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 Table of Contents  
PICTORIAL ESSAY: MAMMOLOGY
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 132-143

Breast pathologies: Kaleidoscope of conventional mammography, sonography, magnetic resonance mammography, and histopathology features


1 Department of CT and MRI, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
2 Department of Pathology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India

Date of Web Publication31-Jul-2014

Correspondence Address:
Dr. Seema Sud
Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.137856

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  Abstract 

Breast can be the seat of a number of benign and malignant pathologies. Even though digital mammography - with or without correlative ultrasonography - is still largely the mainstay of breast imaging, the newer technique of magnetic resonance mammography has come of age. Capable of capturing wide and varied morphology of diverse breast lesions, it can contribute in a major way to the diagnosis and management of some patients. Characteristic magnetic resonance mammography features can help obviate the need of a biopsy in lesions like hamartomas, and benign virginal hyperplasia, whereas in conditions like invasive lobular carcinoma and Paget's disease, it can make a significant difference to the surgical plan. This pictorial kaleidoscope presents the imaging and histopathology characteristics of many usual and unusual breast lesions.

Keywords: Breast, magnetic resonance mammography, mammography, ultrasonography, unusual pathologies


How to cite this article:
Sud S, Buxi T, Ghuman S, Dhawan S, Doda R, Chandra M. Breast pathologies: Kaleidoscope of conventional mammography, sonography, magnetic resonance mammography, and histopathology features. Astrocyte 2014;1:132-43

How to cite this URL:
Sud S, Buxi T, Ghuman S, Dhawan S, Doda R, Chandra M. Breast pathologies: Kaleidoscope of conventional mammography, sonography, magnetic resonance mammography, and histopathology features. Astrocyte [serial online] 2014 [cited 2019 May 20];1:132-43. Available from: http://www.astrocyte.in/text.asp?2014/1/2/132/137856


  Introduction Top


A number of benign and malignant pathologies can affect the breast. Mammography with or without correlative ultrasonography (USG) has been the mainstay of breast imaging, however, magnetic resonance mammography (MRM) has made major inroads into imaging of the breast. [1]

Fibrocystic changes, fibroadenomas, focal adenosis, papillomas, fat necrosis, hamartomas, invasive ductal carcinoma, invasive lobular carcinoma, ductal carcinoma in situ are frequently seen pathologies on MRM in daily practice. However, lesions like benign virginal hyperplasia, sarcoidosis, tubercular mastitis, idiopathic granulomatous mastitis, Paget's disease of the nipple, benign and malignant phylloides, colloid and medullary carcinoma, benign intracystic papillomatosis in male are rarely encountered entities.

The purpose of this article is to make the reader aware of the findings of usual and unusual pathologies of the breast on MRM and correlate with mammogram, USG, and histopathology findings.

Invasive Ductal Carcinoma

Invasive ductal carcinoma is the most common type of breast cancer, and usually has an epithelial morphology with ductal differentiation. It is called invasive ductal carcinoma, of no special type.

Most common finding on mammograms is a radiodense spiculated mass with associated amorphous microcalcification [Figure 1]a.
Figure 1: (a) Medio-lateral oblique (MLO) mammogram showing a radiodense spiculated mass (b) USG showing a hypoechoic lesion, taller than broader with ill defined margins, posterior acoustic shadowing and microcalcifications (c, d, e, f) T2W postcontrast T1W fat suppressed (fs), diffusion and ADC mapping images showing a T2 hypointense irregular mass with heterogenous enhancement and restricted diffusion (g) H and E, 100× shows epithelial tumor cells infiltrating into the stroma.

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On USG, they are hypoechoic lesions, taller than broader with ill defined margins, posterior acoustic shadowing, and microcalcifications [Figure 1]b. [2]

Regardless of the histological type, on MRM they are seen as a T2 hypointense, irregular, spiculated mass with rim or heterogenous internal enhancement, which show restricted diffusion with a mean apparent diffusion coefficient (ADC) value less than 1.1 × 10 -3 mm 2 /s [Figure 1]c-f. [3] MRM is generally used in these patients to see extent of disease, multicentricity, postsurgical scar versus recurrence of disease, and response to chemotherapy. [4]

On histopathology, these tumors display varying grades of stromal desmoplasia and form glands or tubules. They are classified as well differentiated, moderately differentiated, or poorly differentiated tumors based on the tubule formation, mitoses, and nuclear pleomorphism [Figure 1]g. The low grade or well-differentiated tumors show gland/tubule formation in more than 75% of the invasive component and few mitoses. They tend to cause intense desmoplastic reaction in the stroma.

Mucinous Carcinoma

Mucinous carcinoma, also known as colloid carcinoma, is a well differentiated type of invasive adenocarcinoma (epithelial tumor). Histopathologically, two forms are known, the pure and mixed type. The pure type contains tumor cells floating in mucin and the mixed type has an associated solid tubular component [Figure 2]c. [5] The pure types are commonly seen as a noncalcified oval or lobular mass, which has circumscribed or microlobulated margins on mammography [Figure 2]a. The mixed type usually has indistinct margins. [6]
Figure 2: (a) MLO mammogram showing a mass, which has microlobulated margins (b) USG showing a mass with solid and cystic components which are hypo- to isoechoic relative to the subcutaneous fat, with distal enhancement (c) H and E, 100× showing micropapillae of tumor cells floating in mucin.

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At USG, they are generally seen as complex vascular masses with solid and cystic components, which are hypo to isoechoic relative to the subcutaneous fat, with distal enhancement due to high mucin content [Figure 2]b. The pure types show homogenous echoes and are circumscribed or microlobulated, whereas the mixed types are heteroechoic with partially indistinct margins. [6]

On MRM, they appear mass like, round, oval, or lobular lesions and show markedly high signal on T2-weighted images. On dynamic contrast images they show rim-like peripheral or heterogenous internal persistent enhancement pattern. The pure type show homogenous high signal on T2-weighted images, whereas the mixed type show areas of low signal within them. [7],[8] On MRM, they may be misread because of the high signal and rim enhancement, however, special attention should be paid to the diffusion-weighted images (DWI) as they commonly show restricted diffusion due to abundant mucin and show a mean ADC value of less than 1.1 × 10 -3 mm 2 /s [Figure 3].
Figure 3: (a) Turbo inversion recovery magnetization (b) T1W (c) Postcontrast T1W fs (d) Diffusion at b value of 800 showing a T2 hyperintense, lobulated mass with peripheral and heterogenous internal enhancement and restricted diffusion.

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Medullary Carcinoma

Medullary carcinoma is a well differentiated subtype of invasive carcinoma with an incidence of less than 2% of breast carcinomas, usually seen in younger women (<35 years).

It is seen as an uncalcified mass on mammography with irregular or well circumscribed margins [Figure 4]a.
Figure 4: (a) Cranio-caudal (CC) and MLO mammogram shows an uncalcified mass with well circumscribed margins (b) USG shows an inhomogenous hypoechoic mass with lobulated margins (c) T2W (d) T1W (e) Postcontrast T1W fs (f) Diffusion at b value of 800 (g) ADC (h) Maximum intensity projection (MIP) images showing a T2 hyperintense, T1W isointense lobular mass with rim enhancement and internal enhancing septae, homogenous internal enhancement and restricted diffusion.

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On USG, it is seen as a homogenous or inhomogenous hypoechoic mass with well defined margins [Figure 4]b.

They are iso- to hypointense on T1-weighted images and iso- to hyperintense on T2-weighted images. They are oval or lobular in shape, usually with smooth and, less often, irregular margins. They show restricted diffusion and significantly low ADC values, < 1.1 × 10 -3 mm 2 /s. On contrast administration, these tumors exhibit rim enhancement with enhancing internal septations and homogenous to inhomogenous internal enhancement [Figure 4]c-h. [9],[10]

Histologically, these tumors demonstrate a syncytial pattern of growth of poorly differentiated malignant cells with high mitosis. The periphery and the center of the tumor show a characteristic desmoplastic inflammatory reaction. [11]

Invasive Lobular Carcinoma

Invasive lobular carcinoma are quite commonly clinically occult as they are not well circumscribed and hence do not present as discrete palpable masses.

There is a high false negative result on mammography because these tumors classically do not incite any significant desmoplastic reaction.

On mammography, they present most commonly as a mass with ill defined or spiculated margins, followed by areas of architectural distortion [Figure 5]a.
Figure 5: (a) MLO mammogram shows bilateral areas of architectural distortion (b) USG shows bilateral focal iso- to hypoechoic massees.

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On USG, they are most commonly seen as focal shadowing without a discrete mass, however, they can be seen as focal masses with shadowing as well [Figure 5]b.

MRM imaging is the most sensitive modality for detection of invasive lobular carcinoma and has higher sensitivity than USG and mammography for detection of multifocal and multicentric disease. At magnetic resonance imaging (MRI) they may have a variable appearance and commonly present as solitary irregular or spiculated masses or as areas of architectural distortion [Figure 6]a. They can also be seen as a dominant enhancing lesion with adjoining smaller enhancing foci connected with enhancing strands to the dominant lesion, areas of architectural distortion or regional or focal areas of heterogenous enhancement. On contrast imaging, they rarely show the classical washout as seen in the usual invasive carcinoma. [12]
Figure 6: (a) T1W nonfat saturated axial MRM shows bilateral architectural distortion (b) H and E, 100× shows the tumor cells infiltrating into the stroma in a single file fashion.

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Histologically, the tumor cells are seen in a single file fashion within the breast stroma or as small aggregates of tumor cells separated by normal breast tissue [Figure 6]b. [13]

Ductal Carcionoma in situ

Ductal carcionoma in situ (DCIS) is a noninvasive malignancy seen histologically as clonal proliferation of malignant cells without invasion of the basement membrane.

On mammography, microcalcifications are the dominant feature. They can be also seen as areas of architectural distortions, dilated retroaerolar ducts, masses, or nodular abnormalities [Figure 7]a.
Figure 7: (a) MLO mammogram shows retroaerolar architectural distortion with microcalcification (b) USG showing an irregular, hypoechoic mass with irregular margins and no posterior acoustic phenomenon (c) H and E shows large ducts filled with tumors cells.

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On USG, the masses are usually solid, hypoechoic, irregular with indistinct margins, and no posterior acoustic phenomenon. Microcalcifications are commonly seen [Figure 7]b.

On MRM, DCIS can be seen as a mass like or nonmass like, ductal, inhomogenous, clumped, or heterogenous cobblestone like enhancement, which is isointense to slightly hypointense in signal on T2-weighted images. It can be segmental or regional in distribution. They usually show a rapid wash in of contrast on the early contrast images, with persistent, plateau, or washout kinetics on delayed images. DWI show restricted diffusion but a slightly higher ADC value as compared with invasive cancers [Figure 8]. [14]
Figure 8: (a) T2W (b) T1W (c) MIP (d) Diffusion at b value of 800 (e) ADC mapping (f) Postcontrast T1W fs subtracted axial images show nonmass like, inhomogenous, segmental enhancement, which is isointense to slightly hypointense in signal on T2-weighted images and isointense on T1W images with restricted diffusion.

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Paget's disease of the nipple

Paget's disease of the nipple is an uncommon breast malignancy, with a reported incidence of 0.5-5%. It is commonly associated with invasive or DCIS. Patients present with thickening and excoriation of the nipple [Figure 9]a.
Figure 9: (a) Breast showing thickening and excoriation of the nipple (b) MLO mammogram showing bilateral dense breasts with no obvious pathology.

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Mammography is normal in 10-50% of cases [Figure 9]b. Nipple, areolar and subareolar abnormalities like nipple retraction and skin thickening are common. Parenchymal abnormalities include asymmetry, architectural distortion or discrete mass or masses with or without malignant calcification.

On USG, the nipple may show thickening, flattening, or asymmetry. There may be an associated mass with irregular or lobulated margins and micro calcifications and no posterior acoustic shadowing. [15]

The diseased nipple-areolar complex shows thickening with rapid wash in of contrast within the first 2 min, followed by a plateau delayed enhancement kinetic curve, whereas the normal nipple-areolar complex displays a slow wash in of contrast followed by persistent enhancement [Figure 10]a-d. These findings are, however, not specific for Paget's disease of the nipple and are also seen in infiltrating carcinomas involving the nipple. [16] Vascular proliferation is invariably seen associated with DCIS even if the tumor is very small. [17]
Figure 10: (a) T1W non-fs (b) MIP (c) Postcontrast T1W fs axial images (d) Time-signal intensity curve from the nipple shows a thickened enhancing nipple with plateau (type 2) enhancement kinetics and nonmass like, inhomogenous ductal enhancement (curved arrow) (e) H and E, 100× shows tumor cells invading the stroma (f) H and E, 100× shows infiltration of the nipple epidermis by malignant cells.

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Histologically, it is characterized by infiltration of the nipple epidermis by adenocarcinoma cells, which are characterized by oval or round cells with pale, clear, abundant cytoplasm, and enlarged pleomorphic, hyperchromatic nucleus. These Paget cells may be single or occur in nests along the basal epidermal cells. It is commonly associated with intraductal carcinoma of the comedo or solid type with or without an invasive component [Figure 10]e and f. [15]

Phyllodes Tumor

Phyllodes tumor are rare fibroepithelial tumors, constituting 0.3-05% of female breast tumors, with a peak incidence at 45-49 years. They are graded histologically into benign, borderline, and malignant and can grow to large sizes [Figure 11]a.
Figure 11: (a) Markedly enlarged left breast with redness of the skin (b) MLO mammogram shows a large radio dense mass occupying the entire breast (c) USG shows a well circumscribed predominantly cystic mass with echogenic rim and central low level homogenous internal echoes with good through transmission.

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On mammograms, they are seen as well circumscribed or lobulated isodense mass with a radiolucent halo and coarse calcification [Figure 11]b.

On USG, they are well circumscribed masses with smooth margins, echogenic rim, and central low level homogenous internal echoes [Figure 11]c. Fluid-filled clefts in a predominantly cystic mass with good through transmission are highly suggestive of phyllodes.

On MRI, they are seen as T2-weighted iso- to hyperintense oval or lobulated masses with hetergenous internal signal and central nonenhancing septae along with cystic spaces. The benign phyllodes show persistent enhancement with no restricted diffusion. The malignant or borderline subtypes show variable enhancement pattern and areas of restricted diffusion within the mass [Figure 12]a and b. [18]
Figure 12: (a) T2W fs (b) Postcontrast T1W fs axial MRM shows T2- weighted iso- to hyperintense lobulated mass with hetergenous internal signal and central enhancing septae along with cystic spaces (c) H and E, 200× shows moderate pleomorphism and marked increase of the stroma with benign gland showing apocrine metaplasia (d) H and E, 200× shows plump stromal cells with prominent mitosis including atypical tripolar mitosis (black arrow).

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Phyllodes tumors show expansion and increased cellularity of the stroma. The benign lesions show absent or few mitoses, cellular overgrowth, and minimal cellular pleomorphism along with epithelial lined clefts. The malignant tumors show increase in mitoses, including atypical mitosis with marked cellular pleomorphism in the stroma. The epithelial component is benign [Figure 12]c and d. [19]

Idiopathic Chronic Granulomatous Mastitis

Idiopathic chronic granulomatous mastitis is also commonly called granulomatous lobular mastitis. It is a rare benign inflammatory breast disease of unknown etiology.th

It usually affects women of childbearing age or in women with history of oral contraceptive use. The proposed etiologic factors include an autoimmune phenomenon, chemical reaction associated with oral contraceptive pills, autoimmune phenomenon, and localized immune response to extravasated secretions from lobules. Pregnancy, breast-feeding, breast trauma, galactorrhea with hyperprolactinemia and alpha-1-antitrypsin deficiency has been associated with an increased risk of idiopathic granulomatous mastitis. [20]

Mammography findings are not specific and usually include an irregular mass and increased parenchymal density along with skin thickening and nipple retraction [Figure 13]a.
Figure 13: (a) MLO mammogram shows asymmetry of the breasts with bilateral increased parenchymal density (b) H and E, 100× shows dense lympho mononuclear cells infiltrating the lobules (c) USG shows an area of fat necrosis and (d) Subareolar hyper echoic masses.

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On USG, they are seen as hypoechoic confluent lesions often associated with duct ectasia and areas of fat necrosis [Figure 13]c and d. Evaluation of granulomatous mastitis by USG is limited due to the presence of parenchymal or cutaneous edema.

MRI allows a precise and complete delineation of the inflammatory condition. It is seen as multiple hypo- and hyperintense lesions on T1-weighted images and hyperintense signal on T2-weighted images. The lesions show peripheral ring enhancement suggestive of inflammatory fluid pockets. Duct ectasia with peri-ductal enhancement, areas of fat necrosis and skin thickening along with nipple retraction are commonly seen [Figure 14]. It is differentiated from inflammatory breast carcinoma by the enhancement pattern, which is a slow wash in of contrast in the first 2 min in granulomatous mastitis as against a rapid wash in noted in inflammatory breast carcinoma. [21]
Figure 14: (a) T2W (b) T1W (c) Postcontrast T1W fs (d) Diffusion at a b value of 800 (e) ADC (f) MIP axial MRM images shows multiple hypo- and hyperintense lesions on T1-weighted images and hyper intense signal on T2-weighted images, which show peripheral ring enhancement. Duct ectasia with peri-ductal enhancement, areas of fat necrosis and nipple thickening are also seen. No significant restricted diffusion is noted.

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On histopathology, there is extensive necrotic tissue surrounded by heavy polymorph nucleates [Figure 13]b.

Sarcoidosis

Less than 1% of patients of sarcoidosis have involvement of the breast. Primary involvement of the breast is very rare. Most patients have involvement of other organs [Figure 15]a.
Figure 15: (a) Swollen right foot and lower leg with discoloration of the skin (b) H and E, 200× shows noncaseating epithelioid granulomas with multinucleated giant cells and Schaumann body.

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Mammography, sonography, and MRI findings mimic malignancy, granulomatous disease, diabetic mastopathy, and radial scar.

On mammography, spiculated masses may be seen and on USG, lesions are seen as one or multiple irregular hypoechoic lesion.

On MRI, sarcoid appears as irregular mass-like areas of enhancement, which appear iso- to hypointense on T2-weighted images. The lesions may show persistent delayed enhancement or washout delayed enhancement kinetics. They show restricted diffusion [Figure 16]. Associated intramammary edema and lymphadenopathy may be present. [22]
Figure 16: (a) T2W (b) T1W (c) Postcontrast T1W fs (d) Diffusion at a b value of 800 (e) ADC (f) MIP axial MRM images shows irregular mass like and nonmass like areas of enhancement, which appear iso- to hypointense on T2-weighted images, with heterogenous enhancement and restricted diffusion along with skin thickening.

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Histologically they are characterized by noncaseating epithelioid granulomas with multinucleated giant cells [Figure 16]. [23]

Tubercular mastitis

Tubercular mastitis has a prevalence of 0.1% of breast lesions examined histologically and can spread to breast tissue hematogenously via lymphatics or by contiguous spread. Three types are known: nodular, disseminated, and abscess varieties. [24] Patients can present with discharging sinuses [Figure 17]a.
Figure 17: (a) Breast shows redness of the skin with multiple discharging sinuses (b) MLO mammogram shows bilateral dense breasts (c) USG a thick walled subareolar hypoechoic mass with internal echoes (d) H and E, 100× shows necrotizing granulomatous inflammation with langhan's giant cells (e) Postcontrast T1W fs sagittal MRM shows necrotic nodes in the axilla (white arrow) and thick walled sinus tract (black arrow) (f) Postcontrast fs axial MRM shows a thick walled subareolar abscess showing peripheral irregular enhancement.

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Mammography and sonography findings mimic malignancy. The most common finding is coarse echotexture of the breast parenchyma with or without an irregular mass with skin thickening [Figure 17]b and c.

On MRM, there is diffuse inflammation in the breast parenchyma with intramammary edema, commonly retroaerolar along with skin thickening. Presence of areas of restricted diffusion in the areas of inflammation, which also show T2-weighted hyperintensity and peripheral enhancement, are highly suggestive of microabscesses. The extent of disease, presence of sinus tracts, micro to larger abscesses, ipsilateral axillary lymphadenopathy and skin thickening are well demonstrated on MRI. The presence of a sinus tract extending up to a mass is highly suggestive of tuberculosis [Figure 17]e and f. [25]

Histological findings include epithelioid cell granulomas with caseous necrosis [Figure 17]d.

Benign Virginal Hyperplasia

Benign virginal hyperplasia is a benign condition also known as Juvenile mammary hypertrophy or gigantomastia. Usually seen in the adolescent age and is characterized by rapid enlargement of one or both the breasts. It is believed to be an end organ hypersensitivity to normal levels of gonadal hormones.

Imaging is useful for ruling out a tumor. Mammography is difficult to interpret as the breasts are very dense.

USG is also of limited value and shows glandular hyperplasia. MRI helps to rule out an underlying mass. It shows marked proliferation of the glandular tissue with preservation of the fat plane between the hypertrophied glandular tissue and the Pectoralis muscle [Figure 18]a-d. [26]
Figure 18: (a) Turbo inversion recovery axial (b) T1W without fs (c, d) T1W early and delayed postcontrast fs axial MRM shows marked proliferation of the glandular tissue with preservation of the fat plane between the hypertrophied glandular tissue and the Pectoralis muscle.

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Histologically, there is marked proliferation of the normal breast tissues. Varying degree of stromal and ductal hyperplasia is seen, which is out of proportion to the glandular-alveolar development. It is often associated with dilatation and cystic degeneration of the ducts along with peri-ductal and interstitial edema. [26]

Benign intracystic papillomatosis in male

Intracystic papillomatosis in males is extremely rare as the normal male breast primarily consists of subcutaneous fat and remnant of subaerolar ductal tissue. Pathologically, it is a hyperplastic polypoid lesion in a dilated duct, hence it is similar to intraductal papillomas. On histopathology there is proliferation of the ductal epithelium supported by frond-forming fibro vascular stroma. Proliferative ductal epithelium is seen to fill the space between the fibro vascular stalks [Figure 19]b. [27]
Figure 19: (a) MLO mammogram shows enlargement of the right breast with dense masses (b) H and E, 200× shows tumor cells arranged in papillary pattern filling a large duct (c) USG shows smooth walled cystic lesions with central solid component, which show flow within them on color Doppler.

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On mammography, they are seen as discrete dense masses in the subaerolar location [Figure 19]a.

On sonography, they are seen as smooth walled cystic lesions with central solid components. The central solid components show flow within them on color Doppler [Figure 19]c. [28]

On MRI, multiple cystic lesions with internal solid mass like areas of enhancement showing persistent to plateau enhancement kinetics are seen. They are seen as intermediate signal intensity lesions within the hyperintense cysts on T2-weightd images [Figure 20]. Thin walled enhancement of the walls of the cysts is seen. No restricted diffusion is seen in the solid component, unless there is malignant change.
Figure 20: (a) T2W (b) T1W (c) Postcontrast T1W fs (d) Diffusion at a b value of 800 (e) ADC (f) MIP axial MRM images show multiple cystic lesions with internal solid mass like areas of enhancement seen as intermediate signal intensity lesions within the hyperintense cysts on T2-weighted images. No restricted diffusion is seen.

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  Conclusion Top


MRM is now a powerful tool in the diagnosis and management of breast diseases, and breast lesions can show a wide and varied MR morphology. In certain lesions like hamartomas, and benign virginal hyperplasia MRM can obviate the need for biopsy, whereas in other cases like invasive lobular carcinoma and Paget's disease, it may significantly alter surgical management.

 
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    Figures

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