Breast Imaging Review

Biren A. Shah Gina M. Fundaro Sabala Mandava

Breast Imaging Review

A Quick Guide to Essential Diagnoses

123

Biren A. ShahHenry Ford HealthSystem, 2799 West Grand BoulevardDetroit, MI 48202USAbirens@rad.hfh.edu

Gina M. FundaroHenry Ford Health System, 2799 West Grand BoulevardDetroit, MI 48202USAginaf@rad.hfh.edu

Sabala MandavaHenry Ford Health System, 2799 West Grand BoulevardDetroit, MI 48202USAsabalam@rad.hfh.edu

ISBN: 978-1-4419-1727-0 e-ISBN: 978-1-4419-1728-7

DOI: 10.1007/978-1-4419-1728-7

Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2010923244

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v

To my parents, Ashok and Jyoti Shah, who I owe everything I am to them. I am guided by their strong principles of life and work ethic that they instilled in me.

To my sister, Binita Shah Ashar, for her sound advice and constant encouragement.

To my wife, Dharmishtha Shah, for her endless support and love.

To my two sons, Aren and Deven, who make life all worthwhile.

Biren A. Shah

To my mother and father, Jacqueline and William, for their guidance, teaching, and uncondi-tional love.

To my brother, Bill, for his encouragement, friendship, and innate ability to always make me laugh.

To my grandparents, Irene and William Fundaro, for all of the sacrifices they made to provide me with a college education.

To my godfather, Thomas Capraro, and my grandma, Alyce Jarvis, for never giving up once they were diagnosed. They remind me daily to fight for my patients.

Ryan, my love and best friend, words cannot express my gratitude. Thank you for committing to our journey with an open heart. I would not be who I am today without your love and con-stant unwavering support.

Asher Thomas and Arden Joy, my sunshine and butterfly, you have inspired me to put my best efforts forward with this project. My hope is to pave the way for you, so that your lives are full of opportunities and rich experiences. You are the loves of my life, and every day I am so grateful that you are my children.

Gina M. Fundaro

To my parents, Vasu and Saranya, for their guidance and unconditional love and support.

To my sister, Amulya, for always being there for me.

To my children, Milind and Ariana, for the joy and laughter they have brought into all our lives.

To my husband, Rajesh, for his love and tireless belief in me. I wouldn’t be here without him.

Sabala Mandava

Dedication

vii

Over the years many residents have asked me for a concise review book for breast imaging as they study for the boards. They wanted one that would give them examples of the typical find-ings seen in mammography, breast ultrasound, and more recently, breast MRI. They wanted a book that would also provide examples of how to briefly describe the findings of the entity being viewed using correct BI-RADS terminology as would be expected by the examiners they encounter during oral board exams. This book will hopefully answer these needs.

This atlas of classic cases does more than giving examples of cases demonstrating many of the typical presentations of breast disease as seen on mammography and ultrasound. The addi-tion of references to facilitate more reading on any topic the resident desires is an important part of this book. Easy access to the references may lead at least a few of those studying for boards to read a bit more about breast imaging.

The cases that include MRIs and the descriptions of the findings and the examples of the kinetic curves demonstrate pathognomic findings of breast disease on MRI and are a good window into the potential role of MRI in the detection and evaluation of breast cancer. This review book does not include molecular imaging, since these imaging modalities are not yet proven to be helpful in the evaluation of breast disease. Perhaps, in the future, if these tech-niques are shown to be as useful as preliminary results suggest, examples of these breast imag-ing techniques can be added.

The brief summary of the image-guided procedures is a good review for the resident taking the boards. It will provide them with a short description of how to perform biopsies and other breast procedures using each of the 3 methods of guidance. They are likely to be asked how to perform biopsies at least once during their exams. For those who do practice breast imaging, this section will be helpful as a reminder of the steps involved as they begin to perform these procedures on their own.

The above leads to what I feel will be another use for this review book which will be in the reading room for those who are just starting to read mammography on their own. Not only will it provide a quick way to reinforce the most typical breast abnormalities, but again the refer-ences at the end of each case will provide quick access to resources to help the beginning mammographer reinforce her/his decisions. I think many of the residents who purchase this book to help review for boards will also find it useful as they begin to practice.

Janet K. Baum, MDAssociate Professor of Radiology

Harvard Medical SchoolDirector of Breast Imaging and

Director of Radiology EducationCambridge Health Alliance

Cambridge, MA

Foreword

ix

Preface

Breast imaging has evolved over the years into a multimodality specialty encompassing mammo-graphy, ultrasound, MRI, and PET. It is made up of a unique combination of image interpreta-tion, interventions, and patient interactions. Many times we have heard our residents comment “It’s so different from our other rotations.” We are privileged to be surrounded by our residents and fellows who have a keen intellect and a joy for learning. Their innumerable questions and thirst for knowledge are in part the inspiration for this book.

Although written primarily as a review for senior residents preparing for oral boards, we hope it will be a useful tool for all residents and fellows as well as practicing radiologists out in the “real world.” We have tried to make the format of the book a simple one. The book is divided into sections and follows a case-based approach. The images and information for each case are on facing pages so as to make it easy for the reader to move back and forth between the two. We have purposely arranged the cases in random order to more accurately reflect the oral boards format. 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.

Our goal was to write a review book that would be useful for radiologists in all stages of their careers: one that would be comprehensive in content in an easy to read format and serve as a quick reference. We hope that we have managed to achieve this goal.

Anyone who stops learning is old, whether at twenty or eighty. Anyone who keeps learning stays young.

Henry Ford

Biren A. ShahGina M. FundaroSabala Mandava

xi

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 project. 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:

Biren’s resourcefulness and quick solutions to road blocks are belied by his calm and quiet exterior.

Gina, with her attention to detail and task-oriented lists, helped us meet every deadline.Sabala’s 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 Blasé, 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. Janet Baum, MD, who graciously agreed to write the foreword for this book.Andrew Moyer, our editor, who believed in us from the very beginning and gave us this

opportunity.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.

Biren A. ShahGina M. FundaroSabala Mandava

xiii

Contents

1 Mammography and Ultrasound Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Case 1 Mammographic Artifacts ............................................................................ 2Case 2 Secretory Calcifications .............................................................................. 6Case 3 Invasive Ductal Carcinoma (IDC) ............................................................... 8Case 4 Complicated Cyst ........................................................................................ 11Case 5 Desmoid Tumor ........................................................................................... 13Case 6 Gynecomastia .............................................................................................. 16Case 7 Atypical Lobular Hyperplasia (ALH) ......................................................... 18Case 8 Sternalis Muscle .......................................................................................... 20Case 9 Transverse Rectus Abdominus Myocutaneous (TRAM) Flap .................... 22Case 10 Galactocele .................................................................................................. 25Case 11 Milk of Calcium .......................................................................................... 28Case 12 Lymphoma................................................................................................... 30Case 13 Fibroadenoma .............................................................................................. 33Case 14 Paget’s Disease ............................................................................................ 35Case 15 Mastitis ........................................................................................................ 38Case 16 Neurofibromatosis Type I (NF I) ................................................................. 41Case 17 Multiple, Bilateral Circumscribed Masses .................................................. 43Case 18 Vascular Calcifications ................................................................................ 45Case 19 Stromal Fibrosis .......................................................................................... 47Case 20 Reduction Mammoplasty ............................................................................ 49Case 21 Invasive Lobular Carcinoma (ILC) ............................................................. 51Case 22 Lactating Adenoma ..................................................................................... 54Case 23 Silicone Granuloma ..................................................................................... 56Case 24 Lipoma ........................................................................................................ 58Case 25 Adenoid Cystic Carcinoma ......................................................................... 60Case 26 Diabetic Mastopathy ................................................................................... 63Case 27 Diffuse Bilateral Breast Calcifications ........................................................ 66Case 28 Superior Vena Cava (SVC) Syndrome ........................................................ 68Case 29 Postoperative Seroma .................................................................................. 71Case 30 Medullary Carcinoma.................................................................................. 73Case 31 Lobular Carcinoma In-Situ (LCIS) ............................................................. 76Case 32 Juvenile Fibroadenoma ............................................................................... 78Case 33 Simple Cyst ................................................................................................. 80Case 34 Poland Syndrome ........................................................................................ 82Case 35 Intracystic Papillary Carcinoma .................................................................. 84Case 36 Intracapsular Rupture of Silicone Breast Implant ....................................... 87Case 37 Extracapsular Rupture of Silicone Breast Implant ...................................... 89Case 38 Ductal Ectasia.............................................................................................. 91Case 39 Radial Scar .................................................................................................. 94

xiv Contents

Case 40 Dermal Calcifications .................................................................................. 97Case 41 Turner’s Syndrome ...................................................................................... 99Case 42 Invasive Ductal Carcinoma (IDC) in a Male Patient ................................... 101Case 43 Mondor’s Disease (Superficial Thrombophlebitis) ..................................... 104Case 44 Intraductal Papilloma .................................................................................. 107Case 45 Fat Necrosis (Multiple Presentations) ......................................................... 109Case 46 Recurrence at Lumpectomy Site ................................................................. 112Case 47 Enlarged Axillary Lymph Nodes ................................................................ 115Case 48 Inflammatory Breast Carcinoma (IBC) ....................................................... 117Case 49 Intramammary Lymph Node ....................................................................... 119Case 50 Oil Cyst ....................................................................................................... 122Case 51 Hormone Replacement Therapy (HRT) ...................................................... 124Case 52 Complex Cyst .............................................................................................. 126Case 53 Fibroadenoma in a Teenage Patient ............................................................ 128Case 54 Architectural Distortion .............................................................................. 130Case 55 Pseudoangiomatous Stromal Hyperplasia (PASH) ..................................... 132Case 56 Sclerosing Adenosis .................................................................................... 135Case 57 Mucinous Carcinoma .................................................................................. 137Case 58 Apocrine Cyst Cluster ................................................................................. 140Case 59 Calcifications in Axillary Lymph Nodes

in a Patient with Sarcoidosis ....................................................................... 142Case 60 Fibroadenolipoma (Hamartoma) ................................................................. 144Case 61 Atypical Ductal Hyperplasia (ADH) ........................................................... 146Case 62 Angiolipoma ................................................................................................ 148Case 63 Micropapillary Carcinoma .......................................................................... 151Case 64 Intraductal Papilloma on Galactography ..................................................... 153Case 65 Tubular Carcinoma ...................................................................................... 156Case 66 Recurrent Invasive Ductal Carcinoma in a Tram Flap ................................ 159Case 67 Nonpuerperal Abscess of the Breast ........................................................... 162Case 68 Small-Cell Carcinoma Metastasis ............................................................... 164Case 69 Bilateral Axillary Lymphadenopathy .......................................................... 167Case 70 Calcified Fibroadenoma .............................................................................. 169Case 71 Granular Cell Tumor ................................................................................... 171Case 72 Hematoma ................................................................................................... 173Case 73 Angiosarcoma ............................................................................................. 175Case 74 Free Silicone Oil Injections ......................................................................... 178Case 75 Phylloides Tumor ........................................................................................ 180Case 76 DCIS Comedonecrosis ................................................................................ 182Case 77 Bilateral Breast Cancer ............................................................................... 184Case 78 Sebaceous Cyst/Epidermal Inclusion Cyst.................................................. 188Case 79 Displaced Microclip After Stereotactic Core Needle Biopsy ..................... 190

2 MRI Case Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193Case 1 MRI Artifacts .............................................................................................. 194Case 2 Rim Enhancement ....................................................................................... 196Case 3 Simple Cysts................................................................................................ 200Case 4 Invasive Ductal Carcinoma (IDC)

with Axillary Lymph Node Metastasis ....................................................... 202Case 5 Intracapsular Rupture of Silicone Breast Implant ....................................... 205Case 6 Extracapsular Rupture of Silicone Breast Implant ...................................... 207Case 7 Fibroadenoma .............................................................................................. 209Case 8 Inflammatory Breast Carcinoma (IBC) ....................................................... 212Case 9 Papilloma ..................................................................................................... 214

Contents xv

Case 10 Recurrence After Mastectomy .................................................................... 217Case 11 Invasive Lobular Carcinoma (ILC)

with Axillary Lymph Node Metastasis ....................................................... 219Case 12 Chest Wall Involvement of a Breast Cancer ................................................ 221Case 13 Ductal Carcinoma In Situ, Low Grade (DCIS) ........................................... 223

Appendix: Interventional Breast Procedures and High Yield Facts . . . . . . . . . . . . . . 225MRI-Guided Wire Localization ................................................................................... 225MRI-Guided Vacuum-Assisted Biopsy ........................................................................ 226Mammogram-Guided Wire Localization ..................................................................... 227Ultrasound-Guided Core Biopsy .................................................................................. 228Ultrasound-Guided Cyst Aspiration ............................................................................ 229Ultrasound-Guided Wire Localization ......................................................................... 230Galactography .............................................................................................................. 231Stereotactic Guided Vacuum-Assisted Biopsy ............................................................. 232High-Yield Facts .......................................................................................................... 233

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

1B. A. Shah et al. (eds.), Breast Imaging Review, DOI: 10.1007/978-1-4419-1728-7_1, © Springer Science+Business Media, LLC 2010

1Mammography and Ultrasound Review

2 Case 1 Mammographic Artifacts

Case 1 Mammographic artifacts

patient history

Screening mammograms in multiple different patients.

radiology findings

Figure 1: (a) CC and (b) MLO images show a broken ven-tricular peritoneal shunt catheter in the lower inner right breast at posterior depth.Figure 2: AP supine view of the chest reveals a broken right ventricular peritoneal shunt catheter and intact left ven-tricular peritoneal shunt catheter.Figure 3: Left MLO view demonstrates chin artifact obscur-ing the superior posterior tissues.Figure 4: Deodorant artifact. Left MLO view demonstrates (a) scattered radiopaque particles in the skin fold and axil-lary region. (b) Scattered radiopaque particles in the skin fold and axillary region are no longer seen on repeat left MLO view following cleansing of the patient’s axilla.Figure 5: Hair artifact. CC view demonstrates curvilinear densities with intervening lucencies at posterior depth laterally.Figure 6: Motion artifact. Right MLO view demonstrates patient’s motion causing blurring of the upper breast tissues.

diagnosis

Mammographic artifacts.

discussion

Artifacts are any objects or abnormalities that are not native •to the breast.May interfere with image interpretation.•Certain artifacts are typically seen in particular locations:•

Deodorant: Axilla•Catheters or pacemakers: Close to chest wall•Hair: Typically inner breast seen on CC view•

Recognition, awareness, and history are important.•Correct presumed problems and repeat imaging can be done.•

references

Berg WA, Birdwell RL, Gombos EC et al (2006) Diagnostic imaging breast, 1st ed. Amirsys, Salt Lake City, Section IV-7, pp 10–11

Hogge JP, Palmer CH, Muller CC et al (1999) Quality assurance in mammography: artifact analysis. Radiographics 19:503–522

3Case 1 Mammographic Artifacts

a b

Figure 1

4 Case 1 Mammographic Artifacts

a

b

Figure 4

Figure 2

Figure 3

5Case 1 Mammographic Artifacts

Figure 6Figure 5

6 Case 2 Secretory Calcifications

Case 2 Secretory calcifications

patient history

Sixty-year-old female for bilateral screening mammogram.

radiology findings

Figure 1: Bilateral (a, b) CC and (c, d) MLO views demon-strate dense, thick, continuous rod-like calcifications in a duc-tal pattern.

Bi-rads assessment

BI-RADS 2. Benign finding.

diagnosis

Secretory calcifications.

discussion

Secretory calcifications arise from secretions and debris •within the ducts, which calcify and cause inflammation.Typically radiate from the nipple in a ductal pattern.•Size of the calcifications is greater than or equal to 1 mm.•Rarely seen in patients before the age of 60.•Usually bilateral.•Asymptomatic.•No intervention necessary.•

references

Bassett LW, Jackson VP, Fu KL, Fu YS (2005) Diagnosis of diseases of the breast, 2nd edn. Elsevier, Philadelphia, pp 444–445

Berg WA, Birdwell RL, Gombos EC et al (2006) Diagnostic imaging breast, 1st edn. Amirsys, Salt Lake City, Section IV 1, pp 74–75

7Case 2 Secretory Calcifications

a b

c d

Figure 1

8 Case 3 Invasive Ductal Carcinoma (IDC)

Case 3 invasive ductal carcinoma (IDC)

patient history

Fifty-five-year-old female for screening mammogram.

radiology findings

Figure 1: (a) CC and (b) ML images show a mass with spiculated margins at 6 o’clock in the left breast at the ante-rior depth. Another irregular mass with spiculated margins is seen in the upper outer left breast at posterior depth.Figure 2: (a) Grayscale and (b) color Doppler ultrasound images show a hypoechoic mass with spiculated margins and vascular flow.Figure 3: (a) Grayscale and (b) color Doppler ultrasound images show an enlarged lymph node with a thickened hypoechoic cortex and a compromised hyperechoic hilum. There is vascular flow within the hilum.

Bi-rads assessment

BI-RADS 5. Highly suggestive of malignancy (following diagnostic workup, prior to biopsy).

diagnosis

Invasive ductal carcinoma (IDC) (not otherwise specified) with axillary lymph node metastasis.

discussion

Eighty percent of breast cancers are ductal in origin.•Up to 65% of breast cancers diagnosed in the U.S. repre-•sent IDC, not otherwise specified.IDC forms a desmoplastic reaction with cicatrization and •fibrosis, thus commonly seen as a spiculated mass on mammogram.Usually seen as a hypoechoic mass with spiculated or ill-•defined margins on ultrasound. Posterior acoustic shad-owing of the mass can be seen.Secondary signs of IDC on imaging include skin thicken-•ing, nipple inversion, and lymphadenopathy.

references

Kopans DB (1998) Breast imaging, 2nd edn. Lippincott Williams and Wilkins, Philadelphia, pp 577–581

Ruhbar G, Sie AC, Hansen GC (1999) Benign versus malignant breast masses: ultrasound differentiation. Radiology 213:889–894

9Case 3 Invasive Ductal Carcinoma (IDC)

a b

Figure 1

a b

Figure 2

10 Case 3 Invasive Ductal Carcinoma (IDC)

a b

Figure 3

11Case 4 Complicated Cyst

Case 4 complicated cyst

patient history

Fifty-year-old female with a palpable mass in the left breast.

radiology findings

Figure 1: (a, b) Grayscale and (c) color Doppler ultrasound images show an avascular oval circumscribed predominately anechoic mass with floating debris and posterior enhancement.

diagnosis

Complicated cyst.

discussion

A complicated cyst contains:•Fluid-debris level•Imperceptible wall on ultrasound•Mobile debris or homogeneous low-level echoes•

Complex features, such as thick irregular septations, intra-•cystic mass, or thick cyst wall are not seen in complicated cysts.Can have simple cysts within the vicinity.•Less than two percent risk of malignancy.•No further management necessary for an asymptomatic •complicated cyst.A complicated cyst on baseline mammogram or inciden-•tal finding on ultrasound can be followed at 6 months.Aspiration with possible biopsy can be performed if the •following are present:

Symptomatic•New finding•Enlarging complicated cyst•

references

Berg WA, Campassi CI, Ioffe OB (2003) Cystic lesion of the breast: sonographic-pathologic correlation. Radiology 227:183–191

Berg WA, Birdwell RL, Gombos EC et al (2006) Diagnostic imaging breast, 1st edn. Amirsys, Salt Lake City, Section IV-1, pp 34–39

12 Case 4 Complicated Cyst

a

b

c

Figure 1

13Case 5 Desmoid Tumor

Case 5 desmoid tumor

patient history

Eighty-three-year-old female with a palpable mass in the right axilla. History of right breast lumpectomy and radia-tion therapy for ductal carcinoma in-situ (DCIS).

radiology findings

Figure 1: MLO view shows a focal asymmetry in the right axilla seen only on the MLO view.Figure 2: (a) Grayscale and (b) color Doppler images show an irregular spiculated hypoechoic mass that is avascular.

Bi-rads assessment

BI-RADS 2. Benign finding (following diagnostic workup and biopsy).

diagnosis

Desmoid tumor (extrabdominal desmoid).

discussion

Desmoid tumor is an infiltrative, locally aggressive area •of fibromatosis that may recur locally.May be related to prior trauma or surgery, and has been •reported in women with saline breast implants.Can present as a solitary, hard, painless mass.•On mammography, a mass with indistinct or spiculated •margins can be seen.On ultrasound, a hypoechoic mass with posterior acoustic •shadowing can be seen.Treatment is local surgical excision.•

references

Cardenosa G (2008) Breast imaging companion, 3rd edn. Lippincott Williams and Wilkins, Philadelphia, pp 411–412

Ikeda DM (2004) Breast imaging the requisites, 1st edn. Elsevier, Mosby, Philadelphia, p 309

14 Case 5 Desmoid Tumor

Figure 1

15Case 5 Desmoid Tumor

a

b

Figure 2