Common and Unusual Diseases of the Nipple
Transcription
Common and Unusual Diseases of the Nipple
Note: This copy is for your personal, non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, use the RadioGraphics Reprints form at the end of this article. APPLICATIONS OF CURRENT TECHNOLOGY S65 Common and Unusual Diseases of the NippleAreolar Complex1 ONLINE-ONLY CME See www.rsna .org/education /rg_cme.html. LEARNING OBJECTIVES After reading this article and taking the test, the reader will be able to: 䡲 Describe the utility of US and MR imaging as adjuncts to mammography in the evaluation of the nipple-areolar complex. 䡲 Recognize normal characteristics of the nipple-areolar complex on breast images obtained with various modalities. 䡲 Identify indications of common and rare lesions on US and MR breast images as well as on mammograms. Darlene Da Costa, MD ● Abraha Taddese, MD, PhD ● Marina Luz Cure, MD ● Deborah Gerson, MD ● Robert Poppiti, Jr, MD ● Lisa E. Esserman, MD The nipple-areolar complex is often best evaluated as a separate region of the breast. Because of the intricacy of the anatomic structures and their superficial position, the diagnostic techniques required for optimal evaluation of the nipple-areolar complex differ from those routinely used to evaluate the whole breast. Although clinical examination and screening mammography are still of central importance, the adjunct use of multiple imaging modalities (ultrasonography, contrast material– enhanced magnetic resonance imaging, or both) as well as nonstandard mammographic views is often necessary to differentiate benign abnormalities from malignant ones. For accurate diagnosis, familiarity with a wide range of appearances of the normal anatomy, including congenital anomalies (eg, supernumerary nipples), is necessary, as is a thorough knowledge of the features of the benign and malignant processes that commonly occur in the nipple-areolar complex. Benign abnormalities may include mammary duct ectasia, nipple calcifications, cutaneous horn of the nipple, abscess of the Montgomery gland, and nipple adenoma. Malignant abnormalities may include Paget disease and primary lymphoma as well as carcinoma of the breast. Some conditions, such as nipple retraction and inversion, may have either a benign or a malignant cause. In such cases, a thorough radiologic assessment is especially important. © TEACHING POINTS See last page RSNA, 2007 RadioGraphics 2007; 27:S65–S77 ● Published online 10.1148/rg.27si075512 ● Content Codes: 1From the Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140. Recipient of an Excellence in Design award for an education exhibit at the 2006 RSNA Annual Meeting. Received March 9, 2007; revision requested May 1 and received July 6; accepted July 18. L.E.E. is a consultant with Ethicon Endo-Surgery; all remaining authors have no financial relationships to disclose. Address correspondence to D.D.C. (e-mail: dpcosta@bellsouth.net). © RSNA, 2007 S66 October 2007 RG f Volume 27 ● Special Issue Figure 1. Supernumerary nipples. (a) Photograph shows bilateral firm tan papules anterior to the axilla. (b) Mediolateral oblique mammograms from the same patient show bilateral accessory breast tissue in the axillary tail. Introduction Normal and Variant Anatomy Many articles describe, in a cursory way, one or another pathologic condition within the nippleareolar complex. Likewise, various reports of missed and incorrect diagnoses, such as a missed malignancy or a malignancy mistakenly believed to represent dermatitis, can be found (1,2). However, to our knowledge, no focused review of conditions affecting this region of the breast exists in the published literature. Therefore, we offer this overview of the multimodality approach to diagnostic imaging in this region that is so difficult to assess (3). Readers can better recognize the abnormal appearance of the nipple-areolar complex if they have an understanding of the normal anatomy and its appearance at imaging. We therefore begin with a review of the anatomy and of the various imaging techniques used to evaluate the nipple-areolar complex and then proceed with descriptions of the benign and malignant features that may be seen at imaging with various modalities. The normal nipple is in a position slightly medial and inferior to the center of the breast. The nipple and areola are composed of pigmented squamous epithelium. The nipple-areolar complex also contains a layer of circumferential smooth muscle and sebaceous glands that open through small prominences (Montgomery tubercles) that surround the periphery of the areola. Hair follicles around the areola may contain calcification (4). Milk secretion occurs through approximately seven to 15 microscopic openings on the surface of the nipple. Immediately deep to these mammary duct orifices, within each of the major ducts, are areas of dilatation known as milk sinuses, which have a storage function during lactation. The major ducts have numerous branches, each of which ends in a terminal duct lobular unit, where milk is produced during lactation (5). Common minor congenital malformations, including a supernumerary nipple or nipples and related tissue (Fig 1), may be found along the socalled milk line, which extends bilaterally from a point in the axilla toward the chest, abdomen, and groin. The most inferior location of such findings has been in the proximal medial thigh (5). RG f Volume 27 ● Special Issue Da Costa et al S67 Figure 2. Sagittal contrast-enhanced T1-weighted fat-suppressed MR images show various degrees of enhancement in a normal nipple, including none (a), mild enhancement (b), and intense enhancement (c). Figure 3. Axial contrast-enhanced T1-weighted fatsuppressed MR image of the breasts shows symmetric bilateral enhancement of the nipple-areolar complex, with a superficial layer of intense linear dermal enhancement (arrows) and a central region of nonenhancement deep to the dermis. Normal Imaging Appearances The nipple, which is normally everted, should be depicted in profile on at least one standard mammographic view. This orientation allows evaluation of both the nipple-areolar complex and vessels in the normal retroareolar region. At magnetic resonance (MR) imaging after the administration of gadolinium, the degree of nipple enhancement varies; enhancement may be absent, mild, or intense (Fig 2). Intense enhance- ment is due to the presence of numerous vessels (6). Normal nipples show a bilaterally symmetric enhancement pattern (7). The characteristic twolayered appearance of the nipple-areolar complex represents a superficial layer of intense linear dermal enhancement (1–2 mm thick) with an underlying region of nonenhancement deep to the dermis (Fig 3) (7). Normal nipples do not show nodular or irregular enhancement along their posterior borders. Ultrasonography (US) is useful for differentiating between tissue types and for identifying individual mammary ducts in most patients. The ducts are linear hypoechoic or isoechoic structures that appear to radiate from the nipple like the spokes of a wheel from the hub (8). Mammographic Technique Because of x-ray overpenetration, the nippleareolar complex is often poorly depicted and thus overlooked at mammography (9). Moreover, lesions of various kinds may mimic a normal retroareolar density, leading to a false-positive finding; or, in the setting of dense breasts, a lesion may be obscured and the mammogram therefore interpreted as negative (10). Additional mammographic views with spot compression and magnification, as well as US images, may be needed to S68 RG f Volume 27 October 2007 ● Special Issue Figure 4. Additional work-up for a retroareolar density identified at mammography. (a) Magnified view of a craniocaudal mammogram shows a well-defined mass in the retroareolar region (arrow). (b) US image of the same region shows an anechoic cyst with a posterior region of high echogenicity. Figure 5. Image artifact caused by improper scanning technique. US image shows a nipple with a large posterior shadow that simulates a mass (arrows). better evaluate a retroareolar density or pattern of microcalcification that arouses suspicion (Fig 4). The visibility of such features may be further improved with hot-light viewing or with the use of varied contrast settings during soft-copy interpretation at the digital mammography workstation. US Technique Measures for maximizing the quality of depiction at US include the use of warm gel and the maintenance of a sufficiently warm room temperature to avoid muscle contraction within the nipple and areola. In addition, to minimize acoustic shadows, the transducer must be held at an appropriate angle. When scanning is performed with the transducer held flat to the breast, against the surface of the nipple and areola, the nipple may produce an acoustic shadow with a masslike appearance (Fig 5). Proper scanning technique for US evaluation of the intranipple and subareolar portions of the mammary duct—an evaluation that is particularly important in a patient with a nipple discharge—requires angulation of the transducer so that the ultrasound beam is perpendicular to the long axis of the duct during peripheral compression. When the transducer is held at an appropriate angle against the periphery of the nipple, it is easier to maintain the steady contact and pressure needed to achieve optimal depiction of the duct (Figs 6, 7) (8). Other useful maneuvers include the two-handed compression technique and rolled-nipple technique: The twohanded compression technique is used to achieve better visibility of the duct where it enters the base of the nipple and to assess intraductal lesions and ductal compressibility. The rolled-nipple technique is used to depict the portion of the mammary duct within the nipple. Both techniques have been well described by Stavros (8). MR Imaging Technique Two important technical requirements for evaluation of the nipple-areolar complex with MR imaging are the use of a dedicated breast coil and the administration of a contrast agent (6). MR images should be correlated with mammograms and with US images when the latter are available. RG f Volume 27 ● Special Issue Da Costa et al S69 Figures 6, 7. Importance of the transducer position for US of the intranipple portion of the mammary ducts. (6) Drawing shows improper scanning technique, with the transducer held flat against the periphery of the nipple-areolar complex. In this position, the ultrasound beam roughly parallels the abnormal duct (shown in red), and the nipple casts a posterior shadow that obscures the intraductal lesion, represented here as a pale spot within the duct. (7) Drawing shows proper scanning technique, with the transducer held at an angle so that the ultrasound beam is roughly perpendicular to the long axis of the duct. With the transducer in this position, it is easier to maintain proper contact and pressure, and the abnormal duct can be viewed clearly without an acoustic shadow from the nipple. Mammographic Features Mammographic features that are associated with abnormalities of the nipple-areolar complex include asymmetry, a subareolar mass, nipple inversion, microcalcification, and skin thickening. US Features Figure 8. Intraductal lesion in a 42-year-old woman with recent onset of a spontaneous bloody discharge from the nipple. US image shows a solid lesion (arrow) within the dilated duct. Clinical and Imaging Signs of Abnormality Skin thickening and nipple retraction are visible signs of advanced breast cancer that are observable at physical examination. However, more subtle findings that are associated with pathologic changes in the nipple-areolar complex may be seen on mammograms and US and MR images long before clinical symptoms and signs are manifested. US depiction of the mammary ducts is particularly useful for the exclusion of intraductal papillary lesions in the subareolar area in patients with a nipple discharge (Fig 8). It is also useful for the detection of subtle and frequently missed secondary signs of breast carcinoma, such as one or more dilated subareolar ductal segments extending 3 cm or more within the breast (3). MR Imaging Features On MR images of the breast, findings of bulkiness, bilateral asymmetry, or early, delayed, or persistent enhancement of the nipple-areolar complex with a retroareolar mass may be indicative of tumoral involvement of the nipple-areolar complex (Fig 9). In a study of 35 patients, higher sensitivity was demonstrated with MR imaging than with mammography for the diagnosis and assessment of nipple and retroareolar tumors (7). S70 October 2007 RG f Volume 27 ● Special Issue Figure 9. Pathologic nipple enhancement at contrast-enhanced MR imaging for routine screening in a 40-year-old woman with a family history of breast cancer. (a) Sagittal T1-weighted fat-suppressed image shows subtle irregular enhancement in the nipple-areolar complex (arrow), a finding that was interpreted as normal. (b) Sagittal T1weighted fat-suppressed image obtained 1 year later shows progressive irregular masslike enhancement of the nippleareolar complex (arrow). (c) Corresponding craniocaudal mammogram shows a retroareolar mass (arrow). Figure 10. Nipple retraction in the breast of a 68-year-old woman who underwent a lumpectomy for infiltrating ductal cell carcinoma 10 years earlier. Photograph (a) and magnified view from a mediolateral oblique mammogram (b) show the postsurgical scar (white arrow) and retracted nipple (black arrow). Teaching Point Preoperative recognition of nipple involvement in retroareolar breast cancer may be critical when nipple-preserving breast conservation therapy is being considered (7). Breast MR imaging, in most cases, can help differentiate between a tumor that is confined to retroareolar tissue and one that involves the nipple-areolar complex (6). Furthermore, it has been suggested that the use of breast MR images for guidance of nipple-preserving breast-conservation surgery may help reduce the rate of local recurrence (10,11). Benign Processes Nipple Inversion When nipple abnormalities such as inversion are identified, it is important for the technologist to document them in the medical record so that the radiologist will be aware of the findings and the relevant medical history (12). Nipple inversion may be bilateral or unilateral and usually results from a benign process that takes place gradually, over a long period (eg, a few years). When nipple inversion occurs more rapidly (eg, within a few months), the cause is more likely to be a malignancy. Additional mammographic work-up is needed in cases in which the history of nipple inversion is not known or in which nipple inversion developed over a short period of time. The additional work-up should include spot compression views with the nipple in profile (to determine whether there is a retroareolar mass) as well as craniocaudal and lateral spot magnification views to assess microcalcifications. If the mammographic views are unrevealing, US should be performed. Reported histopathologic findings in cases of acute nipple inversion with a benign RG f Volume 27 ● Special Issue Da Costa et al S71 Figure 11. Subareaolar abscess in a 30-year-old woman with pain and erythema of the areola. Photograph (a) and US image (b) show a well-circumscribed oval intradermal mass (arrow). The mass appears anechoic in b, a finding suggestive of benignity. Figure 12. Ductal ectasia in four different patients. (a) Spotcompression magnification of a mediolateral oblique mammogram shows a focal linear density behind the nipple (arrows). (b) Sagittal unenhanced T2weighted fat-suppressed MR image shows high-signalintensity branching tubular structures (arrow) that represent fluid-filled ducts. (c) US image shows branching fluid-filled structures behind the nipple, features representative of dilated mammary ducts (arrow). (d) US image shows histopathologically proved inspissated secretions simulating a papilloma in a dilated duct (arrow). cause include mammary duct ectasia, postsurgical changes (Fig 10), fat necrosis, fibrocystic changes, and Mondor disease (13). usually helps differentiate an abscess from a neoplasm (Fig 11) (15). Mammary Duct Ectasia Inflammation A subareolar abscess results from the blockage of a small gland or duct beneath the areola, with the development of an infection under the skin. Such abscesses are uncommon and occur mostly in nonlactating young and middle-aged women (14). There are no known risk factors. US features include low-amplitude intracystic echoes, which may be difficult to differentiate from those observed in a neoplasm. In this situation, a clinical history that includes fever, or the observation of a lesion response to antibiotics, The clinical manifestations of ductal ectasia may include a nipple discharge, nipple retraction, a palpable mass, and pain or tenderness. At imaging, ductal ectasia may be more confidently diagnosed if similar features are demonstrated bilaterally. If subareolar ductal dilatation is observed on mammograms, spot compression and magnification views should be obtained to exclude an underlying mass (Fig 12a) (16). Calcified, inspissated secretions within the dilated subareolar ducts are a typical mammographic feature. The S72 October 2007 RG f Volume 27 ● Special Issue Figure 13. Benign and malignant nipple calcifications. (a) Magnified mediolateral oblique view shows multiple round calcifications with central lucency suggestive of benign skin calcifications (arrows) in the subareolar region. (b) Magnified mediolateral oblique view obtained in a patient who underwent previous reduction mammoplasty shows coarse calcifications located circumferentially around the nipple (arrow), a configuration that signifies benign calcifications at a suture site. (c) Craniocaudal view obtained in a patient with a history of trauma to the breast shows a coarse subareolar calcification (arrow), a finding indicative of fat necrosis. (d) Magnified craniocaudal view shows clustered pleomorphic subareolar calcifications (arrows) that were subsequently excised. The diagnosis in this case was intraductal carcinoma without associated Paget disease. Figure 14. Cutaneous horn and retracted nipple in the breast of a 78-year-old woman. (a) Photograph obtained during the physical examination shows a crusted excrescence emanating from a retracted nipple (arrow). (b) Craniocaudal mammogram shows dense keratin (arrow), which resembles calcification. Teaching Point calcifications filling the ducts are coarse, smoothbordered, and shaped like a rod or cigar pointing toward the nipple (17). On T1- and T2-weighted MR images, the dilated ducts may be seen as branching tubular structures that converge toward the nipple, with high signal intensity due to intraductal proteinaceous material, blood, or both (Fig 12b) (18). At US, the subareolar ducts appear dilated and fluid filled (Fig 12c). Inspissated secretions often are visible and may be sufficiently echogenic to mimic an intraductal tumor (Fig 12d). The observation of movement of the particulate matter in these secretions at real-time US is another diagnostic feature of ductal ectasia. RG f Volume 27 ● Special Issue Da Costa et al S73 Figure 15. Nipple adenoma in a 47-year-old woman. (a) Photograph shows a small papule (arrow) on the nipple. (b) US image depicts a dilated subareolar mammary duct and an intraductal lesion that extends to the nipple (arrow). Adenoma was diagnosed at biopsy. Figure 16. Paget disease of the breast in a 68-year-old woman. (a) Photograph shows a pink scaly eczematous plaque of the nipple (arrow). (b) Magnified craniocaudal mammographic view shows extensive subareolar pleomorphic calcifications (arrows) with a segmental distribution. Calcifications Nipple calcifications are uncommon. However, the glands and hair follicles of the nipple-areolar complex may contain calcifications (4). These so-called skin calcifications may be extensive and form a pattern that is spherical with a central area of lucency (Fig 13a) (4). Other types of calcifications may occur in association with sutures (Fig 13b), fat necrosis (Fig 13c), intraductal papilloma, Paget disease (extension of intraductal carcinoma to the surface of the nipple), and intraductal carcinoma without associated Paget disease (Fig 13d). Cutaneous Horn A cutaneous horn is a conical projection of keratin above the surface of the skin, in a configuration that resembles a miniature horn (Fig 14). The condition is usually asymptomatic; however, the lesion may grow rapidly and is vulnerable to trauma (19). Malignant lesions, usually squamous cell carcinomas, may be found at the base of the horn (20). Other tumors, more rarely found in that location, include Paget disease of the breast, sebaceous adenoma, and granular cell tumor (21). Nipple Adenoma Nipple adenoma, also known as florid papillomatosis, erosive adenomatosis, and superficial papil- lary adenomatosis (22), is an uncommon variant of intraductal papilloma that involves the nipple (Fig 15). The clinical manifestations may resemble those of Paget disease of the breast: Patients often present with a bloody discharge, crusting, nodularity, tenderness, swelling, and erythema of the nipple. The accepted treatment is complete local excision (23). Malignant Processes Paget Disease The clinical manifestations usually are suggestive of the diagnosis and may include a bloody disTeaching charge from the nipple, itching, erythema, scaly Point or flaky skin, nipple erosion or ulceration, nipple retraction, and a palpable mass. Thickening of the breast also may occur with or without changes in the nipple (24). Mammograms may show malignant calcifications at the level of the nipple or elsewhere in the breast, skin thickening, nipple retraction, and a discrete mass or masses (Fig 16). However, the mammographic appearance is normal in as many as 50% of patients with Paget disease of the breast (25,26). MR imaging may play an important role in the selection of patients with Paget disease for breast-conserving therapy, if there is no clinical or Teaching mammographic evidence of breast carcinoma. Point Abnormal nipple enhancement and linear clumped enhancement indicative of ductal carcinoma in situ in association with Paget disease may be seen on MR images (27). S74 October 2007 RG f Volume 27 ● Special Issue Figure 17. Subareolar mass mimics a normal nipple. (a) Craniocaudal view obtained at screening mammography in a 70-year-old woman shows a small subareolar mass (arrow) that has the density of a normal nipple. The nipple was present but was obscured by the lesion. (b) Craniocaudal view obtained at screening mammography 2 years later shows enlargement of the mass (arrow). A biopsy was performed, and the mass was diagnosed as infiltrating ductal carcinoma. Figure 19. Nipple necrosis due to infiltrating ductal carcinoma in an 85year-old woman. (a) Photograph obtained at physical examination shows destruction and replacement of the nipple by a 3-cm ulcerated plaque with a serosanguineous crust (arrow). (b) Mediolateral oblique mammographic view shows a large, irregular, dense mass with ill-defined borders in the upper part of the breast (white arrow) and with direct extension to the nipple, causing nipple necrosis. Enlarged lymph nodes are visible in the axillary tail (black arrow). RG f Volume 27 ● Special Issue Da Costa et al S75 Figure 18. Nipple retraction due to a malignancy in the right breast of a 68-yearold woman. (a) Mediolateral oblique mammogram shows a retracted nipple (arrow). (b) US image shows an irregular hypoechoic mass in the subareolar region (arrows). The diagnosis, based on histopathologic analysis, was infiltrating ductal carcinoma. Figure 20. Nipple displacement and retraction due to poorly differentiated infiltrating ductal carcinoma with necrosis in a 75-year-old woman. (a) Photograph obtained at physical examination shows a 5-cm subcutaneous lobulated mass (black arrow) and an inverted nipple (white arrow). (b) Mediolateral oblique mammographic view shows a large dense mass (arrow) that fills the breast. Carcinoma Teaching Point Subareolar carcinomas, which are easily confused with normal nipple structures, may be more difficult to diagnose than cancers elsewhere in the breast (Fig 17). Even a small tumor in this location may manifest as a palpable mass (10). Nipple markers may be necessary during the imaging evaluation to help distinguish the nipple from the mass. At mammography, spot compression with or without magnification may be used to improve the visibility of an underlying lesion. On US images, a subareolar mass or intraductal lesion may be identified. Contrast material– enhanced MR imaging may be useful if the mammographic and US findings are suggestive of abnormality but are inconclusive. A minority of breast cancers arise in central mammary ducts near the nipple, in the same location in which intraductal papillomas are found. Some cancers arise from preexisting papillary ductal hyperplasia or large intraductal papillomas. Carcinomas that arise centrally may be intraductal, invasive, or mixed (both invasive and intraductal) (28). Nipple retraction, a secondary sign of malignancy, generally is associated with cancers that are large enough to be visible on mammograms and palpable at physical examination (4,13). The underlying cancer may be subareolar or may have arisen at another location in the breast (Fig 18). Nipple ulceration also may occur with the extension of advanced-stage breast cancer to the skin surface (Fig 19) (29). If nipple retraction is caused by cicatrization and the pull is eccentric, the nipple may deviate in the direction of the cancer; in some cases, it may be fully inverted (Fig 20) (29). S76 RG f Volume 27 October 2007 ● Special Issue Figure 21. Primary malignant lymphoma in the breast of a 75year-old woman. (a) Craniocaudal mammographic view shows a large dense retroareolar mass. (b, c) US images show a homogeneous hypoechoic mass in the retroareolar region (b) and a large lymph node in the axilla (c). (d) Photograph obtained at clinical examination shows a 3-cm shiny reddish tumor that has encompassed the areola. Lymphoma The relative frequency of primary versus secondary breast lymphoma is variably reported; therefore, the preponderance of one type versus the other is unclear (30). There is no association between specific subtype of lymphoma and mammographic findings (31). If a primary breast lymphoma is subareolar, the nipple may appear enlarged or bulging at physical examination, instead of retracted as in infiltrating carcinoma (Fig 21). Since mammographic and US findings are nonspecific and may include single or multiple wellto ill-defined (rarely spiculated) masses of varied size, the clinical appearance of the nipple may provide a clue to the diagnosis (32,33). Conclusions Clinical examination is particularly important, and a tailored imaging evaluation with multiple modalities often is necessary to accurately diagnose an underlying abnormality of the nippleareolar complex. This region of the breast may not be clearly depicted on conventional mammograms. Supplemental mammographic views often are needed, and US may be performed to further characterize a mammographic or clinical finding. Contrast-enhanced MR imaging may be useful for additional evaluation in cases in which there is a substantial suspicion of undiagnosed malignancy or of the extension of a known malignancy to the nipple-areolar complex. References 1. Feig SA, Shaber GS, Patchefsky A. Analysis of clinically occult and mammographically occult breast tumors. AJR Am J Roentgenol 1977;128: 403– 408. RG f Volume 27 ● Special Issue 2. Mitnick JS, Vazquez MF, Plesser KP, Roses DF. Breast cancer malpractice litigation in New York State. Radiology 1993;189:673– 676. 3. Martin JE, Moskowitz M, Milbrath JR. Breast cancer missed by mammography. AJR Am J Roentgenol 1979;132:737–739. 4. Kopans DB. Anatomy, histology, physiology, and pathology. In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 14 –15. 5. Cardenosa G. Nipple-areolar complex. In: Breast imaging companion. Philadelphia, Pa: LippincottRaven, 1997; 172. 6. Morris EA. The normal breast. In: Morris EA, Liberman L, eds. Breast MRI diagnosis and intervention. New York, NY: Springer, 2005; 39. 7. Friedman EP, Hall-Craggs MA, Mumtaz H, Schneidau A. Breast MR and the appearance of the normal and abnormal nipple. Clin Radiol 1997;52:854 – 861. 8. Stavros AT. Breast anatomy: the basis for understanding sonography. In: Breast ultrasound. Philadelphia, Pa: Lippincott Williams & Wilkins, 2004; 85– 89. 9. Stefanoyiannis AP, Costaridou L, Sakellaropoulos P, Panayiotakis G. A digital density equalization technique to improve visualization of breast periphery in mammography. Br J Radiol 2000; 73(868):410 – 420. 10. Giess CS, Keating DM, Osborne MP, Ng YY, Rosenblatt R. Retroareolar breast carcinoma: clinical, imaging, and histopathologic features. Radiology 1998;207:669 – 673. 11. Douek M, Hall-Craggs MA. Can the use of preoperative MR imaging reduce local recurrence rates in patients with retroareolar breast cancer who undergo breast-conservation surgery? Radiology 1999;210:880 – 881. 12. Kalbhen CL, Kezdi-Rogus PC, Dowling MP, Flisak ME. Mammography in the evaluation of nipple inversion. AJR Am J Roentgenol 1998;170: 117–121. 13. Berg WA, Birdwell RL, Gombos EC. Nipple retraction. In: Berg WA, Birdwell RL, eds. Diagnostic imaging: breast. Section IV:3– 6. Salt Lake City, Utah: Amirsys, 2006. 14. Yanai A, Hirabayashi S, Ueda K, Okabe K. Treatment of recurrent subareolar abscess. Ann Plast Surg 1987;18(4):314 –318. 15. Kopans DB. Ultrasound and breast evaluation. In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 431. 16. Huynh PT, Parellada JA, de Paredes ES, et al. Dilated duct pattern at mammography. Radiology 1997;204:137–141. 17. Cardenosa G. Major subareolar ducts. In: Breast imaging companion. Philadelphia, Pa: LippincottRaven, 1997; 184. 18. Berg WA, Birdwell RL, Gombos EC. Lesion imaging characteristics. In: Berg WA, Birdwell RL, Da Costa et al 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. S77 eds. Diagnostic imaging: breast. Section IV:1– 45. Salt Lake City, Utah: Amirsys, 2006. Thornton CM, Hunt SJ. Sebaceous adenoma with a cutaneous horn. J Cutan Pathol 1995;22(2): 185–187. Dabski K, Stoll HL Jr. Paget’s disease of the breast presenting as a cutaneous horn. J Surg Oncol 1985;29(4):237–239. Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol 1991;124(5):449 – 452. Kijima Y, Matsukita S, Yoshinaka H, Owaki T, Aikou T. Adenoma of the nipple: report of a case. Breast Cancer 2006;13(1):95–99. Healy CE, Dijkstra B, Walsh M, Hill AD, Murphy J. Nipple adenoma: a differential diagnosis for Paget’s disease. Breast J 2003;9(4):325–326. Ashikari R, Park K, Huvos AG, Urban JA. Paget’s disease of the breast. Cancer 1970;26:680 – 685. Ikeda DM, Helvie MA, Frank TS, Chapel KL, Andersson IT. Paget disease of the nipple: radiologic-pathologic correlation. Radiology 1993;189: 89 –94. Burke ET, Braeuning MP, McLelland R, Pisano ED, Cooper LL. Paget disease of the breast: a pictorial essay. RadioGraphics 1998;18:1459 –1464. Amano G, Yajima M, Moroboshi Y, Kuriya Y, Ohuchi N. MRI accurately depicts underlying DCIS in a patient with Paget’s disease of the breast without palpable mass and mammography findings. Jpn J Clin Oncol 2005;35(3):149 –153. Stavros AT. Nontargeted indications: breast secretion, nipple discharge, intraductal papillary lesions: the basis for understanding sonography. In: Breast ultrasound. Philadelphia, Pa: Lippincott Williams & Wilkins, 2004; 160. Kopans DB. The mammographic appearance of breast cancer. In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 406. Topalovski M, Crisan D, Mattson JC. Lymphoma of the breast: a clinicopathologic study of primary and secondary cases. Arch Pathol Lab Med 1999; 123:1208 –1218. Liberman L, Giess CS, Dershaw DD, Louie DC, Deutch BM. Non-Hodgkin lymphoma of the breast: imaging characteristics and correlation with histopathologic findings. Radiology 1994; 192:157–160. Domchek SM, Hecht JL, Fleming MD, Pinkus GS, Canellos GP. Lymphomas of the breast: primary and secondary involvement. Cancer 2002; 94(1):6 –13. Firat D, Barista I, Baltali E. Primary breast lymphomas: a retrospective analysis of twelve cases. Acta Oncol 2000;39(2):135–139. This article meets the criteria for 1.0 AMA PRA Category 1 Credit . To obtain credit, see www.rsna.org/education/ rg_cme.html. TM RG Volume 27 • Special Issue • October 2007 Da Costa et al Common and Unusual Diseases of the Nipple-Areolar Complex Darlene Da Costa, MD, et al RadioGraphics 2007; 27:S65–S77 ● Published online 10.1148/rg.27si075512 ● Content Codes: Page S70 Breast MR imaging, in most cases, can help differentiate between a tumor that is confined to retroareolar tissue and one that involves the nipple-areolar complex. Page S72 On T1- and T2-weighted MR images, the dilated ducts [in mammary duct ectasia] may be seen as branching tubular structures that converge toward the nipple, with high signal intensity due to intraductal proteinaceous material, blood, or both. Page S73 The clinical manifestations [of Paget disease of the breast] usually are suggestive of the diagnosis and may include a bloody discharge from the nipple, itching, erythema, scaly or flaky skin, nipple erosion or ulceration, nipple retraction, and a palpable mass. Thickening of the breast also may occur with or without changes in the nipple. Page S73 MR imaging may play an important role in the selection of patients with Paget disease for breastconserving therapy, if there is no clinical or mammographic evidence of breast carcinoma. Abnormal nipple enhancement and linear clumped enhancement indicative of ductal carcinoma in situ in association with Paget disease may be seen on MR images. Page S75 Subareolar carcinomas, which are easily confused with normal nipple structures, may be more difficult to diagnose than cancers elsewhere in the breast. [...] Contrast material–enhanced MR imaging may be useful if the mammographic and US findings are suggestive of abnormality but are inconclusive. RadioGraphics 2007 This is your reprint order form or pro forma invoice (Please keep a copy of this document for your records.) Reprint order forms and purchase orders or prepayments must be received 72 hours after receipt of form either by mail or by fax at 410-820-9765. It is the policy of Cadmus Reprints to issue one invoice per order. Please print clearly. Author Name _______________________________________________________________________________________________ Title of Article _______________________________________________________________________________________________ Issue of Journal_______________________________ Reprint # _____________ Publication Date ________________ Number of Pages_______________________________ KB # _____________ Symbol RadioGraphics Color in Article? Yes / No (Please Circle) Please include the journal name and reprint number or manuscript number on your purchase order or other correspondence. Order and Shipping Information Reprint Costs (Please see page 2 of 2 for reprint costs/fees.) ________ Number of reprints ordered Shipping Address (cannot ship to a P.O. Box) Please Print Clearly $_________ ________ Number of color reprints ordered $_________ ________ Number of covers ordered $_________ Subtotal $_________ Taxes $_________ (Add appropriate sales tax for Virginia, Maryland, Pennsylvania, and the District of Columbia or Canadian GST to the reprints if your order is to be shipped to these locations.) First address included, add $32 for each additional shipping address TOTAL $_________ $_________ Name ___________________________________________ Institution _________________________________________ Street ___________________________________________ City ____________________ State _____ Zip ___________ Country ___________________________________________ Quantity___________________ Fax ___________________ Phone: Day _________________ Evening _______________ E-mail Address _____________________________________ Additional Shipping Address* (cannot ship to a P.O. Box) Name ___________________________________________ Institution _________________________________________ Street ___________________________________________ City ________________ State ______ Zip ___________ Country _________________________________________ Quantity __________________ Fax __________________ Phone: Day ________________ Evening ______________ E-mail Address ____________________________________ * Add $32 for each additional shipping address Payment and Credit Card Details Invoice or Credit Card Information Enclosed: Personal Check ___________ Credit Card Payment Details _________ Invoice Address Please Print Clearly Please complete Invoice address as it appears on credit card statement Checks must be paid in U.S. dollars and drawn on a U.S. Bank. Credit Card: __ VISA __ Am. Exp. __ MasterCard Card Number __________________________________ Expiration Date_________________________________ Signature: _____________________________________ Please send your order form and prepayment made payable to: Cadmus Reprints P.O. Box 751903 Charlotte, NC 28275-1903 Name ____________________________________________ Institution ________________________________________ Department _______________________________________ Street ____________________________________________ City ________________________ State _____ Zip _______ Country ___________________________________________ Phone _____________________ Fax _________________ E-mail Address _____________________________________ Cadmus will process credit cards and Cadmus Journal Services will appear on the credit card statement. Note: Do not send express packages to this location, PO Box. FEIN #:541274108 If you don’t mail your order form, you may fax it to 410-820-9765 with your credit card information. Signature __________________________________________ Date _______________________________________ Signature is required. By signing this form, the author agrees to accept the responsibility for the payment of reprints and/or all charges described in this document. RB-9/22/06 Page 1 of 2 RadioGraphics 2007 Color Reprint Prices Black and White Reprint Prices Domestic (USA only) # of Pages 1-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 Covers 50 $213 $338 $450 $555 $673 $785 $895 $1,008 $95 100 200 300 $228 $260 $278 $373 $420 $453 $500 $575 $635 $623 $728 $805 $753 $883 $990 $880 $1,040 $1,165 $1,010 $1,208 $1,350 $1,143 $1,363 $1,525 $118 $218 $320 Domestic (USA only) 400 500 $295 $495 $693 $888 $1,085 $1,285 $1,498 $1,698 $428 $313 $530 $755 $965 $1,185 $1,413 $1,638 $1,865 $530 # of Pages 1-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 Covers International (includes Canada and Mexico) # of Pages 1-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 Covers 50 100 200 300 400 500 $218 $343 $471 $601 $738 $872 $1,004 $1,140 $95 $233 $388 $503 $633 $767 $899 $1,035 $1,173 $118 $343 $584 $828 $1,073 $1,319 $1,564 $1,820 $2,063 $218 $460 $825 $1,196 $1,562 $1,940 $2,308 $2,678 $3,048 $320 $579 $1,069 $1,563 $2,058 $2,550 $3,045 $3,545 $4,040 $428 $697 $1,311 $1,935 $2,547 $3,164 $3,790 $4,403 $5,028 $530 International (includes Canada and Mexico)) 50 100 200 300 400 500 $263 $415 $563 $698 $848 $985 $1,135 $1,273 $148 $275 $443 $608 $760 $925 $1,080 $1,248 $1,403 $168 $330 $555 $773 $988 $1,203 $1,420 $1,640 $1,863 $308 $385 $650 $930 $1,185 $1,463 $1,725 $1,990 $2,265 $463 $430 $753 $1,070 $1,388 $1,705 $2,025 $2,350 $2,673 $615 $485 $850 $1,228 $1,585 $1,950 $2,325 $2,698 $3,075 $768 Minimum order is 50 copies. For orders larger than 500 copies, please consult Cadmus Reprints at 800-407-9190. Reprint Cover Cover prices are listed above. The cover will include the publication title, article title, and author name in black. # of Pages 1-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 Covers 50 100 200 300 400 500 $268 $419 $583 $742 $913 $1,072 $1,246 $1,405 $148 $280 $457 $610 $770 $941 $1,100 $1,274 $1,433 $168 $412 $720 $1,025 $1,333 $1,641 $1,946 $2,254 $2,561 $308 $568 $1,022 $1,492 $1,943 $2,412 $2,867 $3,318 $3,788 $463 $715 $1,328 $1,941 $2,556 $3,169 $3,785 $4,398 $5,014 $615 $871 $1,633 $2,407 $3,167 $3,929 $4,703 $5,463 $6,237 $768 Tax Due Residents of Virginia, Maryland, Pennsylvania, and the District of Columbia are required to add the appropriate sales tax to each reprint order. For orders shipped to Canada, please add 7% Canadian GST unless exemption is claimed. Ordering Shipping Shipping costs are included in the reprint prices. Domestic orders are shipped via UPS Ground service. Foreign orders are shipped via a proof of delivery air service. Multiple Shipments Reprint order forms and purchase order or prepayment is required to process your order. Please reference journal name and reprint number or manuscript number on any correspondence. You may use the reverse side of this form as a proforma invoice. Please return your order form and prepayment to: Cadmus Reprints P.O. Box 751903 Charlotte, NC 28275-1903 Orders can be shipped to more than one location. Please be aware that it will cost $32 for each additional location. Delivery Your order will be shipped within 2 weeks of the journal print date. Allow extra time for delivery. Note: Do not send express packages to this location, PO Box. FEIN #:541274108 Please direct all inquiries to: Rose A. Baynard 800-407-9190 (toll free number) 410-819-3966 (direct number) 410-820-9765 (FAX number) baynardr@cadmus.com (e-mail) Page 2 of 2 Reprint Order Forms and purchase order or prepayments must be received 72 hours after receipt of form.
Similar documents
Nipple-Areolar Complex
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
More information