CASE 141
History: A 47-year-old woman presents with a palpable cordlike area in the axillary tail of the left breast. The first figure is the right mediolateral oblique (MLO) view from her mammogram 1 year earlier, when she was asymptomatic. The second figure is the right MLO view from the mammogram taken on the day she presented with her concern.
1. What is the differential diagnosis for the mammogram taken at presentation? (Choose all that apply.)
C. Varicose vein in the breast
D. Superficial thrombophlebitis in the left breast
2. What is the next imaging exam to establish the diagnosis?
A. Perform spot compression views.
B. Perform ultrasound of the palpable concern.
C. Perform MRI to evaluate for abnormal enhancement.
D. Perform magnification views to check for microcalcifications.
3. What would an ultrasound exam show?
A. A dilated, tubular, beaded vein with absence of blood flow
4. What are the clinical signs of this disease?
A. The skin typically is normal.
B. There may be a palpable cord.
C. The finding is usually in the lower outer quadrant of the breast.
D. Both breasts are typically involved.
ANSWERS
CASE 141
Mondor’s Disease
1. C and D
2. B
3. A
4. B
Reference
Conant EF, Wilkes AN, Mendelson EB, Feig SA. Superficial thrombophlebitis of the breast (Mondor’s disease): mammographic findings. AJR Am J Roentgenol. 1993;160:1201–1203.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:399.
Comment
Mondor’s disease is a focal, superficial thrombosis of a vein in the breast. It is typically in the upper outer quadrant or axillary tail of the breast, and it has a characteristic appearance, as is seen in the images presented in this patient (see the figures). When this typical beaded appearance is seen, the diagnosis is usually not in question. The patient can present with a tender, palpable cord in her upper outer quadrant. There can be skin dimpling along the cord, caused by retraction of the thrombosed vein. This condition can be associated with trauma, including surgery and needle biopsy, or with dehydration, but it can also be idiopathic. Because it is rarely associated with ipsilateral breast cancer, care should be taken to examine the mammogram, and the patient, for any sign of concomitant malignancy.
Ultrasound is useful in the diagnosis. When the ultrasound is targeted to the patient’s palpable cord, the dilated vein, with a beaded contour, will be seen. Color flow Doppler will demonstrate the absence of flow in this thrombosed vein (see the figures). Low-level echoes of thrombus within the vein may be seen.
The condition is self-limited and resolves spontaneously or with the application of warm compresses. This is a benign condition and, in the absence of the rare associated malignancy, would be categorized as a Breast Imaging Reporting and Data System (BI-RADS) 2.
CASE 142
History: A 54-year-old woman with a personal history of Hodgkin’s disease and mantle radiation 25 years ago.
1. What is the differential diagnosis of the imaging findings on the one sagittal subtraction image on her MRI? (Choose all that apply.)
A. Newly developing invasive cancer
D. Ductal carcinoma in situ (DCIS)
2. What is your recommendation?
A. Continue routine annual screening with mammogram and MRI.
D. Perform targeted ultrasound of the area of abnormality to see if this represents a cyst.
3. What constitutes a high-risk population?
A. Women who have a personal history of breast cancer
B. Women who have greater than 20% to 25% lifetime risk of breast cancer
C. Women who are extremely anxious about breast cancer
D. Women with a personal history of cervical cancer
4. What is pretest probability in interpreting breast cancer on imaging?
A. The likelihood that a patient will survive her disease
B. The likelihood that a woman will have a routine screening mammogram
C. The likelihood that an imaging finding represents cancer in a certain population
D. The likelihood that the patient will reject advice to have a biopsy
ANSWERS
CASE 142
Screening High-Risk Women
1. A, B, C, and D
2. B
3. B
4. C
References
Berg WA. Tailored supplemental screening for breast cancer: what now and what next?. AJR Am J Roentgenol. 2009;192:390–399.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:268.
Comment
In 2007, the American Cancer Society (ACS) published guidelines for screening high-risk women. The ACS advised adding MRI as an adjunct to mammography to increase the detection of early cancer in this population. They recommended MRI in addition to mammography in women who carried a lifetime risk of at least 20% to 25%. An individual woman’s risk of breast cancer can be assessed with risk models such as the BRCAPRO, Tyrer-Cuzick, or BOADICEA models. Multiple trials of women at very high risk found that adding MRI to mammography significantly increased detection of cancer: mammography found only 36% of cancers present, whereas performing MRI in addition increased detection to nearly 93%.
Patients who are at very high risk include those who carry the BRCA1 or BRCA2 mutations; those with several first-degree relatives (mother, father, sister, brother, daughter, son) with breast cancer, particularly diagnosed at a young age; those who were treated with mantle radiation between the ages of 18 and 30 years, with the incidence of breast cancer beginning 8 years after treatment; and those who have Li-Fraumeni or Cowden’s syndrome.
The presence of increased risk factors affects the pretest probability of the lesion, which is the probability that cancer is present in a certain population before the results of the biopsy are known. In this case, the lesion was tiny (see the figure), and morphology and enhancement characteristics were not particularly worrisome. However, the patient’s high-risk status (prior mantle radiation) changes the likelihood that a new mass, however benign in appearance, is malignant. Thus, rather than 6-month follow-up, a biopsy was recommended. The MR-guided biopsy result was DCIS, nuclear grade III.
CASE 143
History: An asymptomatic 60-year-old woman presents for routine screening mammogram.
1. What is the differential diagnosis in this patient with asymmetric breast size? (Choose all that apply.)
A. The breast bud was removed when the patient was a child.
B. This is a normal variant, with one breast smaller than the other.
C. Poor technique was applied, with one breast poorly positioned.
D. Poland’s syndrome should be considered.
2. What is the clinical significance of asymmetric breast size?
B. It is not significant if it is long standing and the patient is asymptomatic.
C. The larger breast is typically the normal breast.
D. The smaller breast is typically the normal breast.
3. If this is a baseline mammogram, and you have no clinical history of palpable mass, what is the next best step?
A. Obtain a history from the patient regarding her experience with breast size asymmetry.
C. Recommend short-interval follow-up.
D. Recommend surgical consultation.
4. What is Poland’s syndrome?
A. It is breast hypoplasia in women from Poland.
B. Only affecting women, it usually includes hypoplasia of pectoral muscle.
C. It is a relatively common congenital defect of known origin.
D. It is a rare congenital abnormality affecting the chest and arm on one side.
ANSWERS
CASE 143
Asymmetric Size of Breasts
1. B, C, and D
2. B
3. A
4. D
References
Samuels TH. Poland’s syndrome: a mammographic presentation. AJR Am J Roentgenol. 1996;166:347–348.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:408.
Comment
Breast asymmetry is usually considered a benign condition, although several features must be established to consider it benign. The condition should be of long standing. The patient herself is usually the best source for this information. The mammogram should be normal, with no evidence of developing mass or developing asymmetric tissue. If there are no prior mammograms for review, and one breast is denser or has skin thickening, further evaluation with ultrasound, physical exam, and perhaps MRI is indicated. The possibility of invasive lobular cancer, infection, or diffuse involvement of the breast with lymphoma must be considered.
History of prior breast cancer, with lumpectomy and radiation therapy, would cause a decrease in the size of the affected breast, so that history must be obtained. Benign surgery, particularly of a large volume of tissue, would cause breast asymmetry. The asymmetry can occur after pregnancy and breast-feeding, with one breast decreasing in size after pregnancy and lactation and the other breast failing to do so.
There are inherited conditions in which one breast may be smaller. One such condition is Poland’s syndrome, which also may include unilateral absence of the pectoralis muscle. There may also be arm abnormalities on the ipsilateral side, as well as rib anomalies. There is also developmental hypomastia, which is not associated with other anomalies or syndromes.
This patient did not have any other anomalies, and the asymmetry was of long standing, possibly related to size change after lactation.
One author has published a series showing an increase in breast cancer in patients who have asymmetric breast size. However, in the absence of other mammographic findings, additional evaluation is not needed. Typically, if the asymmetry is stable and there is no mammographic abnormality (as in the figure), then this condition is given a Breast Imaging Reporting and Data System (BI-RADS) score of 1, and routine mammography is recommended.
CASE 144
History: A 48-year-old asymptomatic woman presents for a routine mammogram.
1. What should be included in the differential diagnosis for this mammogram? (Choose all that apply.)
B. Removal of left breast bud when the patient was a child
C. Left breast that was badly burned in adulthood
2. What injury can cause this condition?
A. Biopsy of the rudimentary nipple-areolar complex
B. Radiation to the breast in adulthood
C. Motor vehicle accident with seat belt trauma in a teen
D. Reduction mammoplasty in a young adult
3. What is premature thelarche?
A. Development of breast tissue before puberty
B. Onset of menstruation earlier than age 8
C. Presence of accessory nipples
4. What BI-RADS (Breast Imaging Reporting and Data System) score would you give this case if you had no prior films for comparison?
A. BI-RADS 0—need additional evaluation
B. BI-RADS 4—suspicious, recommend biopsy
