Breast Imaging: A Core Review (32 page)

Reference: Kopans DB.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:766–772.

63
 
Answer C.
 Atypical ductal hyperplasia (ADH) is considered a high-risk lesion as these lesions are considered along a spectrum of pathology that can develop into intraductal malignancy. Women with a diagnosis of ADH are thought to have a five- to sixfold increased risk of developing breast cancer in 10 years over the normal population. In addition, when ADH is diagnosed at core needle biopsy rather, even with a 9-gauge vacuumassisted device, excision should be recommended as studies have shown approximately one in five cases of ADH diagnosed at core needle biopsy demonstrate DCIS or invasive malignancy at final excision.

References: Eby PR, Oschner JE, DeMartini WB, et al. Frequency and upgrade rates of atypical ductal hyperplasia diagnosed at stereotactic vacuum-assisted core biopsy: 9 versus 11 gauge.
AJR Am J Roentgenol
2009;192(1):229–234.
Liberman L, et al. Atypical ductal hyperplasia diagnosed at stereotaxic core biopsy of breast lesions: An indication for surgical biopsy.
AJR Am J Roentgenol
1995;164(5):1111–1113.
Kopans D.
Breast Imaging
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:797–798.

64
 
Answer C.
 PASH is a benign entity of myofibroblasts in a background of collagen, which can simulate vascular spaces. PASH is often an incidental finding associated with another lesion, with benign breast tissue, or also can present as a mass. If presenting as a mass, as in this case, PASH usually has benign features such as circumscribed margins, an oval shape, hypoechoic appearance, and no posterior shadowing. It can contain slitlike vascular spaces. If imaging features are benign in appearance such as with this case, then this diagnosis can be considered concordant and surgical excision is not needed. If any suspicious imaging features are present, such as suspicious calcifications or a spiculated mass, excision should be performed to exclude malignancy.

References: Hargarden GC, et al. Analysis of the mammographic and sonographic features of pseudoangiomatous stromal hyperplasia.
AJR Am J Roentgenol
2008;191(2):359–363.
Jesinger RA, et al. Vascular abnormalities of the breast: Arterial and venous disorders, vascular masses, and mimic lesions with radiologic-pathologic correlation.
Radiographics
2011;31:E117–E136.

65
 
Answer A.
 The ultrasound images demonstrate an irregular mass with spiculated margins that corresponds to the focal asymmetry seen on mammography. This requires a biopsy and would be easiest for the radiologist and the patient to be performed under ultrasound guidance. The mass was biopsied and the pathology yielded invasive ductal carcinoma. The findings are concerning for malignancy; therefore an annual diagnostic mammogram or 6-month follow-up is inappropriate. MRI may be beneficial after the biopsy is performed if there is concern for multicentric disease, but the ultrasound and subsequent biopsy are more appropriately performed first.

Reference: Stavros AT.
Breast Ultrasound
. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:620–626, 838–845.

66
 
Answer C.
 Tangential view. Although skin calcifications are a frequent finding on mammograms and are generally easily distinguished by their lucent centers, occasionally the diagnosis can be a difficult one. When unclear, tangential views can confirm the diagnosis of dermal calcifications. The technologist does this generally by placing a grid on the breast in the area of the calcifications, a BB placed over the calcifications and an image taken with the BB in tangent.

References: Evans
A. Breast Calcifications: A Diagnostic Manual
. Cambridge University Press, 2002:20.
Andolina VF, Lille SL.
Mammographic Imaging, a Practical Guide
. Lippincott Williams & Wilkins; 2010:196–205.

67
 
Answer D.
 Filariasis is a systemic parasitic infection that is rare in Western countries but endemic in the tropics and parts of Africa. It is caused by the parasite Wuchereria bancrofti. With infiltration, the parasite can cause lymphatic obstruction in the subcutaneous tissues, leading to breast edema. As the parasite dies, it be comes calcified and may be visible on mammography as elongated, serpentine, nonductal calcifications.

Common causes of breast infections are Staphylococcus aureus and Streptococcus species. Skin thickening and underlying trabecular thickening may be seen on mammography in Staphylococcus aureus and Streptococcus species infections. A focal abscess can also be identified as a mass on both mammography and ultrasound.

On mammography congestive heart failure can appear as bilateral, and sometimes unilateral, breast enlargement with associated skin and trabecular thickening. Distended veins often are visualized as well.

Axillary lymphadenopathy can sometimes result in lymphatic obstruction. On mammography, this can present as diffuse skin and trabecular thickening with overall engorgement of the breast and enlarged dense lymph nodes in the lower axilla on the affected side

References: Mashankar A, Khopkar K, Parihar A, Salkade P. Breast filariasis.
Indian J Radiol Imaging
2005;15:203–204.
Ikeda DM.
Breast Imaging: The Requisites
. St. Louis, MO: Elsevier Mosby; 2004:389–394.

68
 
Answer A.
 The areas of palpable abnormalities in both breasts correspond to the “flame-shaped” densities seen in the subareolar region of the breasts bilaterally. This is the characteristic appearance of gynecomastia which represents the overproduction of stroma in the breast leading to enlargement. The causes are varied and include use of certain medications/illicit drugs as well as a myriad of systemic illnesses. Clinical management is indicated to identify the precipitating factor.

Reference: Appleton CM, Wiele KN.
Breast Imaging Cases (Cases in Radiology)
. New York, NY: Oxford University Press; 2012:11–12.

69
 
Answer B.
 Steatocystoma multiplex is a rare familial hamartomatous malformation of the pilosebaceous duct junction that is characterized by the presence of multiple intradermal cysts that usually appear during adolescence and then progress mammography showed characteristic subcutaneous oil cysts as multiple small, round forms with a circumscribed margin, central fat density, and a peripheral high-density rim, which is in agreement with reported descriptions. Multiple steatocystoma multiplex nodules showed typical locations—namely, at the axillae and the anterior chest wall—which was diagnostically helpful. Although the characteristic location of steatocystoma multiplex is the dermis, some lesions resembled intraparenchymal nodules on routine mammography.

Reference: Park KY, et al. Steatocystoma multiplex: Mammographic and sonographic manifestation.
AJR Am J Roentgenol
2003;180(1):271–274.

70
 
Answer A.
 Higher false-negative rates (up to 19%) are reported for invasive lobular carcinoma (ILC) than for other invasive cancers at mammography, because ILC is often difficult to diagnose mammographically.

B.
 ILC most commonly manifests as a mass (44% to 65% of cases), usually with spiculated or ill-defined margins.

C.
 MR imaging has been shown to affect clinical management in 50% of patients with ILC, leading to changes in surgical management in 28% of cases.

D.
 ILC is associated with a higher rate of multiplicity and bilaterality than are the usual type invasive ductal carcinomas.

Reference: Lopez K, Bassett LW. Invasive lobular carcinoma of the breast: Spectrum of mammographic, US, and MR imaging findings.
Radiographics
2009;29:165–176.

71
 
Answer C.
 Inflammatory carcinoma of the breast is considered a stage T4 lesion. Most common presentation is skin thickening. The vast majority of patients with inflammatory breast carcinoma present with skin thickening. Inflammatory breast cancer accounts for 1% to 4% of breast cancers.

Reference: Günhan-Bilgen I, et al. Inflammatory breast carcinoma: Mammographic, ultrasonographic, clinical, and pathologic findings in 142 cases.
Radiology
2002;223:829–838.

72
 
Answer C.
 Pregnancy-associated breast cancer accounts for 3% of breast cancers. Breast cancer is the second most common cancer during pregnancy, cervical cancer being the most frequent. At the time of diagnosis, pregnant women have larger and more advanced cancers than nonpregnant women of the same age. This is thought to be related to the delayed presentation and to a more aggressive growth pattern due to the biological effects of pregnancy. The average age of diagnosis is 32 to 38 years.

References: Ahn BY. Pregnancy- and lactation-associated breast cancer: Mammographic and sonographic findings.
J Ultrasound Med
2003;22:491–497.
Sabate J, et al. Radiologic evaluation of breast disorders related to pregnancy and lactation.
Radiographics
2007;27:S101–S124.
Yang WT, et al. Imaging of breast cancer diagnosed and treated with chemotherapy during pregnancy.
Radiology
2006;239:52–60.

73
 
Answer B.
 When invasive lobular carcinoma (ILC) is large, the affected breast may appear to be decreasing in size on mammogram and/or MRI; this has been termed the “shrinking breast.” The “shrinking breast” is an imaging and not a clinical finding of ILC. Clinically, the size of the breast is not different; however, the patient may have clinical symptoms, such as skin thickening or a palpable lump.

Reference: Harvey J. Unusual breast cancers: Useful clues to expanding the differential diagnosis.
Radiology
2007;242:683–694.

74
 
Answer D.
 One of the roles for breast MRI is monitoring the results of neoadjuvant chemotherapy. Clinical examination was originally used to track tumor response but several studies have shown that MRI is the best for monitoring response to chemotherapy.

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

75
 
Answer A.
 The only reliable MRI finding to indicate tumor muscle invasion is muscle enhancement.

Reference: Morris EA, Schwartz LH, Drotman MB, et al. Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: Early experience.
Radiology
2000;214:67–72.

76
 
Answer C.
 Local recurrence after breast conservation therapy is 1% to 2%. Most cases of recurrence occur 4 to 6 years after treatment. MR does offer an advantage over other methods in assessing recurrence. On MRI, physiologic enhancement at the surgical site can be seen up to 18 to 24 months.

Reference: Macura KF, Ouwerkerk R, Jacobs MA, et al. Patterns of enhancement on breast MR images: interpretation and imaging pitfalls.
Radiographics
2006;26:1719–1734.

77
 
Answer B.
 Poland syndrome is a rare congenital anomaly. Patients with Poland syndrome are born with breast and pectoralis musculature hypoplasia or aplasia and often have hypoplasia of the ipsilateral upper extremity. TRAM flap would be an incorrect answer as a TRAM would appear as diffusely fatty breast compared to the contralateral side. Mastectomies are generally not imaged, and reduction mammoplasty appears as symmetric, increased density along the inferior margins of both breasts.

References: Moir CR, Johnson CH. Poland’s syndrome.
Semin Pediatr Surg
2008;17(3):161–166.
Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: Evaluation and treatment of the chest wall in 63 patients.
Plast Reconstr Surg
2010;126(3):902–911.

78
 
Answer B.
 Kinetic interrogation of the nonmass-like enhancement in the central right breast demonstrates initial rapid and delayed persistent enhancement kinetics, also known as a type I curve. On this enhancement graph, the vertical axis is the percentage change of enhancement and the horizontal axis indicates time in seconds. Early/initial enhancement is <2 minutes. After 2 minutes, the kinetic curve is in its delayed phase. Several postcontrast scans are performed at early (1 to 2 minutes) and delayed (2 to 5 minutes) phases to provide enhancement behavior of a mass or area of enhancement over time. CAD postprocessing software programs can then be used to create subtraction series and provide kinetic information. The provided kinetic curve demonstrates rapid change in the slope of enhancement of the nonmass enhancement (initial rapid enhancement). Therefore, answer choices A and E are incorrect. The delayed component of the enhancement curve is persistent meaning that the percentage change of enhancement continues to increase over time, though at a smaller slope than the initial phase. Therefore, answer choices C and D are incorrect. A delayed plateau kinetic curve is an enhancement pattern that plateaus and does not exhibit percentage change in enhancement in the delayed phase. This type of curve is known as a type II curve. A delayed washout kinetic curve demonstrates a continuous decrease in enhancement in the delayed phase. This type of delayed washout curve is a type III curve; it is classically described in association with breast cancer.