Breast Imaging: A Core Review (34 page)

92
 
Answer A.
 A galactocele is a focal collection of breast milk that is typically seen in a lactating or postlactating woman. On mammography, a galactocele presents as a low- or equal-density mass with a fat-fluid level best appreciated on a lateral view mammogram. On ultrasound, fluid debris is seen with the fat rising to the top of the galactocele and the milk/fluid layering dependently at the bottom. Galactoceles usually spontaneously resolve within a few weeks or months but can be aspirated for symptomatic relief.

Reference: Shah BA, Fundaro GM, Mandava S.
Breast Imaging Review: A Quick Guide to Essential Diagnoses
. 1st ed. New York, NY: Springer; 2010:25–27.

93
 
Answer C.
 Poland syndrome is either congenital unilateral hypoplasia or absence of the pectoralis major muscle. The inheritance pattern for Poland syndrome is autosomal recessive.

Reference: Shah BA, Fundaro GM, Mandava S.
Breast Imaging Review: A Quick Guide to Essential Diagnoses
. 1st ed. New York, NY: Springer; 2010:82–83.

94
 
Answer D.
 The mammogram findings reveal an oval mass in the area of palpable abnormality in the retroareolar region of the right breast. This mass is of fat density with associated dystrophic calcifications. On ultrasound, there is an oval mass of heterogeneous echogenicity that does not demonstrate internal vascularity. Based on the mammogram findings, ultrasound, and clinical history of lumpectomy surgery, these findings are consistent for an area of fat necrosis.

References: Hogge JP, Robinson RE, Magnant CM, et al. The mammographic spectrum of fat necrosis of the breast.
Radiographics
1995;15:1347–1356.
Soo MS, Kornguth PJ, Hertzberg BS. Fat necrosis in the breast: sonographic features.
Radiology
1998;206:261–269.
Taboada JL, Stephens TW, Krishnamurthy S, et al. The many faces of fat necrosis in the breast.
AJR Am J Roentgenol
2009;192:815–825.

95
 
Answer D.
 Focal fibrosis, also known as fibrous mastopathy or fibrous tumor, usually occurs in premenopausal women. When focal fibrosis occurs in postmenopausal women, these women are likely taking hormone replacement therapy. When palpable, focal fibrosis clinically manifests as a firm mass. Mammographic features are variable, and can present as either an ill-defined or a well-circumscribed mass, asymmetry, or architectural distortion. On ultrasound, a hypoechoic mass usually is seen, although heterogeneous echogenicity also can occur.

Reference: Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging
: Breast. Salt Lake City, UT: Amirsys; 2006;IV:2–46–IV:2–49.

96
 
Answer A.
 Unilateral or bilateral patchy isotope uptake frequently corresponds to active fibroglandular tissue or hormonal activity. Therefore, it is preferable to perform the study between day 2 and day 12 of the patient’s menstrual cycle, if possible. If there is diffuse patchy uptake, the test may have to be considered indeterminate.

References: Brem R, Fishman M, Rapelyea J. Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging and magnetic resonance imaging: A comparative study.
Acad Radiol
2007;14:945–950.
Brem R, Ioffe M, Rapelyea J, et al. Invasive lobular carcinoma: Detection with mammography, sonography, MRI, and breast-specific gamma imaging.
AJR Am J Roentgenol
2009;192:379–383.

97
 
Answer B.
 The most common cause of metastatic involvement of the breast is from contralateral breast cancer. The most common nonbreast cancer to metastasize to the breast is melanoma.

Reference: Akcay MN. Metastatic disease in the breast.
Breast
2002;11(6):526–528.

98
 
Answer A.
 Phyllodes tumors are large, rapidly growing circumscribed masses without associated calcifications. Ten percent of phyllodes tumors are malignant. Phyllodes tumors tend to recur in the biopsy site and therefore should be completely excised by surgery. Therefore, all phyllodes tumors should be excised.

Reference: Shah BA, Fundaro GM, Mandava S.
Breast Imaging Review: A Quick Guide to Essential Diagnoses
. 1st ed. New York, NY: Springer; 2010:180–181.

99
 
Answer B.
 Causes of bilateral breast edema: congestive heart failure, anasarca, renal failure, lymphadenopathy, superior vena cava syndrome, and liver disease.

Causes of unilateral breast edema are mastitis, abscess complicating mastitis, recurrent subareolar abscess, inflammatory breast cancer, trauma, coumarin necrosis, unilateral lymph node obstruction, and radiation therapy.

Reference: Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:389–390.

100
 
Answer A.
 The images shown are of a benign intramammary lymph node. No further management is warranted. Benign-appearing intramammary lymph nodes can be seen on up to 5% of screening mammograms. Typically, a circumscribed mass measuring <1 cm with reniform shape and a radiolucent hilar notch is seen in the upper outer quadrant on mammography, although less commonly it may be located in other quadrants. On ultrasound, an intramammary lymph node appears as a well-circumscribed mass with gentle lobulations, a hypoechoic cortex, and an echogenic central hilum with central feeding vessels. When intramammary lymph nodes enlarge, there is generalized or focal cortical thickening (>3-mm cortical thickness), or the node becomes rounded with loss of the normal fatty hilum. A core biopsy should be considered if there is suspicion for metastatic involvement in an intramammary lymph node.

References: Mainiero MB, Cinelli CM, Koelliker SL, et al. Axillary ultrasound and fine-needle aspiration in the preoperative evaluation of the breast cancer patient: An algorithm based on tumor size and lymph node appearance.
AJR Am J Roentgenol
2010;195:1261–1267.
Svane G, Franzen S. Radiologic appearance of nonpalpable intramammary nodes.
Acta Radiol
1993;34:577–580.

101
 
Answer D.
 Up to 9 months after lumpectomy and radiation therapy, there is strong enhancement at the lumpectomy site. From 10 to 18 months after lumpectomy and radiation therapy, the enhancement slowly subsides, with no significant enhancement in 94% of cases.

Reference: Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:307–309.

102
 
Answer B.
 Multiple bilateral similar findings suggest a benign etiology. At least three total and at least one in each breast must be present. This excludes palpable findings.

Reference: Leung JW, Sickles EA. Multiple bilateral masses detected on screening mammography: Assessment of need for recall imaging.
AJR Am J Roentgenol
2000;175:23–29.

103
 
Answer C.
 The mammogram image reveals a radiolucent (fat density) mass with an apparent fibrous capsule within the right pectoralis major muscle corresponding to the patient’s palpable abnormality as indicated by the triangular skin marker. The ultrasound images reveal an oval circumscribed mass that is nearly isoechoic or slightly hyperechoic to subcutaneous fat. Based on the imaging findings and answer choices, the findings are most likely of the diagnosis of a lipoma.

Reference: Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging
: Breast. Salt Lake City, UT: Amirsys; 2006;IV:2–56–IV:2–57.

104
 
Answer B.

Reference: Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:299–300.

105
 
Answer C.
 These are “pseudocalcifications” due to the presence of zinc oxide in certain ointments such as Desitin and Calamine lotions. The mammogram should be repeated after having the patient wipe her breasts clean.

Reference: de Paredes ES.
Atlas of Mammography (electronic resource)
. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:238–240.

106
 
Answer C.
 A post-surgical scar on ultrasound has a track to the overlying skin incision site on ultrasound. Posterior acoustic shadowing is more common in lumpectomy, post-radiation scars than benign surgical scars. Post-surgerical scar should decrease over time.

Reference: Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2006;IV:1–164.

107a 
 
Answer A.
 There is an increasing asymmetry in the upper outer quadrant, which needs to be evaluated with additional imaging and ultrasound.

107b 
 
Answer B.
 Although nothing specific is seen on ultrasound, there is a developing and increasing asymmetry on the mammogram. The cause needs to be determined. The easiest way is to do a needle biopsy under either stereotactic or ultrasound guidance. An excisional biopsy can also be done but is more invasive.

107c 
 
Answer B.
 PASH is a benign entity. Wide local excision is indicated if the mass is enlarging, if there are patient concerns over symptomatic mass, or if imaging features are atypical. Local recurrence is common if excision is incomplete.

Reference: Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2006;IV:2–68.

108
 
Answer D.
 At the site of the palpable marker is an oval lesion with a thin rim of calcification surrounding a lucent tissue. This is the characteristic appearance of an oil cyst/fat necrosis on mammography. Sonographically, they can have a variable appearance ranging from sonolucent masses (like simple cysts) to having internal echoes and posterior acoustic shadowing. Fibroadenoma, complicated cyst, and mucinous carcinoma would all appear dense on mammography.

Reference: Hines N, et al. Cystic masses of the breast.
AJR Am J Roentgenol
2010;194:122–133.

109
 
Answer C.
 Calcium phosphate calcifications are easily seen on H&E staining. Calcium oxalate is not visualized with H&E staining and requires a special polarized light to show the calcifications. If calcifications are still within the paraffin blocks, then radiographing the blocks will show them. Resectioning of that particular block will show the calcifications.

References: Dondalski M, Bernstein JR. Disappearing breast calcifications: Mammographic-pathologic discrepancy due to calcium oxalate.
South Med J
1992;85:1252–1254.
Ikeda D.
Breast Imaging: The Requisites
. 2nd ed. St. Louis, MO: Elsevier Mosby; 2011:168.

110
 
Answer A.
 The image depicts a fibroadenoma, which is the most common breast mass in younger women. On ultrasound, fibroadenomas are usually circumscribed round to ovoid masses of uniform hypoechogenicity. Sometimes a thin echogenic rim–pseudocapsule may be seen sonographically. Typically fibroadenomas do not show rim enhancement on MRI. They contain nonenhancing septations, which if seen on MRI, are pathognomonic. Masses that do show rim enhancement on MRI include complicated cysts, carcinomas, and fat necrosis. Lipomas are composed of adipose cells, and the breast within a breast appearance is indicative of hamartomas. On ultrasound, hamartomas can have a heterogeneous echotexture and also have wide sonographic variability in their appearance.

References: Berg WA, Birdwell R, Gombos EC, et al.
Diagnostic Imaging: Breast
. Salt Lake City, UT: Amirsys; 2006;IV:2–28,34,56.
Chao TC, Chao HH, et al. Sonographic features of breast hemartomas.
J Ultrasound Med
2007;26(4):447–452.
Morris EA, Liberman L.
Breast MRI: Diagnosis and Intervention
. New York, NY: Springer; 2005:427–431.

111
 
Answer B.
 The mass in the mammogram is a lipoma. These are fatty masses containing a radiolucent center that may or may not have a discrete rim. Unlike oil cysts, they never calcify. As with lipomas elsewhere in the body, they are freely mobile and soft. Ultrasound is usually not indicated because the lesion is clearly benign by mammography.