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Imaging Approach to Nipple Masses: What a Radiologist Should Know Toma S

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Imaging Approach to Nipple Masses: What a Radiologist Should Know Toma S Volume 38 • Number 25 December 15, 2015 Imaging Approach to Nipple Masses: What a Radiologist Should Know Toma S. Omofoye, MD, Marion E. Scoggins, MD, and Basak E. Dogan, MD After participating in this activity, the radiologist should be better able to diagnose lesions of the nipple-areolar complex by imaging and selecting the appropriate biopsy technique. Category: Breast Imaging challenges to percutaneous core needle biopsy of a nipple Subcategory: Breast Ultrasound mass, we discuss the range of biopsy techniques available for sampling these lesions. Key Words: Imaging of Nipple Masses, Nipple Adenoma, Nipple Anatomy and Physiology Malignancy, Papilloma The nipple-areolar complex functions to dispense milk dur- ing lactation. It harbors diverse cell types, including squamous The unique milieu of the nipple can give rise to a spectrum epithelium of skin, columnar cells in ducts, and sebaceous of benign and malignant masses. Nipple masses may present and apocrine glands.2,3 The nipple represents the terminus for a diagnostic challenge to the radiologist due to their location major ducts, and in most nipples, there are 5 to 10 ductal or symptoms, resulting in diffi culties in imaging and biopsy orifi ces protected by keratin plugs. The individual ducts are access. The purpose of this article is to examine the imaging surrounded by smooth muscle bundles that aid in nipple con- appearance, workup, differential diagnosis, and management traction. Near the areolar border, raised Morgagni tubercles of lesions of the nipple-areolar complex. are formed by openings of large sweat glands (i.e., Mont- The nipple-areolar complex can be a blind spot for radi- gomery glands). Histopathologic composition of the nipple- ologists, due to poor imaging resolution, confl uence of mul- areolar complex signifi cantly infl uences the differential tiple structures, and lack of specifi c guidelines for image diagnosis of a broad array of disease processes that affect this targeting this area. It is important to note that approximately region, some of which may have similar imaging appearance.2 8% of breast cancers arise in the region of the central mam- mary ducts near the nipple, and subareolar malignancy may Imaging Techniques be obscured by normal nipple anatomy.1 Clinical signs and symptoms associated with nipple masses This article examines nipple-areolar anatomy, multimodal- such as nipple discharge, inversion, retraction, or erythema ity imaging techniques used for diagnostic evaluation of nip- can help guide appropriate imaging workup and management ple lesions, and the differential diagnosis of a nipple mass (Figure 1). The small size and extreme anterior location of (Table 1). In addition, because there are unique diagnostic the nipple-areolar complex preclude optimal x-ray exposure, presenting a challenge for mammographic evaluation. Opti- Dr. Omofoye is Assistant Professor, Dr. Scoggins is Assistant Professor, and Dr. Dogan is Associate Professor, Department of Diagnostic Radiology, University mizing the diagnostic imaging algorithm can help character- of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, ize a nipple mass as benign or malignant. For benign nipple Houston, TX 77030; E-mail: [email protected]. lesions, imaging can help tailor therapy or determine the The authors and all staff in a position to control the content of this CME activity scope of surgical excision. and their spouses/life partners (if any) have disclosed that they have no relation- ships with, or fi nancial interests in, any commercial organizations pertaining to Mammography. Because the superfi cial location of the this educational activity. nipple is susceptible to x-ray overpenetration, placement of a Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This continuing medical education activity expires on December 14, 2016. 1 CCDRv38n25.inddDRv38n25.indd 1 110/27/150/27/15 99:50:50 PPMM Table 1. Clinical Presentation and Imaging Findings of Nipple Masses Pathologic Clinical Process Presentation Ultrasonography Mammography MRI Diagnosis Adenoma Nipple enlargement Isoechoic, hypervascu- May have calcifi ca- T2-hyperintense, Skin punch biopsy, lar mass within the tions within the homogeneous fi ne needle nipple enlarged nipple enhancement, pla- aspiration teau enhancement Papilloma Unilateral nipple Retroareolar, homo- Oval, well-circum- Homogeneous Core biopsy discharge geneous hypoechoic scribed mass enhancement with mass, which may plateau or wash- have a cystic out kinetics component Leiomyoma Nipple enlargement, Isoechoic mass within Enlarged nipple, Intermediate T1- and Skin punch biopsy, skin thickening, the nipple usually well T2-signal intensity, fi ne needle pain circumscribed, peripheral rim aspiration slow-growing enhancement mass, rarely with persistent spiculated enhancement Abscess Erythema, pain, asso- Retroareolar, irregular Spiculated mass Rim or no Aspiration, cell cul- ciated with lactation avascular mass with skin changes enhancement ture and cytology, or idiopathic follow-up imaging Malignancy Nipple discharge, Irregular, vascular May have calcifi ca- Heterogeneous Core biopsy, skin inversion, skin mass, may be within tions, nipple inversion enhancement, punch biopsy, or changes or around the nipple- washout kinetics excisional biopsy areolar complex “bb” marker highlights its loca- tion and facilitates comparison to the contralateral nipple (Figure 2). For optimal evalua- tion, the nipple should be in pro- fi le on at least one mammographic view, as a “pseudomass” can result when the nipple is not in profi le.3 An isolated view of the nipple and anterior breast (front view) may be obtained to achieve an in-profi le nipple position in at least one of the lateromedial (LM) or craniocaudal (CC) views, or both. Our proposed nipple- areolar complex evaluation algo- rithm on mammography views Figure 1. A 58-year-old woman presented with a clinically apparent enlarged and erythematous includes examination for sym- left nipple. Punch biopsy revealed nipple adenoma. metry of the nipple-areolar complex, The continuing education activity in Contemporary Diagnostic Radiology is intended for radiologists. EDITOR: Robert E. Campbell, MD, Clinical Professor of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Contemporary Diagnostic Radiology (ISSN 0149-9009) is published bi-weekly by Lippincott Williams & Wilkins, Inc., 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Customer Service: Phone (800) 638-3030; Fax (301) 223-2400; E-mail: [email protected]. Visit our website at LWW.com. Publisher, Randi Davis. EDITORIAL BOARD: Teresita L. Angtuaco, MD Bruce L. McClennan, MD Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Priority Postage paid at Hagerstown, MD, and at George S. Bisset III, MD Johnny U. V. Monu, MBBS, Msc additional mailing offi ces. POSTMASTER: Send address changes to Contemporary Diagnostic Radiology, Subscription William G. Bradley Jr., MD, PhD Pablo R. Ros, MD, MPH, PhD Dept., Lippincott Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Liem T. Bui-Mansfi eld, MD William M. Thompson, MD PAID SUBSCRIBERS: Current issue and archives (from 1999) are available FREE online at www.cdrnewsletter.com. Valerie P. Jackson, MD Subscription rates: Individual: US $692.00 with CME, $542.00 with no CME; international $1013.00 with CME, Opinions expressed do not necessarily refl ect the views of the Publisher, Editor, $743.00 with no CME. Institutional: US $1001.00, international $1139.00. In-training: US resident $139.00 with or Editorial Board. A mention of products or services does not constitute no CME, international $162.00. GST Registration Number: 895524239. Send bulk pricing requests to Publisher. endorsement. All comments are for general guidance only; professional coun- Single copies: $43.00. COPYING: Contents of Contemporary Diagnostic Radiology are protected by copyright. sel should be sought for specifi c situations. Indexed by Bio-Science Information Reproduction, photocopying, and storage or transmission by magnetic or electronic means are strictly prohibited. Services. Violation of copyright will result in legal action, including civil and/or criminal penalties. Permission to reproduce in any way must be secured in writing; go to the journal website (www.cdrnewsletter.com), select the article, and click “Request Permissions” under “Article Tools,” or e-mail [email protected]. Reprints: For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 or under, e-mail [email protected], call 866-903-6951, or fax 410-528-4434. 2 CCDRv38n25.inddDRv38n25.indd 2 110/27/150/27/15 99:50:50 PPMM practice and thus important for nipple-areolar complex evalu- ation. Most nipples enhance on MRI. This enhancement typically is bilaterally symmet- ric and two-layered, appearing as superficial linear dermal enhancement with underlying
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