The Nipple‐Areolar Complex

Objective. The purpose of this presentation is to show the radiologic findings of normal variants and benign and malignant diseases that affect the nipple‐areolar complex. Methods. We evaluated the imaging findings of nipple‐areolar complex lesions, using multiple breast imaging modalities including mammography, sonography, galactography, contrast‐enhanced magnetic resonance imaging (MRI), and positron emission tomography/computed tomography. Results. Radiologic features of nipple‐areolar complex lesions, including Montgomery tubercles, nipple inversion, benign calcifications, inflammation, duct dilatations, intraductal papillomas, fibroadenomas, neurofibromatosis, dermatosis of the nipple, and breast malignancy, have been illustrated. Conclusions. A clinical examination is essential and an appropriate imaging evaluation with multiple modalities is often necessary to accurately diagnose an underlying abnormality of the nipple‐areolar complex. Given the limitations of conventional mammography, supplemental mammographic views often are needed, and sonography may be performed to further characterize a mammographic or clinical finding. Also, contrast‐enhanced MRI may be useful for additional evaluation.     

Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast.

OBJECTIVE: To evaluate the role of combined mammographic and sonographic imaging in patients with palpable abnormalities of the breast. METHODS: Four hundred eleven consecutive cases of palpable abnormalities of the breast underwent combined mammographic and sonographic evaluation. Patients who did not undergo biopsy had imaging and clinical follow-up; the mean follow-up period was 28.9 months (range, 24-33 months). RESULTS: One hundred sixty-five (40.1%) of 411 palpable abnormalities had a benign assessment; 97 (58.7%) of the 165 benign lesions were visible on both mammography and sonography; 66 (40%) of 165 benign lesions were mammographically occult and identified at sonographic evaluation. In 60 (14.6%) of the 411 cases, imaging evaluation resulted in a suspicious assessment; 49 (81.7%) of the 60 lesions categorized as suspicious underwent biopsy; 14 (28.5%) of 49 lesions were histologically proved to be carcinoma. Nineteen (31.6%) of the 60 lesions categorized as suspicious were mammographically occult and identified only on sonography; 14 (73.7%) of these 19 lesions underwent biopsy; 12 (63.1%) of 19 were benign, and 2 (10.5%) were malignant. One hundred eighty-six (45.2%) of the 411 palpable abnormalities had negative imaging assessment findings; 12 patients with negative imaging findings underwent biopsy, and all had benign findings. The sensitivity (14 of 14) and negative predictive value (186 of 186) for a combined mammographic and sonographic assessment were 100%; the specificity was 80.1% (186 of 232). CONCLUSIONS: Cancer was diagnosed in 14 (3.4%) of 411 women who underwent combined imaging for palpable abnormalities of the breast. Combined mammographic and sonographic assessment was shown to be very helpful in identifying benign as well as malignant lesions causing palpable abnormalities of the breast.     

乳腺叶状肿瘤的影像分析

目的 分析乳腺叶状肿瘤的X线钼靶摄片和超声表现.方法 收集经手术病理证实的19例乳腺叶状肿瘤,术前均行超声检查,其中15例行X线钼靶摄片,回顾分析其临床特点和影像学表现.结果 19例乳腺叶状肿瘤中,良性8例,交界性6例,恶性5例.15例患者X线钼靶摄片中病灶均为高密度孤立肿块影,呈圆形(8例)或浅分叶状(7例),边界清晰(10例)或部分不清(5例),部分肿块周边见"晕"征(4例).超声检查6例发现囊性变,6例表现为后方回声增强.病灶为圆形(8例)、浅分叶状(8例)或有角状突起(3例).所有病例均未发现腋下转移淋巴结及周围组织浸润等恶性征象.结论 认识乳腺叶状肿瘤的病理类型和临床特点,结合影像表现综合分析,可提高术前诊断率.     

Sonographic Features of Gynecomastia

Objective. The purpose of this study was to identify sonographic features of gynecomastia. Methods. .A retrospective analysis was performed on all male patients with breast symptoms imaged with breast sonography over a 5‐year period. Breast sonograms in 158 men were jointly reviewed by 3 investigators. Sonograms were assessed for the presence or absence of a mass: (1) if mass present, (a) location of the mass, (b) vascularity, (c), axis, (d) appearance of posterior tissues, and (e) tissue echo texture; and (2) if mass absent, anteroposterior (AP) depth at the nipple (increased if >1 cm). Results. Of the 237 men with breast symptoms, 79 with only mammography were excluded. Of the 158 who had sonography with or without mammography, 5 without gynecomastia were also excluded. A total of 153 men included in the study presented with pain (n = 38), a lump (n = 95), both pain and a lump (n = 17), or nipple discharge (n = 3). Nine of 153 with gynecomastia had a biopsy. A total of 219 sonographic examinations were performed, which revealed 73 masses (33%): 20 (27%) nodular, 20 (27%) poorly defined, and 33 (45%) flame shaped. All masses were retroareolar, with 57 (78%) hypoechoic, 54 (73%) avascular, 60 (82%) parallel to the chest wall, and 47 (64%) without posterior enhancement or shadowing. Of the 146 without masses (67%), 141 (97%) had increased AP depth at the nipple. Conclusions. Gynecomastia is a clinical diagnosis, and mammography is the primary imaging modality when indicated. However, if sonography is used when mammography is declined or when mammography is inconclusive, it is important to recognize the various described patterns of gynecomastia to avoid unnecessary biopsy based on sonographic findings.     

Breast sonography: technique to mimic mammographic position.

Positional changes in the breast between supine sonography and mammography may cause difficulties in correlating abnormalities. The problem is easily surmounted by performing the breast sonogram with the patient in the upright position. This study is a prospective evaluation of 10 patients examined sonographically in the supine and upright positions. The nipple to lesion distance was measured and the clock position estimated on the upright and supine sonograms. These parameters were compared to the original mammograms. In all patients the mammographic clock position and the distances from the nipple correlated more closely with the upright sonogram. The mammographic clock position was the same on the upright sonogram in six of 10 (60%), and the remaining four (40%) varied from one half to two clock positions. In supine sonography the clock position was the same in two of 10 (20%) patients, and the remaining eight (80%) varied from one to three clock positions. Most lesions were between 4.5 and 11 cm from the nipple on the mammogram. The distances of the lesions from the nipple ranged from 3 to 10 cm on upright sonography and from 0 to 4.5 cm on supine sonography. The difference between clock positions and the distances from the nipple on upright versus supine sonography were statistically significant. Therefore, upright sonography is more accurate in localizing mammographically identified lesions than the standard supine sonographic technique.     

声触诊组织成像量化技术、钼靶X线及两者联合诊断乳腺良恶性病灶

目的 探讨声触诊组织成像量化（VTIQ）技术、钼靶X线及二者联合诊断乳腺良恶性病灶的价值。方法 对99例患者（110个乳腺病灶）行术前VTIQ成像和钼靶X线检查,获得病灶的剪切波速度平均值（SWV_mean）,并进行乳腺影像报告与数据系统（BI-RADS）分类。以病理结果为金标准,分别绘制SWV_mean、钼靶X线及二者联合诊断乳腺病灶良恶性的ROC曲线,评价其诊断效能。比较VTIQ技术、钼靶X线及二者联合诊断乳腺良恶性病灶的AUC的差异。结果 乳腺良性病灶SWV_mean为（3.03±0.78）m/s,恶性为（5.61±2.11）m/s,差异有统计学意义（P<0.001）。SWV_mean诊断乳腺良恶性病灶的截断值为3.93 m/s,钼靶X线为BI-RADS 4B类。VTIQ技术、钼靶X线及二者联合诊断乳腺良恶性病灶的AUC分别为0.870 、0.749 和0.873,VTIQ技术与钼靶X线、二者联合与钼靶X线的AUC差异均有统计学意义（P=0.036、0.015）,二者联合与VTIQ技术AUC差异无统计学意义（P=0.908）。结论 VTIQ技术与钼靶X线联合诊断乳腺良恶性病灶具有较高价值。     

Imaging findings of chest wall lesions on breast sonography.

OBJECTIVE: The purpose of this presentation is to illustrate the sonographic findings of chest wall lesions that were depicted on breast sonography. METHODS: Chest wall lesions detected during breast sonography were collected and reviewed retrospectively. RESULTS: The sonographic findings of normal chest walls and various pathologic chest wall lesions, including inflammatory lesions, benign neoplasms, and malignant neoplasms, are discussed. CONCLUSIONS: Familiarity with normal sonographic anatomy and chest wall lesions could be helpful in differentiating a chest wall lesion from a breast lesion and in showing whether the origin of any palpable breast lump is in the breast parenchyma or the chest wall on breast sonography.     

Sonographic Elastography Combined With Conventional Sonography

Objective. The purpose of this study was to evaluate the diagnostic performance of conventional sonography combined with sonographic elastography for differentiation between benign and malignant breast lesions and to assess the diagnostic performance with two types of interpretation criteria for sonographic elastography. Methods. For this study, we included 281 lesions from 267 patients that were diagnosed as benign or malignant by sonographically guided biopsy and prospectively analyzed by conventional sonography and sonographic elastography from October to December 2007. The histopathologic results from sonographically guided biopsy were used as a reference standard. The final assessments were made prospectively on the basis of conventional sonography alone and then by sonographic elastography combined with conventional sonography. The diagnostic performance using area under the receiver operating characteristic (ROC) curve analysis (A_z) was compared on the basis of conventional sonography alone and on elastography combined with conventional sonography. We also calculated the area ratio of lesions detected by elastography and the elasticity score reported by Itoh et al (Radiology 2006; 239:341–350). Results. The areas under the ROC curve for conventional sonography and the combination of conventional sonography and sonographic elastography were 0.927 and 0.876, respectively. The area ratio of the lesion had better diagnostic performance (A_z, 0.757) than the elasticity score (A_z, 0.54; P < .05). Conclusions. The diagnostic performance of radiologists with respect to the characterization of breast masses as benign or malignant was not significantly improved with sonographic elastography. The area ratio of the lesion had a better diagnostic value in elastography than the elasticity score.     

Benign papillary lesions of the breast: sonographic-pathologic correlation.

We reviewed the sonographic findings of 42 benign papillary lesions of the breast and correlated them with pathologic findings. Sonography detected 95% of papillomas (22 intraluminal masses, four extraductal masses, nine purely solid masses, and five mixed type masses). The sonographic margins of the mass were well defined in 20 lesions and poorly defined in 14 lesions. Poorly defined margins on sonography were frequent in papillomas with pathologic pseudoinvasion and in juvenile papillomatosis. Most benign papillary lesions of the breast have the sonographic findings suggestive of intraductal origin. The sonographic findings of papillary lesions correlated well with pathologic findings.     

超声弹性成像评价乳腺肿块图像质量的影响因素

目的 探讨超声弹性成像评价可疑乳腺病变中影响其成像质量的因素。方法 对134例患者的155个乳腺肿块行超声实时弹性成像,将图像质量评分为0级(不足)、1级(低质量)、2级(高质量),分析年龄、体质量指数、乳腺密度、病灶大小、病变深度和乳腺厚度与图像质量的关系,以及弹性成像鉴别良恶性肿块的敏感度和特异度。结果 病灶图像质量评估为不足10个,低质量67个,高质量78个。较小的病灶、较浅的病变、病变处乳腺厚度较薄、病理为良性与更高的图像质量明显相关;而年龄、体质量指数、乳腺密度、病变与乳头距离与图像质量无关。病变处乳腺厚度是影响弹性图像质量最重要的因素。高质量、低质量图像鉴别良恶性肿块的敏感度差异有统计学意义。结论 病变处乳腺厚度是影响弹性成像图像质量最重要的因素。较高质量评分的超声弹性成像可提高鉴别乳腺良恶性肿块的敏感度。     

Radial scars of the breast: sonographic findings

The purpose of this study was to identify the sonographic features of radial scars of the breast and to determine whether sonography has a role in imaging of radial scars suspected on mammography. Over a period of 4 years and 6 months, patients with a pathologic diagnosis of a radial scar and who had undergone mammographic and sonographic evaluation before biopsy were identified. During the period studied, there were 17 patients with a histopathologic diagnosis of a radial scar who had undergone sonographic and mammographic evaluation before biopsy. A radial scar was sonographically visible in eight of the 17 patients. In three of these patients, the lesion was more apparent on the sonogram than on the mammogram, and in one patient the radial scar was identified only on sonographic evaluation. It was concluded that radial scars of the breast may be sonographically visible; hence, additional sonographic evaluation may be helpful in those patients in whom mammographic findings are subtle or apparent on only one mammographic view to aid in the localization of the lesion before biopsy.     

Metaplastic carcinoma of the breast: mammographic and sonographic findings

PURPOSE: We investigated the mammographic, sonographic, and pathologic findings in metaplastic carcinoma of the breast. METHODS: The mammographic (n = 16) and sonographic (n = 11) findings in 16 patients with metaplastic carcinoma of the breast were analyzed retrospectively along with pathologic findings. Whenever possible, results of preoperative fine-needle aspiration biopsy and immunohistochemical studies were obtained. RESULTS: All patients presented with a palpable breast mass. The mean size of the lesions at pathologic examination was 4.2 cm. On mammography, 15 patients had a mass (1 patient had 2 masses), and 1 patient had only clustered microcalcifications without an associated mass. The mean longest diameter of the 16 masses on mammography was 4.6 cm. Eleven lesions (69%) were round to ovoid in shape, 13 lesions (81%) showed ill-defined or obscured margins, and 10 lesions (63%) showed associated architectural distortion. On sonography, 6 (55%) of 11 lesions were round to ovoid, 9 lesions (82%) had well-defined margins, and 6 lesions (55%) showed complex echogenicity with solid and cystic components. At pathologic examination, 4 of these 6 lesions showed hemorrhagic or cystic necrosis. Axillary lymph nodes were positive in 6 (40%) of 15 patients in whom axillary node dissection was performed. CONCLUSIONS: Metaplastic carcinoma of the breast manifests as a rapidly growing, mammographically ill-defined round mass with associated architectural distortion on mammograms. Complex echogenicity with solid and cystic components may be seen sonographically and is related to hemorrhagic or cystic necrosis seen pathologically.     

Ultrasonographic and Mammographic Findings of Male Breast Disease

Most male breast diseases are benign, although malignancies can also occur. Gynecomastia, the most common abnormality in the male breast, has characteristic imaging findings differentiating it from cancer. Fewer than 1% of patients with breast cancer are men, but the incidence of male breast cancer is increasing worldwide. Additionally, breast cancer often presents at a more advanced stage in men than in women due to delayed diagnosis. Understanding imaging features of male breast disease is important for an accurate diagnosis and optimal care. This article reviews ultrasonography and mammography findings of benign and malignant diseases of the male breast.     

Clinically and mammographically occult breast lesions: detection and classification with high-resolution sonography.

With recent significant advances in ultrasound technology, the potential of high-resolution sonography to improve the sensitivity of cancer diagnosis in women with dense breasts has become a matter of interest for breast imagers. To determine how often physician-performed high-resolution sonography can detect nonpalpable breast cancers that are not revealed by mammography, 8,970 women with breast density grades 2 through 4 underwent high-resolution sonography as an adjunct to mammography. All sonographically detected, clinically and mammographically occult breast lesions that were not simple cysts were prospectively classified into benign, indeterminate, or malignant categories. Diagnoses were confirmed by ultrasound-guided fine-needle aspiration, core-needle biopsy, or surgical biopsy. In 8,103 women with normal findings at mammography and physical examination, 32 cancers and 330 benign lesions were detected in 273 patients with sonography only. Eight additional cancers were found in 867 patients with a malignant (n = 5) or a benign (n = 3) palpable or mammographically detected index lesion. The overall prevalence of cancers detected with screening sonography was 0.41%, and the proportion of sonographically detected cancers to the total number of nonpalpable cancers was 22%. The mean size of invasive cancers detected only by sonography was 9.1 mm, and was not statistically different from the mean size of invasive cancers detected by mammography. The sensitivity of prospective sonographic classification for malignancy was 100%, and the specificity was 31%. In conclusion, the use of high-resolution sonography as an adjunct to mammography in women with dense breasts may lead to detection of a significant number of otherwise occult cancers that are no different in size from nonpalpable mammographically detected cancers. Prospective classification of these lesions based on sonographic characteristics resulted in an acceptable benign-to-malignant biopsy rate of 6.3:1.     

乳腺单纯性浸润性小叶癌的临床、X线、超声特征

目的 观察乳腺单纯性浸润性小叶癌(ILC)的临床、X线和超声检查特征,评价联合应用三种方法的价值.方法 回顾55例经手术病理证实为单纯性ILC的详细检查结果,分析得出假阴性结果的原因.结果 主要临床检查结果为肿块(96.15%)和腺体增厚(3.85%).主要X线检查结果为边缘不规则肿块(65.38%)和结构扭曲(23.08%).主要超声检查结果为肿块(98.00%)和结构紊乱(2.00%).临床、X线、超声对病灶的定性诊断准确率分别为94.55%、83.87%、98.04%,联合应用的准确率为100%.结论 超声检测ILC病灶的准确性高于X线检查.联合应用临床、X线、超声可提高ILC的术前诊断准确率.     

Diagnosis of the intraductal component of invasive breast cancer: assessment with mammography and sonography.

OBJECTIVE: The aim of this study was to investigate mammographic and sonographic features and their sensitivities for depiction of the intraductal component associated with invasive ductal carcinoma (IDC). METHODS: During a 1-year period, 132 patients with IDC underwent surgical treatment. All patients underwent mammography and high-resolution sonography, and the findings were reported according to the American College of Radiology's Breast Imaging Reporting and Data System lexicon. Tumors were classified as "pure IDC" and "IDC with an intraductal component" by histopathologic evaluation. We compared mammographic and sonographic features between the above 2 groups and attempted to correlate them with histopathologic findings. We also investigated separate and combined sensitivities, specificities, and accuracies of both mammography and breast sonography for showing intraductal components. Finally, imaging measurements were compared with pathologic measurements. RESULTS: One hundred four (79%) of the 132 IDCs contained an intraductal component. Patients with IDC with an intraductal component showed calcifications on mammography and showed an echogenic halo, duct dilatation, calcifications, and increased vascularity in surrounding tissue on sonography more frequently than patients with pure IDC. The sensitivities of mammography, sonography, and their combined assessment for detection of an intraductal component were 55%, 80%, and 86%, respectively. The combined assessment (r = 0.90) measured the extent of the tumor more accurately than mammography (r = 0.71) or sonography (r = 0.79) separately. CONCLUSIONS: Combined assessment with mammography and sonography offers more accurate information for the presence of an intraductal component and the extent of a tumor than each separate assessment.     

Sonographic evaluation of focal asymmetric density of the breast

The purpose of this study was to examine the role of sonography in the evaluation of a focal asymmetric density of the breast in patients who subsequently underwent biopsy for this finding. During a 30-month period, the clinical, sonographic, and pathologic findings were retrospectively reviewed in 36 women who underwent biopsy for a focal asymmetric density of the breast after mammographic and sonographic workup. Sonographic evaluation of a focal asymmetric density of the breast in 36 women demonstrated a solid mass in 15, a suspected complicated cyst in two, echogenic tissue in nine women, and no focal sonographic change in 10. Excisional biopsy of the focal asymmetric density revealed infiltrating ductal cancer in seven patients (19.4%: 7/36). Two of these seven patients with breast cancer had no focal abnormality at sonographic examination. Twenty-nine patients had benign pathologic findings. In this retrospective study, the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density undergoing biopsy was found to be 89.4% (17/19). Sonographic evaluation of a focal asymmetric density is helpful, particularly to identify an underlying mass. When sonography demonstrates echogenic tissue corresponding to the focal asymmetric density, a benign process is likely; however, absence of a corresponding focal finding does not exclude malignancy. Therefore, although the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density is high, biopsy is still indicated for this mammographic finding when it is new, enlarging, or palpable, even in the absence of a suspicious sonographic finding.     

Mimickers of Breast Malignancy on Breast Sonography

The aim of this article is to review benign breast lesions that can mimic carcinoma on sonography. Cases of benign lesions mimicking carcinoma on sonography were collected among lesions that were initially assessed as suspicious on sonography according to the American College of Radiology Breast Imaging Reporting and Data System category. Sonographically guided core needle biopsy was performed, and the pathologic types were confirmed to be benign. Cases of benign lesions mimicking carcinoma on sonography were shown to include fat necrosis, diabetic mastopathy, fibrocystic changes, sclerosing adenosis, ruptured inflammatory cysts, inflammatory abscesses, granulomatous mastitis, fibroadenomas, fibroadenomatous mastopathy, and apocrine metaplasia. Benign breast lesions may present with malignant features on imaging. A clear understanding of the range of appearances of benign breast lesions that mimic malignancy is important in radiologic‐pathologic correlation to ensure that benign results are accepted when concordant with imaging and clinical features but, when discordant, there is no delay in further evaluation up to and including excisional biopsy.     

乳腺X线摄影及超声鉴别诊断乳腺叶状肿瘤与纤维腺瘤

目的 探讨乳腺X线摄影及超声诊断及鉴别诊断乳腺叶状肿瘤与纤维腺瘤的价值。方法 回顾性分析并比较经病理证实的110例乳腺叶状肿瘤和102例纤维腺瘤患者的临床、X线和超声特征。结果 乳腺纤维腺瘤最大径（2.71±1.44）cm,叶状肿瘤最大径（4.61±3.35）cm,差异有统计学意义（P<0.001）。乳腺良性与恶性叶状肿瘤最大径差异有统计学意义（P=0.024）。X线检查发现乳腺叶状肿瘤与纤维腺瘤在形状、边界、密度及内部钙化差异均有统计学意义（P均<0.05）;超声发现两者形状、边界、内部囊变、后方回声及血流分级差异均有统计学意义（P均<0.05）。良性、交界性与恶性叶状肿瘤中,肿块内部是否囊变差异有统计学意义（P=0.006）。结论 综合分析乳腺X线、超声及临床特点可以初步鉴别乳腺纤维腺瘤与叶状肿瘤,当肿块最大径>3.0 cm,呈分叶状高密度、伴有内部囊变、血流信号较丰富时提示叶状肿瘤。     

Value of contrast-enhanced power Doppler sonography using a microbubble echo-enhancing agent in evaluation of small breast lesions

PURPOSE: The purpose of this study was to prospectively evaluate the usefulness of contrast-enhanced power Doppler sonography (PDUS) using a microbubble echo-enhancing agent in differentiating between malignant and benign small breast lesions. PATIENTS AND METHODS: Between July 1, 2000, and September 30, 2001, we performed gray-scale sonographic examination of patients in whom diagnostic sonography or screening mammography had revealed solid breast lesions measuring less than 2 cm in the largest dimension. The patients were then examined on PDUS before and after injection of a microbubble contrast agent. The sonographic findings for all 3 techniques, as well as the morphologic features of the Doppler signals for each patient before and after injection of the contrast agent on PDUS, were independently assessed. Each lesion was classified as "benign" or "malignant" on the basis of specific criteria for sonographic interpretation. A hemodynamic study was performed in which time-transit profiles of the Doppler signals on contrast-enhanced PDUS were generated using a computer-assisted program, and the results for each patient were compared with the findings of a histopathologic examination of surgical specimens. RESULTS: Thirty-six patients (35 women and 1 man) with a mean age of 43.5 years (range, 18-69 years) were evaluated. The tumors ranged from 4 to 19 mm in the largest dimension. Histopathologic examination revealed that 19 tumors were benign and 17 were malignant. For morphologic diagnosis of the malignant lesions, the sensitivity of gray-scale sonography was 100%, compared with 29% for PDUS without contrast enhancement. The specificity of gray-scale sonography was 47%, compared with 74% for PDUS without contrast enhancement. Contrast-enhanced PDUS had a sensitivity of 71% and a specificity of 58%. The diagnostic accuracy was 72% for gray-scale sonography, 53% for PDUS without contrast enhancement, and 64% for contrast-enhanced PDUS. The time-transit profiles of the hemodynamic study did not reveal a statistically significant difference in the accuracy rates of contrast-enhanced PDUS between benign and malignant breast lesions. CONCLUSIONS: Compared with PDUS without contrast enhancement, contrast-enhanced PDUS provides better visualization of the morphology of vascular Doppler signals that is characteristic of malignancy and therefore has a higher sensitivity and diagnostic accuracy, albeit a lower specificity. In differentiating between benign and malignant small breast lesions, contrast-enhanced PDUS can be helpful when used with gray-scale sonography and PDUS without contrast enhancement.