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

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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 9:509:50 PMPM 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 location and facilitates comparison to the contralateral nipple (Figure 2). For optimal evaluation, the nipple should be in profi 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 algorithm 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,

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CCDRv38n25.inddDRv38n25.indd 2 110/27/150/27/15 9:509:50 PMPM practice and thus important for nipple-areolar complex evaluation. Most nipples enhance on MRI. This enhancement typically is bilaterally symmetric and two-layered, appearing as superficial linear dermal enhancement with underlying nonenhancement.5 Findings on MRI suspicious for malignancy involving the nipple-areolar complex include thick or nodular enhancement, irregular enhancement poste- riorly, or presence of an associated mass.1,6 MRI is helpful in evaluation of breast malignancy, including Paget disease. In Paget disease, there are malignant cells in the epidermis, character- ized by an eczematous-type rash that may represent invasive or in situ carcinoma. Although Figure 2. An 89-year-old woman with urethral cancer presented with mass-like enlargement of the right Paget disease frequently does nipple. Bilateral craniocaudal mammographic views show marked asymmetric enlargement of the right not present with a mass and nipple (arrow) compared with the left nipple. In addition, there is right retroareolar asymmetry (dashed is mammographically occult arrow). “BB” markers (arrowheads) denote nipple location, facilitating comparison between each side. Image-guided biopsy revealed low-grade, invasive ductal carcinoma. in up to 50% of cases, MRI is highly sensitive for detection evaluation for new or asymmetric nipple retraction, and atten- of Paget disease and may demonstrate additional occult foci tion to presence of calcifi cations in the nipple. Magnifi cation of disease, allowing determination of the optimal medical views are required if routine mammographic views demon- and surgical treatment (Figure 5).1 strate calcifi cations within or approaching the nipple. Most nipples enhance on MRI, and normally the On mammography, a “pseudomass” can result enhancement is bilaterally symmetric. when the nipple is not in profi le. Ductography. Ductography involves cannulation and introduction of contrast medium into a discharging duct. It Ultrasound. The nipple can represent a “blind spot” for ultrasound due to its mobility, superfi cial position introducing an air interface, and inherent acoustic shadowing due to densely arranged connective tissue and dermal elements. In symptomatic patients or patients with mammographic nipple- areolar complex abnormalities, “roll” technique—in which the nipple is rolled over the fi nger of the sonographer’s nonscan- ning hand to stabilize it between the fi nger and transducer— helps visualize ducts that may be parallel to the beam. Using a gel standoff is also benefi cial, as it facilitates near-fi eld focusing, transducer-skin coupling, and gives uniformity to the nipple contour (Figure 3).4 A small saline bag placed over the nipple may be used in lieu of a large amount of gel and provides the same benefi ts. With prolonged scanning and cold, the nipple may contract, which impairs visualization Figure 3. A 38-year-old woman presented with a 1-month history of right nipple enlargement and white nipple discharge. Grayscale of ducts and nipple detail; therefore, the ultrasound gel and longitudinal sonographic image with a gel standoff (white box) to scanning room should be warm to minimize this problem. even the contour around the nipple (arrow) shows a mass To help differentiate between true intraductal masses within (dashed arrow) within the nipple. At real-time examination, the large retroareolar ducts from proteinaceous fluid, power mass contained mobile echogenic debris and posterior acoustic Doppler with a high-frequency transducer (≥13 MHz) should enhancement, suggesting a cyst with inspissated material. A 21-gauge needle was used for ultrasound-guided fi ne needle be used (Figure 4). aspiration biopsy. Pathologic analysis indicated a ruptured epi- MRI. Use of dedicated breast coils and performing breast dermal inclusion cyst. The remainder of cyst contents was MRI before and after contrast administration are now standard expressed manually after the biopsy. 3

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C D

Figure 4. A 53-year-old woman with slight left nipple retraction. A: Grayscale transverse sonography of the nipple shows a mass (arrow) in the nipple and nipple base. B: Power Doppler transverse sonography shows internal vascularity in the nipple mass. C: Grayscale sonography shows a 16-gauge core biopsy needle (arrow) in preﬁ re position, directed at the nipple mass (box). D: Grayscale sonography shows the biopsy needle (arrow) in postﬁ re position through the mass (box). The biopsy result was intraductal papilloma.

RLR L

A B

Figure 5. A 57-year-old woman with a 1-year history of right nipple dryness. Punch biopsy of the nipple revealed Paget disease. Mammogram (not shown) demonstrated a few amorphous calciﬁ cations within the right nipple. A: Axial, T1-weighted, postcontrast subtraction MR image shows abnormal, asymmetric enhancement of the right nipple (box) compared with minimal, normal enhancement of the left nipple (circle). B: Axial, T1-weighted, postcontrast subtraction MR image shows multiple areas of linear and seg- mental nonmass enhancement (arrows), suspicious for multifocal ductal carcinoma in situ (DCIS) underlying the known Paget disease of the nipple. Biopsy of a representative area in the medial right breast at 3-o’clock position demonstrated high-grade DCIS. Paget disease and multifocal DCIS were conﬁ rmed at mastectomy. 4

CCDRv38n25.inddDRv38n25.indd 4 110/27/150/27/15 9:509:50 PMPM sebaceous cyst results from an obstructed sebaceous gland. Sebaceous cysts may be associated with Cowden syndrome. On physical examination, a sebaceous cyst is often palpable. On mammography, the cyst appears as an oval mass that may have central fat density due to sebum. On sonography, an oval mass is appreciated within the skin, which may be indis- tinguishable from an epidermal inclusion cyst. Again, biopsy may be deferred, as cyst contents are proinfl ammatory. Papilloma. A papilloma represents a benign proliferation of ductal epithelium and myoepithelium on a fi brovascular stalk. Papillomas represent the most common cause of bloody nipple discharge. There is a slight associated increase in the risk of breast cancer. Papillomas may be central or peripheral (>70% are central or subareolar). Central papillomas are often solitary, whereas peripheral papillomas are often multiple. Mammography may be nondiagnostic or demonstrate an oval mass with or without accompanying calcifi cations. On sonography, an intraductal, mixed cystic and solid mass may be identifi ed (Figure 4). On MRI, a papilloma may appear as a mass with variable enhancement. Core needle biopsy is recommended to exclude atypia or papillary neo- plasm. Papillomas often are excised, particularly when atypia is diagnosed, as there is a 31% upgrade rate to carcinoma on surgical excision. Malignant lesions are associated with pal- pability, nipple discharge, and higher Breast Imaging Figure 6. A 55-year-old woman with bloody left nipple discharge Reporting and Data System (BIRADS) score.8 and unrevealing mammogram and ultrasound examination. CC magnifi cation view of a ductogram shows a 4-mm persistent fi lling defect in a central large duct (arrow). The patient elected to The most common cause of bloody nipple undergo excisional biopsy, which revealed stromal fi brosis without discharge is a papilloma. atypia or malignancy. is useful in evaluating pathologic nipple discharge, which is Nipple Adenoma. Also known as fl orid papillomatosis, or nonlactational, unilateral involving a single duct, and spon- superfi cial papillary adenomatosis, nipple adenoma repre- taneous.7 Nonmilky, unilateral single-duct discharge is con- sents a rare benign epithelial tumor. Essentially, it is an intra- cerning for an underlying malignant process. Up to 15% of ductal papilloma within the nipple. A nipple adenoma often cases of pathologic nipple discharge are attributable to malig- presents as an erosive or ulcerative nipple lesion with associ- nancy. Ductography (Figure 6) can identify a fi lling defect ated nipple discharge and may be confused with Paget dis- or cut-off sign (potential offending mass) and provide guid- ease.9 On mammography, a nipple adenoma may appear as ance for subsequent targeted ultrasound or surgery. a circumscribed oval mass within the nipple, or as an asym- metrically enlarged nipple. Nipple adenomas may have asso- Nonmilky, unilateral single-duct discharge is ciated calcifications. On ultrasound, there is an oval or concerning for an underlying malignant process. lobulated mass with homogeneous iso- or hypoechoic echotexture, usually within the nipple or a distal major duct. There is marked vascularity on Doppler ultrasound (Figure 7). On Differential Diagnosis of Nipple Mass MRI, nipple adenomas are homogeneously enhancing, Epidermal Inclusion Cyst. This condition presents when T2-bright masses with persistent kinetics. Although nipple there is obstruction of a hair follicle resulting in an epithelial adenomas may be diagnosed by skin punch biopsy, ulti- cyst in the dermis. It may be associated with Gardner syn- mately, surgical excision is recommended because of growth drome. The cyst may be palpable or visible on physical exam- and pain. Many clinicians and radiologists prefer to refer the ination. On mammography, an oval mass may be appreciated patient directly for excision based on imaging fi ndings with- and a tangential view can demonstrate skin location. On out percutaneous biopsy. sonography, the cyst presents as an oval mass with variable Leiomyoma. Leiomyoma is a rare, benign process arising internal echotexture (ranging from anechoic to hypoechoic) from smooth muscle. It presents as a slow-growing, painful (Figure 3). In addition, the hair follicle may be identifi ed as nipple mass. Pain is often episodic related to smooth muscle a linear track extending to the skin. Internal keratin debris contraction from cold exposure or pressure.10 Leiomyomas may give a hyperechoic “whorled” appearance. When infl amed, may be associated with nipple erosion. Mammography dem- an epidermal inclusion cyst may demonstrate vascularity. onstrates nipple enlargement. Ultrasound shows an isoechoic Biopsy can be deferred when imaging is pathognomonic, mass. MRI shows a mass with intermediate T1 and T2 inten- because infl ammation can result if the cyst is disrupted. sity, peripheral rim enhancement, with persistent enhance- Sebaceous Cyst. The pathophysiology of a sebaceous ment kinetics. Percutaneous biopsy by fi ne needle aspiration cyst is similar to that of an epidermal inclusion cyst, but a or skin punch biopsy may be performed. 5

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Figure 7. A 50-year-old woman presented with a right nipple mass. A: Grayscale longitudinal sonography of the nipple shows a subtle isoechoic oval mass (arrow). B: The nipple mass that was subtle on grayscale ultrasound is better seen with the addition of power Doppler, demonstrating abundant vascularity. Skin punch biopsy demonstrated a nipple adenoma.

There is often peripheral vascularity on sonography due to On MRI, a leiomyoma of the nipple shows a infl ammation. Aspi ration may be performed for laboratory mass with intermediate T1 and T2 intensity with analysis to guide treatment. It is recommended to obtain short- peripheral rim enhancement. term clinical follow-up and reimaging after antibiotic therapy to exclude malignancy. Symptoms and imaging fi ndings should improve after 4 weeks of antibiotic treatment. Subareolar Abscess. A subareolar abscess is a focal process resulting from infection of subareolar ducts. Subareolar abscesses are less common than parenchymal abscesses or Following diagnosis of a subareolar abscess, mastitis, usually occurring spontaneously in young or mid- short-term clinical follow-up and re-imaging dle-aged, nonlactating women.6 Clinically, patients com- after antibiotic therapy are recommended to monly present with signs and symptoms of erythema, exclude malignancy. tenderness, and fever. Clinical history is helpful because imaging fi ndings overlap with malignancy. Breast imaging Malignancy. In the nipple, malignancy has a wide range of may demonstrate a mass with spiculation, heterogeneous clinical presentations, including nipple retraction or inversion, echotexture on ultrasound (Figure 8), and skin thickening. enlargement, excoriation, and discharge. Various studies indicate the incidence of unsuspected nipple involvement by breast malignancy, ranging from 8% to 58%. Nipple involvement is more common with central tumor location, large tumor size, metastatic disease to lymph nodes, lymphovascular invasion, and multicentric or multifocal disease.1 On mammography, an irregular mass with potential retroareolar extension may be seen (Figure 9). Calcifi cations may indicate in situ disease. On sonography, malignant masses often have irregular borders with increased vascularity. MRI may be helpful in delineating nipple involvement and extent of disease for surgical planning.

Central tumor location, large tumor size, metastatic lymphadenopathy, lymphovascular invasion, and multicentric or multifocal disease are risk factors for nipple involvement by breast cancer.

Biopsy Percutaneous biopsy of nipple masses is challenging for Figure 8. Subareolar abscess in a 53-year-old woman with left multiple reasons. The rich vascular and nervous supply of breast swelling, pain, and redness involving the nipple-areolar the nipple confers increased risk of pain and bleeding. Some complex. Grayscale longitudinal sonography of the left nipple demonstrates an irregular, primarily hypoechoic, mass containing nipple masses may be exophytic, and cosmetic considera- debris in the subareolar region. Bedside incision and drainage tions limit biopsy approaches. As a result, skin punch or exci- performed by a breast surgeon conﬁ rmed a subareolar abscess. sional biopsy is the most direct approach in many cases. For 6

CCDRv38n25.inddDRv38n25.indd 6 110/27/150/27/15 9:509:50 PMPM within major subareolar ducts. Core biopsy is indicated when mass extension to the sub-nipple-areolar complex location is evident and can be best performed with fully automated cut- ting needles that allow full-thickness tissue acquisition from all tissue layers in this location (Figure 4).

Conclusion This CME activity emphasizes that nipple masses may be subtle and present a diagnostic challenge. Diagnosis depends on optimization of imaging techniques, familiarity with unusual pathology occurring in this location; and, based on their extent of involvement, use of various biopsy techniques.

References 1. Moon JY, Chang YW, Lee EH, et al. Malignant invasion of the nipple-areolar complex of the breast: usefulness of breast MRI. AJR Am J Roentgenol. 2013; 201(2):448-455. 2. Kopans DB. Breast Imaging. 3rd ed. Philadelphia: Lippincott Williams & Figure 9. Nipple malignancy in an 88-year-old woman with right Wilkins; 2007. nipple retraction and a palpable mass. CC spot compression 3. Nicholson BT, Harvey JA, Cohen MA. Nipple-areolar complex: normal mammogram shows a high-density, irregular mass (arrow) involv- anatomy and benign and malignant processes. Radiographics. 2009;29(2): ing and retracting the right nipple (curved arrow denotes the BB 509-523. marker placed on the nipple). A triangular skin marker (dashed 4. Stavros AT. Breast Ultrasound. Philadelphia: Lippincott Williams & Wilkins; 2004. 5. Friedman EP, Hall-Craggs MA, Mumtaz H, et al. Breast MR and the appear- arrow) was placed over the palpable mass. An additional suspi- ance of the normal and abnormal nipple. Clin Radiol. 1997;52(11):854-861. cious high-density, irregular parenchymal mass also is seen (circle). 6. Da Costa D, Taddese A, Cure ML, et al. Common and unusual diseases of Ultrasound-guided biopsy revealed multifocal invasive ductal the nipple-areolar complex. Radiographics. 2007;27(Suppl 1):S65-S77. carcinoma, conﬁ rmed at mastectomy. 7. Lamont JP, Dultz RP, Kuhn JA, et al. Galactography in patients with nipple discharge. Proceedings. 2000;13(3):214-216. 8. Wiratkapun C, Keeratitragoon T, Lertsithichai P, et al. Upgrading rate of lesions with subareolar extension or components extending papillary breast lesions diagnosed by core-needle biopsy. Diagn Interv immediately posterior to the nipple-areolar complex, needle Radiol. 2013;19(5):371-376. biopsy is a less invasive and patient-friendly approach (Figure 4). 9. Di Bonito M, Cantile M, Collina F, et al. Adenoma of the nipple: a clinico- pathological report of 13 cases. Oncol Lett. 2014;7(6):1839-1842. Fine needle aspiration biopsy may help resolve diagnostic 10. Cho HJ, Kim SH, Kang BJ, et al. Leiomyoma of the nipple diagnosed by questions pertaining to intraductal debris versus solid component MRI. Acta Radiol Short Rep. 2012;1(9).

CCDRv38n25.inddDRv38n25.indd 7 110/27/150/27/15 9:509:50 PMPM CME QUIZ: VOLUME 38, NUMBER 25 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. Select the best answer and use a blue or black pen to completely fi ll in the corresponding box on the enclosed answer form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own fi les and mail the original answer form in the enclosed postage-paid business reply envelope. Only two entries will be considered for credit. Your answer form must be received by Lippincott CME Institute, Inc., by December 14, 2016. At the end of each quarter, all CME participants will receive individual issue certifi cates for their CME participation in that quarter. These individual certifi cates will include your name, the publication title, the volume number, the issue number, the article title, your participation date, the AMA credit awarded, and any subcategory credit earned (if applicable). For more information, call (800) 638-3030. All CME credit earned via Contemporary Diagnostic Radiology will apply toward continuous certifi cation requirements. ABR continuous certifi cation requires 75 CME credits every 3 years, at least 25 of which must be self-assessment CME (SA-CME) credits. All SAM credits earned via Contemporary Diagnostic Radiology are now equivalent to SA-CME credits (www.theabr.org). Online quiz instructions: To take the quiz online, log on to your account at www.cdrnewsletter.com, and click on the “CME” tab at the top of the page. Then click on “Access the CME activity for this newsletter,” which will take you to the log-in page for http://cme.lww.com. Enter your username and password. Follow the instructions on the site. You may print your offi cial certifi cate immediately. Please note: Lippincott CME Institute will not mail certifi cates to online participants. Online quizzes expire on the due date.

1. Which one of the following nipple-areolar complex lesions 6. All of the following are risk factors for involvement of the may contain calcifi cations on mammograms? nipple-areolar complex by breast malignancy, except A. Subareolar abscess A. recurrent tumor B. Epidermal inclusion cyst B. large tumor burden C. Nipple adenoma C. metastatic lymphadenopathy D. Sebaceous cyst D. lymphovascular invasion by tumor E. multicentric disease 2. Which one of the following statements concerning papillomas involving the nipple is false? 7. Which one of the following statements regarding MRI of the A. They may contain calcifi cations on mammography. nipple is true? B. They may appear cystic on ultrasound. A. Contrast-medium administration is unnecessary. C. They often present with bloody discharge. B. Nipple enhancement is uncommon. D. They are always benign. C. MRI is more sensitive than mammography for diagnosis E. The central type is more common than the peripheral of nipple tumors. type. D. Normal nipples demonstrate a “three-layered” pattern of enhancement. 3. A 52-year-old woman presented with an enlarged, ulcerated E. MRI is insensitive for the diagnosis of Paget disease of nipple. On mammography, a nipple lesion contained calcifi - the breast. cations. On ultrasound, the oval-shaped nipple mass was hypoechoic and abundantly hypervascular on power Doppler. 8. Which one of the following represents the most worrisome The most likely diagnosis is feature of nipple discharge suggesting underlying breast A. sebaceous cyst malignancy? B. nipple adenoma A. Bilateral and spontaneous C. leiomyoma B. Unilateral and serosanguineous D. subareolar abscess C. Unilateral and milky E. malignancy D. Involvement of multiple ducts and inducible 4. All of the following represent the constellation of treatments 9. All of the following represent features of a leiomyoma within for a subareolar abscess, except the nipple, except A. fl uid aspiration A. peripheral rim enhancement on MRI B. cell culture and cytology B. rapid-growing mass C. appropriate antibiotic therapy C. isoechoic mass on ultrasound D. brachytherapy D. nipple erosion E. follow-up imaging in 4 weeks to exclude malignancy E. episodic painful mass 5. Women with a subareolar abscess generally are 10. Which one of the following breast lesions is the most common A. pregnant cause of bloody nipple discharge? B. lactating A. Malignancy C. middle-aged, nonlactating B. Nipple adenoma D. elderly C. Papilloma E. asymptomatic D. Leiomyoma E. Subareolar abscess

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