Nipple-areolar complex:diagnostic challenges.
Poster No.: C-1547 Congress: ECR 2014 Type: Educational Exhibit
Authors: S. Manso Garcia1, S. Plaza Loma2, Y. Rodríguez de Diego1, V. Zurdo de Pedro1, R. Pintado Garrido1, E. Villacastin Ruiz1, M. Moya de la Calle1, M. J. Velasco Marcos1, H. Calero1; 1Valladolid/ ES, 2Valladolid, 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 intermediate- stage 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.
Page 5 of 12 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.
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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 nipple- areolar complex. Radiographics, 2007, 27: S65-S77.
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