Brandi T. Nicholson

Nipple-Areolar Complex: Normal Anatomy and Benign and Malignant Processes

The nipple-areolar complex may be affected by many normal variations in embryologic development and breast maturation as well as by abnormal processes of a benign or malignant nature. Benign processes that may affect the nipple-areolar complex include eczema, duct ectasia, periductal mastitis, adenomas, papillomas, leiomyomas, and abscesses; malignant processes include Paget disease, lymphoma, and invasive and noninvasive breast cancers. Radiologists should be aware of the best methods for evaluating each of these entities: Many disorders of the nipple-areolar complex are unique or differ in important ways from those that occur elsewhere in the breast, and they require a diagnostically specific imaging evaluation. Patients may present with benign developmental variations; inversion, retraction, or enlargement of the nipple, which may have either a benign or a malignant cause; a palpable mass; nipple discharge; skin changes in and around the nipple; infection with resultant nipple changes or a subareolar mass; or abnormal findings at routine mammographic screening. Further diagnostic imaging may include repeat mammography, breast ultrasonography, galactography, and magnetic resonance imaging. When skin changes are present, a clinical evaluation by the patients primary care physician, dermatologist, or surgeon should be part of the diagnostic work-up.

Short-Term Follow-Up of Palpable Breast Lesions With Benign Imaging Features: Evaluation of 375 Lesions in 320 Women

OBJECTIVE The purpose of this study was to evaluate the feasibility of short-term follow-up of palpable masses that have benign imaging features. MATERIALS AND METHODS The cases of all women with round, oval, or lobular palpable masses with circumscribed margins and homogeneous ultrasound echotexture for which short-term follow-up was recommended from July 1997 through December 2003 were retrospectively identified. Evaluation was by ultrasound and/or mammography and focused clinical examination. Outcome was assessed with imaging or clinical follow-up lasting at least 12 months. The cancer incidence for palpable lesions was compared with that for nonpalpable lesions recommended for short-term follow-up. RESULTS In 379 women, 443 palpable masses with benign features for which short-term follow-up was recommended were identified. Outcome data were available on 375 masses in 320 women. Lesions were evaluated with mammography and ultrasound (n = 186) or ultrasound alone (n = 189). Masses were typically identified only with ultrasound (n = 258, 68.8%); were oval (n = 275, 73.3%), of equal density to normal breast tissue on mammograms (n = 95 on 117 mammograms, 81.2%), and hypoechoic (n = 336 in 372 ultrasound examinations, 90.3%); and were prospectively believed to be fibroadenoma (n = 304, 81.1%). Eighty-five lesions (22.7%) were biopsied soon after evaluation, and one 1.5-mm ductal carcinoma in situ was diagnosed. At follow-up (mean, 2.7 years), 26 lesions (6.9%) had grown. Twenty-four of the 26 lesions were biopsied, and no cancer was diagnosed. The overall cancer prevalence was similar for palpable (0.3%) and nonpalpable (1.6%) masses. The cost of short-term follow-up was less than that of biopsy. CONCLUSION Short-term follow-up is a reasonable alternative to biopsy of palpable breast lesions with benign imaging features, particularly for young women with probable fibroadenoma.

Breast MR Imaging Artifacts: How to Recognize and Fix Them

Patient and technical factors may lead to unwanted artifacts at breast magnetic resonance (MR) imaging. Use of a properly functioning high-field-strength MR imaging system, a dedicated bilateral breast coil, and an optimal imaging protocol provides a solid framework for performing high-quality breast MR imaging. Problems related to breast positioning, selection of imaging volume, and phase-encoding direction can be overcome by training and providing feedback to MR imaging technologists. Common artifacts seen at breast MR imaging include motion, suboptimal fat suppression, metallic susceptibility, phase wrap, radiofrequency noise, and chemical shift. Once they are recognized, many of these artifacts can be corrected. Protocol monitoring and imaging-based feedback from the interpreting radiologist are essential for minimizing artifacts and optimizing breast MR imaging.

Finding Early Invasive Breast Cancers: A Practical Approach

Detection of early invasive breast cancer is important, as patient survival is high when the cancer is 2 cm or smaller. Invasive breast cancers typically manifest mammographically as focal asymmetries or masses. Strategies for detecting focal asymmetries and masses on screening mammograms include side-by-side comparison, looking for parenchymal contour deformity, close inspection of the retromammary fat, identifying the presence of associated findings, and comparison with prior mammograms. Focal asymmetries are often normal but are concerning when there is distortion of the normal breast architecture. Masses and focal asymmetries are best evaluated in the diagnostic setting by using spot compression and true lateral views and, frequently, ultrasonography. Management of a lesion depends on the worst imaging feature. Indications for an assessment of probably benign findings are very specific but are often misapplied. This review for residents provides a practical approach to the detection and management of breast masses and focal asymmetries.

Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or Observation

PURPOSE To assess the utility of precise radiologic and pathologic correlation for establishing imaging-histologic concordance or discordance as a method to limit the number of patients requiring surgical excision when atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is diagnosed at core biopsy. MATERIALS AND METHODS This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The pathology database was searched from 2000 to 2010 for core biopsies yielding ALH or LCIS devoid of any additional lesion that independently necessitated excision. All cases had to have either subsequent surgical excision or a minimum of 2 years of imaging follow-up. This yielded 50 cases from 49 women aged 40-73 years (mean age, 59 years). The authors performed detailed radiologic-pathologic analysis while blinded to subsequent follow-up information, comparing all biopsy-related images with the histologic findings at core biopsy and then designating each core biopsy finding as concordant or discordant. Then, results of subsequent surgery or extended follow-up for each case were unblinded and compared with original concordant or discordant designations. Outcomes and confidence intervals (CIs) were calculated. RESULTS Of the 43 benign concordant core biopsy findings, none were upgraded at surgery (n = 38) or extended follow-up (n = 5) (95% CI: 0%, 8%). Of the seven discordant biopsy findings, two were upgraded to ductal carcinoma in situ at surgery (n = 5); none of the cases were upgraded at follow-up (n = 2). CONCLUSION When careful radiologic-pathologic correlation is performed and concordance is achieved, women with ALH or LCIS at core biopsy can be observed.

The next accreditation system in radiology: A report from the APDR residency structure committee

In a move to emphasize the educational outcomes of training programs, the ACGME has created the Next Accreditation System (NAS). The stated goals of NAS include aiding the ACGME in the accreditation of programs based on educational outcome measures, decreasing program burdens associated with the conventional process-based approach to ACGME accreditation, allowing good programs to innovate while enabling struggling programs to steadily improve, and providing public accountability for outcomes. Diagnostic radiology is among the first group of specialties to undergo NAS implementation and began operating under the NAS in July 2013. This article describes the various components of the NAS and explains the new elements, including the clinical learning environment review program, the milestones, the clinical competency committee, and the self-study visits.

Rim-enhancing breast masses with smooth or spiculated margins on magnetic resonance imaging: histopathology and clinical significance

Rim enhancement is defined as enhancement that is more pronounced at the periphery of a mass. It can have varying appearances, ranging from a thin pattern to one that is thicker. This internal enhancement characteristic is an established characteristic of malignant lesions. Additionally, the use of combined descriptors, especially internal enhancement characteristics and the associated margin, can provide a more powerful predictive value than that of individual descriptors. The margin assessment of rim-enhancing masses is important and can vary in appearance from smooth to spiculated. Moreover, rim enhancement may be dynamic in that it changes appearance during the dynamic phases of contrast- enhanced breast magnetic resonance imaging (ce-MRI), and this feature can lead to confusion in the correct application of this lexicon. Rim-enhancing masses on ce-MRI are typically of two morphological types (i.e., a thin rim-enhancing mass with a smooth margin and a thick rim-enhancing mass with a spiculated margin). It is helpful to review and clarify the lexicon of rim enhancement using combined descriptors based on the pathological findings as doing so can help predict the likelihood of malignancy of ce-MRI lesions.

Incidental pleural effusions detected on screening breast MRI.

OBJECTIVE Pleural effusions are a common complication of malignancy that must be differentiated from physiologic effusions identified on breast MRI. This study aimed to determine the incidence and reference range of physiologic pleural effusions observed in healthy women undergoing screening breast MRI. MATERIALS AND METHODS A retrospective analysis of 200 consecutive women who underwent screening breast MRI between December 2007 and December 2008 was performed. Medical records were reviewed; patients with abnormal MRI findings resulting in a diagnosis of breast cancer, a prior malignancy, or cardiac or pulmonary disease were excluded. Patient age, the presence of pleural effusions, and, if present, the laterality were recorded. The largest size of effusions was measured at the anterior chest wall. A nonparametric Wilcoxon test was used to compare the sizes of right- and left-sided pleural effusions. RESULTS Of the 200 patients, 174 (87%) had a pleural effusion; 124 (62%) were bilateral and 50 (25%) were unilateral. Compared with the left side, right-sided pleural effusions were more frequent (81.5% vs 67.5%, respectively; p < 0.001) and were slightly larger (mean, 3.3 vs 2.8 mm; p = 0.019). Effusions ranged from 1 to 12 mm on the right and from 1 to 8 mm on the left. The reference range for pleural effusions on breast MRI based on this healthy population is up to 7 mm on the right side and 5 mm on the left side. CONCLUSION Small pleural effusions are a common physiologic finding in women undergoing screening breast MRI and should not prompt further testing.

Sarcoidosis of the breast: An unusual presentation of a systemic disease.

A58-year-old female with history of pituitary and pulmonary sarcoidosis, currently in remission, underwent routine bilateral screening mammography that demonstrated multiple new bilateral, round, illdefined, equal density masses (Fig. 1). A diagnostic ultrasound was performed on both breasts to better characterize the lesions (Fig. 2). This revealed multiple, bilateral, round, ill-defined, hypoechoic masses with hyperechoic rims associated with posterior acoustic shadowing, all equal to or less than 10 mm in diameter. The patient was also noted to have bilateral axillary adenopathy. The physical examination was unremarkable. Given that the patient’s sarcoidosis was felt to be in remission there was concern that the lesions represented metastases to the breast. The patient’s pulmonary function tests were recently better than her baseline and her pituitary magnetic resonance imaging (MRI) had been stable. The dominant lesion in the right breast was selected for ultrasound-guided core needle biopsy. The core needle biopsy specimens consisted of dense fibrous tissue entrapping normal fat (Fig. 3). Normal breast lobules and ducts were not present in the samples. The fibrous tissue contained numerous well-formed granulomatous aggregates of discrete, monoand multinucleated histiocytes. The latter were characterized by a wreath-like ring of nuclei at the periphery of the cytoplasm. Scattered, well-formed (a)

3D‐MR Ductography and Contrast‐Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study

We evaluated contrast‐enhanced magnetic resonance (ce‐MR) imaging and an indirect MR galactogram (MRG) sequence against conventional galactography (CG) in women with suspicious nipple discharge who underwent histologic diagnosis. This study was Institutional Review Board approved and HIPAA compliant. Women with suspicious nipple discharge recommended for CG were recruited for our study. Patients underwent both a ce‐MR as well as MRG (MRG‐1 and MRG‐2, variations in isotropic spatial resolution) followed by CG within 60 days. The ce‐MR and MRG studies were interpreted together by a single radiologist separately from CG. Pathology was used as our gold standard and was obtained via image‐guided core needle biopsy or surgery with papilloma, atypia, and malignancy considered positive. Of the 21 patients recruited for the study, 20 patients had known histology results for 26 lesions; 18 patients (90.0%) had successful CG, 20 (100.0%) ce‐MRI, 20 (100.0%) MRG‐1, and 19 (95.0%) MRG‐2. Histology showed 5 cancers (4 women), 15 papillomas (2 with atypia) (11 women), and 6 additional benign lesions (6 women). Five patients (25.0%) had additional lesions detected by ce‐MR that influenced surgical management. Sensitivity, specificity, positive (PPV), and negative predicted values (NPV) for CG, ce‐MRI, MRG‐1 were 65.0, 33.3, 76.5, and 22.2; 95.0, 66.7, 90.5, and 80.8; 55.0, 66.7, 84.6, and 30.8, respectively. ce‐MR had the highest sensitivity, PPV, and NPV compared with CG or MRG. Our MRG protocols show promise, but were not as sensitive as ce‐MRI for women with suspicious nipple discharge.