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Intramammary Node Mimic on Mammography

3/8/2021

Intramammary Node Mimic on Mammography

IMAGING FINDINGS: 

Mediolateral oblique (MLO) and craniocaudal (CC) views of the left breast demonstrate two round circumscribed masses in the upper outer quadrant posteriorly. Spot compression view confirms the finding. Ultrasound evaluation demonstrates two adjacent round hypoechoic masses. They do not have the characteristics of a lymph node. Biopsy revealed multifocal invasive ductal carcinoma.

WHY IT MATTERS:

Intramammary lymph nodes are a common finding in the upper outer quadrant of the breast. They are a normal variant and do not require further evaluation. However, don’t be fooled. Not all circumscribed masses in the upper outer quadrant are lymph nodes.
Intramammary lymph nodes have a classic appearance with a reniform shape, hyperechoic center on ultrasound, a fatty hilum or notch on mammography and central vascularity.

FURTHER READING:
Intramammary Lymph Nodes: Normal and Abnormal Multimodality Imaging Features (BJR 2019)

Suspicious Breast Mass with Calcifications on Ultrasound

2/12/2021

Suspicious breast mass with calcification on ultrasound

IMAGING FINDINGS: 

Sonographic image demonstrates an irregular hypoechoic mass with angular margins. Microcalcifications are present within the mass.

WHY IT MATTERS:

Microcalcifications are one of the main findings of breast cancer on a mammogram, however they are often much more subtle to identify on an ultrasound. They appear as hyperechoic foci on sonographic evaluation.
Sonographic evaluation of suspicious calcifications identified on a mammogram may reveal a corresponding mass that is amenable to ultrasound core biopsy.

FURTHER READING:
Sonographically Guided Biopsy of Suspicious Microcalcifications of the Breast: A Pilot Study (AJR 2002)

COVID Vaccination Findings on Mammography

2/10/2021

COVID vaccination findings on mammography

IMAGING FINDINGS: 

Standard Mediolateral Oblique (MLO) views demonstrate an asymmetrically enlarged lymph node in the left axilla. No abnormality is identified in either breast. Sonographic evaluation of the left axilla demonstrates an abnormal enlarged lymph node with a thickened cortex. The patient reports that she had a COVID vaccination in the left arm two weeks ago.

WHY IT MATTERS:

There is hope in the COVID19 global pandemic as vaccines are being deployed. Vaccinations can cause temporary unilateral axillary lymphadenopathy. This is seen commonly after administration of the COVID19 and Shingles vaccines. The majority of patients with a recent vaccination will show some degree of axillary node enlargement on the side of vaccination. This typically resolves within several weeks.
Short-term follow-up of these patients is likely not required if the story fits, especially as the vaccine becomes more wide-spread. Reactive lymphadenopathy due to other causes is often followed until the nodes return to normal size. But given the prevalence of mild left axillary lymphadenopathy with a recent left arm vaccination site = we recommend to simply continue with regular screening. Please note, that some practices are recommending short-term follow-up, however at a busy practice in an area where COVID vaccination is occurring, this could be dozens of patients per day. Another approach for unilateral axillary lymphadenopathy with recent history of COVID vaccination and a normal screening mammogram is to perform screening ultrasound for those with dense tissue (to help ensure no occult malignancy), but otherwise return to routine screening.

FURTHER READING:
Unilateral axillary Adenopathy in the setting of COVID-19 vaccine (Elsevier 2021)

Fibromatosis of the Breast

2/9/2021

Fibromatosis of the Breast

IMAGING FINDINGS: 

Standard Craniocaudal (CC) view of the right breast shows an irregular hyperdense mass with spiculated margins in the medial aspect of the breast. Architectural distortion is present in the lateral right breast due to prior lumpectomy. Corresponding ultrasound image demonstrates an irregular hypoechoic mass with posterior acoustic shadowing in the medial breast.

WHY IT MATTERS:

The majority of spiculated masses identified on mammography or ultrasound will yield malignancy at biopsy. However, there are a few more rare causes such as fibromatosis. There is no way to make this diagnosis based on the imaging alone.
Fibromatosis of the breast is also known as an extra-abdominal desmoid tumor of the breast. It is benign but locally invasive so surgical excision is required.

FURTHER READING:
Mammary Fibromatosis (AJR 2009)

Benign Fibroadenoma on Ultrasound

2/5/2021

Benign fibroadenoma on ultrasound

IMAGING FINDINGS: 

Single ultrasound image demonstrates an oval, circumscribed hypoechoic mass. The mass is wider than tall and does not demonstrate any suspicious features.

WHY IT MATTERS:

Benign fibroadenomas are the most common solid mass within the breast. As a radiologist you need to be familiar with the imaging characteristics.
Benign features on ultrasound include oval shape, circumscribed margins, wider than tall or parallel orientation.

FURTHER READING:
Fibrous Lesions of the Breast: Imaging-Pathologic Correlation (RadioGraphics 2005)

Poor Quality Ultrasound Hides Cancer

2/3/2021

Poor quality ultrasound hides cancer

IMAGING FINDINGS: 

A mediolateral oblique view demonstrates a large mass with obscured margins in the superior left breast. There are also enlarged left axillary lymph nodes. An ultrasound image demonstrates a large “anechoic” mass.

This was said to be a “cyst” by the sonographer. However, the gain is incorrect on this image. With appropriate sonographic settings this proved to be a suspicious hypoechoic mass and ultimately an invasive ductal carcinoma (which is what was expected based on the mammographic findings.)

WHY IT MATTERS:

Ultrasound evaluation is operator dependent. It is possible to create artifactual “masses” and to turn almost any abnormality into a “cyst” if appropriate settings are not employed.
The radiologist should review (and preferably scan themselves) all diagnostic patients before they are let go.

FURTHER READING:
Breast Ultrasonography: State of the Art (Radiology 2013)

Don’t Do This – Made Up Findings

1/28/2021

made up findings

IMAGING FINDINGS:

Multiple sonographic images obtained at the 5:00 position of the right breast demonstrate normal fibroglandular tissue. A “lesion” was identified and measured in two planes. Color images and harmonic images were also performed for this 1 – 2 mm “lesion.” This case then went on to another institution for a second opinion.

WHY IT MATTERS:

Ultrasound is operator dependent. Artifacts and pseudo-lesions are frequent findings. A common interpretative error is to call normal tissue or a “trapped fat lobule” an abnormality.
Just because a sonographer took multiple images of a potential “finding” does not mean it is a real mass. Feel free to take a step back and always go and scan the patient yourself if you are unsure.

FURTHER READING:
Breast Ultrasonography: State of the Art (RSNA 2013)

Don’t Do This – Axillary Lymph Nodes

1/26/2021

Axillary Lymph Nodes

IMAGING FINDINGS: 

Sonographic image of the right axilla demonstrates a normal axillary lymph node with a thin cortex. The sonographer (or radiologist) is incorrectly measuring the dimensions of the lymph node.

WHY IT MATTERS:

Do not measure axillary lymph nodes simply by their greatest dimension. What matters is the cortical thickness and their internal morphology. The lymph node depicted above is totally normal but was errantly stated to be “abnormally enlarged”.
There is no reason to report length x width measurements of axillary lymph nodes on ultrasound, especially if they have a thin cortex and normal morphology.

FURTHER READING:
Axillary Staging of Breast Cancer: What the Radiologist Should Know (RadioGraphics 2013)

Accessory Breast Tissue on Ultrasound

1/21/2021

Accessory breast tissue on ultrasound

IMAGING FINDINGS: 

Sonographic image of a palpable area of concern in the left axilla demonstrates normal dense fibroglandular tissue consistent with prominent accessory breast tissue.

WHY IT MATTERS:

At least 6% of the population has accessory breast tissue in their axilla. It frequently presents as a palpable axillary lump. Any pathologic process that occurs in the breast can also occur in the accessory tissue.
Radiologists should be able to recognize the imaging appearance of this normal variant on mammography and ultrasound.

FURTHER READING:
The ABCs of Accessory Breast Tissue: Basic Information Every Radiologist Should Know (AJR 2014)

Ultrasound Evaluation of the Nipple Areolar Complex

1/20/2021

IMAGING FINDINGS: 

Sonographic image of the nipple and subareolar region shows no abnormality. Notice the large amount of ultrasound gel used to adequately image the subareolar region.

WHY IT MATTERS:

Approximately 20% of breast cancers occur in the subareolar region of the breast. In addition, thorough evaluation of this region is required in the workup of nipple discharge, nipple inversion and other common pathology.
Sonographic evaluation of the nipple-areolar complex can be challenging. The nipple causes extreme shadowing which can limit the ability to visualize underlying pathology. Use a large amount of gel as a standoff to better visualize the nipple and subareolar region.

FURTHER READING:
Nipple-Areolar Complex: Normal Anatomy and Benign and Malignant Processes (RadioGraphics 2009)

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