Nipple-areolar complex:diagnostic challenges.

Nipple-areolar complex:diagnostic challenges.
Poster No.:
C-1547
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
S. Manso Garcia , S. Plaza Loma , Y. Rodríguez de Diego , V.
1
1
2
1
1
1
Zurdo de Pedro , R. Pintado Garrido , E. Villacastin Ruiz , M.
1
1
1 1
Moya de la Calle , M. J. Velasco Marcos , H. Calero ; Valladolid/
2
ES, Valladolid, VA/ES
Keywords:
Inflammation, Hyperplasia / Hypertrophy, Biopsy, Ultrasound,
Mammography, Breast
DOI:
10.1594/ecr2014/C-1547
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Page 1 of 12
Learning objectives
We describe normal anatomy and clinical and radiological findings of nipple-aerolar
complex (NAC) disorders.
Background
The nipple-areolar complex may be affected by different diseases with similar
appearances.
The complex anatomy of this region make it more difficult to detect the disorders of the
nipple-areolar region.
We review the most representative cases of nipple aerolar complex pathology diagnosed
in our hospital between 2008-2012.
Findings and procedure details
The nipple-areolar complex contains the Montgomery glands and large intermediatestage sebaceous glands that are capable of secreting milk. The Montgomery glands open
at the Morgagni tubercles, which
are small (1-2-mm-diameter) raised papules on the areola. The nipple-areolar complex
also contains many sensory nerve endings, smooth muscle, and an abundant lymphatic
system called the subareolar or Sappey plexus.
The nipple aerolar complex may be affected by any type of benign and malignant
pathology, many of which are unique to this region of the breast.
The most frequent benign proccess that may affect the nipple-areolar is duct ectasia.
Duct ectasia: Increased caliber ducts with or without detritus or infection (Fig. 1 on
page 3). Duct ectasia may be associated with periductal mastitis, fibrosis and nipple
inversion.
Page 2 of 12
Inflammatory pathology also includes mastitis and retroareolar abscess (Fig. 2 on page
4). Clinical manifestations and ultrasound findings may be helpful in differential
diagnosis.
Papilomas are most frequently found on retroareolar region and are sonographycally
manifested as intraductal masses with or without associated duct ectasia, intracystic and
solid masses (Fig. 3 on page 4).
Nipple adenoma is a very rare disease characterized by proliferation of small tubules
(Fig. 4 on page 5).
Retroaerolar cyst: In adolescent girls, Montgomery cysts (Fig. 5 on page 6) are the
most common lesion and may cause the secretion of glandular fluid at the areolar surface.
Among malignant pathology, infiltrating ductal carcinoma is the most frequent lesion
(Fig. 6 on page 7, Fig. 7 on page 7 and Fig. 8 on page 8). Unilateral nipple
inversion is a characteristic symptom and may be associated with eritema and ezcema.
Paget disease is diagnosed by the presence of neoplastic cells in the epidermis at
histological analysis. It is most often associated with
underlying DCIS and rarely with invasive ductal cancer. Mammographic findings
include skin thickening, nipple inversion, microcalcifications (Fig. 9 on page 9) and
retroareolar mass, although mammography can also be normal. MRI is a very useful
technique in these patients.
In the male, gynecomastia is the most frequent cause of palpable lump, with primary
breast malignancy accounting for less than 1% of the total lesions.
Images for this section:
Page 3 of 12
Fig. 1: Unilateral nipple retraction at physical examination. US image shows a
retroareolar dilated duct. Histological examination revelaed mastitis.
Fig. 2: Retroareolar abscess. Mammogram shows an ill-defined retroareolar mass with
nipple inversion and thickening. US image demonstrates a complex cystic lesion with
internal echoes.
Page 4 of 12
Fig. 3: Woman with bloody discharge at physical examination. MRI shows retroareolar
ductal enhancement. US demonstrates a dilated retroareolar duct with intraductal lesions.
Percutaneous biopsy yielded intraductal papilloma and epithelial hyperplasia.
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Fig. 4: Areolar nodule with well-circunscribed margins and plateau kinetics (type II
curve)on MRI. Histological examination revealed nipple adenoma.
Page 6 of 12
Fig. 5: 12 year-old girl with recurrent inflammation and nipple discharge. US
demonstrates a retroareolar cyst with drainage duct.
Fig. 6: Mammogram depicts NAC thickening and retroareolar architectural distortion. US
and MRI(MIP)show a retroareolar mass with nipple retraction. Histological examination
yielded infiltrating lobular carcinoma.
Page 7 of 12
Fig. 7: Woman with bloody discharge and nipple retraction at clinical examination.
Mamogramm shows pleomorphic microcalcifications. Ultrasound demostrates echogenic
foci with acoustic shadowing representing microcalcifications (superior image on the
right) and a suspicious nodule (inferior image on the right). Histological examination
revealed DCIS and multifocal IDC grade II(5 and 0.5mm foci).
Page 8 of 12
Fig. 8: Patient with inflammatory changes in NAC at clinical examination. Mamogramm
and spot compression show thickening of NAC. Ultrasound image demostrates a
suspicious retroareolar nodule. Histology revealed IDC grade II.
Page 9 of 12
Page 10 of 12
Fig. 9: Mammogram shows thickening of nipple-areolar complex. Histology revealed
Paget disease and DCIS.
Page 11 of 12
Conclusion
The detection of disorders of the nipple-areolar region may be challenging because of
the complex anatomy and specific disorders.
Clinical-radiological correlation and ocassionally intervention are necessary for definitive
diagnosis.
Personal information
smansog@gmail.com
References
1. Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex:normal anatomy and
benign and malignant processes. Radiogrphics 2009;29:509-523.
2. An HY, Kim KS, Yu IK et al. The nipple-areolar complex: a pictorial review of common
and uncommon conditions. J Ultrasound Med. 2010 Jun;29(6):949-62.
3. Da Costa D, Taddese A, Cure ML et al. Common and unusual diseases of the nippleareolar complex. Radiographics, 2007, 27: S65-S77.
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