23.21 ) = perforation. disease (differential diagnosis is malignancy and Crohn \200\231s disease). CT angiography is used in active bleeding. Information for the radiologist Accurate clinical history, with attention to features sugge sting bleeding, malignancy, \201 stula, etc. Sigmoidoscopy \201 ndings. SUBASH KC/NMC-15TH/2014 DIVERTICULAR DISEASE 399 Fig. 23.21 Axial CT image showing a length of thickened sigmoid colon, with diverticulitis, pericolonic in \202 ammatory change, and locules of pericolonic gas. SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 400 CHAPTER 23 Gastrointestinal conditions Volvulus \200 Twisting of a segment of bowel with subsequent obstruction. The sigmoid colon and caecum are most commonly affected due to the long, mobile mesentery. Risk factors: increased age (caecal younger 30 \200\22360 years), chronic constipation, mental handicap, institutionalization. Clinical presentation \200 Sigmoid: lower abdominal pain and progressive abdominal disten sion, may be spontaneously relieved by passage of a large amount of \202 atus/ feces, may devel op complete obstruction. Caecal: symptoms are those of acute bowel obstruction including pain, distension, and vomiting. Treatment is with decompression via a rectal tube through the twisted segment (sigmoid), su rgical resection of redundant loop sometimes required. Unrelieved obstruction may lead to b owel infarction/perforation. Imaging Plain \201 lm \200 Sigmoid: bowel loop dilated to occupy the whole abdomen, wit h the appearance of an inverted \200\230U \200\231 (resembling a \200\230coffee bean \200\231). Sigmoid loop typically devoid of haustra, with apex on the left of the abdomen. Remaining large bowel is often dilated, which is not seen in caecal volvulus. SUBASH KC/NMC-15TH/2014 Caecal: caecum usually twists and inverts so the caecal pole occupies the left upper quadra nt. The attached gas- \201 lled appendix is sometimes seen. 1 or 2 haustral markings can s till be seen. Often marked gaseous or \202 uid distension of small bowel. The left colon is usually collapsed. CT Performed when clinical and plain \201 lm assessment is inconclusive. As well as the s igns previously described on plain \201 lm, the \200\230whirl sign \200\231 on CT re \202 ects the twisted bowel and mesentery, along with demonstration of complications such a s ischaemia and perforation. Fluoroscopy If diagnostic doubt, a water-soluble contrast enema can be performed (risk of p erforation contraindicates the use of barium). Features at the point of torsion include a s mooth, curved tapering of the colonic lumen to give a \200\230bird \200\231s beak appearan ce \200\231, although CT increasingly used as \201 rst line. Information for the radiologist \200 Presenting symptoms and signs, any clinical suspicio n of ischaemia. SUBASH KC/NMC-15TH/2014 VOLVULUS 401 SUBASH KC/NMC-15TH/2014 Fig. 23.22 Abdominal X-ray showing grossly dilated loop of large bowel within the left abdo men in a patient with sigmoid volvulus. SUBASH KC/NMC-15TH/2014 402 CHAPTER 23 Gastrointestinal conditions Intussusception Intussusception is the telescoping, or prolapse of one part of bowel into a n adjacent segment. The prolapsed segment is referred to as the intus- susceptum and the re ceiving segment is the intussuscipiens. The most common sites are ileo \200\223colic and il eo \200\223ileo \200\223colic. Clinical presentation Commonest in children 3 months \200\2233 years. Majority are idiopath ic with no lead point other than lymphoid hyperplasia. In adults 90 point including lymphom a, polyps, tumors, Meckel \200\231s diverticulum, etc. % have a lead- In children, presenting features are of intermittent colicky pain with drawing up of the legs with or without vomiting. The child may be completely well between e pisodes. Initially there may be watery stools but later the patient may pass blood and mucu s in the classically described \200\230redcurrant jelly stools \200\231. In late presentat ions, there may be features of bowel obstruction and shock, with possible ischaemia. In adu lts, abdominal pain, nausea and vomiting are common over weeks \200\223months. Imaging Plain \201 lm Abdominal X-ray normal in 50 (most commonly in the right upper quad rant) and air crescent sign out- lining the apex of the intussusceptum. % . Classic \201 ndings include a soft tissue mass SUBASH KC/NMC-15TH/2014 Ultrasound (Fig. First-line investigation for intussusception. Free \202 uid is a common \201 nding and does not preclude air enema. 23.23a ) CT (Fig. In adults, CT is usually the \201 rst investigation, and may reveal the lead poi nt. 23.23b ) Fluoroscopy Single contrast/air enema demonstrates the obstruction, and reduction with air enema is the mainstay of treatment in uncomplicated pediatric intussusception. Air reductio n should only be carried out in a center with pediatric surgery and the child must be adequ ately resuscitated and haemodynamically stable. An NG tube is advised to decompress the sto mach. Absolute contraindications are peritonism, perforation, or persisting shock. There is no role for this in adults. Information for the radiologist Predisposing conditions, duration of symptoms, and clinical condition of the patient. SUBASH KC/NMC-15TH/2014 INTUSSUSCEPTION 403 (a) SUBASH KC/NMC-15TH/2014 (b) Fig. 23.23 a) Ultrasound image showing \200\230donut \200\231 appearance in a 2-year-old w ith intussusception. b) Axial CT showing intussuscepting loop of bowel within the right \202 ank, giving the typical \200\230bowel within bowel \200\231 appearance. SUBASH KC/NMC-15TH/2014 404 CHAPTER 23 Gastrointestinal conditions Acute pancreatitis Around 80 % mild and self-limiting, 20 necrosis and marked systemic resp onse, may lead to multi organ failure. Causes : alcohol, gallstones, iatrogenic (post ERCP) , drugs, trauma, meta- bolic e.g. increased Ca pancreas), tumor, idiopathic. % severe, associated with pancreatic 2 + , infection, congenital (pancreas divisum/annular Pathophysiology: unregulated activation of pancreatic enzymes leads to autodigestion of the gland causing in \202 ammation and necrosis. Leakage of enzymes into the surrounding stru ctures causes local complications. Clinical presentation Epigastric/central abdominal pain. Vomiting. Imaging \200 Con \201 rm diagnosis and identify cause. \200 Assess severity of pancrea titis, progression and complications. \200 Guide interventional procedures, e.g. drainage of peripancreatic abscess. Ultrasound Detects gallstones. Pancreas often obscured by body habitus and bowel gas. CT (Fig. Triple phase CT is the imaging modality of choice. CT <72 hours may not re \202 e ct the true severity of pancreatitis, only used if diagnostic doubt. 23.24 ) SUBASH KC/NMC-15TH/2014 Mild May be normal/mild enlargement/in \202 ammation. Severe \200 Necrosis: non-enhancement of the gland. \200 Peripancreatic \202 uid coll ections. \200 Infection: may see locules of gas. \200 Pseudocyst: collection of secreti ons. Extra-pancreatic complications \200 Pleural effusions, ascites, pseudoaneurysm of SMA/spl enic artery, thrombosis SMV/splenic vein, secondary GI tract involvement. MRI Comparable to CT but CT usually more readily available/quicker test in ill patients. MR CP assesses integrity of the ducts as well as detect anatomical anomalies. Information for the radiologist Likely etiology, how far into the disease process, clinical signs of sepsis, clotting if need for intervention. SUBASH KC/NMC-15TH/2014 ACUTE PANCREATITIS 405 Fig. 23.24 Axial CT showing ill-de \201 ned in \202 ammation of the pancreatic head, and a large \202 uid-collection occupying the body of the pancreas, in keeping with a pseudoc yst. SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 406 CHAPTER 23 Gastrointestinal conditions Chronic pancreatitis Irreversible, in \202 ammatory \201 brosis of the pancreas leading to endocrine and exocrine insuf \201 ciency. Causes : alcohol ( 70 haemochromatosis, pancreatic duct obstruction, hyperparathyroidism, p ancreas divisum. % ), idiopathic ( 20 % ), rarely: familial, cystic \201 brosis, Clinical presentation Abdominal pain, normal/mildly elevated pancreatic enzymes; later dia- betes mellitus and steatorrhoea. Imaging Imaging \201 ndings re \202 ect parenchymal \201 brosis, atrophy, duct strictu res, and dilation with calci \201 cation. Ultrasound \200 Calci \201 cations. \200 Heterogeneous echo texture. \200 Focal hypo echoic mass; dif \201 cult to distinguish from malignancy. \200 Alternating strictures/d ilatation of main pancreatic duct. \200 Complications: pseudocysts, vascular complication s (use Doppler). EUS Overcomes bowel gas and body fat which limits TA ultrasound. High- resolution images id entify more subtle features including: \200 Lobular outer margin of the gland. \200 Pro minent hyperechoic septa in the parenchyma due to \201 brosis. \200 Duct abnormalities: hyperechoic margins, ectasia of side branches, SUBASH KC/NMC-15TH/2014 intraductal stones. MRI/MRCP (Fig. In early chronic pancreatitis, signal intensity changes in keeping with \201 brosis. In late chronic pancreatitis there is atrophy and pseudocyst formation. MRCP d emonstrates ductal strictures and dilation, ectasia, sacculations, and intraductal stones ( signal voids). 23.25 ) CT \200 Dilated pancreatic duct and side branches. \200 Calci \201 cations: most speci \201 c CT \201 nding. \200 Atrophy (may be normal aging). \200 Focal in \202 ammat ory mass/enlargement. \200 Complications, e.g. pseudocyst, vascular complications. Information for the radiologist Any known risk factors, any clinical suspicion of malignanc y. SUBASH KC/NMC-15TH/2014 CHRONIC PANCREATITIS 407 SUBASH KC/NMC-15TH/2014 Fig. 23.25 Coronal MRCP image showing ectatic dilatation of the main pancreatic duct, with dilated side-branches, in keeping with chronic pancreatitis. SUBASH KC/NMC-15TH/2014 408 CHAPTER 23 Gastrointestinal conditions Cirrhosis Characterized by diffuse parenchymal necrosis, regeneration, and scarring with ab normal reconstruction of pre-existing lobular architecture. The abnormal liver architecture interferes with the function and blood \202 ow within the liver, which leads to portal h ypertension. Commonest cause in the West is alcohol, and viral infection (hepatitis) is the commonest worldwide cause. Clinical presentation Early symptoms are non-speci \201 c: anorexia, weakness, fatigue, we ight loss, and pyrexia. In advanced disease patients may have signs of portal hypertension, such as ascites, bleeding from oesophageal varices, hepatic encephalopathy. Imaging Characteristic features are regenerating nodules separated by \201 brous septae a nd loss of normal lobular architecture within the nodules. Nodular lesions may be regenerat ive nodules, dysplastic nodules or hepatocellular carcinoma (HCC). Ultrasound \200 Hepatomegaly with a nodular surface. \200 Signs of fatty in \201 ltrat ion/coarsening of the liver texture. \200 Signs of portal hypertension (ascites, splenome galy), abnormal Doppler SUBASH KC/NMC-15TH/2014 of hepatic artery/portal vein. Ultrasound-guided liver biopsy. (Transjugular biopsy can be performed if deranged uncorrectable clotting.) CT (Fig. Finding similar to ultrasound. CT may be more sensitive identifying liver lesions. 23.26 ) MRI Used as a problem-solving tool, to differentiate regenerative nodules from hepatocellul ar carcinoma. Intervention In severe portal hypertension a shunt between the portal and hepatic veins can be created to decrease pressure in the portal system: Transjugular intrahepatic portosyste mic shunt (TIPSS) procedure. Information for the radiologist Etiology of cirrhosis (if known), clinical symptoms (i.e. s everity of sus- pected portal hypertension), clotting (if intervention is to be performed). SUBASH KC/NMC-15TH/2014 CIRRHOSIS 409 Fig. 23.26 Axial CT showing shrunken, nodular liver, ascites and dilated vessels adjacent t o the stomach, in keeping with varices in a patient with alcoholic liver disease. SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 410 CHAPTER 23 Gastrointestinal conditions Ascites This is the presence of \202 uid in the peritoneal cavity. In the supine position , ascitic \202 uid collects in the most dependent parts, initially around the liver, then in the pelvis and paracolic gutters. Clinical presentation There is fullness in the \202 anks with shifting dullness. Tense as cites is uncom- fortable and may produce respiratory distress. A pleural effusion (usually right-sided) and peripheral oedema may be present. Imaging Plain \201 lm There is generalized haziness of the abdomen with loss of the psoas out- lines. Gas-containing small bowel loops \202 oat centrally. Ultrasound (Fig. This accurately localizes \202 uid in the abdomen and helps to estimate the degree of ascites. Fluid appears anechoic (dark), and bowel loops are usually seen \202 oating freely within it. Ascitic \202 uid can be aspirated under ultrasound guidance for a diagnostic tap and the following examined: \200 WCC. \200 Gram stain and culture . \200 Protein (transudate \211 11g/L; exudate <11g/L). \200 Cytology for malignant c ells. \200 Amylase to exclude pancreatic ascites. 23.27a ) SUBASH KC/NMC-15TH/2014 Percutaneous drainage by means of a catheter can also be performed under ultrasound guidanc e where indicated. Further indication for ultrasound is in the examination of the abdomen and pelvis for a pos sible cause of ascites, such as cirrhosis or malignancy, with clinical guidance as to the m ost likely suspected cause. CT (Fig. This demonstrates ascites as a low density margin around the intra- abdominal orga ns. The attenuation values of ascites range from 0 to HU. CT attenuation values increase wi th increasing protein content as a general rule. Haemorrhagic ascites can be identi \201 e d by its higher attenua- tion value ( > 30HU). 23.27b ) + 30 Information for the radiologist \200 Underlying cause (if known). \200 INR \200\224 sh ould not have been obtained > 24 hours prior to any planned ascitic tap or drain insertion. SUBASH KC/NMC-15TH/2014 ASCITES 411 (a) SUBASH KC/NMC-15TH/2014 (b) Fig. 23.27 a) Ultrasound image of the abdomen in a patient with liver disease showing free intraperitoneal \202 uid. b) Coronal CT from a different patient showing widespread intra -abdominal \202 uid, secondary to primary peritoneal carcinomatosis. SUBASH KC/NMC-15TH/2014 412 CHAPTER 23 Gastrointestinal conditions Hernia The protrusion of a viscus/part of a viscus from the cavity in which it is normally contained. Most hernia occur in the abdomen. Hernias are irre- ducible if they cannot be pu shed back into the right place. Incarcerated hernias are no longer reducible. Obstruction m eans that bowel contents can \200\231t pass through the hernia. Strangulated hernia occur w hen the vascular supply is compromised. Inguinal: commonest type, men see b OHCM , p614. > women. For a full list of hernia types, Clinical presentation Generally asymptomatic \200\224 may complain of a fullness at the he rnia site, aching, or the lump may enlarge on increasing intra-abdominal pressure/standing. If the hernia becomes incarcerated, there may be enlargement of the hernia, and it may bec ome obstructed. Strangulated hernia may present with systemic toxicity secondary to ischaem ic bowel. Imaging Plain \201 lm An inguinal hernia may be identi \201 ed, but this isn \200\231t s ensitive or speci \201 c. Useful if present with a small bowel obstruction. Ultrasound Increasingly used in the outpatient investigation of groin pain to con \201 rm the presence of a groin hernia if equivocal examination. This has replaced herniography. SUBASH KC/NMC-15TH/2014 CT May be helpful to diagnose spigelian or obturator hernia, or if unable to examine the pa tient due to body habitus, and ultrasound failed. Information for the radiologist Any signs of ischaemic compromise clinically. Fig. 23.28 Axial CT scan showing dilated loops of \202 uid- \201 lled obstructed small b owel, secondary to a right-sided groin hernia (arrow). SUBASH KC/NMC-15TH/2014 413 Chapter 24 Breast differential diagnosis Gynaecomastia Solitary lesion at mammography Multiple lesions at mammography 414 414 414 SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 414 CHAPTER 24 Breast differential diagnosis Gynaecomastia Abnormal amount of breast tissue in men. \200 Physiological. \200 Drugs: Estrogen, anti-androgens, etc. Pathological: Hypogonadism. \200 Cirrhosis. \200 Hyperthyroidism. \200 Tumors: estrogen producing, e.g. testicular; HCG producing, e.g. testicular, bronchial cancers. Solitary lesion at mammography Malignant: \200 Carcinoma. \200 Phyllodes tumor. Benign: \200 Cyst. \200 Fibroadenoma. \200 Intramammary lymph node. \200 Galactocoe le. \200 Papilloma. \200 Abscess. SUBASH KC/NMC-15TH/2014 Multiple lesions at mammography \200 Cysts. \200 Fibroadenomas. \200 Skin lesions, e. g. neuro \201 bromas. \200 Intramammary lymph nodes. \200 Metastases. SUBASH KC/NMC-15TH/2014 415 Chapter 25 Breast conditions Mammography 416 Breast cancer 418 Breast abscess 422 Breast cyst Fibroadenoma 426 Papilloma 428 424 SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 416 CHAPTER 25 Breast conditions Mammography A mammogram is an X-ray examination of the breast. It is a highly effective ima ging method for detecting, diagnosing, and managing a variety of breast diseases, especiall y cancer. Indications 1. Evaluation of breast symptoms as part of triple assessment Females may prese nt with symptoms such as a breast lump, pain, nipple thickening or discharge, skin or nippl e retraction, or a change in breast size and shape. Symptomatic females have a mammogram an d ultrasound as appropriate depending on the clinical presentation. However, young women ha ve higher breast parenchymal density, making it dif \201 cult to dif- ferentiate between t umor and normal breast tissue on mammography. Ultrasound is more sensitive than mammography in young women and is the \201 rst-line investigation in women aged <35 years. Triple assessment involves clinical examination, imaging (mammography and ultrasound), and pathology. All components of triple assessment are graded 1 to 5: 1 = normal, 2 = benign, 3 = indeterminate, 4 = suspicious, 5 = malignant. Any discordance betwe en the three arms of triple assessment requires further investigation. For example, a palpa ble lump that is suspicious on clinical examination but has no correlate on imaging still r equires clinical core biopsy to secure a histological diagnosis. It is always the arm with the highest suspicion that drives further management. SUBASH KC/NMC-15TH/2014 2. Surveillance following breast cancer surgery Annual mammograms are performed for 5 \200 \22310 years following surgery for breast cancer. The duration of follow-up is in \202 uen ced by local policies and the patient \200\231s individual risk taking into account factors such as tumor size and axillary node involvement. 3. NHS Breast Screening Program UK population screening started in 1988. The screening prog ram has been shown to reduce mortality from breast cancer by 30 women aged 50 \200\22370 ye ars are invited for 3-yearly mammograms. By 2012, the screening program will be extended to include women aged 47 \200\22373 years. % . Asymptomatic 4. Family history surveillance Annual or 18-monthly mammograms are performed in women with mod- erate to very high risk of breast cancer. MRI will also be performed in the very high- risk group. Technique Two views of each breast are obtained, a mediolateral oblique (MLO) view and a cr aniocaudal (CC) view (Fig. two plates so that the maximum amount of tissue can be imaged wi th minimum X-ray dose. Both analog and digital mammography are available. Analog mammograph y utilizes \201 lm as both a receptor and a display for the image, producing static, \201 xed images. However, digital mammography uses detectors that change the X-rays into el ectrical signals. These signals are then transferred to a digital receptor that converts th e X-ray energy 25.1 ). The breast is compressed between SUBASH KC/NMC-15TH/2014 MAMMOGRAPHY 417 to numbers, processes the numbers, and produces an image that can be displayed on a monitor . The main advantage of digital mammography is the opportunity to manipulate and further op timize image quality following the original acquisition. Dose The accepted measure of dose in mammography is the mean glandular dose, which is the a verage dose to the glandular tissue of the breast. It is expressed in unit of milligray (mG y). The radiation dose for a standard two-view exami- nation is approximately 4.5mGy. This is equivalent to a few months of natural background radiation. A risk:bene \201 t calculat ion has established that the bene \201 ts of screening far outweigh the risk of inducing a cancer, with the ratio of lives saved to lives lost calculated as approximately 100:1. SUBASH KC/NMC-15TH/2014 (a) (b) (c) (d) Fig. 25.1 Normal mammogram projections. a) Right MLO (mediolateral oblique). b) Left MLO. c ) Right craniocaudal (CC). d) Left CC. SUBASH KC/NMC-15TH/2014 418 CHAPTER 25 Breast conditions Breast cancer Breast cancer is the most common cancer in the UK. The lifetime risk of devel oping breast cancer is 1 in 9 for women and 1 in 1014 for men. The majority of invasive bre ast cancers are adenocarcinomas (85 15 % lobular). The main risk factors are increasing age , personal history of breast cancer, previous breast biopsies demonstrating atypia, positiv e family history, early menarche, late menopause, and nulliparity. % ductal, Clinical presentation Females usually present with a painless palpable lump which is often \201 rm or irregular. Nipple changes (inversion, discharge, eczema) and skin changes (tet hering, peau d \200\231orange) can also occur. Imaging Mammography Invasive carcinomas typically appear as an ill-de \201 ned, spiculate mass causing architectural distortion (Fig. as pleomorphic segmental microcalci \201 catio n. 25.2 ). Non-invasive carcinomas typically present Ultrasound Targeted breast ultrasound helps to further characterize the mass. Classically a carcinoma is seen as an irregular, hypoechoic mass with pos- terior acoustic shadowing (Fi g. is wide as it disrupts tissue planes. Color Doppler imaging demonstrates abnormal vascul arity with centrally penetrating vessels. 25.3 ). The tumor tends to be taller than it SUBASH KC/NMC-15TH/2014 Ultrasound of the axilla is performed for local staging. Features concerning for malignant in \201 ltration of lymph nodes include a short axis diameter of > 5mm, thickened cortex central fatty hilum. Lymph nodes with malignant or suspicious featu res require \201 ne needle aspiration cytology. If the lymph nodes are con \201 rmed to be positive for metastatic disease on cytology, the patient will undergo axillary clearance . If the nodes are negative, then the patient will have sentinel node biopsy at the time of surgery. > 2mm, or complete loss of the MRI Contrast-enhanced MRI highlights neovascularity in malignant lesions that demonstrate r apid uptake and washout of contrast. It is utilized selectively to aid local staging in pat ients who have tumors that are dif \201 cult to accu- rately size both clinically and with routine imaging. In particular, lobular carcinoma has a propensity for multifocality and d e \201 ning the true extent of disease is vital. If the tumor proves too large for breast conserving surgery (wide local excision), then a mastectomy is necessary. In addition, MRI is used to assess the response to neoadjuvant chemotherapy and the detection of recurrence in the post-surgical breast. CT Complete staging with CT of the thorax, abdomen, and pelvis is performed in patients wit h malignant involvement of the axillary lymph nodes or features suspicious for metastatic s pread. SUBASH KC/NMC-15TH/2014 BREAST CANCER 419 (a) (b) Fig. 25.2 a) and b) Spiculate mass seen in the 12 o \200\231clock position of the right bre ast. SUBASH KC/NMC-15TH/2014 Fig. 25.3 Ultrasound image demonstrating an irregular hypoechoic mass at the 12 o \200\231c lock position of the right breast, with extensive posterior shadowing. SUBASH KC/NMC-15TH/2014 420 CHAPTER 25 Breast conditions Bone scan Bone metastases are the most common site of distant spread in breast cancer. Bone scan is used routinely in patients with involved axillary nodes or with bone pain. Image-guided biopsy All indeterminate to malignant lesions in the breast require needle cor e biopsy for histological con \201 rmation. This can be performed clinically but increasin gly biopsies are done under imaging control because this is more accurate. If the mass can be localized with ultrasound, this is the preferred imaging modality as it is the quickest technique with real-time visualization of the needle sam- pling the mass. However, if the l esion can only be seen with mammography, then X-ray-guided biopsy is utilized. MRI-guided b iopsy is performed if the mass is occult on both mammography and ultrasound. This technique is only available in specialist centers and is very time consuming. Information for the radiologist Relevant risk factors including the patient \200\231s age, personal history of breast cancer and positive family history. The clinical score (P1 = nor mal, P2 = benign, P3 = indeterminate, P4 = suspicious for malignancy, P5 = malignant) is vi tal to ensure appropriate correlation with imaging \201 ndings. The presence of chronic k idney disease (GFR <30ml/min) is signi \201 cant as this may preclude giving iodinated (CT ) or gadolinium based (MR) contrast. SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 422 CHAPTER 25 Breast conditions Breast abscess A breast abscess is a localized collection of pus, usually in a periareolar location. Breast infections are fairly common, particularly during breast- feeding. The nip ple and areola can become dry and chapped, with suckling causing cracks in the skin through which bacteria can in \201 ltrate. The most common organism is smokers can present with r ecurrent periareolar sepsis related to duct ectasia which is benign dilatation of the main subareolar milk ducts. Staphylococcus aureus . Older women, particularly Clinical presentation Presenting features include pain associated with a localized area of erythema and induration. In later stages, there may be a tender, \202 uctuant mass rep- r esenting the abscess. Systemic features include pyrexia, tachycardia, and vomiting. The app earance of the skin is similar to what can be seen with an in \202 ammatory cancer. Howeve r, an infective process is typically painful, while an in \202 ammatory cancer rarely is. If there is a high clinical suspicion for malignancy or the patient fails to respond to the rapy, a biopsy should be performed. Imaging A breast abscess is usually managed clinically and treated conservatively with anti biotics. Imaging is not required unless the patient fails to respond to therapy. SUBASH KC/NMC-15TH/2014 Mammography It is not used in the acute phase because it is extremely painful. Mammography should be performed in women resolved to rule out an underlying malignancy. > 35 years of age once the acute infection has Ultrasound The skin appears thickened with pockets of \202 uid between the skin and subcu taneous tissue consistent with oedema. An abscess can have a varied appearance (Fig. nature with low level internal echoes. In certain cases, it can appear more complex resembling a solid, hypoechoic mass. If the infectious process does not resolve with antibiotics, then u ltrasound-guided aspiration of the abscess is helpful. 25.4 ). At one end of the spectrum, it can appear cystic in Information for the radiologist Is the patient currently breastfeeding? If they have been t reated with anti- biotics, has there been a positive response? If not, is ultrasound guided aspiration required? The clinical score (P1 = normal, P2 = benign, P3 = indeterminate, P4 = suspicious for malignancy, P5 = malignant) is vital to ensure appropriate correlation wit h imaging \201 ndings. SUBASH KC/NMC-15TH/2014 BREAST ABSCESS 423 Fig. 25.4 Ultrasound image demonstrating a mixed solid/cystic lesion consistent with an abs cess. SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 424 CHAPTER 25 Breast conditions Breast cyst Cysts arise in the terminal ductal lobular unit as a result of an imbalance bet ween the production and resorption of secretions. Often, cysts are multiple and bilateral. Cysts are common in the perimenopausal years, with a peak incidence between the ages of 40 and 50 years. In younger lac- tating females, the cysts may be \201 lled with milk and te rmed a galactocoele. Simple cysts are not associated with malignancy. Clinical presentation One or several palpable smooth, \202 uctuant, benign feeling lumps. Occasionally, a tense cyst can present as a discrete hard mass. Imaging Mammography A cyst appears as a well-de \201 ned, round or oval mass (Fig. 25.5 ). Sometimes a thin lucent halo is seen surrounding the mass. Occasionally, \201 ne curvi- linear \200\230eggshell \200\231 calci \201 cation is seen in the cyst wall. A galactocoe le that has suf \201 cient fat content may be visible as a radiolucent mass or even demons trate a fat- \202 uid level in upright lateral mammograms. These fea- tures are not speci \201 c and ultrasound imaging is necessary to evaluate if the mass is solid or a \202 ui d- \201 lled cyst. Ultrasound A simple cyst has well-de \201 ned margin (Fig. there is increased through tran smission of the ultrasound beam re \202 ecting its \202 uid content. A galactocoele can look like a simple cyst or occasionally have low level internal echoes due to the fat conte nt (Fig. a complex cyst include the presence of internal echoes, thin septations or a thick ened irregular wall. A cyst may be aspirated if the patient is symp- tomatic or if there is any diagnostic uncertainty. Fluid is sent for cytology only if blood-stained or if there a re atypical sonographic features. 25.6 ). It has no internal echoes and SUBASH KC/NMC-15TH/2014 25.7 ). Features of Information for the radiologist It is useful to document if lactating. Relevant risk factor s including the patient \200\231s age, personal history of breast cancer, and positive fami ly history. The clinical score (P1 = normal, P2 = benign, P3 = indeterminate, P4 = suspicio us for malignancy, P5 = malignant) is vital to ensure appropriate correlation with imaging \201 ndings. SUBASH KC/NMC-15TH/2014 BREAST CYST 425 (a) (b) Fig. 25.5 a) MLO projection and b) CC projections of the right breast demonstrating a well- de \201 ned mass in the upper outer quadrant of the right breast. SUBASH KC/NMC-15TH/2014 Fig. 25.6 Ultrasound demonstrating a well-de \201 ned simple cyst with posterior acoustic enhancement. Fig. 25.7 Ultrasound demonstrating thick walled cyst with internal echoes in keeping with a galactocoele. SUBASH KC/NMC-15TH/2014 426 CHAPTER 25 Breast conditions Fibroadenoma A \201 broadenoma is the result of idiopathic overgowth of the specialized s tromal connective tissue within the breast lobule. It is the most common cause of a benign solid mass in the breast. In the majority of cases they are solitary, but in 20 % of female s they can be multiple. Fibroadenomas are hormone sensitive and tend to increase in size du ring pregnancy and invo- lute in the perimenopausal period. Peak incidence is in the 3 rd decade. Clinical presentation Fibroadenomas present clinically as a smooth, \201 rm, mobile mass. It is some- times referred to as a \200\230breast mouse \200\231 because of its mobility within the breast tissue. Imaging Mammography A \201 broadenoma is seen as a well-circumscribed, oval mass. Sometim es a thin, lucent halo is seen surrounding the mass. In older women, as the \201 broad- e noma involutes, coarse \200\230popcorn \200\231 calci \201 cation may be seen associated with the mass. Ultrasound It is seen as a well-de \201 ned, ovoid, hypoechoic mass with a thin echogenic pseudocapsule (Fig. 25.8 ). As the tumor grows along tissue planes, it tends to be wider th an it is tall. Despite sonographic features consistent with benign disease, needle core bio psy for histological diagnosis is per- formed either clinically or under direct vision with ultrasound guidance. This is necessary to ensure that well-circumscribed cancers are not m issed. Once a benign histological diagnosis is obtained, no further inter- vention is requi red. SUBASH KC/NMC-15TH/2014 Information for the radiologist Relevant risk factors including the patient \200\231s age, personal history of breast cancer, and positive family history. The clinical score (P1 = no rmal, P2 = benign, P3 = indeterminate, P4 = suspicious for malignancy, P5 = malig- nant) is vital to ensure appropriate correlation with imaging \201 ndings. SUBASH KC/NMC-15TH/2014 FIBROADENOMA 427 SUBASH KC/NMC-15TH/2014 Fig. 25.8 Ultrasound demonstrating a well-de \201 ned solid hypoechoic mass with a thin ec hogenic capsule in keeping with a \201 broadenoma. SUBASH KC/NMC-15TH/2014 428 CHAPTER 25 Breast conditions Papilloma A papilloma is a tumor that arises in a duct, either centrally or peripherally wi thin the breast. It represents a focal proliferation of the ductal epithelium that projects into the lumen of the duct. Papillomas are largely considered benign lesions, especially i f solitary within a large subareolar duct. Multiple papillomas tend to be within smaller, p eripheral ducts and are associated with an increased likelihood of atypia and malignancy. Clinical presentation Papillomas are associated with overproduction of secretions that are not balanced by the normal resorptive mechanisms of the duct. This results in distension of the duct and nipple discharge. As they are friable structures that bleed easily, the nippl e discharge may be blood-stained. Occasionally, a palpable mass is evident. Imaging Mammography Papillomas are often not appreciated on mammography due to their small size and intraductal location. When imaging \201 ndings are present, they include a well- circumscribed subareolar mass, solitary or multiple dilated ducts, and infrequently a clust er of microcalci \201 cations. Ultrasound Characteristically, papillomas appear as a hypoechoic, lobulated mass within a d ilated duct or cyst ( malignancy, needle core biopsy under ultrasound guidance is performed for histological diagnosis. If there are no features of atypia, it can be removed percutan eously with a vacuum-assisted biopsy device. If there are features of atypia, then surgical excision is necessary. SUBASH KC/NMC-15TH/2014 Figs. 25.9 and 25.10 ). Due to the association with Information for the radiologist If there is nipple discharge, is it blood-stained? Relevant risk factors including the patient \200\231s age, personal history of breast cancer, and p ositive family history. If there is a palpable mass, the clinical score (P1 = normal, P2 = benign, P3 = indeterminate, P4 = suspicious for malignancy, P5 = malignant) is vital to ens ure appropriate correlation with imaging \201 ndings. SUBASH KC/NMC-15TH/2014 PAPILLOMA 429 Fig. 25.9 Ultrasound image demonstrating 7mm solid papilloma seen projecting into the lumen of the cyst. SUBASH KC/NMC-15TH/2014 (a) (b) Fig. 25.10 a) and b) Ultrasound images demonstrating 6mm papilloma seen sitting within a di lated duct. SUBASH KC/NMC-15TH/2014 This page intentionally left blank SUBASH KC/NMC-15TH/2014 SUBASH KC/NMC-15TH/2014 431 Index A abdominal aortic 122 \200\2233 angiomyolipoma ankle \200\223brachial pressure 234 \200\2235 diaphyseal benign tumors 298 \200\2239 index 124 metastases moth-eaten pain 260 sclerotic lesions tumors 292 \200\2233 258 aneurysm ankle fracture classi \201 cation abdominal calci \201 cation 342 abdominal distension 355 abdominal pain abdominal trauma 3 20 \200\2231 abdominal ultrasound 8 achalasia 374 \200\2235 acoustic neuroma acromio-clavic ular joint subluxation/ dislocation system 337 ankle trauma 3 ankylosing , 336 \200\2237 300 \200\2231 263 , 290 \200\2231 346 spondylitis 272 \200\2233 bone scan 13 \200\22314 anterior humeral line 326 aortic coarctation 110 \200\22311 aortic dissection aortic stenos is appendicitis apple-core deformity avascular necrosis 304 bone metastases 292 bone pain 260 bone tumors 263 , 290 420 breast c ancer diaphyseal benign bone 154 \200\2235 102 \200\2233 112 \200\22313 376 \200\2237 324 \200\2235 acute disseminated encephalomyelitis (ADEM) 148 acute myocardial 106 \200\2237 , 364 arteriography 29 arteriovenous \201 stula asbestos exposure 362 tumors 298 increased uptake 258 myeloma 294 osteomalacia osteomyelitis 278 302 Paget \200 \231s disease prostate cancer 222 proximal femoral fractures 332 renal cell cancer 218 308 superscan appearance 130 \200\2231 308 infarction benign lung disease 84 \200\2235 mesothelioma 404 \200\2235 acute pancreatitis acute pelvic pain 204 acute pyelonephritis 236 acute renal failure 207 acyanotic heart disease 116 adrenal calci \201 cation adrenal masses 232, s16 .f ALARM symptoms alkaptonuria altered consciousness 138 anemia, iron de \201 ciency 353 a neurysmal bone cysts 296 \200\2237 88 \200\2239 ascites astrocytoma atelectasis 64 avascular necrosis 342 , 410 \200\22311 156 304 \200\2235 SUBASH KC/NMC-15TH/2014 201 9 Bosniak classi \201 cation 234 268 Boutonniere deformity bowel, see large bowel; B bamboo spine 272 bare orbit 170 barium examination 4; 380 system 270 small bowel brain abscess 150 \200\2231 brain metastases 160 \200\2231 branchial cleft cysts 196 \200 \2238 Branham \200\231s sign 130 breast; see also mammography 422 \200\2233 abscess cancer 418 \200\22319 cyst 424 \200\2235 differential 413 diagnosis \201 broadenoma needle core biopsy 420 see also double contrast barium enema angiography 6; see also coronary angiography; pulmonary angiography achalasia 374 \200\2235 colonic cancer 354 diarrhea diverticular disease 398 gastrointestin al lymphoma 366 iron de \201 ciency 362 acoustic neuroma 154 acutely painful blue leg 99 aortic stenosis 112 cardiomyopathy coarcta tion of aorta 110 complications 7 contrast agents glioma 156 hypertension indications 6 int ermittent 109 353 systemic sclerosis 78 weight loss 356 31 wheeze becquerels 14 Bennett \200\231s fractur e- anemia 426 \200\2237 6 210 NHS Breast Screening Program 416 dislocation beta-decay 16 bird \200\231s beak 329 papilloma triple assessment 428 \200\2239 claudication 98 416 melaena 352 meningioma 115 mitral valve disease pelvic pain, chronic 206 peripheral vascula r 70 \200\2231 bronchiectasis 184 Brown \200\231s tumors 158 esophagus bladder cancer bladder \201 lling 374 \200\2235 216 \200\22317 defects 200 C caecal volvulus 400 calcaneal fractures calcium pyrophosphate deposition disease 7 , 124 disease procedure 6 thoracic trauma 318 vascular Boehler \200\231s angle 338 bone 338 \200\2239 avascular necrosis benign lesions 296 \200\2237 cysts 296 \200\2237 304 \200\2235 interventions 20 \200\2231 270 SUBASH KC/NMC-15TH/2014 432 INDEX cancer interstitial lung 76 \200\2237 communicating