CASE 81
History: A 63-year-old woman for routine mammogram. Two years previously, she was diagnosed with ductal carcinoma in situ in the left breast, which was treated with breast conservation therapy. A new mass was noted to develop in the right breast.
1. What should be included in the differential diagnosis, based on the right mammogram and ultrasound images shown? (Choose all that apply.)
A. Simple cyst in the right breast
C. Papilloma in the right breast
D. Complex cystic mass in the right breast
2. Which of the following statements is true about color Doppler imaging?
A. If there is no flow, you can be confident there is no malignancy.
B. Flow seen at the edge of the mass excludes a benign cyst.
C. Flow seen within an intracystic mass raises the suspicion for malignancy.
D. If the lesion is round and anechoic, color Doppler is not needed.
3. What is the next step in management?
A. Short-interval follow-up for this likely benign mass
B. Return to routine mammogram for this likely benign lesion
C. Biopsy using ultrasound guidance
D. MRI to check for abnormal enhancement
4. If the tissue diagnosis from the core needle biopsy is “benign breast tissue,” what is the next step?
A. Consider the biopsy nondiagnostic and repeat.
B. Consider the biopsy result definitive, and recommend mammogram in 1 year.
D. Consider the biopsy diagnostic, and recommend that she be followed by her surgeon.
ANSWERS
CASE 81
Cystic-Appearing Cancer
1. B, C, and D
2. C
3. C
4. A
References
Berg WA, Campassi C, Ioffe OB. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology. 2003;227(1):183–191.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:159.
Comment
A complex cystic mass is a mass that contains fluid but also has a thick wall, intracystic masses, thick internal septations, or mural projections and requires biopsy. These masses may represent malignancy, intracystic papilloma, necrotic tumor, hematoma, or abscess.
This patient had a new mass develop in her right breast, seen on mammography (see the figures). On the mammogram the mass has an appearance more suggestive of a benign process, such as a cyst. It has low density and relatively sharp margins on the standard views. However, this postmenopausal woman who has survived breast cancer in the contralateral breast is at increased risk for a new cancer. Spot compression views and ultrasound are needed for further evaluation of the developing mass. On ultrasound, the mass appears cystic, with internal masses. The walls are not thick, but the shape of the mass is irregular, not round or oval (see the figures). These are suspicious characteristics, and biopsy is recommended.
It is important to differentiate a complex cystic mass from a complicated cyst. A complicated cyst is oval or round, has a thin wall, and has diffuse low-level internal echoes or internal debris. A complex cystic mass has a thick wall or an internal mass, or both, such as in this patient (see the figures). In one series, 35% of cystic masses with a thick wall or thick septations were malignant. High-grade infiltrating ductal carcinoma may have circumscribed borders. This patient had infiltrating ductal carcinoma, high grade on core biopsy.
Core biopsy of the complex cystic mass is preferred rather than aspiration. The cyst fluid may be necrotic or acellular, which may result in a false-negative result. If a nonspecific benign result is received after needle biopsy of a suspicious lesion, the biopsy should be repeated. The nonspecific benign diagnosis is nonconcordant and does not explain the reason for the intracystic masses or thick wall of the complex cystic mass. Lesions with a specific benign diagnosis such as papilloma or atypical hyperplasia should be excised. Clips should be placed at the time of needle biopsy because the lesion may be poorly seen after biopsy, particularly if small.
CASE 82
History: A 73-year-old woman presents with recent left breast enlargement. Her medical history includes long-term hypertension and multiple previous hospitalizations for shortness of breath and edema of the legs.
1. What should be included in the differential diagnosis? (Choose all that apply.)
D. Congestive heart failure (CHF)
2. Considering the differential diagnosis, which of the following does not constitute a reasonable alternative in management?
B. Treatment with antibiotics and short-term follow-up
D. Treatment with diuretics and cardiotherapeutic agents and short-term follow-up
3. Other conditions associated with unilateral breast edema include all of the following except:
A. Changes after lumpectomy or radiation
C. Arteriovenous hemodialysis complications
4. Which of the following statements regarding breast edema secondary to CHF is true?
A. Unilateral breast edema is a common manifestation of CHF.
B. The edema is secondary to decreased hydrostatic pressure.
C. Pitting edema can help distinguish between CHF and malignancy.
D. A known clinical history of CHF excludes other etiologies of unilateral breast edema.
ANSWERS
CASE 82
Unilateral Breast Edema
1. B, C, and D
2. C
3. D
4. C
References
Cao MM, Hoyt AC, Bassett LW. Mammographic signs of systemic disease. Radiographics. 2011;31(4):1085–1100.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:389.
Comment
Unilateral breast edema raises concern for inflammatory breast carcinoma. However, edema can have different etiologies, including benign and malignant conditions. Conditions associated with unilateral breast edema include inflammatory breast carcinoma, mastitis, changes following surgical and radiation treatments, lymphatic obstruction, central venous obstruction, arteriovenous hemodialysis complications, granulomatous diseases, nephrotic syndrome, scleroderma, CHF, some skin conditions, lymphoma, leukemia, and metastasis.
Knowledge of these entities, in conjunction with a thorough clinical history including preexisting medical conditions and previous procedures, is important in developing an accurate diagnosis, affecting the patient’s management. If inflammatory breast cancer is suspected, biopsy should be performed to obtain a definitive diagnosis; biopsy specimens of the skin and of any identifiable discrete mass should be obtained.
Clinically, breast edema, thickening, and associated enlargement are common to all of the above-mentioned etiologies. Nevertheless, additional distinctive features may be helpful in distinguishing some of these conditions. Inflammatory breast cancer also manifests with erythema that may be associated with sensation of heat in the affected breast; mastitis is accompanied by erythema, breast pain, and fever that regress after antibiotic treatment; CHF has pitting edema on clinical examination, with absence of a discrete palpable mass, and signs and symptoms resolve after standard treatment. Other entities can be suspected based on the clinical history (e.g., previous lumpectomy with axillary dissection or sentinel node biopsy, radiation to the breast, hemodialysis with upper extremity arteriovenous fistula).
The appearance of breast edema on mammography is characterized by skin thickening, increased parenchymal density, and prominent interstitial markings (trabecular thickening), regardless of the etiology (see the figures). The presence of a discrete mass or microcalcifications, or both, may help to diagnose breast malignancy.
On ultrasound, there is skin thickening, with associated lymphatic engorgement. The presence of a discrete mass may be helpful in diagnosing breast malignancy and can be targeted for biopsy.
On MRI, breast edema manifests as skin thickening and prominent interstitial markings, which appear hyperintense on T2-weighted images. If breast edema is the only finding, no enhancement is seen after injection of contrast material.
In the presented case, the edema of the left breast was secondary to CHF, which is a common clinical condition in the general population. When CHF causes breast edema, usually both breasts are affected because of increased hydrostatic pressure and subsequent lymphatic obstruction. Unilateral breast edema secondary to CHF is rare, and it may be due to lateralization to the dependent breast if the patient lies on one side for extended periods.
CASE 83
History: A 68-year-old woman presents with a chronic scaly red patch on her left nipple. Magnification views of the left subareolar area are shown.
1. What is the differential diagnosis and Breast Imaging Reporting and Data System (BI-RADS) category for these special views? (Choose all that apply.)
A. Benign-appearing calcifications in the subareolar breast, BI-RADS 2
B. Indeterminate calcifications in subareolar ducts, BI-RADS 3
2. What significance is the clinical finding of the scaly red patch on the nipple?
A. This is not related to the mammographic concern.
B. The area of concern is likely eczema, not related to breast disease.
C. This might represent Paget’s disease and may be related to the calcifications on the mammogram.
3. What is the next step in diagnosis?
A. Send the patient to a surgeon for a biopsy of the nipple abnormality.
B. Schedule a 6-month follow-up of indeterminate calcifications.
C. Perform an image-guided biopsy of the microcalcifications.
D. The radiologist should perform a skin biopsy.
4. How often is there a mammographic abnormality in the setting of red, scaly nipple abnormality?
ANSWERS
CASE 83
Paget’s Disease
1. C
2. C
3. C
4. C
References
Ikeda DM, Helvie MA, Frank TS, et al. Paget disease of the nipple: radiologic-pathologic correlation. Radiology. 1993;189(1):89–94.
Valdes EK, Feldman SM. Paget’s disease of the breast. Breast J. 2006;12(1):83.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:397.
Comment
This patient presents with a suspicious clinical finding. When a red scaly patch is seen on or adjacent to the nipple-areolar complex, Paget’s disease should be suspected. Skin biopsy will be needed, but the first step is to evaluate the mammogram for any evidence of intraductal or invasive malignancy. In this case (see the figures), there are casting-type calcifications filling the subareolar ducts, highly suspicious for ductal carcinoma in situ (DCIS). Note the calcifications within the nipple in the second figure.
The extent of disease should be established before the patient goes to surgery. Abnormal mammographic findings require a biopsy. Calcifications may be targeted for stereotactic biopsy; however, stereotactic biopsy can be difficult in the immediate subareolar area, and ultrasound can be used to try to image the calcifications in the distended ducts (see the figures). In this patient, ultrasound-guided biopsy was performed. The biopsy result was DCIS, grade III. On skin biopsy performed by the surgeon, the nipple area contained the same cells as were present in the breast biopsy, which is typical for Paget’s disease.
Paget’s disease is an uncommon form of breast cancer, accounting for less than 5% of all breast cancers. More than 97% of patients with pagetoid changes of the nipple have underlying breast cancer. The mammogram might not demonstrate the underlying malignancy, however. Only about 50% have a mammographic abnormality, including nipple, areolar, or subareolar distortion, nipple retraction, masses, or calcifications. The breast abnormality may be subareolar, as in this case (see the figures), or may be distant from the nipple. The disease may be multicentric or multifocal. MRI can be used to evaluate extent of disease, prior to definitive treatment.
CASE 84
History: Two different patients present for routine screening mammograms. Portions of the view showing axillary nodes are provided.
1. What should be included in the differential diagnosis for this mammographic appearance? (Choose all that apply.)
2. If the patient has a history of gold therapy for rheumatoid arthritis, what is the Breast Imaging Reporting and Data System (BI-RADS) category for this finding?
A. BI-RADS 0—incomplete; further evaluation with magnification views is needed
B. BI-RADS 4—biopsy of a node to confirm gold deposits
C. BI-RADS 3—short-interval follow-up
3. If this is a new finding in a patient with a history of ipsilateral breast cancer, what is the BI-RADS category for this finding?
A. BI-RADS 4—biopsy should be considered
C. BI-RADS 3—short-interval follow-up
4. If you elected to perform a biopsy of an axillary lymph node, can this procedure be accomplished with needle biopsy with image guidance?
A. No, the node must be excised surgically.
B. No, calcifications require stereotactic biopsy, which is not an option in the axilla.
C. Yes, ultrasound-guided core needle biopsy is an option.
ANSWERS
CASE 84
Calcifications in Axillary Lymph Nodes
1. B, C, D, and E
2. D
3. A
4. C
References
Bruwer A, Nelson GW, Spark RP. Punctate intranodal gold deposits simulating microcalcifications on mammograms. Radiology. 1987;163(1):87–88.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:396.
Comment
Calcifications or dense particulate matter may be seen in axillary lymph nodes, often in the setting of an asymptomatic woman undergoing a screening mammogram. If the material is calcium density, the differential diagnosis includes granulomatous disease, such as sarcoidosis and metastatic disease from breast cancer or ovarian cancer (psammomatous calcifications). In cases of metastatic disease, the lymph nodes have other features of malignancy in addition to calcifications, including loss of hilum and increased density. Axillary lymph node calcifications are identified in 3% of patients with breast cancer.
If the particulate matter in the nodes is of metal density, gold therapy (chrysotherapy) is often the reason. Other possibilities are silicone material in the nodes in patients who have had silicone implants or injections and tattoo pigment.
In the cases presented here, the woman in the first figure had a history of gold therapy for rheumatoid arthritis. The patient in the second figure underwent an ultrasound-guided core needle biopsy of an axillary node because of a concern that it might represent metastatic disease from ovarian cancer. The histology of the core biopsy was consistent with sarcoid, a granulomatous disease.
CASE 85
History: A woman with a personal history of left breast cancer presents for routine mammogram. New calcifications were seen in the right breast.
1. What should be included in the differential diagnosis for the magnification views shown? (Choose all that apply.)
B. Suspicious microcalcifications
D. Indeterminate calcifications
2. Why would ultrasound be utilized to evaluate calcifications?
A. It is not useful; mammography is the only way to evaluate calcifications.
B. Ultrasound is used to evaluate for a mass at the site of calcifications.
C. It may be used to identify a mass but would not be used to target the biopsy.
D. It is not helpful; MRI is better than ultrasound in evaluating extent of DCIS.
3. If ultrasound is performed and shows a mass associated with calcifications, what is the next step in management?
A. Referral of the patient to a surgeon for excision
C. Ultrasound-guided core biopsy
D. Short-interval follow-up in 6 months
4. Which of the following is not an advantage of ultrasound-guided biopsy compared with stereotactic biopsy?
A. Real-time imaging during the sampling
D. Improved samples from a larger bore needle
ANSWERS
CASE 85
Use of Ultrasound to Evaluate Suspicious Microcalcifications
1. B and D
2. B
3. C
4. D
References
Cho N, Moon WK, Cha JH, et al. Ultrasound-guided vacuum-assisted biopsy of microcalcifications detected at screening mammography. Acta Radiol. 2009;50(6):602–609.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:212.
Comment
Newly developing microcalcifications detected on routine mammography may indicate malignant disease. The likelihood of calcifications representing malignancy is greater in elderly patients and in women with increased risk (see the figures). Biopsy is necessary unless the developing calcifications are characteristic of a benign type, such as milk of calcium, or lucent-centered calcifications. Stereotactic biopsy is often the method of choice for biopsy of calcifications. However, there are advantages to using ultrasound guidance, and if the finding can be seen on ultrasound, the biopsy can be performed using ultrasound guidance. Advantages of ultrasound-guided biopsy over stereotactic biopsy include real-time assessment of needle location during the sampling, patient comfort, quicker biopsy time, and lack of radiation exposure.
Several studies have shown that calcifications may not be seen on ultrasound, but if they are identified, there is a higher likelihood of malignancy. The calcifications may be in a mass, as in the patient in this case (see the figures) or in a duct. The presence of a hypoechoic mass heightens the visibility of tiny hyperechoic calcifications. Calcifications associated with a mass seen on ultrasound are more likely to be malignant (69% positive predictive value in one series).
Seeing a mass associated with microcalcifications on ultrasound and using ultrasound guidance to sample the mass, rather than just the calcifications on mammogram, increases the chances of sampling the invasive component of the disease. It is helpful to perform a specimen radiograph of the biopsied cores of tissue to check for calcifications.
In one study of 75 patients with microcalcifications seen on mammogram, 71% had calcifications retrieved on ultrasound-guided biopsy. The retrieval chance was higher when there was a mass or dilated duct associated with the calcifications (85% vs. 41% retrieval of calcifications not associated with a mass or dilated duct).
CASE 86
History: A 43-year-old woman presents with intermittent bloody discharge from the left nipple. The mammogram was negative (not shown). Ductography, ultrasound, and MRI were performed for further evaluation.
1. What should be included in the differential diagnosis? (Choose all that apply.)
B. Ductal carcinoma in situ (DCIS)
2. Which of the following statements regarding nipple discharge is true?
A. Bilateral nipple discharge and discharge from multiple openings should be evaluated with imaging.
B. It is more common in postmenopausal women.
C. Spontaneous bloody nipple discharge may be a sign of malignancy.
D. Nipple discharge is a manifestation of breast pathology only.
3. Regarding imaging appearance of papillary lesions, which of the following statements is false?
A. They may appear on the mammogram as microcalcifications.
B. Ductogram usually shows involvement of multiple ductal systems.
D. On MRI, papillomas appear as enhancing masses with or without a dilated duct.
4. Which of the following statements is false?
A. Intraductal papillomas are considered high-risk lesions.
B. Management of intraductal papillomas is controversial.
C. A benign papilloma may evolve to a papillary carcinoma.
D. Distinction between benign papillary lesions and papillary carcinoma is important.
ANSWERS
CASE 86
Intraductal Papilloma
1. B, C, and D
2. C
3. B
4. C
References
Brookes MJ, Bourke AG. Radiological appearances of papillary breast lesions. Clin Radiol. 2008;63(11):1265–1273.
Ibarra JA. Papillary lesions of the breast. Breast J. 2006;12(3):237–251.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:383.
Comment
Papillary lesions are rare tumors, accounting for 0.7% to 4% of solid breast lesions. They include various pathologic processes, ranging from benign papillomas to papillary carcinomas. Benign papillary lesions are the most common intraductal mass. Histologically, they are benign ductal neoplasms with a papillary fibrovascular core covered with ductal epithelium and myoepithelial cells (the presence of myoepithelial cells differentiates benign papillomas from papillary carcinoma). Papillomas can be solitary or multiple, often arising in contiguous areas of a duct system. Solitary papillomas usually arise in a large duct near the nipple (central), whereas multiple papillomas most commonly occur in smaller, more peripheral ducts.
Many patients with solitary central papillomas present with nipple discharge. Bloody nipple discharge may occur if the papilloma twists on its fibrovascular stalk and becomes ischemic and necrotic, whereas clear (serous) nipple discharge may occur owing to secretions produced by the papilloma. Unilateral, bloody or serous nipple discharge from a single duct raises the level of concern because it may also be a manifestation of carcinoma. Bilateral or multiple duct, milky or green to brown discharges are not clinically significant, and they are usually associated with other conditions, such as fibrocystic change, hormonal imbalance, pregnancy and lactation, prolactinoma, and medication. In these cases, further evaluation with imaging is unnecessary. Nipple discharge generally may be present at any age.
Intraductal papillomas may be difficult to recognize with mammography. When visible, they may appear as round, often well-circumscribed subareolar masses with or without calcifications or as a small cluster of calcifications without a mammographically evident mass. Ductography can be helpful in localizing a papilloma within the discharging duct, which appears as an intraductal filling defect, sometimes with irregular borders (see the figures). On ultrasound, intraductal papillomas appear as a solid mass or masses with internal vascularity inside a duct, which may be focally dilated (see the figures).
MRI usually gives a more global picture and may reveal additional lesions in women with nipple discharge. On MRI, papillomas appear as enhancing masses with or without an accompanying dilated duct. The duct contents may have a different appearance depending on the fluid composition; serous content appears hypointense on T1-weighted images and hyperintense on T2-weighted images, whereas hemorrhagic content appears hyperintense on both T1-weighted and T2-weighted images.
Papillary lesions are considered high-risk lesions because some of them may be malignant, and many of them may contain atypical ductal hyperplasia or DCIS. In addition, DCIS and infiltrating ductal carcinoma may manifest as an intraductal mass. A benign papilloma does not evolve to a papillary carcinoma.
Histologic diagnosis is needed to exclude intraductal cancer. Recommendations on management vary. Although some clinicians advocate needle biopsy for initial diagnosis followed by excision, others recommend surgical excision only. If needle biopsy has been performed, some institutions excise all papillomas, whereas others excise only the ones with atypia. The patient in this case had a vacuum-assisted, ultrasound-guided core biopsy, which revealed an intraductal papilloma, with no atypia.
CASE 87
History: Three different patients present with a left breast palpable mass. The left mediolateral oblique (MLO) view and ultrasound images have been provided.
1. What should be included in the differential diagnosis of the palpable finding? (Choose all that apply.)
C. Invasive ductal carcinoma (IDC), mucinous type
D. Invasive ductal carcinoma, medullary type
2. What is the next step in management?
A. MRI to differentiate benign from malignant
B. Ultrasound-guided needle biopsy
C. Fine-needle aspiration biopsy
D. Short-interval follow-up ultrasound
3. What is mucinous carcinoma?
A. A special type of invasive lobular carcinoma
B. A tumor characterized by extracellular mucin
C. Another name for medullary carcinoma
4. What imaging characteristics are not seen with mucinous carcinoma?
A. A dense mass on mammogram and isoechoic mass on ultrasound
B. High signal intensity on T2-weighted MRI
C. Markedly spiculated mass on mammography and dense shadowing on ultrasound
D. Well-defined mass on mammography and cystic spaces seen on ultrasound
ANSWERS
CASE 87
Mucinous Carcinoma
1. B, C, and D
2. B
3. B
4. C
References
Bode MK, Rissanen T. Imaging findings and accuracy of core needle biopsy in mucinous carcinoma of the breast. Acta Radiol. 2011;52(2):128–133.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:114.
Comment
Mucinous carcinoma is a special type of IDC. The other special types are medullary, invasive papillary, and tubular carcinoma. The special types, as differentiated from IDC not otherwise specified (NOS), indicate a more differentiated cell type, with a better prognosis. Mucinous carcinoma manifests as a pure or mixed form. In the pure form, there are larger amounts of mucin (50% to 75%), and the lesion appears more well defined on mammography. The density of the tumor on mammography has been reported as denser than water, as in the patients in this case (see the figures), but also reported to be lower in density. In the pure form, the borders are smooth and lobulated. With the mixed form, the borders become more ill defined.
The pure form of mucinous carcinoma occurs more commonly in older women, average age 63, and is less likely to be palpable or, if palpable, is relatively soft. The pure form has positive axillary nodes in only 6%, and prognosis is better than in IDC NOS. However, in the mixed form, the tumor behavior is closer to IDC NOS, with a higher percentage of patients presenting with a hard palpable mass, positive nodes in 36%, and a worse prognosis.
The ultrasound appearance varies. Smaller masses (see the figures) are often isoechoic to fat and difficult to identify, and their appearance overlaps with fibroadenoma. However, in contrast to fibroadenomas, the tumors tend to be taller than wide, with a microlobulated surface (see the figures). They do not cause shadowing and may have enhanced through-transmission (see the figures). They may also contain cystic spaces.
On MRI, the mucinous carcinoma is bright on T2-weighted images and may have nonenhancing internal septa. These septa should be thicker than in fibroadenoma, but differentiating mucinous carcinoma from fibroadenoma on MRI may be difficult, particularly with the pure form of mucinous carcinoma. After contrast agent administration, the initial enhancement curve may be slow, intermediate, or rapid and then may be persistent or plateau, also overlapping with benign tumors.
CASE 88
History: A 62-year-old woman presents with a palpable mass near the left nipple.
1. What should be included in the differential diagnosis based on the mammogram and ultrasound images shown? (Choose all that apply.)
D. Infiltrating ductal carcinoma
2. Is the ultrasound appearance diagnostic of a benign mass?
A. No, because there is irregular solid material within the mass
B. Yes, because the mass is oval and wider than tall
C. Yes, because the location suggests it is in the dermal layer
D. Yes, because the borders are smooth and well defined
3. What is the next step in management?
B. Fine-needle aspiration biopsy
C. Short-interval follow-up because this may be a sebaceous cyst
D. MRI of both breasts to evaluate for abnormal enhancement
4. If pathology is benign papilloma on core biopsy, what is the next step?
C. Surgical consultation for excision
D. MRI to evaluate enhancement of the mass
ANSWERS
CASE 88
Palpable Subcutaneous Mass
1. A, B, and D
2. A
3. A
4. C
References
Berg WA, Campassi CI, Ioffe OB. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology. 2003;227(1):183–191.
Cross-Reference
Ikeda D. Breast Imaging. In: THE REQUISITES. 2nd ed Philadelphia: Saunders; 2010:120. 383
Comment
This 62-year-old woman presented with a palpable mass near the nipple. Mammography was performed first (see the figures). Ultrasound was then performed, and the images showed an oval, sharply circumscribed, complex cystic mass, located in the superficial breast adjacent to the nipple. All of the ultrasound features are benign except for the echogenic, irregular material within the mass (see the figures).
The BI-RADS (Breast Imaging Reporting and Data System) code and the decision to perform a biopsy of a mass should be based on the worst characteristic, which is the irregular material within the cystic mass in this patient. This mass is termed a complex cystic mass, which has an increased chance of being malignant compared with a complicated cyst or simple cyst. (A complicated cyst contains internal echoes on ultrasound.) Ultrasound features of a complex cystic mass are thick, irregular septations; thick, irregular wall; indistinct or angular margins; intracystic mass; and associated solid component. In one series, 18 of 79 complex cystic lesions were malignant.
Core biopsy of this mass was performed, and histology showed intraductal papilloma. The mass was excised, and the surgical histopathology was infiltrating ductal carcinoma, grade II/III, micropapillary type, with ductal carcinoma in situ at the surgical margin.
This case illustrates that biopsy should be performed on cystic lesions that contain intracystic masses. If a papilloma is diagnosed at core biopsy, surgical excision should be considered. There is a 12% to 14% risk of “upgrading” the benign papillary lesion to carcinoma on excision.
This case also illustrates that palpable masses that are negative on mammography should be evaluated further with ultrasound. This is true particularly for a mass felt near the nipple, where a mass may be overlooked or obscured by the nipple and subareolar ducts.
CASE 89
History: A 70-year-old man presents with a tender palpable right breast mass.
1. What is the differential diagnosis in this patient? (Choose all that apply.)
