Retroareolar breast carcinoma: clinical, imaging, and histopathologic features

Prolonged Time from Diagnosis to Breast-Conserving Surgery is Associated with Upstaging in Hormone Receptor-Positive Invasive Ductal Breast Carcinoma

BACKGROUND

Time to surgery (TTS) has been suggested to have an association with mortality in early-stage breast cancer.

OBJECTIVE

This study aims to determine the association between TTS and preoperative disease progression in tumor size or nodal status among women diagnosed with clinical T1N0M0 ductal breast cancer.

METHODS

Women diagnosed with clinical T1N0M0 ductal breast cancer who had breast-conserving surgery as their first definitive treatment between 2010 and 2016 (n = 90,405) were analyzed using the National Cancer Database. Separate multivariable logistic regression models for hormone receptor (HR)-positive and HR-negative patients, adjusted for clinical and demographic variables, were used to assess the relationship between TTS and upstaging of tumor size (T-upstaging) or nodal status (N-upstaging).

RESULTS

T-upstaging occurred in 6.76% of HR-positive patients and 11.00% of HR-negative patients, while N-upstaging occurred in 12.69% and 10.75% of HR-positive and HR-negative patients, respectively. Among HR-positive patients, odds of T-upstaging were higher for 61-90 days TTS (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.05-1.34) and ≥91 days TTS (OR 1.47, 95% CI 1.17-1.84) compared with ≤30 days TTS, and odds of N- upstaging were higher for ≥91 days TTS (OR 1.35, 95% CI 1.13-1.62). No association between TTS and either T- or N-upstaging was found among HR-negative patients. Other clinical and demographic variables, including grade, tumor location, and race/ethnicity, were associated with both T- and N-upstaging.

CONCLUSION

TTS ≥61 and ≥91 days was a significant predictor of T- and N-upstaging, respectively, in HR-positive patients; however, TTS was not associated with upstaging in HR-negative breast cancer. Delays in surgery may contribute to measurable disease progression in T1N0M0 ductal breast cancer.

Visualization of the Nipple in Profile: Does It Really Affect Selected Outcomes in Organized Mammographic Screening?

OBJECTIVE

To investigate whether having the nipple imaged in profile was associated with breast characteristics or compression parameters, and whether it affected selected outcomes in screening with standard digital mammography or digital breast tomosynthesis.

METHODS

In this IRB-approved retrospective study, results from 87 450 examinations (174 900 breasts) performed as part of BreastScreen Norway, 2016-2019, were compared by nipple in profile status and screening technique using descriptive statistics and generalized estimating equations. Unadjusted and adjusted odds ratios with 95% confidence intervals (95% CIs) were estimated for outcomes of interest, including age, breast volume, volumetric breast density, and compression force as covariates.

RESULTS

Achieving the nipple in profile versus not in profile was associated with lower breast volume (845.1 cm3 versus 1059.9 cm3, P < 0.01) and higher mammographic density (5.6% versus 4.4%, P < 0.01). Lower compression force and higher compression pressure were applied to breasts with the nipple in profile (106.6 N and 11.5 kPa) compared to the nipple not in profile (110.8 N and 10.5 kPa, P < 0.01 for both). The adjusted odds ratio was 0.95 (95% CI: 0.88-1.02; P = 0.15) for recall and 0.92 (95% CI: 0.77-1.10; P = 0.36) for screen-detected cancer for nipple in profile versus not in profile.

CONCLUSION

Breast characteristics and compression parameters might hamper imaging of the nipple in profile. However, whether the nipple was in profile or not on the screening mammograms did not influence the odds of recall or screen-detected cancer, regardless of screening technique.

Diagnosis, Management, and Percutaneous Sampling of Nipple-Areolar Calcifications: How Radiologists Can Help Patients Avoid the Operating Room

OBJECTIVE

Both benign and malignant causes of calcifications in the nipple-areolar complex exist. BI-RADS terminology applies to the description and classification of nipple-areolar calcifications in the same way it does to calcifications elsewhere in the breast. Minimally invasive sampling can be performed safely and accurately with ultrasound-guided techniques, with a few technical modifications.

CONCLUSION

This article provides insight regarding the management algorithm and image-guided interventional techniques for sampling nipple-areolar calcifications as an essential competency for breast imaging practices.

Association between body mass index and localization of breast cancer: results from a nationwide inpatient database in Japan

PURPOSE

Although both localization of breast cancer and body mass index (BMI) are associated with prognosis, the association between localization of breast cancer and BMI remains unclear. This study aimed to investigate the association between localization of breast cancer and BMI at diagnosis.

METHODS

Patients who underwent surgery for stage 0-III breast cancer July 2010-March 2017 were identified retrospectively in a Japanese nationwide inpatient database. Multinomial logistic regression analyses adjusting for patient's age were conducted to compare the outcomes among five BMI groups: < 18.5 kg/m² (n = 31,724; 9.3%), 18.5-24.9 kg/m² (n = 218,244; 64.3%), 25.0-29.9 kg/m² (n = 69,813; 20.6%), 30.0-34.9 kg/m² (n = 16,052; 4.7%), and ≥ 35.0 kg/m² (n = 3716; 1.1%). The outcomes were the quadrant and side of the breast where tumors were detected.

RESULTS

In total, about half of the patients had breast cancer in the upper-outer quadrant (49.7%) and in the left breast (51.1%). In the multinomial analysis, BMI ≥ 25.0 kg/m² was associated with the occurrence of breast cancer in the upper-inner and lower-outer quadrants and in the central area, whereas BMI < 18.5 kg/m² was associated with the occurrence of breast cancer in the central area only. The side of breast cancer did not differ significantly among the five BMI groups.

CONCLUSIONS

Localization of breast cancer was associated with BMI in this large nationwide cohort. The findings may benefit patients' self-checks and doctors' examinations, potentially resulting in early detection and treatment.

Multimodality approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm

The anatomic and histologic characteristics of the nipple-areolar complex make this breast region special. The nipple-areolar complex can be affected by abnormal development and a wide spectrum of pathological conditions, many of which have unspecific clinical and radiological presentations that can present a challenge for radiologists. The nipple-areolar complex requires a specific imaging workup in which a multimodal approach is essential. Radiologists need to know the different imaging modalities used to study the nipple-areolar complex, as well as their advantages and limitations. It is essential to get acquainted with the acquisition technique for each modality and the spectrum of findings for the different conditions. This review describes and illustrates a combined clinical and radiological approach to evaluate the nipple-areolar complex, emphasizing the findings for the normal morphology, developmental abnormalities, and the most common benign and malignant diseases that can affect this region. We also present a diagnostic algorithm that enables a rapid, practical approach to diagnosing condition involving the nipple-areolar complex.

Do breast quadrants explain racial disparities in breast cancer outcomes?

PURPOSE

Tumors of the inner quadrants of the breast are associated with poorer survival than those of the upper-outer quadrant. It is unknown whether racial differences in breast cancer outcomes are modified by breast quadrant, in addition to comparisons among Asian subgroups.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we analyzed data among women diagnosed with non-metastatic invasive breast cancer between 1990 and 2014. We performed Cox proportional hazards regression models to assess the associations of race with breast cancer-specific survival and overall survival, stratified by breast quadrants. The models were adjusted for age, year of the diagnosis, tumor size, grade, histological type, tumor laterality, lymph node, estrogen receptor, progesterone receptor, and treatments.

RESULTS

Among 454,154 patients (73.0% White, 10.0% Black, 7.8% Asian/PI, and 9.2% Hispanic), 54.3% had tumors diagnosed in the upper-outer quadrant of the breast. Asian/PI women were more likely than White to have tumors diagnosed in the nipple/central portion of the breast and were less likely to have diagnosed in the upper-outer quadrant (P < 0.001), despite a similar distribution of breast quadrant between Black, Hispanic, and White women. Compared with White women, the multivariable-adjusted hazard ratios of breast cancer-specific mortality were 1.41 (95% CI 1.37-1.44) in Black women, 0.82 (95% CI 0.79-0.85) in Asian women, and 1.05 (95% CI 1.02-1.09) in Hispanic women. Among Asian subgroups, Japanese American women had a lower risk of breast cancer-specific mortality (HR = 0.68, 95% CI 0.62-0.74) compared with White women. Overall survival was similar to breast cancer-specific survival in each race group. The race-associated risks did not vary significantly by breast quadrants for breast cancer-specific mortality and all-cause mortality.

CONCLUSIONS

Differences in breast cancer survival by race could not be attributed to tumor locations. Understanding the cultural, biological, and lifestyle factors that vary between White, African American, and ethnic subgroups of Asian American women may help explain these survival differences.

Sonoelastography of retroareolar carcinomas

PURPOSE

To review the sonographic and elastographic features of retroareolar carcinomas.

MATERIALS

Institutional review board approval was obtained. Among 967 sonographically guided biopsies (2013-2014) (14-gauge cores), 53 yielded the diagnosis of retroareolar carcinoma (located less than 2cm from the nipple on mammograms). Out of these 53 lesions, 30 were assessed additionally with strain elastography prior to the biopsy in addition to conventional sonographic analysis. Imaging features were analyzed in consensus by two radiologists. Elasticity score was evaluated by the score defined by Itoh (Tsukuba score). Descriptive analysis was performed.

RESULTS

A total of 30 lesions were included (30 patients; mean age, 66.03 (±12.88)). The mean size of the lesions at diagnosis was 23.97mm (±13.64). Sonographically, most of lesions appeared as hypoechoic masses (96.5%, 28/29) displaying an irregular shape (75.9%, 22/29), non parallel orientation (58.6%, 17/29), non circumscribed margins (86.2%, 25/29), posterior attenuation (93.3%, 28/29). Among the 30 lesions, 3.3% (1/30) of lesions appeared as an attenuation and distortion without discrete mass. Most of the lesions were categorized as BI-RADS category 5 (76.7%, 23/30). Approximately half of lesions (53.3%, 16/30) appeared as firm and larger than 2D mode with strain elastography according to the Tsukuba score.

CONCLUSION

Retroareolar carcinoma displayed malignant features at US and elastographic examination. In our study population, the addition of elastography to breast US in this location did not improve diagnostic accuracy.

Retroareolar masses and intraductal abnormalities detected on screening ultrasound: can biopsy be avoided?

To investigate the malignancy rate of retroareolar masses and intraductal abnormalities discovered in asymptomatic females during screening whole breast ultrasound (US-S) and determine if biopsy can be avoided.

METHODS:

This is a HIPAA compliant retrospective study. Our radiology electronic medical records were searched for the phrases "retroareolar mass" or "intraductal mass" combined with "screening whole breast ultrasound" performed between 10/1/2009 and 5/30/2015. Inclusion criteria included retroareolar masses in asymptomatic females with normal mammography, mammographically dense breast tissue and imaging or biopsy follow-up.

RESULTS:

1136 charts were reviewed. 87 BI-RADS 3 and 4 retroareolar findings were included in final analysis. The average lesion size was 9.5 mm (range 4-28 mm). 47/87 lesions were classified as BI-RADS 3 and 40/87 BI-RADS 4. Of the 47 BI-RADS 3 lesions, 36 were stable on follow-up; 6 benign lesions were biopsied at patients' request; and 5 biopsied due to suspicious interval change on follow-up imaging, including 4 benign lesions and a 5 mm Grade 2 ductal carcinoma in situ . 3/40 BI-RADS 4 lesions were not biopsied and stable at follow-up; 37/40 lesions underwent benign biopsy. The malignancy rate of BI-RADS 3 and 4 lesions was 2.1% [CI (0.4-11.1)] and 0% [CI (0.0-8.8)], respectively. The overall combined malignancy rate was 1/87 [1.1%, CI (0.2-6.2)].

CONCLUSION:

The malignancy rate for BI-RADS 3 and 4 retroareolar masses and intraductal abnormalities detected on US-S is low (<2%).

ADVANCES IN KNOWLEDGE:

Careful imaging surveillance in lieu of biopsy of these lesions may be appropriate in asymptomatic females with negative mammography.

Intradermal invasive lobular carcinoma presenting: Not everything in the skin is benign

In this case report, the history and imaging of two patients with invasive lobular carcinoma (ILC) in the skin are presented, followed by a discussion of both benign and malignant intradermal findings on breast ultrasound. Although the majority of dermal findings are benign, these cases are a reminder that malignancy can manifest within the skin. The purpose of presenting these cases together is to remind breast imagers of the importance of considering malignancy in the differential diagnosis of intradermal lesions on breast ultrasound, especially in special circumstances such as a personal history of breast cancer or associated clinical findings.

Retroareolar Carcinomas in Breast Ultrasound: Pearls and Pitfalls

Breast Ultrasound (US) is an important tool for both screening and diagnostic examinations. Although breast US has benefitted from significant recent technical improvements, its use for the retroareolar region is known to be more challenging than for other locations. The retroareolar location was defined by Giess et al. in 1998 as the region where any lesion is situated at less than two cm from the nipple and/or involves the nipple-areolar complex on mammogram. Understanding of the complex anatomy and physiology of the nipple-areolar region is important to avoid misinterpretation and misdiagnosis. The ability for the breast imager to manage difficulties related to the retroareolar area is paramount by adjusting settings (compounding, frequency, Doppler) and utilizing specific manoeuvers. Cases illustrating difficulties encountered in diagnosis of retroareolar carcinomas are presented.

Tumour location within the breast: Does tumour site have prognostic ability?

Introduction

Tumour location within the breast varies with the highest frequency in the upper outer quadrant (UOQ) and lowest frequency in the lower inner quadrant (LIQ). Whether tumour location is prognostic is unclear. To determine whether tumour location is prognostic, associations between tumour site and clinicopathological characteristics were evaluated.

Materials and Methods

All patients enrolled in the Clinical Breast Care Project whose tumour site—UOQ, upper inner quadrant (UIQ), central, LIQ, lower outer quadrant (LOQ)—was determined by a single, dedicated breast pathologist were included in this study. Patients with multicentric disease (n = 122) or tumours spanning multiple quadrants (n = 381) were excluded from further analysis. Clinicopathological characteristics were analysed using chi-square tests for univariate analysis with multivariate analysis performed using principal components analysis (PCA) and multiple logistic regression. Significance was defined as P < 0.05.

Results

Of the 980 patients with defined tumour location, 30 had bilateral disease. Tumour location in the UOQ (51.5%) was significantly higher than in the UIQ (15.6%), LOQ (14.2%), central (10.6%), or LIQ (8.1%). Tumours in the central quadrant were significantly more likely to have higher tumour stage (P = 0.003) and size (P < 0.001), metastatic lymph nodes (P < 0.001), and mortality (P = 0.011). After multivariate analysis, only tumour size and lymph node status remained significantly associated with survival.

Conclusions

Evaluation of tumour location as a prognostic factor revealed that although tumours in the central region are associated with less favourable outcome, these associations are not independent of location but rather driven by larger tumour size. Tumours in the central region are more difficult to detect mammographically, resulting in larger tumour size at diagnosis and thus less favourable prognosis. Together, these data demonstrate that tumour location is not an independent prognostic factor.

Ultrasound elastography for the differential diagnosis of nipple retraction

PURPOSE

Nipple retraction is difficult to diagnose radiologically and extremely worrisome for patients. It occurs most commonly due to pathologies such as previous mastitis or an infiltrative malignancy. With this in mind, the goal of this study was to differentiate benign from malignant lesions of nipple retraction, using the differential characteristics of retroareolar area stiffness, observed by means of the new technological modality of ultrasound elastography (USE).

MATERIALS AND METHODS

Nineteen unilateral nipple retraction cases, including five cases of mammary ductal carcinoma posteriorly infiltrated the areola, two cases of Paget disease, and 12 cases of mastitis, were investigated. Imaging findings [gray-scale ultrasound (US) and USE analyses of the breasts' nipple-areolar complex], pathological evaluation, and the results of 4 years of follow-up treatment were obtained. The recorded images were evaluated by two different radiologists, and all data were analyzed statistically.

RESULTS

Statistical analysis showed that there was a strong correlation between the two radiologists' evaluations. The US images were not diagnostic for either the malignant or benign conditions. The correlation between the diagnosis using US and the final diagnosis was calculated as 0.436 (p = 0.006). However, the USE images were more informative since the correlation ratio between the USE results and the final diagnosis was found to be 0.723 (p < 0.001). While the area under the concentration curve (AUC) values that were used for the diagnostic determination of the US results were inconclusive at 0.274 (p < 0.021), the AUC values for USE were significant, with a diagnostic value of 0.866 for all cases (p < 0.01).

CONCLUSION

The USE modality, which is not commonly used in routine practice, has the potential to solve the problem of differentiation of nipple retraction etiologies in the near future.

Distinguishing breast skin lesions from superficial breast parenchymal lesions: diagnostic criteria, imaging characteristics, and pitfalls

Superficial lesions are commonly encountered in the breast and may be located in the dermis, hypodermis (subcutaneous fat), or parenchyma. The differential diagnosis varies for each anatomic layer. Dermal lesions that are seen by breast imagers are usually benign skin cysts. Hypodermal lesions, although usually benign, may include lesions that arise from anterior terminal duct lobular units and include papilloma, adenosis, fibroadenoma, and breast cancer. To avoid misclassifying a small superficial breast cancer as a benign dermal lesion, it is necessary to understand superficial breast and skin anatomy and the mammographic, ultrasonographic (U.S.), and magnetic resonance (MR) imaging signs that indicate that a lesion is dermal. Mammography is the optimal modality for localizing calcifications to the dermis or hypodermis. However, U.S. typically has higher resolution for localizing masses than mammography and MR imaging. At US, a lesion may be categorized as dermal (a) if it is contained entirely within the dermis, (b) if a tract that extends from the lesion to the skin is seen, or (c) if a claw of tissue surrounding the margin of the lesion is present. As with other breast lesions, suspicious imaging features should be sought in addition to determining the anatomic origin. If histologic analysis is necessary to characterize lesions with an unknown cause or origin, precautions must be taken to decrease patient morbidity.

One-to-one comparison between digital spot compression view and digital breast tomosynthesis

OBJECTIVE

To assess if digital breast tomosynthesis (DBT) is at least equal to digital spot compression view (DSCV).

METHODS

Following institutional approval and written informed consent, both DBT and DSCV were obtained in women with a screening abnormality. The diagnostic accuracy of DBT and DSCV was evaluated by two radiologists of varying experience (Reader1 and Reader2).

RESULTS

52 consecutive recalled women without calcification (mean age: 51 ± 12 years) underwent DSCV and DBT. Overall sensitivity was equal for both techniques (100% [95% CI, 91-100%] for DBT and 100% [95% CI, 91-100%] for DSCV). Overall specificity was higher for DBT (100% [95%CI, 91-100%]) than for DSCV (94% [95% CI, 91-100%]). Specificity for DSCV was higher for Reader1 (95% [95% CI, 91-100%]). Reader2 had lower values of specificity (92% [95% CI, 90-92%]). On DSCV, three and two false positives were recorded by Reader2 and Reader1, respectively. Overall, the area under the curve (AUC) was greater for DBT (AUC = 1) than for DSCV (AUC = 0.963). The mean difference between the two techniques was not significantly different (P = 0.43).

CONCLUSION

In this dataset, diagnostic accuracy of digital breast tomosynthesis is at least equal to that of digital spot compression.

KEY POINTS

• Digital spot compression views (DSCVs) are often needed in breast screening programmes. • Digital breast tomosynthesis (DBT) now offers an alternative to DSCV • In recalls without calcification, DBT was at least equally accurate as DSCVs • DBT has a lower mean glandular dose than DSCVs • Thus DBT has the potential to help reduce the recall rate.

Image presentation. The nipple-areolar complex: a pictorial review of common and uncommon conditions

OBJECTIVE

The purpose of this presentation is to show the radiologic findings of normal variants and benign and malignant diseases that affect the nipple-areolar complex.

METHODS

We evaluated the imaging findings of nipple-areolar complex lesions, using multiple breast imaging modalities including mammography, sonography, galactography, contrast-enhanced magnetic resonance imaging (MRI), and positron emission tomography/computed tomography.

RESULTS

Radiologic features of nipple-areolar complex lesions, including Montgomery tubercles, nipple inversion, benign calcifications, inflammation, duct dilatations, intraductal papillomas, fibroadenomas, neurofibromatosis, dermatosis of the nipple, and breast malignancy, have been illustrated.

CONCLUSIONS

A clinical examination is essential and an appropriate imaging evaluation with multiple modalities is often necessary to accurately diagnose an underlying abnormality of the nipple-areolar complex. Given the limitations of conventional mammography, supplemental mammographic views often are needed, and sonography may be performed to further characterize a mammographic or clinical finding. Also, contrast-enhanced MRI may be useful for additional evaluation.

Nipple-areolar complex: normal anatomy and benign and malignant processes

The nipple-areolar complex may be affected by many normal variations in embryologic development and breast maturation as well as by abnormal processes of a benign or malignant nature. Benign processes that may affect the nipple-areolar complex include eczema, duct ectasia, periductal mastitis, adenomas, papillomas, leiomyomas, and abscesses; malignant processes include Paget disease, lymphoma, and invasive and noninvasive breast cancers. Radiologists should be aware of the best methods for evaluating each of these entities: Many disorders of the nipple-areolar complex are unique or differ in important ways from those that occur elsewhere in the breast, and they require a diagnostically specific imaging evaluation. Patients may present with benign developmental variations; inversion, retraction, or enlargement of the nipple, which may have either a benign or a malignant cause; a palpable mass; nipple discharge; skin changes in and around the nipple; infection with resultant nipple changes or a subareolar mass; or abnormal findings at routine mammographic screening. Further diagnostic imaging may include repeat mammography, breast ultrasonography, galactography, and magnetic resonance imaging. When skin changes are present, a clinical evaluation by the patient's primary care physician, dermatologist, or surgeon should be part of the diagnostic work-up.

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

Ruptured epidermal inclusion cysts in the subareolar area: sonographic findings in two cases

Epidermal inclusion cyst of the breast is an uncommon benign lesion and it is usually located in the skin layer. We report here on two cases of ruptured epidermal inclusion cysts in the subareolar area, which is a very unusual location for these cysts and these lesions can be mistaken for breast malignancies.

Subareolar breast cancers

BACKGROUND

Despite the high rate of pathologic involvement of the nipple-areola complex (NAC) with subareolar cancers and the suboptimal cosmetic results when lumpectomy removes the NAC, breast conservation surgery has been extended to include these patients.

METHODS

Ninety-five patients with subareolar cancers operated on between 1979 and 1998 were identified and the relationships between the pathologic findings, treatment, and outcome were studied.

RESULTS

Clinical involvement of the NAC (P = 0.001), clinical presentation (P <0.001, mammographic calcium or Paget's disease), and pathologic tumor size (P = 0.019) were significantly related to pathologic involvement of the NAC in univariate analysis. After consideration for clinical NAC involvement, no other variable was significantly related to pathologic NAC involvement in multivariate analysis. Thirty-three patients underwent mastectomy, and 62 were treated with breast conservation. Radiation therapy (P = 0.005), clinical (P = 0.031), and pathologic (P = 0.037) involvement of the NAC were significantly related to local disease-free survival in breast conservation patients in univariate analysis. After consideration for radiation therapy in multivariate analysis, clinical involvement of the NAC was the only additional variable significantly related to local recurrence in breast conservation patients. Clinical or pathologic involvement of the NAC was not significantly associated with local and distant recurrence after mastectomy. No other variable was significantly related to local outcome in univariate analysis in patients treated with mastectomy.

CONCLUSIONS

Subareolar cancers can be successfully treated with breast conservation surgery provided adjuvant radiation therapy is always given. Clinical involvement of the nipple-areola complex is associated with high risk of local failure when treated with breast conservation without radiation therapy.