Breast Imaging: A Core Review (30 page)

References: Berg WA, Birdwell RL.
Diagnostic Imaging: Breast
. 1st ed. Salt Lake City, UT: Amirsys; 2006:IV:66–122.
Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:482, 489–502.

33
 
Answer A.
 According to data from the American Cancer Society (ACS), ~1% of all breast cancers occur in men.

Reference: American Cancer Society.
Cancer Facts & Figures 2012
. Atlanta, GA: American Cancer Society; 2012.
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf

34
 
Answer C.
 Calcifications are seen in the postbiopsy mammogram, thus you are sure the specimen has calcifications in it despite the pathologist’s initial conclusion. Calcium oxalate crystals can be seen in benign and secretory processes that may not show up on standard H&E stains but are birefringent on polarized light microscopy.

35
 
Answer B.
 Mammographic images demonstrate a classic breast hamartoma with a “breast in breast” appearance. Hamartomas are benign breast lesions containing fat, fibrous connective tissue, and varying amounts of disorganized glandular tissue. Routine annual mammogram is appropriate, and this should be given a BI-RADS category 2—benign finding category assessment.

Reference: Basset LW.
Diagnosis of Diseases of the Breast
. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.

36a
 
Answer D.
 The high-density material in the breast tissues, outside of the implant, indicates free silicone. The silicone is much more uniformly dense than the surrounding fibroglandular tissue. Free silicone indicates implant compromise and can only occur with both intracapsular and extracapsular rupture. If there was only intracapsular rupture of the implant shell, the silicone would likely have been contained by the fibrous capsule without definitive mammographic evidence of the implant integrity abnormality. Implant contour irregularity is an unreliable sign of rupture.

No mass is present in this case, although free silicone can eventually lead to a silicone granuloma. Calcifications around the implant can often be seen, although the important finding in this case is the free silicone.

36b
 
Answer B.
 Although a mammographic abnormality is identified, the ruptured implant with resultant free silicone in the breast tissue does not indicate a malignancy. BI-RADS assessment is for evidence of malignancy, which there is not in this case.

References: Berg WA, et al. Diagnosing breast implant rupture with MR imaging, US, and mammography.
Radiographics
1993;13:1323–1336.
Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

37
 
Answer A.
 According to the BI-RADS Manual, fourth edition, high-risk lesions include atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), peripheral duct papillomas, and phyllodes tumor (not specified as malignant). Intracystic papilloma and intraductal papilloma are benign and papillary carcinoma in situ is malignant.

Reference: American College of Radiology (ACR). ACR BI-RADS—Mammography. ACR
Breast Imaging Reporting and Data System, Breast Imaging Atlas
. 4th ed. Reston, VA: American College of Radiology; 2003:300.

38a
 
Answer B.

38b
 
Answer D.
 According to well-established sonographic criteria for simple cysts and the BI-RADS lexicon description for simple cysts set forth by Stavros, a mass is classified as a simple cyst when these features are met: anechoic, well circumscribed with a thin echogenic capsule, increased through transmission (or posterior acoustic enhancement), and thin edge shadows (sharp border). A simple cyst confers an assessment of BI-RADS 2, benign finding, and the patient can return to routine screening or ageappropriate follow-up.

References: Hines N, et al. Cystic masses of the breast.
Am J Roentgenol
2010;194:W122–W133.
Rumack CM, et al.
Diagnostic Ultrasound
. 3rd ed. St. Louis, MO: Elsevier Mosby; 2005:811,823.

39
 
Answer C.
 Fibroadenolipoma or hamartoma of the breast was first described in 1971 as a benign proliferation of fibrous, glandular, and fatty tissue surrounded by a thin capsule of connective tissue. Its appearance has led some to describe it with the key term “breast-within-a-breast.” The majority of these lesions occur in women over 35 years of age. At mammography, they are typically well-circumscribed, round to oval masses containing both fat and soft-tissue density with a thin, radiopaque pseudocapsule that becomes visible around a portion of the mass when fat is present on both sides. None of the other answer choices fit the described keywords. Be aware that because these lesions are made-up of otherwise normal breast tissue, breast cancer of any type can arise in hamartomas.

References: Cardeñosa G. Clinical Breast Imaging: A Patient Focused Teaching File. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:200.
Feder JM, De Paredes ES, et al. Unusual breast lesions: Radiologic–pathologic correlation. Radiographics 1999;19:S11–S26.

40
 
Answer C.
 The history of a rapidly growing mass in a postmenopausal female with the above imaging characteristics is most likely a metaplastic carcinoma.

References: Gunhan-Bilgen I, Aysenur M, Ustun EE, et al. Metaplastic carcinoma of the breast: Clinical, mammographic and sonographic findings with histopathologic correlation.
AJR Am J Roentgenol
2002;178:1421–1425.
Irshad A, Ackerman S, Pope T, et al. Rare breast lesions: Correlation of imaging and histologic features with WHO classification.
Radiographics
2008;28:1399–1414.
Leddy R, Irshad I, Rumboldt T, et al. Review of metaplastic carcinoma of the breast: Imaging findings and pathologic features.
J Clin Imaging Sci
2012;2:21.
Soo MS, Dash N, Bentley R, et al. Tubular adenomas of the breast: Imaging findings with histologic correlation.
AJR Am J Roentgenol
2000;174:757–761.

41
 
Answer B.
 The histopathologic findings at core biopsy are consistent with diabetic mastopathy in a patient with a known history of diabetes. Diabetic mastopathy is a benign process with no known malignant potential; therefore, these patients can be followed rather than undergoing surgical excision.

References: Camuto PM, Zetrenne E, Ponn T. Diabetic mastopathy: A report of 5 cases and a review of the literature.
Arch Surg
2000;135:1190–1193.
Sakuhara Y, Shinozaki T, Hozumi Y, et al. MR imaging of diabetic mastopathy.
AJR Am J Roentgenol
2002;179:1201–1203.
Wong KT, Tse GMK, Yang WT. Ultrasound and MR imaging of diabetic mastopathy.
Clin Radiol
2002;57:730–735.

42
 
Answer A.
 Duct ectasia is nonspecific ectatic dilatation of the major collecting ducts that can be seen by mammography and ultrasound as tubular structures beneath the nipple. Ectatic ducts may be found deeper in the breast as well. The etiology of duct ectasia has not been clearly elucidated. Duct ectasia may present clinically by nipple discharge or bleeding.

B.
 Ductal carcinoma in situ (DCIS) usually appears as a dilated duct with indistinct walls on ultrasound. Isolated single or multiple dilated duct(s) is an uncommon presentation of DCIS.

C.
 The most common cause of a unilateral, single-duct discharge is a large duct papilloma. These are benign hyperplastic growths with a fibrovascular core. They have no known predisposition toward malignancy and usually occur within a few centimeters of the nipple, in the large ducts. The discharge from a papilloma may be serous or sanguineous. Although papilloma cases often present with spontaneous bloody nipple discharge, there is no intraductal mass on the presented ultrasound to suggest papilloma.

D.
 Papillary carcinoma usually presents as a complex cystic and solid mass in elderly patients. No mass is identified in this case.

E.
 These patients usually present with serous or bloody nipple discharge, with nipple and areolar thickening. Paget disease per se is not identifiable on ultrasound.

References: Berg WA, Birdwell RL, eds.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2008;IV:1,45–46.
Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:792–794.

43
 
Answer E.
 Radial scar is one of the few benign lesions that can form spiculations that are indistinguishable from those formed by some cancers. Therefore, upon diagnosis, surgical excision is recommended. Tubular carcinoma can coexist with radial scar. Tubular carcinoma is a well-differentiated form of invasive ductal carcinoma. It makes up 0.6% of invasive breast cancers and 6% to 8% of all cancers (invasive plus DCIS). Although it is an invasive cancer, its differentiation results in the production of what appear to be poorly formed ductal structures consisting of haphazardly arranged tubules lined by a single layer of cuboidal epithelium. Although sometimes palpable, the lesions are frequently detected by mammography. They are slow growing and are usually very small when detected. Perhaps because of its differentiation, tubular cancer has a favorable prognosis with a low metastatic potential, and the axillary nodes are rarely involved.

References: Berg WA, Birdwell RL, eds.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2008;IV:2,84–86.
Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:859.

44
 
Answer B.
 Approximately 10% of all invasive breast malignancies are invasive lobular carcinoma. Invasive ductal carcinoma is the most common, representing at least 55% of all cases when the diagnosis is purely invasive ductal carcinoma or up to 80% when combined with other subtypes. Less common invasive breast carcinomas include inflammatory, medullary, mucinous, and tubular carcinomas as well as breast sarcomas.

Reference: Rubin R, Strayer DS.
Rubin’s Pathology: Clinicopathologic Foundations of Medicine
. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:850–853.

45
 
Answer D.
 The spot views demonstrate an irregular mass with indistinct margins. Per history, the prior mammogram was negative in this location. The absence of a sonographic correlate should not prevent biopsy of a suspicious finding on mammography. Stereotactic core biopsy can be used to biopsy masses and focal asymmetries in addition to the more common indication of calcifications. This mass was an invasive ductal carcinoma.

46
 
Answer C.
 Any mass-like enhancement, new or increasing areas of enhancement, or nonmass-like enhancement should be considered suspicious. Skin thickening, architectural distortion, resolving edema, signal voids, or signal flare from surgical or biopsy clips or from prior bleeding (hemosiderin) are considered benign postconservation therapy findings. The majority of these findings progressively decrease over time.

Reference: Drukteinis JS, Gombos EC, Raza S, et al. MR imaging assessment of the breast after breast conservation therapy: Distinguishing benign from malignant lesions.
Radiographics
2012;32:219–234.

47
 
Answer D.
 According to American College of Radiology (ACR) Appropriateness Criteria, bilateral diagnostic mammography should be performed after ultrasound of a suspicious palpable mass, to help characterize the mass and evaluate for any additional lesions. Core biopsy is recommended after bilateral diagnostic mammographic evaluation.

Reference: Parikh JR, Bassett LE, Mahoney MC, et al. Expert Panel on Breast Imaging. ACR Appropriateness Criteria Palpable Breast Masses. Reston, VA: American College of Radiology; 2009.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/PalpableBreastMasses.pdf
, Accessed August 31, 2012.

48
 
Answer D.
 Given the patient’s age and sonographic findings of hypoechoic mass with microlobulations and posterior acoustic enhancement, the most likely diagnosis is mucinous carcinoma.