the solid component of the mass.
oval predominately anechoic mass with an intracystic
hypoechoic mass with vascularity in the right breast.
REFERENCES
a b c
Fig. 1.1
a b
Fig. 1.2
Case 53 Fibroadenoma in a Teenage Patient 129
REFERENCES
BI-RADS ASSESSMENT
Cardenosa G. Breast imaging companion. 3rd ed. Philadelphia:
Lippincott Williams and Wilkins; 2008. p. 1123.
BI-RADS 2. Benign finding (following diagnostic workup Harvey JA, Nicholson BT, LoRusso PT, et al. Short term follow-up of
and biopsy). palpable breast lesions with benign imaging features: evaluation of
375 lesions in 320 women. AJR. 2009;193:172330.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 11720.
DIAGNOSIS
DISCUSSION
Fig. 1.1
a
b
Case 54 Architectural Distortion 131
CASE 54 DISCUSSION
ARCHITECTURAL DISTORTION
In the absence of clinical history of surgery or trauma,
PATIENT HISTORY architectural distortion is suspicious for malignancy or
radial scar, and therefore biopsy is recommended.
A 55-year-old female for a screening mammogram. No his- Architectural distortion can be associated with a mass,
tory of prior breast surgery or breast biopsy. asymmetry, or calcifications.
On mammography, linear opacities radiating from a focal
point or area with no definite central mass are seen.
RADIOLOGY FINDINGS On ultrasound, an associated mass that is central to archi-
tectural distortion can be seen. There can also be thicken-
Fig. 1.1 Spot-magnification (a) CC and (b) ML views show ing and tethering of Cooper ligaments.
an area of architectural distortion in the upper outer left On MRI, an enhancing lesion with distortion or spicu-
breast at middle depth. lated enhancement around the lesion is seen.
Fig. 1.2 (a) Grayscale and (b) color Doppler images demon- Differential diagnosis includes:
strate an irregular hypoechoic mass with spiculated margins Postsurgical scar
and posterior acoustic shadowing. There is vascular flow Radial scar
within the mass. Fat necrosis
IDC
ILC
BI-RADS ASSESSMENT
a b
Fig. 1.1
a b
Fig. 1.2
Case 55 Pseudoangiomatous Stromal Hyperplasia (PASH) 133
CASE 55 DISCUSSION
PSEUDOANGIOMATOUS STROMAL HYPERPLASIA (PASH)
PASH is a benign mesenchymal lesion.
PATIENT HISTORY Most commonly occurs in premenopausal women.
Typically seen as a circumscribed mass on mammogram,
A 51-year-old female for screening mammogram. but spiculated, indistinct, or partially obscured margins
can rarely be seen.
Sonographically, PASH is seen as a solid hypoechoic cir-
RADIOLOGY FINDINGS cumscribed mass.
PASH may clinically present as a firm palpable painless
Fig. 1.1 (a) CC, (b) ML, and (c) spot-compression CC views breast mass.
show a lobular mass at 6 oclock in the right breast at middle Histologically, PASH needs to be distinguished from
depth. angiosarcoma.
Fig. 1.2 (a, b) Grayscale and (c) color Doppler ultrasound If imaging findings are concordant, excision is not indicated.
images show a circumscribed lobular mass with no vascular
flow.
REFERENCES
BI-RADS ASSESSMENT Goel NB, Knight TE, Shilpa P, Riddick-Young M, Shaw de Paredes E,
Trivedi A. Fibrous lesions of the breast: imaging-pathologic correla-
tion. Radiographics. 2005;25:154759.
BI-RADS 2. Benign finding (following diagnostic workup Harvey JA, March DE. Making the diagnosis: a practical guide to breast
and biopsy). imaging. Philadelphia: Elsevier; 2013. p. 304.
Polger MR, Denison CM, Lester S, Meyer JE. Pseudoangiomatous stro-
mal hyperplasia: mammographic and sonographic appearances.
AJR. 1996;166:34952.
DIAGNOSIS
a b
Fig. 1.1
Case 55 Pseudoangiomatous Stromal Hyperplasia (PASH) 135
a b
Fig. 1.2
136 1 Mammography and Ultrasound Review
CASE 56 DISCUSSION
SCLEROSING ADENOSIS
Sclerosing adenosis is a benign lesion caused by mam-
PATIENT HISTORY mary lobular hyperplasia.
Characterized by stromal sclerosis and adenosis.
A 44-year-old female for a screening mammogram. Most common mammographic finding is calcifications.
Calcifications may be amorphous, round, or punctuate.
Rarely, may appear pleomorphic.
RADIOLOGY FINDINGS Less common presentations are spiculated (if associated
with radial sclerosing lesion), circumscribed, or irregular
Fig. 1.1 Spot magnification (a) CC and (b) ML views dem- masses.
onstrate two groups of amorphous and punctuate calcifica- When sclerosing adenosis is diagnosed on core needle
tions in the upper outer and upper inner left breast at anterior biopsy, excision is recommended for suspicious presenta-
depth. tion such as:
Fig. 1.2 MLO view in a different patient demonstrates a Pleomorphic or linear branching calcifications
high-density, oval mass in the retroareolar region of the left Spiculated mass
breast. Architectural distortion
Diagnosis of sclerosing adenosis increases the risk of
invasive cancer by 1.72.5 times.
BI-RADS ASSESSMENT
a b
Fig. 1.1
Fig. 1.2
138 1 Mammography and Ultrasound Review
CASE 57 DISCUSSION
MUCINOUS CARCINOMA
Mucinous carcinoma accounts for 23 % of all breast
PATIENT HISTORY cancers.
Most commonly seen in older postmenopausal women.
A 62-year-old female for a screening mammogram. Family Slow rate of growth.
history of aunt with breast cancer. On mammography, mucinous carcinoma is typically seen
as a circumscribed or ill-defined mass.
A nonspecific hypoechoic mass with posterior acoustic
RADIOLOGY FINDINGS shadowing is seen on ultrasound.
On MRI, T1-weighted images demonstrate a low to high
Fig. 1.1 (a) CC, (b) LM, (c) spot-compression CC, and (d) signal mass, while T2-weighted images demonstrate a high
spot-compression MLO images show an irregular mass with signal mass due to the large mucin component of the tumor.
spiculated margins in the upper inner right breast at posterior On MRI, mucinous carcinoma usually shows gradual per-
depth. sistent or plateau enhancement after the initial upstroke.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound Washout enhancement kinetics not readily seen with
images show a mass with heterogeneous echotexture and mucinous carcinoma.
microlobulated margins. There is vascular flow within the A core biopsy containing mucin can represent a benign
mass. mucocele or a mucinous carcinoma; thus, excision should
be recommended.
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 5. Highly suggestive of malignancy (following
Cardenosa G. Breast imaging companion. 2nd ed. Philadelphia:
diagnostic workup, prior to biopsy). Lippincott Williams and Wilkins; 2001. p. 256.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
imaging. Philadelphia: Elsevier; 2013. p. 299.
DIAGNOSIS Kawashima M, Tamaki Y, Nonaka T, et al. MR imaging of mucinous
carcinoma of the breast. AJR. 2002;179:17983.
Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
Mucinous carcinoma and Wilkins; 1998. p. 587.
Case 57 Mucinous Carcinoma 139
a b
c d
Fig. 1.1
140 1 Mammography and Ultrasound Review
Fig. 1.2
a
b
Case 58 Apocrine Cyst Cluster 141
CASE 58 DISCUSSION
APOCRINE CYST CLUSTER
Epithelial lining of the cysts is composed of columnar/
PATIENT HISTORY cuboidal cells with granular eosinophilic cytoplasm,
resembling the epithelium of apocrine sweat glands.
A 43-year-old female for a screening mammogram. On mammography, apocrine cyst cluster appears as lobu-
lated, circumscribed masses or amorphous and punctuate
calcifications.
RADIOLOGY FINDINGS May contain milk of calcium.
On T1-weighted postcontrast MRI, apocrine cyst cluster
Fig. 1.1 Grayscale ultrasound image demonstrates multiple, appears as lobulated masses with thin rim enhancement
small, adjacent anechoic masses with posterior acoustic and enhanced internal septations.
enhancement. On ultrasound, if clustered microcysts demonstrate a clas-
Fig. 1.2 Color Doppler ultrasound image demonstrates no sic appearance, then no intervention is needed.
vascular flow within the masses. If appearance is not classic, then short-term (6 months)
follow-up is required.
Biopsy is recommended if a solid component is present or
BI-RADS ASSESSMENT if mass is rapidly enlarging.
Fig. 1.1
Fig. 1.2
Case 59 Calcifications in Axillary Lymph Nodes in a Patient with Sarcoidosis 143
REFERENCES
DIAGNOSIS
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-3, p. 367.
Calcifications in axillary lymph nodes in a patient with Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
sarcoidosis Mosby; 2011. p. 396.
DISCUSSION
Fig. 1.1
a
b
Case 60 Fibroadenolipoma (Hamartoma) 145
CASE 60 DISCUSSION
FIBROADENOLIPOMA (HAMARTOMA)
Pathognomonic appearance of a hamartoma on mammo-
PATIENT HISTORY gram is a breast within a breast appearance.
Classic appearance of a hamartoma is an oval or round
A 44-year-old female for a bilateral screening circumscribed mass containing fat and fibroglandular tis-
mammogram. sues. Benign calcifications may be present.
Can occur anywhere in the breast and may be multiple.
Typically asymptomatic and no intervention is necessary.
RADIOLOGY FINDINGS Very rare for breast cancer to develop in a hamartoma.
Fig. 1.1 (a) CC and (b) MLO views show an oval circum-
scribed mass in the lower inner right breast at anterior depth REFERENCES
containing fat and fibroglandular tissue within it, surrounded
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
by a thin capsule. Mosby; 2011. p. 1357.
Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
ed. Cambridge: Cambridge University Press; 2013. p. 623.
Wahner-Roedler DL, Sebo TJ, Gisbold JJ. Hamartomas of the breast:
BI-RADS ASSESSMENT
clinical, radiologic, and pathologic manifestations. Breast J.
2001;7(2):1015.
BI-RADS 2. Benign finding.
DIAGNOSIS
Fibroadenolipoma (hamartoma)
146 1 Mammography and Ultrasound Review
a b
Fig. 1.1
Case 61 Atypical Ductal Hyperplasia (ADH) 147
CASE 61 DISCUSSION
ATYPICAL DUCTAL HYPERPLASIA (ADH)
ADH is considered as a high-risk lesion, which should be
PATIENT HISTORY surgically excised.
Most common presentation is amorphous calcifications.
A 45-year-old female for a screening mammogram. Grouped distribution occurs more often than regional
distribution.
Four to five times increased risk for developing invasive
RADIOLOGY FINDINGS breast cancer in either breast.
Fig. 1.1
a
b
Case 62 Angiolipoma 149
CASE 62 DISCUSSION
ANGIOLIPOMA
Angiolipoma typically presents as a painless mass.
PATIENT HISTORY Pathologically, the hallmark of an angiolipoma is scat-
tered microthrombi in small blood vessels.
A 54-year-old female with a history of a palpable mass at 9 There is no typical mammographic appearance of an
oclock in the left breast. angiolipoma. Mammogram may be negative and show an
asymmetry or a mass.
The key to diagnosis is suggested by the homogeneous
RADIOLOGY FINDINGS echogenic ultrasound appearance.
Differential diagnosis for a hyperechoic mass includes the
Fig. 1.1 Spot-compression (a) CC and (b) MLO images following:
show a predominately fatty breast with no mammographic Acute hemorrhage
finding corresponding to the triangular marker. Acute hematoma
Fig. 1.2 (a) Grayscale and (b) color Doppler images of the Focal fibrosis
left breast corresponding to the palpable mass reveal a homo- Hemangioma
geneously hyperechoic oval avascular mass with circum- Angiolipoma
scribed margins. Lipoma
Malignancy
Angiolipoma of the breast is noninfiltrative, and thus
BI-RADS ASSESSMENT treatment is surgical excision.
Weinstein SP, Conant EF, Acs G. Case 59: angiolipoma of the breast.
Radiology. 2003;227:7735.
DIAGNOSIS
Angiolipoma
150 1 Mammography and Ultrasound Review
a b
Fig. 1.1
Case 62 Angiolipoma 151
Fig. 1.2
a
b
152 1 Mammography and Ultrasound Review
CASE 63 DISCUSSION
MICROPAPILLARY CARCINOMA
Micropapillary carcinoma accounts for 0.73 % of all
PATIENT HISTORY breast cancers.
Metastasis to axillary lymph nodes is common.
A 31-year-old female with a history of right breast DCIS sta- Micropapillary carcinoma is an aggressive tumor with
tus postbilateral mastectomies with reconstruction; patient poor prognosis.
for screening MRI. On mammography, a high-density irregular mass with
spiculated margins is seen, commonly with associated
microcalcifications.
RADIOLOGY FINDINGS Sonographically seen as an irregular solid hypoechoic
mass with indistinct margins.
Fig. 1.1 Sagittal (a) contrast-enhanced T1-weighted and (b) On MRI, an enhancing mass or area of non-mass-like
subtracted T1-weighted images demonstrate adjacent enhancement is seen.
enhancing masses posterior to the implant.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound
images show an irregular hypoechoic mass with indistinct REFERENCES
margins and vascular flow.
Adrada B, Arribas E, Gilcrease M, Yang WT. Invasive micropapillary
carcinoma of the breast: mammographic, sonographic and MRI fea-
tures. AJR. 2009;190:W5863.
BI-RADS ASSESSMENT Gunhan-Bilgen I, Zekioglu O, Ustun EE, Memis A, Erhan Y. Invasive
micropapillary carcinoma of the breast: clinical, mammographic
BI-RADS 4. Suspicious abnormality (following diagnostic and sonographic findings with histopathologic correlation. AJR.
2002;179:92731.
workup, prior to biopsy).
DIAGNOSIS
Micropapillary carcinoma
Case 63 Micropapillary Carcinoma 153
a b
Fig. 1.1
a b
Fig. 1.2
154 1 Mammography and Ultrasound Review
CASE 64 DISCUSSION
INTRADUCTAL PAPILLOMA ON GALACTOGRAPHY
Galactography is an examination to visualize lesions in
PATIENT HISTORY mammary ducts using contrast.
Once an intraductal lesion is visualized, image-guided
A 45-year-old female with unilateral spontaneous clear nip- biopsy or wire localization and excision can be performed.
ple discharge. Bloody nipple discharge whether spontaneous or with
stimulation is an indication for galactography.
Spontaneous, clear, or serous nipple discharges from a
RADIOLOGY FINDINGS single duct are also indications for galactography.
Patient may experience increased discharge for several
Fig. 1.1 (a) CC and (b) ML views after contrast administra- days after the procedure.
tion demonstrate a frond-like filling defect in a retroareolar Complications include the following:
central duct in the right breast. Ruptured duct
Fig. 1.2 CC view in a different patient demonstrates an oval Mastitis
filling defect in a retroareolar duct. Vasovagal reaction
ASSESSMENT REFERENCES
High-risk lesion. Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section V-2, p. 45.
Slawson SH, Johnson B. Ductography: how to and what if?
Radiographics. 2001;21:13350.
DIAGNOSIS
a b
Fig. 1.1
156 1 Mammography and Ultrasound Review
Fig. 1.2
Case 65 Tubular Carcinoma 157
DIAGNOSIS
Tubular carcinoma
DISCUSSION
Fig. 1.2
Fig. 1.1
Case 65 Tubular Carcinoma 159
Fig. 1.3
160 1 Mammography and Ultrasound Review
CASE 66 DIAGNOSIS
RECURRENT INVASIVE DUCTAL CARCINOMA
IN A TRAM FLAP Recurrent invasive ductal carcinoma in a TRAM flap
PATIENT HISTORY
DISCUSSION
A 44-year-old female with a history of left breast cancer sta-
tus postmastectomy and TRAM (transverse rectus abdomi- TRAM flap is an autologous means of breast reconstruc-
nis myocutaneous) flap reconstruction for screening tion following mastectomy.
mammogram. A TRAM flap appears radiolucent on mammogram; pre-
dominantly fatty appearance with variable density depend-
ing on muscle component and postoperative scarring.
RADIOLOGY FINDINGS Controversy exists about whether routine screening mam-
mogram is indicated to detect nonpalpable recurrent breast
Fig. 1.1 (a) CC and (b) MLO images show an irregular mass cancer in a TRAM flap.
with spiculated margins in the upper outer left TRAM flap at Mammographic presentation of cancer in a TRAM flap has
posterior depth. There is a microclip from a prior biopsy in an appearance similar to that of primary breast cancer.
the upper TRAM flap at posterior depth.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound
images show a hypoechoic irregular mass with spiculated REFERENCES
margins and vascular flow.
Fig. 1.3 (a) Sagittal subtracted T1-weighted and (b) axial Helvie MA, Bailey JE, Roubidoux MA, et al. Mammographic screen-
ing of TRAM flap breast reconstructions for detection of nonpalpa-
contrast-enhanced delayed T1-weighted images show a het- ble recurrent cancer. Radiology. 2002;224:2116.
erogeneously enhancing irregular mass with spiculated mar- Hogge J, Zuurbier RA, de Paredes ES. Mammography of autologous
gins in the left TRAM flap at posterior depth. myocutaneous flaps. Radiographics. 1999;19:S6372.
Lee JM, Georgian-Smith D, Gazelle GS, et al. Detecting nonpalpable
recurrent breast cancer: the role of routine mammographic screen-
ing of transverse rectus abdominis myocutaneous flap reconstruc-
BI-RADS ASSESSMENT tions. Radiology. 2008;248:398405.
a b
Fig. 1.1
a b
Fig. 1.2
162 1 Mammography and Ultrasound Review
Fig. 1.3
Case 67 Nonpuerperal Abscess of the Breast 163
a b
Fig. 1.1
a b
Fig. 1.2
Case 68 Small Cell Carcinoma Metastasis 165
CASE 68 DISCUSSION
SMALL CELL CARCINOMA METASTASIS
Small cell carcinoma is an aggressive neuroendocrine
PATIENT HISTORY tumor, which most commonly occurs in the lung.
Small cell carcinoma has been seen ranging from a circum-
A 67-year-old male with shortness of breath. scribed to an ill-defined marginated mass on mammogram.
On ultrasound, small cell carcinoma has been seen as a
hypoechoic mass with microlobulated borders.
RADIOLOGY FINDINGS Most common metastatic lesion to the breast is metastasis
from a contralateral breast cancer.
Fig. 1.1 PA view of the chest shows right perihilar fullness. Most common extramammary metastatic diseases to the
Fig. 1.2 Contrast-enhanced CT scan shows (a) right hilar breast include:
adenopathy and (b) a mass in the right breast adjacent to the Melanoma
pectoralis muscle. Non-Hodgkins lymphoma
Fig. 1.3 A portion of a dense mass is seen in the retroareolar Lung carcinoma
plane at posterior depth only on MLO view. Metastatic disease to the breast is more likely to be bilat-
Fig. 1.4 (a) Grayscale and (b) color Doppler ultrasound eral or multiple when compared with primary breast
images show a hypoechoic mass with indistinct margins and cancers.
no vascular flow. Usually metastatic diseases to the breast present as round
masses with circumscribed or ill-defined margins.
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 5. Highly suggestive of malignancy (following
Feder JM, Shaw de Paredes E, Hogge JP, Wilken JJ. Unusual breast
diagnostic workup, prior to biopsy). lesions: radiologic and pathologic correlation. Radiographics.
1999;19:S1126.
Irshad A, Ackerman SJ, Pope TL, Moses CK, Rumboldt T, Panzegrau
DIAGNOSIS B. Rare breast lesions: correlation of imaging and histologic fea-
tures with WHO classification. Radiographics. 2008;28:1399414.
Mariscal A, Balliu E, Diaz R, Casas JD, Gallant AM. Primary oat cell
Small cell carcinoma rarely metastasizes to the breast carcinoma of the breast: imaging features. AJR. 2004;183:116971.
166 1 Mammography and Ultrasound Review
Fig. 1.1
a b
Fig. 1.2
Case 68 Small Cell Carcinoma Metastasis 167
DIAGNOSIS Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-3, p. 303.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Bilateral axillary lymphadenopathy in a patient with chronic Mosby; 2011. p. 3957.
lymphocytic leukemia Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
ed. Cambridge: Cambridge University Press; 2013. p. 633.
DISCUSSION
a b
c d
Fig. 1.1
170 1 Mammography and Ultrasound Review
CASE 70 DISCUSSION
CALCIFIED FIBROADENOMA (INVOLUTING FIBROADENOMA)
Fibroadenomas are the most common benign breast mass.
PATIENT HISTORY Fibroadenomas are oval masses that can occasionally
present with coarse or popcorn-like calcifications.
A 57-year-old female for a bilateral screening mammogram. Usually, calcified fibroadenomas are seen after menopause.
Calcifications within a fibroadenoma typically start at its
periphery, moving toward the center. Fibroadenomas can
RADIOLOGY FINDINGS often become completely calcified.
Coarse or popcorn calcifications are pathognomonic of a
Fig. 1.1 (a) CC and (b) MLO views show an oval mass with fibroadenoma that has undergone involution and hyaline
associated coarse calcifications in the lower outer left breast degeneration.
at middle depth. There is a microclip incidentally seen in the
upper outer left breast at middle depth.
REFERENCES
Calcified fibroadenoma
Case 70 Calcified Fibroadenoma (Involuting Fibroadenoma) 171
a b
Fig. 1.1
172 1 Mammography and Ultrasound Review
CASE 71 DISCUSSION
GRANULAR CELL TUMOR
A granular cell tumor is composed of a nest or sheets of
PATIENT HISTORY cells that contain eosinophilic cytoplasmic granules.
Usually benign; malignant in approximately 2 %.
A 50-year-old female with a palpable lump in the right On mammography, a high-density mass without calcifica-
breast. tions is seen.
On ultrasound, an irregular, hypoechoic mass is seen,
which may have posterior acoustic shadowing.
RADIOLOGY FINDINGS Imaging appearance may mimic a breast cancer.
Although granular cell tumor is most commonly benign,
Fig. 1.1 (a) CC, (b) MLO, and spot-compression (c) CC and surgical excision is recommended.
(d) MLO views show an irregular spiculated mass in the
lower inner quadrant of the right breast posteriorly.
Fig. 1.2 (a, b) Grayscale and (c) color Doppler ultrasound REFERENCES
show an irregular avascular hypoechoic mass with angular
margins. Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging: breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 945.
Gogas J, Markopoulos C, Kouskos E, et al. Granular cell tumor of the
breast: a rare lesion resembling breast cancer. Eur J Gynaecol
BI-RADS ASSESSMENT Oncol. 2002;23(4):3334.
DIAGNOSIS
a b
c d
Fig. 1.1
174 1 Mammography and Ultrasound Review
a b
Fig. 1.2
Case 72 Hematoma 175
DIAGNOSIS
DISCUSSION
Fig. 1.1
a
b
Case 73 Angiosarcoma 177
CASE 73 DISCUSSION
ANGIOSARCOMA
Angiosarcoma is a malignant stromal breast neoplasm.
PATIENT HISTORY Mean age at diagnosis is 35 years.
Increased risk of developing angiosarcoma following
An 83-year-old female with complaints of palpable mass radiation exposure.
with associated breast pain and tenderness in the right breast; Usually a palpable rapidly enlarging mass. May have
history of right lumpectomy in 1998. associated overlying bluish skin discoloration.
On mammography, angiosarcoma appears as a mass with
microlobulated or indistinct margins.
RADIOLOGY FINDINGS On ultrasound, angiosarcoma appears as a hypoechoic
circumscribed or spiculated mass.
Fig. 1.1 (a) CC, (b) ML, and spot-compression (c) CC and On MRI, angiosarcoma is low signal on T1-weighted
(d) MLO views show a contour deformity in the retroareolar images, is higher signal on T2-weighted images, and dem-
right breast, compatible with history of right lumpectomy. onstrates enhancement of the mass with a low-intensity
Adjacent to this area, there is a focal asymmetry with associ- central region.
ated architectural distortion on the CC view.
Fig. 1.2 (a, b) There is also skin thickening and increased
trabecular pattern when compared to the prior mammogram REFERENCES
1 year ago. Targeted ultrasound was negative.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging: breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 1767.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
BI-RADS ASSESSMENT Mosby; 2011. p. 399.
Lilaia C, Pereira F, Andre S, Cabrita B. Breast angiosarcoma. Internet J
BI-RADS 4. Suspicious abnormality (following diagnostic Gynecol Obstet. 2007;6(2).
workup, prior to biopsy).
DIAGNOSIS
Angiosarcoma
178 1 Mammography and Ultrasound Review
Fig. 1.1
a b
c d
Case 73 Angiosarcoma 179
a b
Fig. 1.2
180 1 Mammography and Ultrasound Review
CASE 74 DISCUSSION
FREE SILICONE OIL INJECTIONS
Silicone oil injections into breast parenchyma are per-
PATIENT HISTORY formed for cosmetic augmentation.
The procedure is most frequently performed in China.
A 46-year-old female for a bilateral screening mammogram. Patients can complain of focal or diffuse lumps, pain, or
discomfort.
Typically, mammography and ultrasound are not sensitive
RADIOLOGY FINDINGS for breast cancer detection following free silicone injection.
Postcontrast MRI of the breast may be more useful for
Fig. 1.1 (a, b) CC and (c, d) MLO views demonstrate mul- breast cancer detection.
tiple, diffuse, bilateral, innumerable, round, and oval dense
masses with rim calcifications.
REFERENCES
BI-RADS ASSESSMENT Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
Mosby; 2011. p. 845, 34950.
Scaranelo AM, de Fatima Ribeiro Maia M. Sonographic and mammo-
BI-RADS 2. Benign findings. graphic findings of breast liquid silicone injection. J Clin Ultrasound.
2006;34(6):2737.
Yang WT, Suen M, Ho WS, Metreweli C. Paraffinomas of the breast:
mammographic, ultrasonographic and radiographic appearances
DIAGNOSIS with clinical and histopathological correlation. Clin Radiol.
1996;51:1303.
Free silicone oil injections
Case 74 Free Silicone Oil Injections 181
a b
c d
Fig. 1.1
182 1 Mammography and Ultrasound Review
CASE 75 DISCUSSION
PHYLLODES TUMOR
Phyllodes tumor is a large rapidly growing circumscribed
PATIENT HISTORY mass without calcifications.
Phyllodes tumor contains papillary growths of epithelial-
A 52-year-old female with a palpable mass in the upper inner lined stroma in a leaflike configuration.
left breast. Has both stromal and epithelial elements.
Median age is 4549 years.
About 25 % of phyllodes tumors are malignant and 20 %
RADIOLOGY FINDINGS of the malignant subtype may metastasize.
Complete surgical excision is recommended and often
Fig. 1.1 (a) CC and (b) MLO views show an oval circum- curative.
scribed mass in the upper inner left breast at posterior depth Twenty-one percent risk of recurrence, most within
corresponding to the triangular marker indicating a palpable 2 years.
mass.
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound
images show an oval circumscribed hypoechoic avascular REFERENCES
mass.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 968.
Ikeda DM. Breast imaging the requisites. 2nd ed. Philadelphia: Elsevier,
BI-RADS ASSESSMENT Mosby; 2011. p. 120, 126.
Mandell J. Core radiology: a visual approach to diagnostic imaging. 1st
BI-RADS 4. Suspicious abnormality (following diagnostic ed. Cambridge: Cambridge University Press; 2013. p. 627.
workup, prior to biopsy).
DIAGNOSIS
Phyllodes tumor
Case 75 Phyllodes Tumor 183
a b
Fig. 1.1
a b
Fig. 1.2
184 1 Mammography and Ultrasound Review
CASE 76 DISCUSSION
DCIS COMEDONECROSIS
DCIS comedonecrosis is a high-grade type of DCIS.
PATIENT HISTORY It is associated with rapid growth and necrosis of the cen-
tral duct.
A 43-year-old female for a screening mammogram. Calcifications are the hallmark of DCIS comedonecrosis.
Classic appearance is fine, linear branching-type calcifi-
cations, in either a linear or segmental distribution.
RADIOLOGY FINDINGS Majority of patients are asymptomatic at time of
presentation.
Fig. 1.1 (a) CC, (b) LM, and spot-magnification (c) CC view Associated with higher rate of recurrence than other sub-
and (d) LM views demonstrate a segmental area of fine lin- types of DCIS due to high nuclear grade and radiation
ear branching calcifications at 12 oclock in the right breast resistance of the tumor.
at anterior to middle depth.
REFERENCE
BI-RADS ASSESSMENT
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV-2, p. 11821.
BI-RADS 5. Highly suggestive for malignancy (following
diagnostic workup, prior to biopsy).
DIAGNOSIS
DCIS comedonecrosis
Case 76 DCIS Comedonecrosis 185
a
c
Fig. 1.1
186 1 Mammography and Ultrasound Review
CASE 77 DISCUSSION
BILATERAL BREAST CANCER
There is a one in eight lifetime probability of developing
PATIENT HISTORY breast cancer.
Breast cancer is the second leading cause of cancer mor-
A 90-year-old female with a history of palpable masses in tality (15 % of all cancer deaths).
both breasts. Risk factors for breast cancer include the following:
Higher incidence in women
Increasing age
RADIOLOGY FINDINGS Personal history of breast cancer
First-degree relative with breast cancer
Fig. 1.1 (a, b) CC and (c, d) MLO images show an oval mass Early menarche
with angular margins and associated coarse calcifications at Late menopause
12 oclock in the right breast at middle depth. There is also an Nulliparous
irregular mass with spiculated margins and associated coarse First birth after the age of 30 years
calcifications at 3 oclock in the left breast at middle depth. Atypical ductal hyperplasia (ADH)
Fig. 1.2 (a) Grayscale and (b) color Doppler ultrasound Atypical lobular hyperplasia (ALH)
images show an oval hypoechoic mass with angular margins Lobular carcinoma in situ (LCIS)
that has internal vascularity in the right breast. Juvenile papillomatosis
Fig. 1.3 (a) Grayscale and (b) color Doppler ultrasound BRCA-1, BRCA-2 gene mutations
images show an irregular spiculated hypoechoic mass that is History of radiation exposure to the chest wall
avascular and demonstrates posterior acoustic shadowing in Patients with breast cancer have increased risk of devel-
the left breast. oping either synchronous or metachronous breast cancer,
which ranges between 0.5 and 0.8 % each year.
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 5. Highly suspicious for malignancy (following
diagnostic workup, prior to biopsy). Cardenosa G. Breast imaging companion. 3rd ed. Philadelphia:
Lippincott Williams and Wilkins; 2008. p. 12.
Tousimis E. Synchronous bilateral invasive breast cancer. Breast Cancer
Online. 2008;8(4).
DIAGNOSIS
a b
c d
Fig. 1.1
188 1 Mammography and Ultrasound Review
Fig. 1.2
a
b
Case 77 Bilateral Breast Cancer 189
Fig. 1.3
190 1 Mammography and Ultrasound Review
CASE 78 Can arise anywhere in the skin of the breast and axilla.
SEBACEOUS CYST/EPIDERMAL INCLUSION CYST Clinically and on imaging, sebaceous cysts and epidermal
inclusion cysts are indistinguishable from each other.
PATIENT HISTORY Equally seen in males and females.
Clinically, sebaceous and epidermal inclusion cysts pres-
A 52-year-old female with a palpable finding in the left ent as elevated, palpable, smooth, and firm skin lesions.
breast for 2 months. The claw sign on ultrasound is an echogenic line repre-
senting the skin which wraps around the lesion. It helps
determine the dermal location of these lesions.
RADIOLOGY FINDINGS There is no malignant potential for sebaceous cysts, and it
is extremely rare in epidermal inclusion cysts.
Fig. 1.1 (a) MLO and (b) spot-compression CC views dem- Biopsy of sebaceous cysts and epidermal inclusion cysts
onstrate a partially visualized circumscribed, high-density should be avoided, as it may incite an inflammatory
oval mass in the upper outer left breast at posterior depth, at response.
the site of the palpable finding. Excision is for symptomatic relief.
Fig. 1.2 Grayscale ultrasound image demonstrates an oval, Calcifications are present in 20 % of epidermal inclusion
hypoechoic mass with posterior acoustic enhancement. cysts.
Hypoechoic line is seen extending from the mass to the skin.
Fig. 1.3 MLO view in a different patient demonstrates an
oval mass with circumscribed margins containing punctuate REFERENCES
calcifications in the upper left breast.
Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of diseases of the
breast. 2nd ed. Philadelphia: Elsevier; 2005. p. 399400.
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
BI-RADS ASSESSMENT 1st ed. Salt Lake City: Amirsys; 2006. Section IV-3, p. 16.
Bergmann-Koester CU, Kolberg HC, Rudolf I, Krueger S, Gellissen J,
BI-RADS 2. Benign finding (following diagnostic workup). Stoeckelhuber BM. Epidermal cyst of the breast mimicking malig-
nancy: clinical, radiological, and histological correlation. Arch
Gynecol Obstet. 2006;273(5):3124.
Harvey JA, March DE. Making the diagnosis: a practical guide to breast
DIAGNOSIS imaging. Philadelphia: Elsevier; 2013. p. 189.
DISCUSSION
Fig. 1.2
Fig. 1.1
Fig. 1.3
192 1 Mammography and Ultrasound Review
DIAGNOSIS
REFERENCES
Displaced biopsy site marker after stereotactic core needle
biopsy Esserman LE, Cura MA, DaCosta D. Recognizing pitfalls in early and
late migration of clip markers after imaging-guided directional vac-
uum-assisted biopsy. Radiology. 2004;24:14756.
Rosen EL, Vo TT. Metallic clip deployment during stereotactic breast
DISCUSSION biopsy: retrospective analysis. Radiology. 2001;218:5106.
a b
Fig. 1.1
MRI Case Review
B.A. Shah et al., Breast Imaging Review: A Quick Guide to Essential Diagnoses, 195
DOI 10.1007/978-3-319-07791-8_2, Springer International Publishing Switzerland 2015
196 2 MRI Case Review
REFERENCES
DISCUSSION
Genson CC, Blane CE, Helvie MA, Waits SA, Chenevert TL. Effects
on breast MRI of artifacts caused by metallic tissue marker clips.
Artifacts from metallic artifacts are also called black hole Am J Roentgoenol. 2007;188:37276.
artifacts or susceptibility artifacts. Harvey JA, Hendrick RE, Coll JM, Nicholson BT, Burkholde BT,
Susceptibility artifacts manifest as signal voids on gradi- Cohen MA. Breast MR imaging artifacts. How to recognize and fix
ent echo sequences. On spin echo sequences, a signal them. Radiographics. 2007;27:S13745.
Case 1 MRI Artifacts 197
Fig. 2.1
Fig. 2.3
Fig. 2.2
Fig. 2.4
198 2 MRI Case Review
Fig. 2.5
Fig. 2.6
Case 1 MRI Artifacts 199
Fig. 2.7
200 2 MRI Case Review
Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section IV 1, p. 17477.
DIAGNOSIS Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. 1st ed. New York: Springer; 2005. p. 614.
Rim enhancement (edge enhancement)
DISCUSSION
Fig. 2.1
a b
Fig. 2.2
202 2 MRI Case Review
Fig. 2.3
a
b
Case 2 RIM Enhancement 203
Fig. 2.4
a
b
204 2 MRI Case Review
CASE 3 DISCUSSION
SIMPLE CYSTS
Simple cysts are the most common breast masses seen on
PATIENT HISTORY MRI.
Simple cysts are of low signal intensity or equal to adja-
A 52-year-old female for screening breast MRI. cent fibroglandular tissue on T1-weighted images and of
high signal intensity on T2-weighted images.
If there is protein content in the fluid, the cyst may be
RADIOLOGY FINDINGS intermediate to high signal on T1-weighted images.
There is no enhancement on postcontrast imaging.
Fig. 2.1 (a) Sagittal T2-weighted image demonstrates mul- There may be thin, peripheral rim enhancement if the
tiple round and oval circumscribed high-signal-intensity cysts are inflamed.
masses in the breast. (b) Sagittal subtracted T1-weighted
image demonstrates no enhancement of the masses.
REFERENCES
BI-RADS ASSESSMENT Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. p. 4851. Section IV 1.
Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
BI-RADS 2. Benign findings. tion. New York: Springer; 2005. p. 14752.
DIAGNOSIS
Simple cysts
Case 3 Simple Cysts 205
Fig. 2.1
a
b
206 2 MRI Case Review
CASE 4 DIAGNOSIS
INVASIVE DUCTAL CARCINOMA (IDC)
WITH AXILLARY LYMPH NODE METASTASIS Invasive ductal carcinoma (not otherwise specified) with
axillary lymph node metastasis (IDC)
PATIENT HISTORY
a b
Fig. 2.1
Fig. 2.2
208 2 MRI Case Review
Fig. 2.3
a b
Fig. 2.4
Case 5 Intracapsular Rupture of Silicone Breast Implant 209
BI-RADS ASSESSMENT
REFERENCES
BI-RADS 2. Benign finding.
Deangelis GA, Lange EE, Miller LR, Morgan RF. MR imaging of
breast implants. Radiographics. 1994;14:78394.
Everson LI, Parantainen H, Detlie T, et al. Diagnosis of breast implant
DIAGNOSIS rupture: imaging findings and relative efficacies of imaging tech-
niques. AJR. 1994;163:5760.
Intracapsular rupture of silicone breast implant Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. New York: Springer; 2005. p. 23949.
DISCUSSION
a b
Fig. 2.1
Fig. 2.2
Case 6 Extracapsular Rupture of Silicone Breast Implant 211
BI-RADS ASSESSMENT Caskey CI, Berg WA, Hamper UM, Sheth S, Chang BW, Anderson
ND. Imaging spectrum of extracapsular silicone: correlation of
ultrasound, MR imaging, mammographic and histopathologic find-
BI-RADS 2. Benign finding. ings. Radiographics. 1999;19:S3951.
Everson LI, Parantainen H, Detlie T, et al. Diagnosis of breast implant
rupture: imaging findings and relative efficacies of imaging tech-
niques. AJR. 1994;163:5760.
DIAGNOSIS Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. New York: Springer; 2005. p. 23949.
Extracapsular rupture of silicone breast implant
DISCUSSION
a b
c d
Fig. 2.1
Case 7 Fibroadenoma 213
CASE 7 DISCUSSION
FIBROADENOMA
Most common benign breast mass.
PATIENT HISTORY More common in young women.
Fibroadenomas contain epithelial and stromal elements.
A 46-year-old female with a strong family history of breast In younger women, fibroadenomas contain greater amount
cancer. BRCA1 gene carrier. of epithelial elements than stromal elements. In postmeno-
pausal women, fibroadenomas contain greater amount of
stromal elements.
RADIOLOGY FINDINGS Signal intensity and contrast enhancement depend on
fluid content in the mass.
Fig. 2.1 (a) Sagittal T1-weighted image demonstrates an Fibroadenomas are of low signal on T1-weighted images.
oval low-signal-intensity mass in the upper breast at anterior Myxoid fibroadenomas are high signal on T2-weighted
depth. (b) Sagittal subtracted T1-weighted image demon- images and have homogeneous enhancement.
strates the mass in the upper breast to be homogeneously As the fibroadenomas become less cellular and more scle-
enhancing. rotic, enhancement decreases.
Fig. 2.2 Sagittal fat-suppressed T2-weighted image in a dif- Nonenhancing internal septations are diagnostic of
ferent patient demonstrates a mass in the retroareolar plane fibroadenomas.
at middle depth to be high signal relative to adjacent tissue. Kinetic curve is persistent or plateau.
A cyst is seen in the lower breast.
Fig. 2.3 Kinetic curve demonstrates plateau enhancement
(type II). REFERENCES
Hochman MG, Orel SG, Powell CM, Schnall MD, Reynolds CA, White
LN. Fibroadenomas: variety of MR appearances with radiologic
BI-RADS ASSESSMENT histopathologic correlation. Radiology. 1997;204:12329.
Morris EA, Liberman L, editors. Breast MRI Diagnosis and Intervention.
BI-RADS 2. Benign finding (following diagnostic workup New York: Springer; 2005. p. 141.
and biopsy).
DIAGNOSIS
Fibroadenoma
214 2 MRI Case Review
Fig. 2.2
Fig. 2.1
Case 7 Fibroadenoma 215
Fig. 2.3
216 2 MRI Case Review
DISCUSSION
a b
Fig. 2.1
Fig. 2.2
Fig. 2.3
218 2 MRI Case Review
CASE 9 DISCUSSION
PAPILLOMA
Papillomas seen on MRI tend to be associated with dilated
PATIENT HISTORY ducts.
Papillomas and associated dilated ducts are of low signal
A 45-year-old female with lifetime risk of breast cancer intensity on noncontrast T1-weighted images unless the
>20 %. Screening breast MRI. duct fluid has increased protein or hemorrhage.
On postcontrast T1-weighted images, papillomas enhance
uniformly unless there are areas of sclerosis.
RADIOLOGY FINDINGS Papillomas tend to be mammographically occult.
May be solitary or multiple.
Fig. 2.1 Axial subtracted T1-weighted image demonstrates Solitary papillomas are mostly central in location in a
an enhancing mass with circumscribed margins in the ret- major duct.
roareolar plane at middle depth. There is an adjacent enhanc- Multiple papillomas are mostly peripheral and can be
ing tubular structure representing a dilated duct. bilateral.
Fig. 2.2 Kinetic curve demonstrates plateau enhancement They arise from a terminal ductal lobular unit.
(type II) of the mass. When diagnosed by core needle biopsy, excision is gener-
Fig. 2.3 Axial subtracted T1-weighted image in a different ally recommended due to potential of upgrade to high-
patient demonstrates an enhancing oval mass with circum- risk lesion or malignancy.
scribed margins in the retroareolar plane at a middle depth.
REFERENCES
BI-RADS ASSESSMENT
Morris EA, Liberman L, editors. Breast MRI diagnosis and interven-
tion. New York: Springer; 2005. p. 14147.
High-risk lesion. Rovno HD, Siegelman ES, Reynolds C, Orell HG, Schnall MD. Solitary
intraductal papilloma: findings at MR imaging and MR galactogra-
phy. AJR. 1999;172:1515.
DIAGNOSIS
Papilloma
Case 9 Papilloma 219
Fig. 2.1
Fig. 2.2
220 2 MRI Case Review
Fig. 2.3
Case 10 Recurrence After Mastectomy 221
BI-RADS 4. Suspicious abnormality (following diagnostic Berg WA, Birdwell RL, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. p. 547. Section IV.
workup, prior to biopsy). Molleran VM, Mahoney M. Breast MRI. 1st ed. Philadelphia: Saunders;
2014. p. 1323.
DIAGNOSIS
DISCUSSION
CASE 11 DISCUSSION
INVASIVE LOBULAR CARCINOMA (ILC)
WITH AXILLARY LYMPH NODE METASTASIS ILC accounts for 1015 % of all invasive breast cancers,
being the second most common breast cancer.
PATIENT HISTORY Presentations of ILC on MRI include the following:
Ill-defined mass with spiculated margins
A 50-year-old female with recent diagnosis of left invasive Enhancing architectural distortion
lobular carcinoma. MRI for treatment planning. Single mass with surrounding multiple enhancing foci
Enhancing foci with interconnecting strands or
regional or focal heterogeneous enhancement
RADIOLOGY FINDINGS No imaging findings (negative MRI)
Unlike other invasive breast cancers that demonstrate
Fig. 2.1 Axial (a) contrast-enhanced T1-weighted and (b) rapid enhancement and washout, ILC has a tendency to
subtracted T1-weighted images show two adjacent heteroge- demonstrate delayed maximal enhancement. Only the
neously enhancing irregular masses with spiculated margins minority of ILC exhibit washout kinetics.
in the left breast at middle depth.
Fig. 2.2 Sagittal contrast-enhanced delayed T1-weighted
image demonstrates the larger of the two heterogeneously REFERENCES
enhancing masses in the upper left breast at middle depth.
Fig. 2.3 Axial subtracted T1-weighted image shows an Lopez JK, Bassett LW. ILC of the breast: spectrum of mammography,
US and MRI imaging findings. Radiographics. 2009;29:16576.
enlarged enhancing lymph node in the left axilla. Qayyum A, Birdwell RL, Daniel BL. MRI imaging features of infiltrat-
ing lobular carcinoma of the breast: histopathologic correlation.
AJR. 2002;178:122732.
BI-RADS ASSESSMENT
DIAGNOSIS
a b
Fig. 2.1
Fig. 2.3
Fig. 2.2
Case 12 Breast Cancer with Involvement of the Pectoralis Muscle 225
a b
Fig. 2.1
Case 13 Ductal Carcinoma In Situ, Low Grade (DCIS) 227
CASE 13 DIAGNOSIS
DUCTAL CARCINOMA IN SITU, LOW GRADE (DCIS)
Ductal carcinoma in situ, low grade (DCIS)
PATIENT HISTORY
a b
Fig. 2.1
Fig. 2.2
Fig. 2.3
Appendix 1: Interventional Breast Procedures
B.A. Shah et al., Breast Imaging Review: A Quick Guide to Essential Diagnoses, 229
DOI 10.1007/978-3-319-07791-8, Springer International Publishing Switzerland 2015
230 Appendix 1: Interventional Breast Procedures
Mammography-Guided Wire Localization Image is obtained to assure the hub of the needle is seen
over the lesion on the mammogram, thus assuring that the
Indication X and Y coordinate is accurate.
The breast is taken out of compression and placed in
Excision of previously diagnosed cancer or high-risk orthogonal compression.
lesion and localization of lesion not amenable to stereo- An image is obtained in the orthogonal view to assess the
tactic or ultrasound guided biopsy. depth of the needle, noting that the needle should traverse
the lesion (the actual amount that the needle should tra-
Procedure Steps verse the lesion depends on the needle/wire system being
Obtain informed written consent. used).
Determine approach by assessing shortest distance to the The wire is placed through the hollow needle.
lesion on craniocaudal view (superior or inferior Using the pinchpull technique, the wire is held in place
approach) or on lateral view (medial or lateral approach). while the needle is removed from the breast.
Place breast in grid compression with opening of window The hook of the wire is deployed within the breast once
placed over the skin of the determined approach (e.g., if the needle is removed.
taking a superior approach, the breast is placed in cranio- The final image is obtained to document that the wire is
caudal compression with the open grid window over the through the lesion.
superior aspect of the breast). The specimen is sent for radiograph to assure that the
Imaging obtained to localize the lesion is within the win- lesion is within the specimen and that the wire has been
dow of the grid. removed from the breast intact.
X and Y coordinates of the lesion determined using the
grid. Reference
Crosshairs are placed to form a target on the breast. Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 1998. p. 63792.
Skin is cleansed and local anesthesia is used to anesthe-
tize the skin and deeper tissue.
The needle is advanced through the lesion, perpendicular
to the skin at the determined target, allowing the cross-
hairs to be seen forming a cross over the hub of the needle.
232 Appendix 1: Interventional Breast Procedures
Ultrasound-Guided Core Biopsy Inner stylet of coaxial trocar removed. Biopsy device
placed through coaxial trocar.
Indication Samples obtained of the mass.
Stainless steel or titanium biopsy site marker placed in the
Sonographically detected mass or axillary lymph node mass through coaxial trocar.
requiring a pathologic diagnosis. Postprocedure 2-view mammogram of the breast biopsied
should be obtained to demonstrate clip placement.
Procedure Steps
Obtain informed consent. References
Skin is cleansed and a local anesthetic is administered to Berg WB, Birdwell RB, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section V-2, p. 403.
the skin and deeper tissues. Cardenosa G. Breast imaging companion. 3rd ed. Philadelphia:
Insert a coaxial trocar corresponding to the biopsy device Lippincott Williams and Wilkins; 2008. p. 52332.
under ultrasound guidance with tip to the edge of the
mass.
Appendix 1: Interventional Breast Procedures 233
Ultrasound-Guided Wire Localization The wire tip should be just beyond the lesion.
Using the pinchpull technique, the wire is held in place
Indication while the needle is removed from the breast.
The hook of the wire is deployed within the breast once
Excision of previously diagnosed cancer or high-risk lesion the needle is removed.
by prior core biopsy. Other indication is the localization of Make an X mark on the overlying skin with a perma-
lesion that is best seen by ultrasound. nent marker directly over the lesion. Depth from the mark
to the lesion should be provided to the surgeon.
Procedure Steps Orthogonal mammograms are not necessary if the appro-
Obtain informed written consent. priate wire placement is documented on ultrasound.
Review prior ultrasound images. Specimen imaging is required. If the lesion is not seen mam-
Skin is cleansed and local anesthesia is used to anesthe- mographically, ultrasound imaging can be performed in a
tize the skin and deeper tissue. saline bath to demonstrate the lesion within the specimen.
Choose the length of the needle by measuring the distance
from the distal end of the lesion to the estimated skin References
entry +2 cm. Berg WB, Birdwell RB, Gombos EC, et al. Diagnostic imaging breast.
1st ed. Salt Lake City: Amirsys; 2006. Section V 2, p. 201.
A hollow needle is advanced through the lesion. Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
Once the needle is placed through the lesion, a wire is and Wilkins; 1998. p. 63792.
advanced through the hollow needle.
Appendix 1: Interventional Breast Procedures 235
Galactography Special attention is paid not to inject air into the duct,
as it can mimic a filling defect on the mammogram.
Indication If resistance occurs while injecting, it may be the result
of the cannula being placed against the wall of the duct
Single-duct spontaneous bloody, serous, or clear nipple or extravasation of contrast outside of the duct. Stop
discharge. injection and reposition cannula.
Once contrast has been injected, a magnification cranio-
Procedure Steps caudal and lateral view is obtained.
Obtain informed consent. Images are assessed for a filling defect within the duct or
Breast placed on the magnification stand (or the patient abrupt termination of the duct. Both findings will require
placed in the supine position) with gooseneck light posi- biopsy.
tioned to illuminate the nipple. Galactography can assess for a mass within or compro-
Nipple is cleansed. mising a duct, but cannot differentiate benign or malig-
Duct opening is identified by squeezing the nipple to nant etiology.
express a small drop of nipple discharge.
The cannula is connected to the tubing and syringe con- References
taining 13 mL of Optiray contrast. Fajardo LL, Jackson VP, Hunter TB. Interventional procedures in dis-
eases of the breast: needle biopsy, pneumocystography and galac-
A blunt (27 or 30 gauge), straight, or right-angled can- tography. AJR. 1992;158:12318.
nula, connected to tubing and a contrast filled syringe, is Kopans DB. Breast imaging. 2nd ed. Philadelphia: Lippincott Williams
inserted into the duct opening. and Wilkins; 1998. p. 7034.
The cannula is taped in place to the patients breast.
Contrast is injected slowly into the duct until the patient
feels fullness in her breast or there is reflux of contrast
from the duct.
236 Appendix 1: Interventional Breast Procedures
BI-RADS lexicon mnemonic for RIO Lobular carcinoma in situ (LCIS) or atypical lobular
mass shape Round hyperplasia (ALH).
(For mammography, ultrasound, Irregular
and MRI) Atypical ductal hyperplasia (ADH).
Oval Heterogeneously or extremely dense breast on
BI-RADS lexicon mnemonic for COMIS mammography.
mass margins Circumscribed
(For mammography ONLY) Women with a personal history of breast cancer,
Obscured
including ductal carcinoma in situ (DCIS).
Microlobulated
Recommend against MRI screening (based on expert con-
Indistinct
sensus opinion).
Spiculated
BI-RADS lexicon mnemonic for Circumscribed
Women at <15 % lifetime risk
mass margins OR
(For ultrasound ONLY) Not circumscribed (AIMS)
Angular Breast Lesion Triangulation Mnemonic
Indistinct
Microlobulated
Spiculated Muffins (Medial) Rise and Lead (Lateral) Falls.
BI-RADS lexicon mnemonic for Circumscribed If a lesion is only seen on the CC view, obtain a lateral
mass margins OR view.
(For MRI ONLY) Not circumscribed (IS) If the lesion is located medially on the CC view, it
Irregular
Spiculated will be more superior in the lateral view when com-
pared with that in the MLO view.
If the lesion is located laterally on the CC view, it
will be more inferior in the lateral view when com-
ACS Recommendations for Breast MRI pared with that in the MLO view.
Screening as an Adjunct to Mammography
Recommend annual MRI screening (based on evidence). Mammography Findings That Can
BRCA mutation. Be Categorized by BI-RADS 3
First-degree relative of BRCA carrier, but untested. (Short-Term Follow-Up)
Lifetime risk 2025 % or greater, as defined by
BRCAPRO or other models that are largely dependent Findings must be seen on a baseline mammogram or a
on family history. mammogram without comparison studies available.
Recommend annual MRI screening (based on expert con- Cluster of calcifications on spot-magnification views that
sensus opinion). are round or oval.
Radiation to chest between age 10 and 30 years. Solid nonpalpable noncalcified mass with round or oval
LiFraumeni syndrome and first-degree relatives with shape and circumscribed margins.
breast cancer diagnosis. Nonpalpable focal asymmetry seen on two views with
Cowden and BannayanRileyRuvalcaba syndromes concave margins and interposed fat.
and first-degree relatives. Miscellaneous findings:
Insufficient evidence to recommend for or against MRI Single dilated duct
screening. Architectural distortion at known biopsy site without
Lifetime risk 1520 %, as defined by BRCAPRO or other dense central mass
models that are largely dependent on family history. Multiple similar lesions of intermediate suspicion
237
238 Appendix 2: High-Yield Facts
Signal intensity
r
Branch pattern Pe
Extension into a duct
Plateau (type II)
Microlobulation
Not parallel
st
m
Wa
Fa
iu
Calcifications sho
ed
ut (
M
typ
w e II
Slo I)
Fig. A.5
Fig. A.3
Fig. A.6
241
242 Appendix 3: BI-RADS Key Facts
Reprinted with permission of the American College of Radiology (ACR). No other representation of this material is autho-
rized without expressed, written permission from the ACR. Refer to the ACR website at www.acr.org/Quality-Safety/
Resources/BIRADS for the most current and complete version of the BI-RADS Atlas.
Appendix 3: BI-RADS Key Facts 243
Term Definition
True-positive (TP) Tissue diagnosis of cancer within 1 year after a positive examination. BI-RADS 3 category assessments made at
screening examination are considered positive examinations
True-negative (TN) No known tissue diagnosis of cancer within 1 year of a negative examination (BI-RADS categories 1 or 2 for
screening; BI-RADS categories 1,2, or 3 for diagnostic)
False-negative (FN) Tissue diagnosis of cancer within 1 year of a negative examination (BI-RADS categories 1 or 2 for screening;
BI-RADS categories 1, 2, or 3 for diagnostic)
False-positive 1 (FP1) No known tissue diagnosis of cancer within 1 year of a positive mammogram. Includes BI-RADS category 3
assessments made at screening
False-positive 2 (FP2) No known tissue diagnosis of cancer within 1 year after recommendation for tissue diagnosis or surgical
consultation on the basis of a positive examination (BI-RADS category 4 or 5)
False-positive 3 (FP3) Concordant benign breast tissue diagnosis (or discordant benign breast tissue and no known diagnosis of cancer)
within 1 year after recommendation of the basis of a positive examination (BI-RADS category 4 or 5).
Positive predictive value The percentage of all screening examinations (BI-RADS categories 0, 3, 4, and 5) that result in a tissue diagnosis of
1 (PPV1) (abnormal cancer within 1 year
finding at screening) PPV1 = TP/(number of positive screening examinations) = TP/(TP + FP1)
Positive predictive value The percentage of all diagnostic (or rarely, screening) examinations recommended for tissue diagnosis or surgical
2 (PPV2) (biopsy consultation (BI-RADS categories 4 and 5) that result in a tissue diagnosis of cancer within 1 year
recommended) PPV2 = TP/(number of screening or diagnostic examinations recommended for tissue diagnosis) = TP/(TP + FP2)
Positive predictive value The percentage of all known biopsies done as a result of positive diagnostic examinations (BI-RADS categories 4
3 (PPV3) (biopsy and 5) that resulted in a tissue diagnosis of cancer within 1 year. Also known as biopsy yield of malignancy or the
performed) positive biopsy rate (PBR)
PPV3 = TP/(number of biopsies) = TP/(TP + FP3)
Sensitivity The probability of interpreting an examination as positive when cancer exists. Calculated as the number of positive
examinations for which there was tissue diagnosis of cancer within 1 year of imaging examination, divided by all
cancers present in the population examined in the same time period
Sensitivity = TP/(TP + FN)
Specificity The probability of interpreting an examination as negative when cancer does not exist. Calculated as the number of
negative examinations for which there is no tissue diagnosis of cancer within 1 year of examination, divided by all
the examinations for which there is no tissue diagnosis of cancer within the same time period
Cancer detection rate The number of cancers detected at imaging per 1,000 patients examined
Abnormal interpretation Percentage of examinations interpreted as positive. For screening, positive examinations usually involve BI-RADS
rate (also known as categories 0 assessments for mammography and (for auditing purposes) breast US, but BI-RADS categories 4 and 5
recall rate) for breast MRI. This also includes BI-RADS 3 category assessments made at screening for all imaging modalities.
For diagnostic imaging, positive examinations involved BI-RADS category 4 and 5 assessments
Abnormal interpretation rate = (positive examinations)/(all examinations)
Source: These Statistical Terms are based on material from the Follow-up and Outcome monitoring section of the ACR BI-RADS Atlas 5th
Edition
A patient history, 19
Abscess, 200 radiology findings, 19, 20
Adenoid cystic carcinoma treatment, 19
analysis, 61 Axillary lymph node metastasis
BI-RADS assessment, 61 IDC (see Invasive ductal carcinoma (IDC))
diagnosis, 61 ILC
patient history, 61 BI-RADS assessment, 223
radiology findings, 6163 diagnosis, 223
ADH. See Atypical ductal hyperplasia (ADH) MRI, 223
Aliasing artifact, 196 patient history, 223
Angiolipoma radiology findings, 223224
BI-RADS assessment, 149 patient with sarcoidosis, 143, 144
breast, 149
diagnosis, 149
differential diagnosis, 149 B
mammogram, 149 Bilateral axillary lymphadenopathy
patient history, 149 abnormal appearance, 168
radiology findings, 149151 BI-RADS assessment, 168
Angiosarcoma diagnosis, 168
BI-RADS assessment, 177 differential diagnosis, 168
diagnosis, 177 patient history, 168
mammography, 177 radiology findings, 168169
MRI, 177 Bilateral breast cancer
patient history, 177 BI-RADS assessment, 186
radiology findings, 177179 diagnosis, 186
ultrasound, 177 patient history, 186
Apocrine cyst cluster radiology findings, 186189
analysis, 136 risk factors, 186
biopsy, 141 Black hole artifacts, 196
BI-RADS assessment, 141 BRCA-1 gene, 186, 213
diagnosis, 141 BRCA-2 gene, 186
epithelium, 141 Breast-conserving therapy (BCT), 113
patient history, 141
radiology findings, 141, 142
T1-weighted postcontrast MRI, 141 C
Architectural distortion Calcifications
BI-RADS assessment, 131 amorphous and peripheral microcalcifications, 143
Cooper ligaments, 131 axillary lymph nodes, 143
diagnosis, 131 BI-RADS assessment, 143
patient history, 131 diagnosis, 143
radiology findings, 131, 132 gold deposition, 143
Atypical ductal hyperplasia (ADH) patient history, 143
BI-RADS assessment, 147 radiology findings, 143, 144
diagnosis, 147 silicone deposition, 143
high-risk lesion, 147 Calcified fibroadenoma
patient history, 147 BI-RADS assessment, 170
radiology findings, 147, 148 diagnosis, 170
Atypical lobular hyperplasia (ALH) pathognomonic, 170
amorphous calcifications, 19 patient history, 170
assessment, 19 popcorn calcifications, 170
diagnosis, 19 radiology findings, 170171
B.A. Shah et al., Breast Imaging Review: A Quick Guide to Essential Diagnoses, 245
DOI 10.1007/978-3-319-07791-8, Springer International Publishing Switzerland 2015
246 Index