DOI: 10.1148/rg.27si075512
RadioGraphics 2007;27:S65-S77
© RSNA, 2007
Common and Unusual Diseases of the Nipple-Areolar Complex1
Darlene Da Costa, MD,
Abraha Taddese, MD, PhD,
Marina Luz Cure, MD,
Deborah Gerson, MD,
Robert Poppiti, Jr, MD, and
Lisa E. Esserman, MD
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.
Address correspondence to D.D.C. (e-mail: dpcosta{at}bellsouth.net).
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Abstract
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The nipple-areolar complex is often best evaluated as a separate region of the breast. Because of the intricacy of the anatomic structures and their superficial position, the diagnostic techniques required for optimal evaluation of the nipple-areolar complex differ from those routinely used to evaluate the whole breast. Although clinical examination and screening mammography are still of central importance, the adjunct use of multiple imaging modalities (ultrasonography, contrast material–enhanced magnetic resonance imaging, or both) as well as nonstandard mammographic views is often necessary to differentiate benign abnormalities from malignant ones. For accurate diagnosis, familiarity with a wide range of appearances of the normal anatomy, including congenital anomalies (eg, supernumerary nipples), is necessary, as is a thorough knowledge of the features of the benign and malignant processes that commonly occur in the nipple-areolar complex. Benign abnormalities may include mammary duct ectasia, nipple calcifications, cutaneous horn of the nipple, abscess of the Montgomery gland, and nipple adenoma. Malignant abnormalities may include Paget disease and primary lymphoma as well as carcinoma of the breast. Some conditions, such as nipple retraction and inversion, may have either a benign or a malignant cause. In such cases, a thorough radiologic assessment is especially important.
© RSNA, 2007
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Describe the utility of US and MR imaging as adjuncts to mammography in the evaluation of the nipple-areolar complex.
- Recognize normal characteristics of the nipple-areolar complex on breast images obtained with various modalities.
- Identify indications of common and rare lesions on US and MR breast images as well as on mammograms.
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Introduction
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Many articles describe, in a cursory way, one or another pathologic condition within the nipple-areolar complex. Likewise, various reports of missed and incorrect diagnoses, such as a missed malignancy or a malignancy mistakenly believed to represent dermatitis, can be found (1, 2). However, to our knowledge, no focused review of conditions affecting this region of the breast exists in the published literature. Therefore, we offer this overview of the multimodality approach to diagnostic imaging in this region that is so difficult to assess (3). Readers can better recognize the abnormal appearance of the nipple-areolar complex if they have an understanding of the normal anatomy and its appearance at imaging. We therefore begin with a review of the anatomy and of the various imaging techniques used to evaluate the nipple-areolar complex and then proceed with descriptions of the benign and malignant features that may be seen at imaging with various modalities.
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Normal and Variant Anatomy
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The normal nipple is in a position slightly medial and inferior to the center of the breast. The nipple and areola are composed of pigmented squamous epithelium. The nipple-areolar complex also contains a layer of circumferential smooth muscle and sebaceous glands that open through small prominences (Montgomery tubercles) that surround the periphery of the areola. Hair follicles around the areola may contain calcification (4).
Milk secretion occurs through approximately seven to 15 microscopic openings on the surface of the nipple. Immediately deep to these mammary duct orifices, within each of the major ducts, are areas of dilatation known as milk sinuses, which have a storage function during lactation. The major ducts have numerous branches, each of which ends in a terminal duct lobular unit, where milk is produced during lactation (5).
Common minor congenital malformations, including a supernumerary nipple or nipples and related tissue (Fig 1), may be found along the so-called milk line, which extends bilaterally from a point in the axilla toward the chest, abdomen, and groin. The most inferior location of such findings has been in the proximal medial thigh (5).
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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.
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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.
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Normal Imaging Appearances
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The nipple, which is normally everted, should be depicted in profile on at least one standard mammographic view. This orientation allows evaluation of both the nipple-areolar complex and vessels in the normal retroareolar region.
At magnetic resonance (MR) imaging after the administration of gadolinium, the degree of nipple enhancement varies; enhancement may be absent, mild, or intense (Fig 2). Intense enhancement is due to the presence of numerous vessels (6). Normal nipples show a bilaterally symmetric enhancement pattern (7). The characteristic two-layered appearance of the nipple-areolar complex represents a superficial layer of intense linear dermal enhancement (1–2 mm thick) with an underlying region of nonenhancement deep to the dermis (Fig 3) (7). Normal nipples do not show nodular or irregular enhancement along their posterior borders.
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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).
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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).
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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).
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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.
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Ultrasonography (US) is useful for differentiating between tissue types and for identifying individual mammary ducts in most patients. The ducts are linear hypoechoic or isoechoic structures that appear to radiate from the nipple like the spokes of a wheel from the hub (8).
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Mammographic Technique
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Because of x-ray overpenetration, the nipple-areolar complex is often poorly depicted and thus overlooked at mammography (9). Moreover, lesions of various kinds may mimic a normal retroareolar density, leading to a false-positive finding; or, in the setting of dense breasts, a lesion may be obscured and the mammogram therefore interpreted as negative (10). Additional mammographic views with spot compression and magnification, as well as US images, may be needed to better evaluate a retroareolar density or pattern of microcalcification that arouses suspicion (Fig 4). The visibility of such features may be further improved with hot-light viewing or with the use of varied contrast settings during soft-copy interpretation at the digital mammography workstation.
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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.
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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.
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US Technique
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Measures for maximizing the quality of depiction at US include the use of warm gel and the maintenance of a sufficiently warm room temperature to avoid muscle contraction within the nipple and areola. In addition, to minimize acoustic shadows, the transducer must be held at an appropriate angle. When scanning is performed with the transducer held flat to the breast, against the surface of the nipple and areola, the nipple may produce an acoustic shadow with a masslike appearance (Fig 5). Proper scanning technique for US evaluation of the intranipple and subareolar portions of the mammary duct—an evaluation that is particularly important in a patient with a nipple discharge—requires angulation of the transducer so that the ultrasound beam is perpendicular to the long axis of the duct during peripheral compression. When the transducer is held at an appropriate angle against the periphery of the nipple, it is easier to maintain the steady contact and pressure needed to achieve optimal depiction of the duct (Figs 6, 7) (8). Other useful maneuvers include the two-handed compression technique and rolled-nipple technique: The two-handed compression technique is used to achieve better visibility of the duct where it enters the base of the nipple and to assess intraductal lesions and ductal compressibility. The rolled-nipple technique is used to depict the portion of the mammary duct within the nipple. Both techniques have been well described by Stavros (8).
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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.
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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.
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MR Imaging Technique
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Two important technical requirements for evaluation of the nipple-areolar complex with MR imaging are the use of a dedicated breast coil and the administration of a contrast agent (6). MR images should be correlated with mammograms and with US images when the latter are available.
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Clinical and Imaging Signs of Abnormality
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Skin thickening and nipple retraction are visible signs of advanced breast cancer that are observable at physical examination. However, more subtle findings that are associated with pathologic changes in the nipple-areolar complex may be seen on mammograms and US and MR images long before clinical symptoms and signs are manifested.
Mammographic Features
Mammographic features that are associated with abnormalities of the nipple-areolar complex include asymmetry, a subareolar mass, nipple inversion, microcalcification, and skin thickening.
US Features
US depiction of the mammary ducts is particularly useful for the exclusion of intraductal papillary lesions in the subareolar area in patients with a nipple discharge (Fig 8). It is also useful for the detection of subtle and frequently missed secondary signs of breast carcinoma, such as one or more dilated subareolar ductal segments extending 3 cm or more within the breast (3).
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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.
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MR Imaging Features
On MR images of the breast, findings of bulkiness, bilateral asymmetry, or early, delayed, or persistent enhancement of the nipple-areolar complex with a retroareolar mass may be indicative of tumoral involvement of the nipple-areolar complex (Fig 9). In a study of 35 patients, higher sensitivity was demonstrated with MR imaging than with mammography for the diagnosis and assessment of nipple and retroareolar tumors (7).
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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).
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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).
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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).
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Preoperative recognition of nipple involvement in retroareolar breast cancer may be critical when nipple-preserving breast conservation therapy is being considered (7). 
Breast MR imaging, in most cases, can help differentiate between a tumor that is confined to retroareolar tissue and one that involves the nipple-areolar complex (6). Furthermore, it has been suggested that the use of breast MR images for guidance of nipple-preserving breast-conservation surgery may help reduce the rate of local recurrence (10,11).
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Benign Processes
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Nipple Inversion
When nipple abnormalities such as inversion are identified, it is important for the technologist to document them in the medical record so that the radiologist will be aware of the findings and the relevant medical history (12). Nipple inversion may be bilateral or unilateral and usually results from a benign process that takes place gradually, over a long period (eg, a few years). When nipple inversion occurs more rapidly (eg, within a few months), the cause is more likely to be a malignancy. Additional mammographic work-up is needed in cases in which the history of nipple inversion is not known or in which nipple inversion developed over a short period of time. The additional work-up should include spot compression views with the nipple in profile (to determine whether there is a retroareolar mass) as well as craniocaudal and lateral spot magnification views to assess microcalcifications. If the mammographic views are unrevealing, US should be performed. Reported histopathologic findings in cases of acute nipple inversion with a benign cause include mammary duct ectasia, postsurgical changes (Fig 10), fat necrosis, fibrocystic changes, and Mondor disease (13).
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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).
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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).
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Inflammation
A subareolar abscess results from the blockage of a small gland or duct beneath the areola, with the development of an infection under the skin. Such abscesses are uncommon and occur mostly in nonlactating young and middle-aged women (14). There are no known risk factors.
US features include low-amplitude intracystic echoes, which may be difficult to differentiate from those observed in a neoplasm. In this situation, a clinical history that includes fever, or the observation of a lesion response to antibiotics, usually helps differentiate an abscess from a neoplasm (Fig 11) (15).
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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.
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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.
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Mammary Duct Ectasia
The clinical manifestations of ductal ectasia may include a nipple discharge, nipple retraction, a palpable mass, and pain or tenderness. At imaging, ductal ectasia may be more confidently diagnosed if similar features are demonstrated bilaterally. If subareolar ductal dilatation is observed on mammograms, spot compression and magnification views should be obtained to exclude an underlying mass (Fig 12a) (16). Calcified, inspissated secretions within the dilated subareolar ducts are a typical mammographic feature. The calcifications filling the ducts are coarse, smooth-bordered, and shaped like a rod or cigar pointing toward the nipple (17). On T1- and T2-weighted MR images, the dilated ducts may be seen as branching tubular structures that converge toward the nipple, with high signal intensity due to intraductal proteinaceous material, blood, or both (Fig 12b) (18). At US, the subareolar ducts appear dilated and fluid filled (Fig 12c). Inspissated secretions often are visible and may be sufficiently echogenic to mimic an intraductal tumor (Fig 12d). The observation of movement of the particulate matter in these secretions at real-time US is another diagnostic feature of ductal ectasia.
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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).
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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).
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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).
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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).
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Calcifications
Nipple calcifications are uncommon. However, the glands and hair follicles of the nipple-areolar complex may contain calcifications (4). These so-called skin calcifications may be extensive and form a pattern that is spherical with a central area of lucency (Fig 13a) (4). Other types of calcifications may occur in association with sutures (Fig 13b), fat necrosis (Fig 13c), intraductal papilloma, Paget disease (extension of intraductal carcinoma to the surface of the nipple), and intraductal carcinoma without associated Paget disease (Fig 13d).
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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.
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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.
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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.
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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.
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Cutaneous Horn
A cutaneous horn is a conical projection of keratin above the surface of the skin, in a configuration that resembles a miniature horn (Fig 14). The condition is usually asymptomatic; however, the lesion may grow rapidly and is vulnerable to trauma (19). Malignant lesions, usually squamous cell carcinomas, may be found at the base of the horn (20). Other tumors, more rarely found in that location, include Paget disease of the breast, sebaceous adenoma, and granular cell tumor (21).
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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.
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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.
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Nipple Adenoma
Nipple adenoma, also known as florid papillomatosis, erosive adenomatosis, and superficial papillary adenomatosis (22), is an uncommon variant of intraductal papilloma that involves the nipple (Fig 15). The clinical manifestations may resemble those of Paget disease of the breast: Patients often present with a bloody discharge, crusting, nodularity, tenderness, swelling, and erythema of the nipple. The accepted treatment is complete local excision (23).
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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.
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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.
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Malignant Processes
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Paget Disease
The clinical manifestations usually are suggestive of the diagnosis and may include a bloody discharge from the nipple, itching, erythema, scaly or flaky skin, nipple erosion or ulceration, nipple retraction, and a palpable mass. Thickening of the breast also may occur with or without changes in the nipple (24).
Mammograms may show malignant calcifications at the level of the nipple or elsewhere in the breast, skin thickening, nipple retraction, and a discrete mass or masses (Fig 16). However, the mammographic appearance is normal in as many as 50% of patients with Paget disease of the breast (25,26).
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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.
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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.
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MR imaging may play an important role in the selection of patients with Paget disease for breast-conserving therapy, if there is no clinical or mammographic evidence of breast carcinoma. Abnormal nipple enhancement and linear clumped enhancement indicative of ductal carcinoma in situ in association with Paget disease
Carcinoma
Subareolar carcinomas, which are easily confused with normal nipple structures, may be more difficult to diagnose than cancers elsewhere in the breast (Fig 17). Even a small tumor in this location may manifest as a palpable mass (10). Nipple markers may be necessary during the imaging evaluation to help distinguish the nipple from the mass.
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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.
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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.
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At mammography, spot compression with or without magnification may be used to improve the visibility of an underlying lesion. On US images, a subareolar mass or intraductal lesion may be identified. Contrast material–enhanced MR imaging may be useful if the mammographic and US findings are suggestive of abnormality but are inconclusive.
A minority of breast cancers arise in central mammary ducts near the nipple, in the same location in which intraductal papillomas are found. Some cancers arise from preexisting papillary ductal hyperplasia or large intraductal papillomas. Carcinomas that arise centrally may be intraductal, invasive, or mixed (both invasive and intraductal) (28).
Nipple retraction, a secondary sign of malignancy, generally is associated with cancers that are large enough to be visible on mammograms and palpable at physical examination (4,13). The underlying cancer may be subareolar or may have arisen at another location in the breast (Fig 18). Nipple ulceration also may occur with the extension of advanced-stage breast cancer to the skin surface (Fig 19) (29). If nipple retraction is caused by cicatrization and the pull is eccentric, the nipple may deviate in the direction of the cancer; in some cases, it may be fully inverted (Fig 20) (29).
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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.
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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.
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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).
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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).
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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.
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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.
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Lymphoma
The relative frequency of primary versus seconda
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Abstract
LEARNING OBJECTIVES
