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Common and Unusual Diseases of the Nipple-Areolar Complex¹

¹ From 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.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  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.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  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.

 

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  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).

 

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  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).

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  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).

 

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Axial contrast-enhanced T1-weighted fat-suppressed 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.

 

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  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.

 

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  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.

 

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 5.  Image artifact caused by improper scanning technique. US image shows a nipple with a large posterior shadow that simulates a mass (arrows).

 

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 6.  Importance of the transducer position for US of the intranipple portion of the mammary ducts. 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.

 

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 7.  Importance of the transducer position for US of the intranipple portion of the mammary ducts. 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.

 

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   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.

 

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  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 T1-weighted fat-suppressed image obtained 1 year later shows progressive irregular masslike enhancement of the nipple-areolar complex (arrow). (c) Corresponding craniocaudal mammogram shows a retroareolar mass (arrow).

 

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  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 T1-weighted fat-suppressed image obtained 1 year later shows progressive irregular masslike enhancement of the nipple-areolar complex (arrow). (c) Corresponding craniocaudal mammogram shows a retroareolar mass (arrow).

 

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  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 T1-weighted fat-suppressed image obtained 1 year later shows progressive irregular masslike enhancement of the nipple-areolar complex (arrow). (c) Corresponding craniocaudal mammogram shows a retroareolar mass (arrow).

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  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).

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  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).

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  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.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  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.

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Ductal ectasia in four different patients. (a) Spot-compression magnification of a mediolateral oblique mammogram shows a focal linear density behind the nipple (arrows). (b) Sagittal unenhanced T2-weighted fat-suppressed MR image shows high-signal-intensity 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).

 

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Ductal ectasia in four different patients. (a) Spot-compression magnification of a mediolateral oblique mammogram shows a focal linear density behind the nipple (arrows). (b) Sagittal unenhanced T2-weighted fat-suppressed MR image shows high-signal-intensity 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).

 

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 12c.  Ductal ectasia in four different patients. (a) Spot-compression magnification of a mediolateral oblique mammogram shows a focal linear density behind the nipple (arrows). (b) Sagittal unenhanced T2-weighted fat-suppressed MR image shows high-signal-intensity 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).

 

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 12d.  Ductal ectasia in four different patients. (a) Spot-compression magnification of a mediolateral oblique mammogram shows a focal linear density behind the nipple (arrows). (b) Sagittal unenhanced T2-weighted fat-suppressed MR image shows high-signal-intensity 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).

 

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  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.

 

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  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.

 

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 13c.  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.

 

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 13d.  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.

 

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 14a.  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.

 

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 14b.  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.

 

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 15a.  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.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 15b.  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.

 

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  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.

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  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.

 

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 17a.  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.

 

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 17b.  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.

 

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 18a.  Nipple retraction due to a malignancy in the right breast of a 68-year-old 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.

 

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 18b.  Nipple retraction due to a malignancy in the right breast of a 68-year-old 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.

 

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  Nipple necrosis due to infiltrating ductal carcinoma in an 85-year-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).

 

View larger version (61K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  Nipple necrosis due to infiltrating ductal carcinoma in an 85-year-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).

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 20a.  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.

 

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 20b.  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.

 

View larger version (64K): [in this window] [in a new window] [Download PPT slide]   Figure 21a.  Primary malignant lymphoma in the breast of a 75-year-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.

 

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 21b.  Primary malignant lymphoma in the breast of a 75-year-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.

 

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 21c.  Primary malignant lymphoma in the breast of a 75-year-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.

 

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 21d.  Primary malignant lymphoma in the breast of a 75-year-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.

 

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