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 Mahesh K. Shetty
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Breast & Gynecological

Diseases
Role of Imaging in the Management

123
Breast & Gynecological Diseases
Mahesh K. Shetty
Editor

Breast & Gynecological

Diseases
Role of Imaging in the Management
Editor
Mahesh K. Shetty
Baylor College of Medicine
Houston, TX
USA

ISBN 978-3-030-69475-3    ISBN 978-3-030-69476-0 (eBook)

https://doi.org/10.1007/978-3-030-69476-0

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This text book is dedicated to all women who have influenced, enriched,
and blessed my professional life. To the women whom I have had the pleasure
of providing care to, during a career spanning 26 years. To Veena,
my daughters Ambika and Sarika, my mother Sundari, and my sisters Vinoda,
Shoba, Shaku, and Geeta.
Mahesh K. Shetty, MD
Foreword

If you are planning for a year, sow rice;

If you are planning for a decade, plant trees;
If you are planning for a lifetime, educate people
Ancient Chinese Proverb

I am honored to be asked to write the foreword for this book, edited by Dr. Shetty. As a
result of accepting the task at hand, I have had the pleasure of reading the chapters relating to
breast diseases, my own area of expertise. From this review and subsequent conversations with
Dr. Shetty, it has become evident that in accordance with the proverb above, Dr. Shetty is plan-
ning for a lifetime: it is his clear intent to educate, and to educate not only those practicing his
specialty of radiology, but also, and even in particular, the clinicians who on a daily basis
request our assistance and seek our advice and interpretive skills. It is no secret that the fields
of breast and gynecologic imaging are rapidly expanding with new or enhanced modalities,
evolving imaging sequences highlighting differing underlying histologic processes, and per-
mutable algorithms seeking to best and most cost-effectively guide the evaluation of patients
with an array of symptoms. In addition to recognizing the overwhelming and often perplexing,
at times even contradictory, volume of imaging-related material confronting our clinician col-
leagues, Dr. Shetty also presciently recognizes that technology has largely eliminated the
information exchange and teaching that formerly transpired multiple times daily in diagnostic
reading rooms around the world: with images hung on a view box before them, radiologist and
clinician side by side peering intently, a clinical history presented, imaging findings reviewed,
questions asked and answered, plans made. The underpinning of the exercise: education…of
both clinician and radiologist, each deriving benefit from the other. When does that happen
anymore? Technology permits the clinician to view the images on an office computer screen
alongside the radiologist’s written report, a certain time saver and effective in many/most cases
but look what is missing…an aliquot of learning, a morsel of teaching, and assuredly an oppor-
tunity to improve and expand. The educational void Dr. Shetty perceives is precisely the void
he seeks to fill.
I am a fortunate foreword writer because Dr. Shetty has unknowingly written a portion of
my assignment. I will explain. When inviting me to write the foreword, Dr. Shetty naturally
included the book title which unambiguously declared a “symptom-based” approach to the
contents. Doing my diligence, I read through the chapter titles and then inquired, “Mahesh,
if this is a symptom-based textbook, why are you also including chapters on breast cancer
screening (specifically no symptoms), women at elevated risk (again, no symptoms), and
multispecialty management of breast cancer (again, not symptom-related)?” His response to
my e-mail query is most telling. “Michael,” he said, “having been in practice with obstetri-
cians and gynecologists for this long, I have seen a great need for educating our frontline
physician colleagues caring for women…I do hope this provides some guidance.” Dr. Shetty
is planning for a lifetime, not simply his alone but also the lives of our many clinical col-
leagues who manage our collective patients. Theirs is not an easy task, the responsibility for
managing a life is huge. The chapters in Dr. Shetty’s book are beautifully articulated, accu-
rate, and specifically designed to educate radiologists in practice, residents, and interns of

vii
viii Foreword

many specialties, and importantly our clinical brethren as they seek clarity and precision in
what they ask from us and the information they receive in return. No “trees” or “rice” from
Dr. Shetty…. just education.

Michael Cohen
Department of Radiology and Imaging Services
Emory University School of Medicine
Atlanta, GA, USA
Division of Breast Imaging
Emory Healthcare
Atlanta, GA, USA
Foreword

Substantial advances over the past several decades in diagnostic imaging of breast and gyne-
cologic conditions have solidified the marriage between imaging and women’s health. Now,
clinicians taking care of breast and gynecologic conditions rely on high-quality, focused imag-
ing when making management and treatment decisions. This textbook serves as a guide to
radiologists and women’s health providers who wish to deeply understand the ways in which
these two disciplines are inextricably linked and use that knowledge to take excellent care of
their patients.
The chapters of this book truly demonstrate that there is no aspect of breast and gynecologic
care in which imaging does not play a vital role. Dr. Shetty leaves no stone unturned in this
regard. This comprehensive guide considers both screening and diagnostic breast imaging for
women of all ages as well as for male patients. Our understanding of major gynecologic condi-
tions is enhanced by the images used as tools for both diagnosis and management. Perhaps
most interesting, Dr. Shetty also gives us a view into the exciting world of emerging imaging
technologies and considers the economic implications of women’s’ health imaging.
By providing us with beautiful, meticulously labeled images, this textbook serves the radi-
ologist and the women’s health practitioner alike as a veritable encyclopedia of references to
be used throughout daily practice. This book is not one to be read and put away, but, rather, it
deserves a prominent place on our office shelves, easily accessible for frequent consultation.

Laurie S. Swaim
Division of Gynecologic and Obstetric Specialists
Department of Obstetrics and Gynecology
Baylor College of Medicine
Houston, TX, USA
Chief Gynecologic Services Texas Children’s Pavilion for Women
Houston, TX, USA

J. Biba Nijjar
Division of Minimally Invasive Gynecologic Surgery
Department of Obstetrics and Gynecology
Baylor College of Medicine
Houston, TX, USA

ix
Preface

This book is primarily a symptom-based guide to breast and gynecologic imaging. Most text
books generally focus on a specific pathology such as “imaging and/or management of ovarian
cancer,” but in clinical practice, patients do not present with a diagnosis. Physicians are pre-
sented with clinical symptoms, and appropriate use of imaging after a clinical assessment is
critical from the point of view of effective intervention to treat a patient. CMS now mandates
a clinical decision support system to justify imaging. This is based on making use of appropri-
ate modalities for specific clinical problems that are deemed so by professional society guide-
lines. In an era of emphasis on cost-effective, high-quality healthcare delivery, it is critical for
clinicians in training and practice to have a resource that outlines scientifically sound and
professional society-endorsed criteria for appropriate work up of patients’ symptoms. Authors
are focused on providing a scientifically proven resource to gynecologists, obstetricians, radi-
ologists, and internists involved in the management of common symptoms affecting women.
Chapter topics focus on a common breast or gynecological symptom and the content explains
how patients are triaged for imaging, what is the most optimal imaging modality, and how the
imaging aids in the management. The text book focuses on providing the most effective meth-
ods currently available to investigate commonly encountered symptoms in women’s health.
The intended audience are radiologists in practice and in training who are focused on women’s
imaging and gynecologists in practice and in training. The latter gain an in-depth understand-
ing of the indications, appropriate imaging, and the findings.
The part on breast includes a chapter on screening mammography, which remains a contro-
versial subject with continuing debate on the benefits and harms of mammography. The current
data on the efficacy of screening for breast cancer and the possible harms resulting from
screening are discussed. Breast symptoms are a common reason for a visit to the gynecologist;
the imaging methodology, findings, and management of such symptoms varies based on
patients age and pregnancy status; two chapters are dedicated to describe the role of imaging,
one in the age group where mammography is not a primary modality to investigate breast
symptoms, namely in the young, pregnant, and the lactating woman, and another in older age
group of women in whom diagnostic mammography is the primary modality of investigation.
Male breast symptoms, the underlying diseases, and the imaging findings are discussed in
depth. Management of the breast cancer patient requires a multidisciplinary approach for opti-
mal patient management of the cancer; a chapter devoted to describing how this is done pro-
vides useful insight for the gynecologist who is providing primary care for such patients.
Although screening mammography remains the core modality for screening, functional imag-
ing overcomes some of the limitations of morphology-based imaging such as mammography
and ultrasound and is outlined in a chapter on emerging technologies. Women with an elevated
risk for breast cancer need to be identified by primary care doctors, often do not have a clear
understanding of what this entails and how such patients need to be managed with a higher
level of surveillance utilizing supplemental methods to screen for breast cancer. The chapter on
the management of a patient with an elevated risk focusses on providing much needed knowl-
edge and current literature on how best to manage such women with an increased risk of devel-
oping breast cancer.

xi
xii Preface

The section on gynecological imaging discusses management of a patient with pelvic mass
and the varied causes of such masses. Appropriate triaging of imaging to provide the treating
gynecologist the most optimal way to decide on surgical or conservative management of
women presenting with a pelvic mass is described. Pelvic pain is another commonly encoun-
tered symptom with a wide spectrum of underlying etiologies that the treating clinician and the
women’s imager need to have a clear knowledge of so as to tailor imaging to be effective in the
diagnosis of the cause of the pelvic pain. Pregnant patients may present with complications
unrelated to pregnancy; use of radiological methods have to be carefully considered to mini-
mize risk to the developing fetus; there is, however, widespread lack of understanding of the
true risks and potential to miss a diagnosis that may prove critical to outcome because of a
hesitancy to utilize radiological studies. A detailed description is provided of the radiation
risks and the appropriate imaging of non-obstetrical complications in pregnancy. Radiologic
imaging is more frequently utilized to diagnose and evaluate in the setting of an upper urinary
tract infection. Ultrasound, computed tomography (CT), and magnetic resonance imaging
(MRI) are all useful tools in evaluating the upper urinary tract. Post-menopausal bleeding is a
common presenting symptom after menopause and lends itself to accurate initial imaging with
a transvaginal ultrasound; differential diagnosis and management of this symptom is presented
in this book. Urinary and anal incontinence and pelvic organ prolapse prompt imaging of the
pelvic floor, which is optimally imaged with 3d/4d ultrasound. The chapter on role of imaging
in pelvic floor disorders describes in detail the basic and advanced methodology of pelvic floor
assessment. Imaging has a central role in the infertility evaluation, management, and treat-
ment. The advances in imaging that allows appropriate management of the infertile patient is
explained in the chapter on infertility imaging. About 20% of gynecological visits prior to
menopause is triggered by abnormal uterine bleeding, and underlying causes may be benign or
malignant; the role of imaging in the diagnosis of the underlying cause is presented in detail
on the chapter dealing with abnormal uterine bleeding and menstrual disorders. In an era of
increasing awareness of the skyrocketing healthcare costs in the United States, the chapter on
health economics highlights the challenges in reining in the cost and the relevance of econom-
ics specific to women’s imaging.
Contributors are recognized experts and well published in the area of contribution. The
team effort has been successful in achieving the primary goal of compiling a useful, compre-
hensive, and ready reference for women’s imagers and gynecologists to understand and appro-
priately use imaging to aid in optimal management of the gynecological patient.

Houston, TX, USA Mahesh K. Shetty

Contents

1 Imaging the Symptomatic Breast in the Pediatric, Young,

Pregnant, Lactating, and Transgender Patient �������������������������������������������������������   1
Mahesh K. Shetty, Avice M. O’Connell, Daniel Kawakyu-­O’Connor, and
Nidhi Sharma
2 Imaging of the Symptomatic Breast ������������������������������������������������������������������������� 27
Mahesh K. Shetty
3 Imaging of the Symptomatic Male Breast ��������������������������������������������������������������� 81
Tamara Ortiz-Perez, Ashley A. Roark, and Alfred B. Watson Jr.
4 Management of a Woman at Elevated Risk for Breast Cancer ����������������������������� 107
Sabrina K. Sahni, Nidhi Sharma, and Holly J. Pederson
5 The Multidisciplinary Approach to Breast Cancer Management ������������������������� 137
Brittany L. Murphy, Kelly K. Hunt, and
Sarah M. DeSnyder
6 Screening for Breast Cancer ������������������������������������������������������������������������������������� 157
Mahesh K. Shetty
7 Emerging Technologies in Breast Cancer Screening and Diagnosis ��������������������� 193
Avice M. O’Connell and Daniel Kawakyu-O’Connor
8 Pelvic Pain: Role of Imaging in the Diagnosis and Management��������������������������� 203
Mahesh K. Shetty and Raj Mohan Paspulati
9 Imaging of Abnormal Uterine Bleeding and Menstrual Disorders ����������������������� 257
Anisa Hussain, Jacqueline Sehring, Angeline Beltsos, and Roohi Jeelani
10 Non-obstetric Complications in Pregnancy: Role of Imaging ������������������������������� 289
Mahesh K. Shetty and Raj Mohan Paspulati
11 Pelvic Mass: Role of Imaging in the Diagnosis and Management������������������������� 327
Mahesh K. Shetty, Raghu Vikram, and Mohammed Saleh
12 Postmenopausal Bleeding: Role of Imaging in the
Diagnosis and Management��������������������������������������������������������������������������������������� 375
Mahesh K. Shetty and Sandra Hurtado
13 Pelvic Floor Dysfunction: Role of Imaging in
Diagnosis and Management��������������������������������������������������������������������������������������� 405
Hans Peter Dietz
14 Role of Imaging in the Management of Female Infertility������������������������������������� 441
Jacqueline Sehring, Anisa Hussain, Angeline Beltsos, and Roohi Jeelani

xiii
xiv Contents

15 Urinary Tract Infections: Role of Imaging in the Management����������������������������� 465

Tristi Muir, Emily C. Rutledge, and Ramon P. Saucedo
16 Health Economics in Women’s Imaging������������������������������������������������������������������� 475
Ezequiel Silva III, Cristin Dickerson, and Mahesh K. Shetty

Index������������������������������������������������������������������������������������������������������������������������������������� 493
Contributors

Angeline Beltsos, MD Vios Fertility Institute, Chicago, IL, USA

Sarah M. DeSnyder, MD Department of Breast Surgical Oncology, The University of Texas
MD Anderson Cancer Center, Houston, TX, USA
Cristin Dickerson, MD Green Imaging PLLC, Houston, TX, USA
Hans Peter Dietz, MD Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW,
Australia
Kelly K. Hunt, MD Department of Breast Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Sandra Hurtado, MD Gynecologic Clinical Research, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX, USA
Anisa Hussain, MD Vios Fertility Institute, Chicago, IL, USA
Roohi Jeelani, MD Vios Fertility Institute, Chicago, IL, USA
Wayne State University School of Medicine, Detroit, MI, USA
Daniel Kawakyu-O’Connor, MD Department of Imaging Sciences, University of Rochester
Medical Center, Rochester, NY, USA
Tristi Muir, MD Department of Obstetrics and Gynecology, Houston Methodist Hospital,
Houston, TX, USA
Brittany L. Murphy, MD, MS Department of Breast Surgical Oncology, The University of
Texas MD Anderson Cancer Center, Houston, TX, USA
Avice M. O’Connell, MD, FACR Department of Imaging Sciences, University of Rochester
Medical Center, Rochester, NY, USA
Tamara Ortiz-Perez, MD Department of Radiology, Baylor College of Medicine, Houston,
TX, USA
Raj Mohan Paspulati, MD Digestive Health Institute, GI & GYN Radiology, Abdominal
Imaging, Department of Radiology, Case Western Reserve University, Cleveland, OH, USA
Holly J. Pederson, MD Department of General Surgery, Digestive Disease Institute,
Cleveland Clinic, Cleveland, OH, USA
Ashley A. Roark, MD Department of Radiology, Baylor College of Medicine, Houston, TX,
USA
Emily C. Rutledge, MD Department of Obstetrics and Gynecology, Houston Methodist
Hospital, Houston, TX, USA
Sabrina K. Sahni, MD, NCMP Department of Internal Medicine, Jacoby Center for Breast
Health, Mayo Clinic Jacksonville, Jacksonville, FL, USA

xv
xvi Contributors

Mohammed Saleh, MD Division of Diagnostic Imaging, MD Anderson Cancer Center,

Houston, TX, USA
Ramon P. Saucedo, MD Department of Radiology, Houston Methodist Hospital,
Houston, TX, USA
Jacqueline Sehring, MD Vios Fertility Institute, Chicago, IL, USA
Nidhi Sharma, MD Department of Diagnostic Medicine, University of Texas at Austin,
Austin, TX, USA
Mahesh K. Shetty, MD, FRCR, FACR Baylor College of Medicine, Houston, TX, USA
Ezequiel Silva III, MD, FACR, FSIR, FRBMA, RCC South Texas Radiology Group, San
Antonio, TX, USA
Department of Radiology, UT Health – San Antonio, San Antonio, TX, USA
Raghu Vikram, MD Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston,
TX, USA
Alfred B. Watson Jr., MD, MPH, FACR, FACPM Department of Radiology, Baylor
College of Medicine, Houston, TX, USA
 Imaging the Symptomatic Breast
in the Pediatric, Young, Pregnant,
Lactating, and Transgender Patient
Mahesh K. Shetty, Avice M. O’Connell,
Daniel Kawakyu-­O’Connor, and Nidhi Sharma
I maging of the Breast During Pregnancy
and Lactation
Physiologic Changes in the Breast During Pregnancy and
Lactation During pregnancy and lactation, the breast under-
goes diffuse enlargement and is nodular on clinical palpa-
tion. These changes are hormonally driven in preparation for
milk production and breastfeeding and produced by the
actions of estrogen, progesterone, and prolactin. The physi-
ology underlying this change involves lobular, alveolar, and
ductal proliferation, secretory change in the alveolar epithe-
lium, involution of the fibrofatty stroma, and increase in the
gland vascularity [1]. Transitioning into lactation, rapid drop
in the levels of progesterone, and under the influence of pro-
lactin, there is filling of the alveoli and the ducts with colos-
trum. These changes lead to increasing density of the breast
on mammograms, and changes in breast density are most
pronounced during lactation [2]. When such changes are
localized, they may lead to clinically palpable breast lumps
and may be concerning if such a change occurs in the axilla.
Ultrasound often is able to identify lactational changes and
distinguish such changes from a suspicious solid mass pre-
cluding a biopsy (Fig. 1.1). Breastfeeding patient is encour-
aged to pump the breast prior to a diagnostic mammogram or
a breast MRI examination to reduce the breast density. On
ultrasound, the background echotexture becomes homoge-
neous during pregnancy, appearing light gray, and during
lactation, there is increased echogenicity, prominence of the
ductal system, and increased vascularity.
M. K. Shetty (*)
Baylor College of Medicine, Houston, TX, USA
e-mail: mshetty@bcm.edu
A. M. O’Connell · D. Kawakyu-O’Connor
Department of Imaging Sciences, University of Rochester Medical
Center, Rochester, NY, USA
N. Sharma
Department of Diagnostic Medicine, University of Texas at Austin,
Austin, TX, USA
e-mail: sharmanmd@ausrad.com
© Springer Nature Switzerland AG 2021
M. K. Shetty (ed.), Breast & Gynecological Diseases, https://doi.org/10.1007/978-3-030-69476-0_1
1
Palpable breast lump is the most common reported breast
symptom in pregnancy and lactation (64–100%) [3, 4].
Furthermore, due to the predominantly young patient age
and the decreased sensitivity of mammography in the setting
of dense breast tissue, breast ultrasound (US) is the first-line
imaging examination in pregnant and lactating patients. If
breast US is negative and does not explain the clinical find-
ings, or if there are suspicious sonographic findings, addi-
tional imaging with mammography may be indicated.
Diagnostic mammography is not contraindicated in preg-
nancy or during lactation [5]. In a series of 77 pregnant
patients evaluated for a breast lump, three had invasive breast
cancers, and majority were without a sonographic correlate
(n = 28) or had cysts and galactoceles (n = 21). A solid mass
with predominantly benign features was seen less often
(n = 13) and was assigned a BI-RADS 3 probably benign
assessment, followed by ultrasound [6]. Table 1.1 summa-
rizes appropriate imaging of palpable lumps in pregnancy.
Table 1.2 shows the common causes of palpable breast lumps
in pregnancy.
Lactating Adenoma These are common benign tumors
encountered in pregnancy and lactation and result from the
influence of the pregnancy state hormones. Lactating adeno-
mas are non-encapsulated tumors that are histologically
composed of lobules with secretory epithelium with a deli-
cate connective tissue stroma. On imaging the morphologic
features of these benign tumors are indistinguishable from
the more commonly seen fibroadenomas, appearing as cir-
cumscribed, oval solid masses. These tumors typically
regress post cessation of lactation (Fig. 1.2). Lactating ade-
nomas can be very vascular (Fig. 1.3). They can undergo
infarction like fibroadenomas which may make them symp-
tomatic and tender. Uncommonly fat within a lactating ade-
noma may produce lucency on a mammogram or
hyperechogenicity on ultrasound. Occasionally irregular
margins, posterior acoustic shadowing, or an intense
hypoechogenicity may simulate a malignant mass. Rapid
growth, skin changes, and severe pain have been o­ ccasionally
1
2 M. K. Shetty et al.

a b

Fig. 1.1 (a, b) A 33-year-old with a right axillary palpable lump during breastfeeding. Grayscale ultrasound and color Doppler ultrasound show
localized lactational changes with peripheral increased vascular flow in accessory breast tissue

Table 1.1 Imaging in pregnant women with a palpable breast mass [5] due to the size or due to the fact that breasts were never
Appropriateness imaged may manifest during pregnancy due to an increase in
Procedure category size induced by the hormonal changes of pregnancy and lac-
Ultrasound Breast Usually appropriate tation [1, 9]. The conspicuity of a fibroadenoma may be
Digital breast tomosynthesis diagnostic May be appropriate decreased due to the hypoechogenicity of the glandular
Diagnostic mammography May be appropriate parenchyma in pregnancy [10]. These usually present as
MRI breast without and with IV contrast Usually not
appropriate
painless mobile breast lumps. Gravidic changes may occur
MRI breast without IV contrast Usually not in a fibroadenoma during pregnancy. These include enlarge-
appropriate ment, cystic changes within, and increased vascularity
Tc-99m sestamibi MBI Usually not (Fig. 1.4). A fibroadenoma may undergo lactational changes
appropriate and exhibit intratumoral ductal structures; aspiration/biopsy
Image-guided core biopsy breast Usually not may reveal milk products. Ultrasound may reveal a heteroge-
appropriate
neous solid mass with areas of hyperechogenicity. Imaging
Image-guided fine-needle aspiration Usually not
biopsy breast appropriate features may overlap with a galactocele and/or a lactating
adenoma. Typical appearance is that of an oval-shaped mass
with circumscribed margins in a parallel orientation.
Table 1.2 Etiology of palpable lumps during pregnancy and lactation Occasionally the margins may be irregular necessitating a
Non-tender Tender core needle biopsy to exclude breast cancer [11]. Secretory
Galactocele Granulomatous mastitis hyperplasia may also lead to formation of calcifications in a
Lactating adenoma Breast abscess fibroadenoma undergoing lactational change; such calcifica-
Fibroadenoma Infected galactocele tions may show up on a mammogram. In late pregnancy or
Breast cancer Uncommon: diabetic mastopathy after delivery a fibroadenoma may undergo infarction, in
such cases patients may present with an acutely tender breast
reported simulating malignancy; ultrasound shows an avas- lump or an existing painless lump may become tender induc-
cular rapidly enlarging mass that on core needle biopsy ing anxiety in the patient. Ultrasound may show a hypoechoic
shows gestational hyperplasia [7, 8]. mass with a heterogeneous echotexture, posterior acoustic
shadowing, and sometimes with irregular margins. A combi-
Fibroadenoma Fibroadenoma is the most common benign nation of clinical presentation and imaging features is an
tumor seen in young women and results from proliferation of indication for core needle biopsy to exclude malignancy
the lobular stroma. Fibroadenomas that have remained occult (Fig. 1.5) [1, 9].
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 3

a b

c d

Fig. 1.2 (a, b) Radial and antiradial ultrasound images of a palpable (c, d) Radial and antiradial ultrasound 6 months post-cessation of lac-
lump in a breastfeeding patient shows a heterogeneous oval solid tation shows interval shrinkage of the lactating adenoma that now
mass with indistinct borders. Patient preferred to undergo biopsy for appears more homogeneously solid
confirmation. Ultrasound-guided biopsy showed lactating adenoma.

a b

Fig. 1.3 (a) Grayscale ultrasound image of a palpable mass in a lactating patient shows a 5 cm oval heterogeneous solid mass with circumscribed
margins. (b) Color Doppler shows marked increased vascular flow within the solid mass. Ultrasound-guided biopsy showed a lactating adenoma
4 M. K. Shetty et al.

a b

Fig. 1.4 (a) Palpable breast lump in a 39-year-old lactating woman. gravidic fibroadenoma. (b) A follow-up ultrasound scan 6 months post-
An oval hypoechoic solid mass with cystic heterogeneous internal partum shows the solid mass to be smaller and more homogeneous with
echotexture and some vascularity was seen. Histological diagnosis was scattered internal vascularity

a b

Fig. 1.5 (a, b) Grayscale and color Doppler ultrasound image of a ten- significant flow within the mass. Ultrasound-guided biopsy showed an
der palpable lump in a 33-year-old lactating woman shows an oval het- inflamed fibroadenoma
erogeneous solid mass with areas of hyperechogenicity; there was no

Galactocele These are the most common causes of a palpa-
ble lump during pregnancy and lactation and are seen in 22%
of patients presenting with a palpable lump and evaluated
with ultrasound [3]. Galactoceles have been reported in axil-
lary tissue as a painful lump, and ultrasound may reveal an
irregular shape and margins thereby mimicking malignancy.
Aspiration revealing milky secretions and resolution post-­
aspiration is confirmatory and reassuring [12]. In a non-­
breastfeeding patient, a chronic galactocele can appear as a
radiolucent mass, with ultrasound showing a mixed echo-
genicity mass with central hyperechogenicity [13]. A false-­
positive PET scan with a high F-FDG uptake may be seen in
a galactocele, and again aspiration of milk contents is confir-
matory [14]. Galactoceles are the most common benign
lesions of the breast during lactation. They are more com-
mon after cessation of lactation. They result from duct dilata-
tion, obstruction, and rupture. These cystic masses are lined
by cuboidal or flattened epithelium and often associated with
acute or chronic inflammation. They contain milk products,
depending on the predominant content, protein, milk, and
lactose. Imaging appearance is dependent on the predomi-
nant content. There are three patterns, a pseudo lipoma
appearance results when fat content predominates, mammo-
gram shows a radiolucent mass that resembles a lipoma,
ultrasound demonstrates an echogenic mass. A cystic mass
pattern with a fat fluid level is seen when there is fat, milk
and water, fat will rise and float on the heavier water that
settles at the bottom, the fat fluid level is seen on the straight
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 5

a b

Fig. 1.6 (a) Ultrasound image of a palpable breast lump in a breast- not performed due to a presumed diagnosis of a galactocele containing
feeding patient shows mildly hyperechoic solid mass. (b) Mammogram fat giving the mass a pseudohamartoma appearance
shows a mixed density mass with radiolucent fat content. Biopsy was

mediolateral view with patient upright, this feature is charac-

teristic of a galactocele, but may occasionally be seen in fat
necrosis. A pseudohamartoma appearance is seen when the
contents are old inspissated milk, mammogram shows a
mixed density mass with lucent and increased density, and
ultrasound shows a mixed hyperechoic and hypoechoic
echotexture. When infected, palpable lump is tender, ultra-
sound shows thick wall and increased peripheral vascularity,
and confirmatory finding on aspiration would reveal purulent
fluid [1, 15, 16] (Fig. 1.6).

Nipple Discharge During Pregnancy Nipple discharge in

pregnancy may be physiologic or related to infection and
trauma to the nipple or is caused by benign papillary tumors
and uncommonly result from an underlying breast cancer.
Spontaneous bloody discharge from the nipple is uncom-
mon and usually manifests in the third trimester of preg-
nancy; because of known association with pregnancy,
Fig. 1.7 Ultrasound with color Doppler of the left breast in a 29-year-
appropriate evaluation including ultrasound is needed to old pregnant patient presenting with a unilateral spontaneous bloody
exclude intraductal masses. Mammography is generally not nipple discharge shows a solid heterogeneous mass with scattered
helpful; spot magnification views of the retroareolar breast peripheral flow and indistinct margins. Ultrasound-guided core biopsy
showed a papilloma without atypia
should nevertheless be performed to identify calcifications
associated with rare intraductal cancer. Cytology of the dis-
charge is not helpful, and the discharge is seen from multi- appropriate imaging in pregnant patients with a clinically
ple ducts [1, 17]. Nipple discharge usually resolves in suspicious nipple discharge.
2 months. Lobular proliferation and increased vasculariza-
tion are the likely underlying factors and occur in about Pregnancy-Associated Breast Cancer (PABC) PABC is
20% of pregnancy [9] (Fig. 1.7). Table 1.3 summarizes breast cancer diagnosed during or within 1 year of pregnancy
6 M. K. Shetty et al.

and reported to account for 4.3% of all breast cancers and nonpregnant patient [18, 19]. PABC is more likely to be tri-
affects 1 in 3000 live births [2, 5, 18]. The incidence is ple negative and stage 3 and stage 4, with a 5-year survival
increasing as women defer childbearing age to the fourth and rate of 65% compared to nonpregnant cohort of 82% and a
fifth decades [1]. PABC tends to be diagnosed at a more disease-free survival of 47.5% compared to 65.4% in the
advanced stage and with poorer prognosis compared to the nonpregnant population [18]. Microenvironment changes
induced in the breast tissue by pregnancy hormones may be
Table 1.3 Imaging in women with clinically suspicious nipple dis- contributory to aggressiveness of cancer in pregnancy, and
charge during pregnancy delay in diagnosis is attributed to difficulty in clinical assess-
Procedure Appropriateness category ment of the breast due to pregnancy-induced changes [19]. A
US breast Usually appropriate higher rate of inflammatory breast cancers has been reported,
DBT diagnostic Usually appropriate more than 50% present with lymph node involvement, and
Mammography diagnostic Usually appropriate nodal assessment is important once a suspicious finding is
MRI with IV contrast Usually not appropriate identified when evaluating a palpable lump [1, 18] (Figs. 1.8,
MRI without IV contrast Usually not appropriate and 1.9). Most common clinical presentation is a painless
Tc-99m sestamibi MBI Usually not appropriate palpable lump (86%), while unilateral breast enlargement

a b

Fig. 1.8 A 38-year-old pregnant patient with skin erythema and a clini- mass or an abscess. Skin biopsy revealed inflammatory breast carci-
cal presentation of mastitis not responding to antibiotics. (a) and (b) are noma. Mammogram was not performed. (c) High-power photomicro-
ultrasound images done 4 weeks apart, each time showed only skin graph (original magnification, ×10; H&E stain) shows malignant cells
thickening (arrowhead) at the affected site without an underlying solid in dermal lymphatics, a hallmark of inflammatory breast cancer
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient
Fig. 1.9 Ultrasound of the
breast in a patient with
progressively enlarging breast
lump on postpartum day 1
shows a large (arrows)
irregular mass with ill-defined
interface. There was
associated skin thickening
(arrowhead). Histological
diagnosis was inflammatory
breast cancer
(6%), skin thickening, spontaneous bloody nipple discharge
(8%), axillary lymph node enlargement, and milk rejection
are less common presentations [9]. Imaging features are sim-
ilar to those in the nonpregnant patient. Ultrasound has a
100% sensitivity in diagnosing PABC, and the most frequent
finding is a mass [18, 20, 21]. A solitary hypoechoic mass
with irregular margins was the most common finding on
ultrasound. Posterior acoustic enhancement has been
reported to be a common finding, 12/22 in one series. A sub-
stantial number of masses may have circumscribed margins,
42% in one series [19, 22]. Parallel orientation also may be
seen as are complex cystic and solid masses. A relatively
benign appearance should not preclude biopsy. Bilateral
ultrasound is valuable and may yield additional concurrent
cancer in the other breast. Mammography is abnormal in
most cases and malignant calcifications may be seen in up to
26% of cases including in asymptomatic disease in the con-
tralateral breast [19, 20]. MRI is useful for local staging and
detects contralateral disease and can be performed postpar-
tum if breastfeeding exam is undertaken after pumping
breast milk [19]. There is no need to discontinue breastfeed-
ing since amount of injected gadolinium in milk is negligi-
ble. If patient prefers, 24 h milk following gadolinium
injection can be discarded. Breast cancer diagnosed during
pregnancy is generally mammographically evident despite
dense parenchymal background. Ultrasound when performed
demonstrates all masses and provides information regarding
response to neoadjuvant chemotherapy [21]. Surgical treat-
ment is similar to a nonpregnant woman; to reduce fetal mor-
tality surgery is deferred to after second trimester, and
radiation treatment is not an option due to the attendant risk
to the fetus. Chemotherapy can be safely administered after
organogenesis, i.e., after 14 weeks [9]. A retrospective study
of all cancers in women under the age of 35 years showed
that 15.6% were PABC. Patients with PABC had more
7
advanced T (tumor size) and N (nodal status) classification,
compared to the non-PABC young patients. There was no
statistically significant difference in the overall survival
rates, 10-year locoregional recurrence or in distant metasta-
sis between the two groups. Timely treatment was critical for
overall survival. Pregnancy did contribute to a delay in diag-
nosis of breast cancer [23]. Rare malignancies during preg-
nancy include malignant phyllodes tumor (Fig. 1.10). Benign
tumors may have an appearance mimicking malignancy,
with solid enlarging irregular masses with increased vascular
flow, and tubular adenoma is one such mass that can mimic
breast cancer (Fig. 1.11). A complex cystic mass with
increased vascular flow is also worrisome for malignancy,
and a papilloma with cystic degeneration and pregnancy-­
induced increased blood flow may appear suspicious for
malignancy (Fig. 1.12).
Granulomatous Mastitis Idiopathic granulomatous mastitis
is a rare benign inflammatory disease of the breast that is
characterized by sterile non-caseating lobulocentric granulo-
mas. It is a chronic recurrent condition that can be associated
with pregnancy, lactation, or hyperprolactinemia. Less com-
mon associations include α1-antitrypsin deficiency, oral con-
traceptive use, trauma, diabetes, autoimmune disease, and
smoking [24]. Majority of patients are diagnosed with IGM
6 months to 2 years after cessation of breastfeeding, diagno-
sis of IGM during pregnancy and lactation is uncommon,
and there is a possible increased involvement of the non-­
lactating breast [24]. The most common presentation is a
painful breast lump or multiple lumps that may be associated
with diffuse enlargement of the breast, sometimes with skin
erythema, and contralateral breast involvement is rare.
Nipple changes, skin changes, and axillary node enlarge-
ment may be associated [24–26]. Abscesses, ulcers, and
cutaneous fistulas may be encountered, and such abnormali-
8 M. K. Shetty et al.

a b

c d

Fig. 1.10 (a, b) Grayscale and color Doppler ultrasound in a 29-year-­
old pregnant patient shows a 3.8 cm solid mass with heterogeneous
hyperechogenicity and indistinct margins and scattered peripheral vas-
cularity. Ultrasound-guided biopsy revealed benign phyllodes tumor.
Surgical excision was performed. (c, d) Repeat grayscale and color
Doppler ultrasound in the same patient 4 months later shows a recurrent
markedly hypoechogenic irregular solid mass at the same site, with no
vascular flow detected within the mass. Ultrasound biopsy revealed a
malignant phyllodes tumor

ties require aspiration for microbiologic analysis. A higher
incidence among Hispanic population has been reported,
with other reports showing increased predominance in non-­
White populations [24–26]. An association between IGM
and history of tuberculosis (TB) and AIDS has been reported
[26]. A significant number of patients have systemic disease,
38% in one series [27]. Clinical and imaging features can
mimic malignancy, particularly inflammatory breast carci-
noma, and infective mastitis is also a principal differential
diagnostic consideration. IGM has also been described out-
side the expected pregnancy and lactational history in post-
menopausal women [28].
Imaging Features Mammographically, focal or global
asymmetry is the most common finding, followed by an
irregular focal mass, and less common findings include
asymmetrically increased breast density, architectural distor-
tion, axillary adenopathy, and circumscribed mass. There
may uncommonly be a normal mammogram in these patients
[24]. IGM can rarely show calcifications as the sole finding
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 9

a b

Fig. 1.11 (a, b) Ultrasound of the right breast in a 29-year-old pregnant patient shows a large mass with lobulated margins and indistinct interface;
color Doppler shows vascular flow within the mass. Ultrasound-guided biopsy showed a benign tubular adenoma

a b c

Fig. 1.12 (a, b) A 25-year-old breastfeeding patient with a palpable LMLO mammogram shows the palpable mass to be a hyperdense mass
lump shows an oval complex echo pattern. Doppler ultrasound shows with partly obscured margins. Ultrasound-guided biopsy showed a pap-
the solid components of the cystic mass with prominent vascularity. (c) illoma without atypia

with ultrasound showing irregular hypoechoic masses [28].
Ultrasound commonly shows an irregular hypoechoic mass
with tubular extension, circumscribed hypoechoic mass,
axillary adenopathy, confluent masses, abscesses, and skin
thickening. Occasionally parenchymal distortion or edema
may be associated [24]. A normal ultrasound is less com-
monly encountered. MRI features mimic malignancies and
include non-mass-like enhancement, and clustered ring
enhancement is commonly seen as well as architectural dis-
tortion, skin thickening, and focal skin enhancement, all of
which are hallmarks of malignancies [28–30]. Diffusion-­
weighted imaging (DWI) has not been found helpful in the
diagnosis. Ductal ectasia and periductal enhancement were
common, kinetic analysis was helpful, and most IGM cases
showed slow initial enhancement and a type-1 time signal
intensity curve [30]. Others have shown DWI to be more use-
ful with IGM showing significantly lower mean and mini-
mum ADC values when compared with the normal
parenchyma. Most common feature was non-mass-like
lesions with restricted diffusion, and clustered ringlike
enhancement may be observed as in malignant lesions [31].
Fine-needle aspiration is generally to be avoided. Core nee-
dle biopsy has a reported accuracy of 94–100%. Vacuum-­
assisted biopsy may provide a definitive diagnosis more
readily than core needle biopsy. Open surgical biopsy needs
to be avoided, since this can lead to substantial scarring,
breast deformity, and sinus tract formation. Such complica-
tions were seen in 44% of patients undergoing an open surgi-
cal biopsy, and the latter should be reserved for cases where
there is a discordance between imaging findings and histo-
10
logical diagnosis following core needle or vacuum-assisted
biopsy [9]. Prognosis is excellent, and treatment is with oral
steroids, immunosuppressive therapy, and prolactin-­reducing
medications in those cases with hyperprolactinemia. IGM is
a sterile condition and antibiotics are generally not helpful.
Failure to respond to antibiotics should prompt the clinician
to consider IGM. Only a minority of patients, 3% in a large
series of 206 women, respond to antibiotics [32]. Patients
often require long-term steroid therapy with its attendant
side effects, when it fails, methotrexate is recommended fol-
lowed by prolactin-reducing agents. When medical treat-
ment fails and condition is recurrent or persistent, surgical
excision may be the only option [24]. Distinction between
IGM and inflammatory breast cancer can be clinically and
imaging-wise challenging. IBC more often presents with
skin erythema occupying greater than one-third of the breast.
Clinically palpable axillary lymph nodes and unilateral
breast enlargement are more common features of IBC, as is
the patient’s age. Mean age of patients with cancer is
55.4 years, compared to the mean age of women with IGM,
which is 32–34 years [33]. Diabetic fibrous mastopathy, sar-
coidosis, Wegener’s granulomatosis, and tuberculosis can
present with similar clinical and imaging findings, but under-
lying condition is helpful in the distinction. Mammary duct
ectasia presents usually in a different age demographic,
affecting older postmenopausal women, and shows charac-
teristic secretory calcifications that are uncommon in IGM.
Juvenile Papillomatosis Juvenile papillomatosis of the
breast (JPB), also known as Swiss cheese disease, is a rare
ailment that typically afflicts young females and presents as
a painless breast lump. The mass is made up of multiple cysts
and duct stasis with proliferative and nonproliferative epithe-
lial changes. The proliferative changes include papillary
hyperplasia, florid hyperplasia, and papillary apocrine hyper-
plasia. Associated intraductal and invasive cancer is present
in approximately 10% of cases at presentation, and subse-
quent carcinoma develops in about 10% of patients. About
20% of patients have a strong family history of breast carci-
noma [34]. Core needle biopsy may be misdiagnosed as duc-
tal carcinoma in situ, necessitating wide excisional biopsy
that may reveal juvenile papillomatosis [35]. There is an
increased frequency of benign proliferative disease during
pregnancy and lactation. Juvenile papillomatosis is generally
seen in young women. An association with pregnancy has
been proposed based on finding 5 cases of this entity in a
series of 18 pregnant patients [1]. On ultrasound, juvenile
papillomatosis appears as an ill-defined mass that is com-
posed of multiple cysts surrounded by fibrous septa and well
demarcated histologically from surrounding tissue. The cys-
tic and ductal hyperplasia is associated with papillary hyper-
plasia lining the cystic spaces [36]. Definitive treatment is by
M. K. Shetty et al.
surgical excision with negative margins required to avoid
local recurrence. In young women juvenile papillomatosis is
a risk factor for breast cancer with a reported association
with breast cancer in 15% of cases and a reported incidence
of breast cancers in up to 50% of female relatives [1].
Granular Cell Tumor This is a rare benign tumor seen in
young women. Granular cell tumor also known as a granular
cell myoblastoma, granular cell nerve sheath tumor, and
granular cell schwannoma is a rare soft tissue mass that can
develop in any soft tissue. Most commonly it appears in the
tongue (40%), the oral cavity, or the subcutaneous tissue. In
rare occasions, it is reported as a breast mass, mimicking a
carcinoma [37–39]. This is an uncommon tumor with seven
cases reported over a 10 year period in one study [39].
Clinically and on mammography, ultrasonography, and
macroscopy, this abnormality can mimic malignancy
­
(Fig. 1.13). Definitive diagnosis can only be made on histol-
ogy after a core needle biopsy. About 5–6% are seen in the
breast and more commonly seen in African American
women. They arise from perineural cells. Clinically these
present as superficial firm masses and there may be associ-
ated skin changes [1]. Histologically they tend to form an
infiltrative growth and simulate an infiltrative carcinoma,
clinically and on imaging. At sonography these appear as
1–2 cm irregular masses with posterior acoustic shadowing
and tend to exhibit characteristics of a malignant mass. At
mammography these may appear as spiculated masses and
simulate invasive ductal cancers, and these can also appear
as well-circumscribed masses. Despite the malignant
appearance on imaging, these tumors are benign, and preop-
erative diagnosis is important to treat appropriately with
wide excision [1].
Puerperal Mastitis and Breast Abscess The WHO recom-
mends exclusive breastfeeding for the first 6 months of life
and continuing breastfeeding until age 2. Many women stop
breastfeeding due to lactational breast abscesses [40].
Infection of the breast predominantly affects young women
and occurs most commonly during lactational period, usu-
ally within 8 weeks of postpartum. Staphylococcus aureus is
the most common causative organism, reported to be the
causative pathogen in 64.9% of cases followed by
Streptococcus [41]. Staphylococcus infection tends to be
invasive and localized with a greater propensity for abscess
formation, whereas Streptococcus infection presents as
­diffuse mastitis with abscess formation seen only in late
phases [42]. There are several types of clinical presentation
of mastitis (Fig. 1.14).
Puerperal Mastitis Mastitis is said to occur in 1–24% of
breastfeeding women [43]. Breast abscess is reported to
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 11

a b

Fig. 1.13 (a) Ultrasound image of a palpable mass in the left breast of
a 24-year-old breastfeeding patient shows an oval sold mass with poste-
rior border obscured by intense posterior acoustic shadowing.
Ultrasound-guided biopsy showed granular cell tumor. (b) High-power
photomicrograph (original magnification, ×10; H&E stain) shows infil-
trating nests and cords of large polygonal cells, separated by prominent
fibrous septa; cells show abundant granular eosinophilic cytoplasm and
small nuclei within the cells, features indicative of granular cell tumor.
Patient was managed with wide surgical excision of the tumor

a b

Fig. 1.14 (a, b) Breast abscess. Ultrasound images show a complex fluid collection surrounded by hyperechogenicity and increased vascularity
characteristic of breast abscesses in two breastfeeding patients presenting with mastitis and tender palpable breast lumps

complicate puerperal mastitis in up to 44% of cases [40].
The underlying factors are milk stasis, blocked ducts, or
physical injury to the breast. Milk stasis provides a medium
for bacterial proliferation [2]. The organism gains entry
through cracked nipples during lactation originating from
the nasopharynx or mouth of the infant and proliferate in
the stagnant lactiferous ducts. Breastfeeding is encouraged
during mastitis to drain such engorged ducts. Breastfeeding
cessation is only advised following surgical drainage or if
mother is on an antibiotic that is contraindicated for the
newborn [42]. Pain, redness, heat, and palpable lumps are
frequently seen in those with mastitis and abscess, and
12 M. K. Shetty et al.

fever is uncommon. In a series of breast abscesses with I maging of the Breast in the Teenage
lumps, 80% were painful, and 71% were associated with and Transgender Population
redness of the overlying skin with only 12% associated
with fever [44]. Abscess is seen in 40–65% of cases on Teens and Twenties Ultrasound is the only imaging modality
ultrasound and at more than one site in 21% of cases [43]. that should be used in young women in their teens and twen-
At ultrasound which is the initial and often the only imag- ties who have clinical problems. The indication is almost
ing modality that is used for diagnosis and management, always for evaluation of a palpable mass. Targeted breast
mastitis appears as ill-defined areas of increased echo- ultrasound (US) is the initial examination of choice. If the
genicity in the fat lobules and as areas of decreased echo- mass has the classic ultrasound appearance of a fibroade-
genicity in the glandular parenchyma. Skin thickening is noma, it will be followed for 24 months with ultrasound at
frequently observed. Reactive lymphadenopathy is seen as 6- to 12-month intervals to confirm features of this typically
lymph nodes that are enlarged with diffuse thickening of benign lesion (Fig. 1.15). Biopsy or excision is not indicated
the cortex and preservation of the fatty hilum and increased in the absence of unusual findings such as rapid growth, large
vascularity. Abscess is seen as an irregular fluid collection size (greater than 5 cm), or other atypical ultrasound features.
with multiloculation and posterior acoustic enhancement Primary breast malignancy is not a diagnostic consideration
and sometimes with a hyperechoic rim showing increased in a teenager, although rare soft tissue malignancies such as
vascularity. Mammography is performed in older women, sarcomas may be associated with a breast mass, even though
in those not responding to treatment, or for those who are there are not considered breast cancers. Targeted diagnostic
not lactating mainly to exclude malignancy. Mammography breast ultrasound will be highly abnormal for these lesions,
is deferred until the acute phase has subsided to avoid the and the history and other clinical parameters will be highly
added discomfort of compression. Skin thickening, focal suggestive of this diagnosis, which is then further evaluated
asymmetry, or a mass are nonspecific and do not help in the by use of ultrasound-guided breast biopsy. A representative
distinction from malignancy. Presence of suspicious micro- example of this unusual diagnosis is the case of a previously
calcifications however is worrisome and should prompt healthy 18-year-old woman with a palpable breast mass.
biopsy. In a series of 975 cases of suspected mastitis, there Diagnostic ultrasound was performed, and imaging features
were 6 cases of inflammatory breast cancer [42]. In two of were highly abnormal and not typical of a benign breast
these cases, there were suspicious microcalcifications seen lesion (Fig. 1.16). Ultrasound-guided biopsy was performed
at mammography. Mastitis that is seen in a non-­puerperal and indicated a tissue diagnosis of rhabdomyosarcoma.
setting or one that is not responding to treatment should
raise the suspicion of IBC particularly in older women.
Pain in IBC is generally less severe than in mastitis, and
skin thickening is also more localized than in
IBC. Suspicious microcalcifications are seen in up to 47%
of cases of IBC and hence when seen is the most specific
sign of an underlying malignancy [42]. The finding of a
mass on mammography and more frequently on an ultra-
sound is also more indicative of an underlying malignancy.
There can still be some overlap in the imaging findings
between mastitis and abscess and IBC posing diagnostic
challenges. Treatment of breast abscess can be with aspira-
tion or incision and drainage with or without use of antibi-
otics. A study was undertaken to assess the effectiveness of
various treatment for management of breast abscesses in
breastfeeding women. This review found insufficient evi-
dence to determine if needle aspiration was more effective
than incision and drainage or for use of antibiotics in
women undergoing I and D for lactational breast abscesses
[40]. Neoplasm should be suspected and rapidly excluded
in patients whose condition does not improve with antibi- Fig. 1.15 A 16-year-old woman presented with a palpable breast mass.
Diagnostic ultrasound shows typical appearance of fibroadenoma, a
otic therapy. Fine-needle aspiration, cytologic analysis, or
benign lesion; follow-up US for 2 years is recommended to document
core biopsy is mandatory in this clinical setting [1]. stability
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient
Fig. 1.16 A 18-year-old woman presented with a painful, palpable
mass. Diagnostic ultrasound shows a highly suspicious mass; needle
biopsy showed rhabdomyosarcoma. Further extensive workup demon-
strated no additional lesions, consistent with primary rhabdomyosar-
coma originating in the breast
The workup for a palpable breast mass for a woman
30 years old or younger is as follows. First, perform targeted
breast ultrasound. If ultrasound findings are consistent with
a benign or probably benign lesion by the radiologist, fol-
low-­up with breast ultrasound is recommended to assess
stability of size and features for up to 2 years. If the initial
or subsequent breast ultrasound exams have atypical or oth-
erwise suspicious features, other diagnostic imaging, such
as ultrasound-­guided core needle biopsy with or without
diagnostic mammography, may be indicated. Palpable
masses in women 30 years of age and older will typically
require both diagnostic mammography and targeted breast
ultrasound at the time of initial presentation. Another pre-
senting symptom for young women is breast pain. Although
breast imaging is typically not indicated initially for evalua-
tion of breast pain, there are important exceptions. Breast
abscesses, which are quite common in young women and
particularly in patients with nipple piercings and cigarette
smokers, can be managed entirely by clinical presentation
and ultrasound. Ultrasound can effectively distinguish
between mastitis, which does not have a drainable collec-
tion, and abscess, which is managed by ultrasound-guided
aspiration for culture and sensitivity testing and for partial
relief of associated pain. In addition, follow-up breast ultra-
sound after completion of antibiotic therapy is commonly
used to document resolution.
Risk-factors for very early breast malignancy that may
present with pain include a specific history of radiation ther-
13
apy for Hodgkin lymphoma 8 or more years prior to presen-
tation and known or suspected germ line mutations, and
when present, these situations are exceptions to the “ultra-
sound only” rule for the evaluation of young women. Patients
with a history of radiation to the breast for Hodgkin lym-
phoma or any one of the 11 known mutations associated with
breast cancer (e.g., BRCA 1, BRCA 2, ATM, CDH1, Chek 2)
should be referred for annual screening breast MRI, typically
performed with gadolinium-based contrast. Screening mam-
mography is rarely initiated before 30 years of age, and
almost never before 25 years of age, in large part due to the
unacceptably low sensitivity of mammography in dense
breast tissue and the greater radiosensitivity of breast tissue
in younger patients. Screening for breast cancer in asymp-
tomatic patients under the age of 40 and without specific risk
factors is not routinely performed. However young women at
high risk due to known or suspected germ line mutation,
strong family history of breast cancer, or a history of radia-
tion therapy should start screening for breast cancer 10 years
earlier than the time of diagnosis of their youngest first
degree relative. For example, if the patient’s biological
mother or sibling was diagnosed with breast cancer at
36 years of age, screening breast imaging for that patient
should begin at 26 years of age, using screening (not tar-
geted) ultrasound and/or MRI and screening mammography
in patients over the age of 25.
Transgender Women In the United States, less than 1% of
the population presently self-identify as transgender, and this
number is increasing as education, awareness, and overall
acceptance has decreased the associated social stigma.
Transgender women by definition are assigned male sex or
intersex at birth but experience specific psychological syn-
drome known as gender dysphoria, which leads them to self-
identify as women. For an increasing number of transgender
women, the process of transitioning includes both hormonal
and/or surgical measures to mitigate gender dysphoria.
Hormonal supplement regimens commonly consist of
estrogen and spironolactone, which has both antiandrogenic
and diuretic properties. Some patients undergo orchiectomy,
which is referred to as “gender-affirming surgery” in this
population, at which time they may discontinue antiandro-
genic management. The estrogen dose is usually initiated
with estradiol 2–4 mg/day and increases to 8 mg/day for
most transgender women. Resulting breast development is
not referred to as gynecomastia, and the appearance and
physical exam findings are usually indistinguishable from
cisgender women (Fig. 1.17). Estrogen supplementation will
commonly result in transient breast lumps and discomfort,
and these are expected side effects. Similar to palpable lumps
or pain in cis-women, targeted breast ultrasound may be per-
formed to provide reassurance if patients are particularly
anxious or otherwise concerned about these symptoms; how-
14
a b
Fig. 1.17 A 52-year-old transgender woman with history of estrogen
hormone therapy for greater than 10 years presented for breast cancer
screening. Screening CC (a) and MLO (b) mammograms show hetero-
ever, primary breast malignancy is highly uncommon in
younger transgender women.
Specific screening and management recommendations
are an active topic of discussion in the breast imaging com-
munity. Importantly, there are no commonly accepted guide-
lines for breast cancer screening in transgender women of
average risk. A reasonable screening regimen for transgender
women with significant risk factors should probably undergo
screening mammography beginning 5–10 years after initia-
tion of estrogen supplementation, and especially after
40 years of age. The risk of breast cancer in transgender
women of average risk is likely to be greater than for natal
males following long-term estrogen supplementation, and
less than natal women, who have ductal and glandular tissue
that is more extensive and suspectable to primary breast
malignancy than in transgender women [44].
Breast Cancer in Young Women
A majority of breast cancers occur in women over 50 years
age group, but it affects younger women as well. Nearly
11% of all new breast cancer cases in the United States are
diagnosed in premenopausal patients under 45 years of age
[45]. Most of these younger women have hormone
receptor-­positive breast tumors: 51.4% in patients under
35 years of age and 67.6% in 40–44 years of age [46–48].
Breast cancer is still the most common cancer in women
younger than 35 [49]. There is also an increasing evidence
of increasing rate of breast cancer in the young population
under age 40. The Group for Cancer Epidemiology and
M. K. Shetty et al.
geneously dense breasts, BI-RADS 1, indistinguishable in appearance
from a cisgender woman of the same age
Registration in Latin Language countries (GRELL) study
analyzing epidemiologic data from European countries
showed the rate to be increasing by 1.2% every year from
1990 to 2008 [50]. Every year over thousand women die
from breast cancer under age 40 [50]. Triple-negative
breast cancer, subtype with poorest outcomes, is more typ-
ically noted in premenopausal age group [51]. There is
limited research for breast cancer in this age group as
breast cancer occurs at a much lower rate in young adults
than their older counterparts [52].
Risk Factors In comparison to postmenopausal breast can-
cer which is typically associated with modifiable risk factors
like overweight, obesity, and diabetes mellitus type 2, the
premenopausal age group is related to less modifiable fac-
tors. Young patients at higher risk as compared to other
women their age have many contributing factors play this
role like close relatives diagnosed with breast or ovarian can-
cer at age younger than 45, genetic susceptibility to BRCA1/2
genes, Ashkenazi Jewish heritage, radiation therapy to chest
wall in childhood or early adulthood, or personal history of
breast cancer or other high-risk breast lesions. These factors
limit risk assessment, early diagnosis, treatment, and long-­
term disease-free outcomes [53]. BRCA1 and 2 genetic
mutations comprise a majority of genes in young patients
and affect overall patient survival. TP53 and
CHEK2*1100delC mutations are also associated with pre-
menopausal breast cancer [54, 55]. TP53 mutations are
responsible for almost one-fifth of all hereditary ­malignancies
and are also present in 2–6% of breast cancers in younger
than 35-year age group [56, 57].
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient
Pregnancy by itself is not a risk factor, though it can
increase the early stage cancers that are present in a pregnant
patient. Other additional risk factors include smoking, high
alcohol intake, and in utero radiation exposure [58]. Dense
breast tissue is a moderate independent risk factor for breast
cancer. This refers to heterogeneously dense and extremely
dense tissue, as defined by ACR-BIRADS atlas. Younger age
is strongly associated with increased mammographic den-
sity. In a study by Stomper et al., 55% of women under 50
had dense breast tissue, in comparison to 30% women over
50 years of age [59]. Race plays an important role in breast
cancers detected at an earlier age. African American women
younger than 35 years have twice as many breast cancers in
comparison to their Caucasian counterparts [60]. The cancer
tends to be more aggressive in this demographic with a three
times higher mortality in comparison to their counterparts of
same age. Access to healthcare and its quality may play a
role in this population [60]. Improving access to breast imag-
ing and creating awareness can potentially help diagnose the
cancers early in this group, when they are more treatable.
Screening Guidelines Most screening national guidelines
recommend starting screening mammograms at age
40–45 years. The American College of Radiology (ACR)
and Society of Breast Imaging (SBI) continue to recommend
that women at average breast cancer risk begin screening at
age 40. American Cancer Society (ACS) recommends that
women start regular mammograms no later than age 45 and
those who want to start at age 40 should have insured access
to mammograms. U.S. Preventive Services Task Force breast
cancer screening guidelines do not recommend routine mam-
mograms for women ages 40–49 and recommend screening
every other year for those ages 50–74. Published analysis
shows that following these USPSTF guidelines would lead
to missing a third of cancers and result in 6500–10,000 addi-
tional breast cancer deaths each year [61]. Patients younger
than 40 years are not typically screened, unless at high risk
for breast cancer. This is discussed in detail in chap. 4. These
younger patients typically present for diagnostic evaluation
of a palpable abnormality in the breast or the axilla.
Imaging of Breast Cancer in Young Women The mammo-
graphic signs suspicious for cancer are more difficult to
detect in dense breast tissue, thus decreasing sensitivity
which is well established in literature. As radiologists, it is a
hard task to interpret the dense mammograms, but many
non-symptomatic breast cancers are still detectable in dense
breasts. The findings are usually subtle, and technically good
exam with appropriate exposure, compression, and absence
of significant motion help improve detection. Ultrasound and
magnetic resonance imaging (MRI) are additional imaging
modalities helpful in detecting breast cancer at earlier age, in
high-risk patients and independent of breast density. Digital
15
mammography has been shown to be superior to film-screen
mammography in diagnostic accuracy in young patients with
dense breasts. It is thus useful to triage patients with dense
breasts for imaging with digital technique. With the advent
of tomosynthesis, a digital mammogram that acquires mul-
tiple images from different angles that are processed for a
three-dimensional image, it is noted to improve detection
and decrease call back rates. This was initially approved by
Food and Drug Administration (FDA) in 2011 and has over-
come many known limitations of conventional mammogra-
phy including tissue overlap. The ongoing national
Tomosynthesis Mammographic Imaging Screening Trial
(TMIST) is the first randomized controlled trial to identify
women in which digital breast tomosynthesis (DBT) may
outperform 2D digital mammography in reducing advanced
breast cancer development. This study is aimed at curating a
database of clinical information, imaging, and bio-specimens
to help tailor future screening to a patient’s individual risk.
The study enrolls women between 45 and 74 years, thus
excluding most young patients under 45 years of age [62].
It is a challenging task to detect breast cancer in young
patients with dense breast tissue. Self and clinical breast
exams may be limited given lumpy nature of breast tissue.
Margins of a mass may be detectable and close attention is
paid to the margins of the breast at the time of exam interpre-
tation. Retraction of tissue border and soft tissue density pro-
trusions into adjacent fat and spicules extending peripherally
point towards suspicious underlying findings and warrant
additional evaluation. Asymmetries should be closely evalu-
ated for associated features, given dense tissue can obscure
details. This also results in a harder diagnosis of invasive
lobular carcinoma for which findings are typically single
view or very subtle on mammography. Architectural distor-
tion may be the presentation of a spiculated mass in dense
breasts where central mass is obscured [63]. Fine pleomor-
phic and amorphous calcifications may be difficult to detect
and present in a subtle fashion. Coarse heterogeneous calci-
fications that are larger may be more easily noted in young
patients with dense breast tissue. Linear distribution calcifi-
cations that are not typical secretory or vascular in presenta-
tion should be recalled for magnification views as they are
particularly suspicious in young patients not typically prone
to benign causes as in postmenopausal women [64].
Screening ultrasound (US) detected three additional can-
cers per 1000 high-risk patients who were also screened with
mammography in the ACRIN 6666 trial. The study also con-
cluded that cancer detection rate with US was comparable
with mammography, with a greater proportion of invasive
and node-negative cancers among US detections. False posi-
tives were also noted to be more common with US screening.
The positive predictive value for cancer with recommended
biopsies was 7% in this trail and likely lower in average risk
patients [65]. Due to its low specificity, the use of this screen-
16
ing modality remains controversial. MRI is another impor-
tant modality not affected by patient breast density. It is
commonly used in young patients under 50 years with new
diagnosis of breast cancer to evaluate extent of disease pro-
cess. The American Cancer Society and Society of Breast
Imaging do not currently recommend for or against screen-
ing MRI for women with dense tissue who are otherwise at
average risk of breast cancer. Young patients previously diag-
nosed with breast cancer are recommended to be screened
with MRI. Patients with histories of breast cancer and those
with atypia at biopsy should consider additional surveillance
with MRI, especially if other risk factors are present. All
women, especially Black women and those of Ashkenazi
Jewish descent, should be evaluated for breast cancer risk no
later than age 30, so that those at higher risk can be identified
and can benefit from supplemental screening [66].
Interesting Cases A few interesting cases of breast cancer in
young patients and their unique imaging findings.
Case 1
A 44-year-old woman was recalled from screening for eval-
uation of an asymmetry in the upper outer quadrant. She
elicited no family history of breast cancer. Diagnostic
images confirmed persistence of the finding seen on screen-
ing mammography. Subsequent targeted ultrasound demon-
strated a cyst with a thin septation. The patient returned a
month later with focal breast pain and palpable abnormality
corresponding to the previously evaluated right breast find-
ing. Repeat right breast targeted ultrasound was performed
and therapeutic aspiration was performed for the cyst. Post-
aspiration imaging demonstrated complete collapse of the
complicated cyst. No biopsy clip was placed. Aspirate was
non-bloody and yellow in color. The aspirate was sent for
cytologic evaluation at the discretion of the radiologist.
Pathology demonstrated numerous large malignant cells in
cohesive clustered and in single cells, consistent with a
high-grade carcinoma. Targeted sonographic evaluation was
performed for reevaluation of the aspirated area, as marker
clip was not placed at the time of the aspiration. Ultrasound
demonstrated re-­ accumulation of the cystic contents in
under 2 weeks of the aspiration. Sonography-guided core
biopsy was performed through the cyst wall for tissue diag-
nosis revealing triple-­negative invasive ductal carcinoma
and ductal carcinoma in situ with high nuclear grade, suspi-
cious for lymphovascular space invasion. Post clip mammo-
gram revealed biopsy clip in the upper outer breast.
M. K. Shetty et al.
Contrast-enhanced MRI was performed to evaluate extent
of disease and surgical approach. MRI of the breasts demon-
strated a 5.5 × 5.5 × 4.5 cm cystic mass at 11:00 the right
breast, corresponding with biopsy proven cancer. The cystic
mass demonstrated a thickened rim with plateau and wash-
out enhancement kinetics. The inner cystic area demon-
strated mostly debris with septations. Multiple incidental
lesions were noted bilaterally on the MRI and underwent
second look ultrasounds, and bilateral ultrasound and MRI
guided biopsies, all demonstrating benign breast tissue. The
patient underwent four cycles of neoadjuvant chemotherapy,
followed by surgical lumpectomy with sentinel lymph node
excision and radiation therapy. Based on initial imaging
appearance and the patient’s history, this likely represented
a complicated cyst with no suspicious features. The ultra-
sound-guided aspiration was performed for therapeutic pur-
pose. While the aspirated fluid was clear yellow, it was sent
for pathologic evaluation. In most instances it is discarded
post-aspiration. The reimaging ultrasound within 2 weeks
post-pathology results of malignant aspirate showed inter-
val change in appearance with thickened walls and associ-
ated increased vascularity. Ultrasound-guided biopsy of the
suspicious thickened wall confirmed a grade-3 triple-nega-
tive invasive ductal cancer. This case illustrates a challeng-
ing and unusual presentation of a complex cystic mass
initially presenting as a benign complicated cyst in this
young patient (Fig. 1.18).
Case 2
A 32-year-old patient with no high-risk factors or family his-
tory presented with a palpable abnormality in the left breast
for 2 months. She underwent a diagnostic mammogram with
a BB marker in place. The diagnostic images revealed het-
erogeneously dense breast tissue and a subtle focal asym-
metry in the upper outer left breast. She underwent a
diagnostic ultrasound for further evaluation. This showed an
oval, parallel, hypoechoic mass measuring 1.2 cm with indis-
tinct margins, posterior acoustic enhancement, and no asso-
ciated vascularity at the site of palpable abnormality in the
outer breast. Given this was a newly palpable mass at base-
line exam and the margins were not clearly defined, an
ultrasound-­guided biopsy was recommended for further
assessment. Biopsy revealed invasive ductal carcinoma,
nuclear grade 3. MRI of the breasts with contrast was per-
formed to evaluate extent of disease and showed the enhanc-
ing irregular mass in the left outer breast consistent with
known carcinoma (Fig. 1.19).
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 17

a b c

d e

Fig. 1.18 The right CC (a) and MLO (b) views from the screening
mammogram show an oval focal asymmetry (arrows) in the upper outer
breast at the palpable abnormality with focal pain. (c) The right spot
MLO view on the diagnostic mammogram shows that the focal asym-
metry persists on additional imaging. The right breast targeted ultra-
sound transverse (d) and sagittal (e) images depict an oval anechoic
circumscribed mass with posterior acoustic enhancement, minimal wall
thickening (arrow), and no associated vascularity (f) with a thin internal
septation (arrow) in the upper outer breast at 11:00 1 cm from nipple at
the site of focal pain. (g) The right breast targeted ultrasound transverse
preaspiration image shows a stable oval anechoic circumscribed mass
with posterior acoustic enhancement, and layering debris (arrow) in the
upper outer breast at the palpable site with focal pain. No associated
vascularity was noted. Ultrasound images in transverse (h), sagittal (i),
and color flow (j) of the right breast at 11:00 1 cm from the nipple at the
aspirated cyst site show reaccumulation of the cyst with layering inter-
nal debris (arrow), concentric wall thickening with associated increased
vascularity, consistent with a complex cyst. The right breast ultrasound-­
guided biopsy was performed through the thickened wall of the com-
plex cyst (k). The right CC (l) and ML (m) views from the post clip
mammogram show the clip at the biopsy site. MR images axial STIR
(n), axial interview (o), post-contrast subtraction axial (p), and post-­
contrast subtraction sagittal images (q) of the right breast show the rim
enhancing cystic mass. A biopsy clip susceptibility artifact is associated
along the anterior wall
18 M. K. Shetty et al.

f g

h i

Fig. 1.18 (continued)

1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 19

j k

l m

Fig. 1.18 (continued)

20 M. K. Shetty et al.

n o

p q

Fig. 1.18 (continued)

1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 21

a b

Fig. 1.19 (a) CC view of the left breast shows heterogeneously dense
breast tissue with BB metallic marker at the site of palpable abnormal-
ity in the left outer breast. (b) MLO view of the left breast shows an
asymmetry correlating to the palpable abnormality in the left outer
breast. Targeted ultrasound transverse (c), longitudinal (d), and color
(e) images of the left breast at 3:00 10 cm from the nipple depict an
oval, parallel, hypoechoic mass measuring 1.2 cm with indistinct mar-
gins, posterior acoustic enhancement, and no associated vascularity at
the site of palpable abnormality. MR images of the left breast post-­
contrast subtraction axial (f) and sagittal (g) show an irregular enhanc-
ing mass in the left outer breast. A biopsy clip susceptibility artifact is
associated with the mass
22 M. K. Shetty et al.

d e

f g

Fig. 1.19 (continued)

Case 3 the diagnosis and care challenging in comparison to post-

A 28-year-old woman presented with new onset palpable
lumps in the right upper breast for 3 weeks. She underwent
initial diagnostic mammogram (Fig. 1.13), which revealed a
dense focal asymmetry in the right upper breast corresponding
to the two sites of palpable abnormalities. Subsequent ultra-
sound demonstrated two irregular masses in the right breast in
the upper inner and outer quadrants at the sites of palpable
areas at 11:00 and 1:00 (Fig. 1.14). These were biopsy-proven
sites of DCIS. Post clip mammogram reveals the clips within
initial mammographic finding of concern (Fig. 1.20).
Unique Challenges in Imaging Young Women Many fac-
tors impact the quality of life in younger patients making
menopausal age group. Younger patients are in the child-
bearing years of their life and can have issues related to
pregnancy. Breast cancer treatment can affect fertility and
subsequent planning. Some patients can experience early
menopause and sexual dysfunction. Many women raising
young children encounter social side effects. Anxiety and
depression also demonstrate higher prevalence in young
breast cancer survivors [67]. There is possibility of early
menopause onset and sexual dysfunction secondary to
treatment. Some patients experience concerns regarding
body image and personal life related to surgery and treat-
ment. Many challenges are also noted to be related to
financial instability, lack of healthcare insurance, and cost
of cancer care.
1 Imaging the Symptomatic Breast in the Pediatric, Young, Pregnant, Lactating, and Transgender Patient 23

b c

Fig. 1.20 (a) Diagnostic mammogram right MLO view demonstrates
a dense focal asymmetry in the right upper breast corresponding to the
two sites of palpable abnormalities marked by metallic BB markers.
Targeted right breast ultrasound images at the sites of palpable abnor-
malities in the right upper outer breast at 11:00 7 cm from the nipple (b)
and inner breast at 1:00 7 cm from the nipple (c) demonstrate irregular,
taller than wide, hypoechoic masses with angular margins and associ-
ated vascularity. Post-clip mammogram CC (d) and ML (e) views of the
right reveal the biopsy clips within initial mammographic finding of
concern
24 M. K. Shetty et al.

d e

Fig. 1.20 (continued)

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L, Gentilini O, Peccatori F, Fourquet A, Delaloge S, et al. The
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https://doi.org/10.1016/j.canep.2013.05.001.
51. American Cancer Society. Breast cancer facts & figures 2015–2016.
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BA, Courneya KS, Knight JA, Olivotto IA, Quan ML, Friedenreich
CM. Breast cancer survival among young women: a review of
the role of modifiable lifestyle factors. Cancer Causes Control.
2016;27:459–72. https://doi.org/10.1007/s10552-­016-­0726-­5.
53. Partridge AH, et al. Breast cancer in younger women. In: Harris J,
editor. Diseases of the breast. 4th ed. Philadelphia: Wolters Kluwer-
Lippincott Williams and Lipkin; 2010. p. 1073–83.
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54. Fröhlich H, Patjoshi S, Yeghiazaryan K, Kehrer C, Kuhn W,
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 Imaging of the Symptomatic Breast
Mahesh K. Shetty
Palpable Abnormalities of the Breast
A breast lump may be discovered during a breast self-­
examination or during a clinical breast examination. Most
breast lumps are caused by benign breast diseases; a small
but significant percentage of breast lumps result from breast
cancer. A breast lump is a common presenting sign of breast
cancer in women not undergoing screening because of age or
personal preference. A cancer can also manifest as a lump in
between screening intervals, generally caused by obscura-
tion of the cancer by dense fibroglandular parenchyma before
being clinically manifest or less commonly due to a rapidly
growing interval cancer. Breast cancer that presents as a pal-
pable lump is generally more aggressive and with a poorer
prognosis than those diagnosed on a screening mammogram
before becoming symptomatic. There are descriptive vari-
ants of palpable abnormalities of the breast. These include a
palpable breast mass or lump, which is felt distinct from the
surrounding tissue and is three dimensional, a palpable ridge
which is often benign and may not have an imaging corre-
late, a palpable cord as seen in Mondor’s disease of the breast
or a palpable thickening which is an area of the breast that
has more firmness than the rest of the ipsilateral and/or the
opposite breast. There is a 5% reported association with
breast cancer in patients with palpable thickening [1]. All
palpable abnormalities should be evaluated with imaging
and clinical judgment should generally not be the deciding
factor on the need for imaging. Cysts cannot be reliably diag-
nosed by clinical examination; in one series of patients with
palpable abnormalities only 58% of the palpable cysts were
correctly identified. In one study, four surgeons agreed on
the need for a biopsy after independent evaluation in 73% of
15 cases that were subsequently proven to be malignant [2,
3]. Normal structures mistaken for a mass include a promi-
nent rib, a costochondral junction, or a firm margin at the
edge of a breast or at the edge of a biopsy defect. Firm ridges
M. K. Shetty (*)
Baylor College of Medicine, Houston, TX, USA
e-mail: mshetty@bcm.edu
© Springer Nature Switzerland AG 2021
M. K. Shetty (ed.), Breast & Gynecological Diseases, https://doi.org/10.1007/978-3-030-69476-0_2
2
Table 2.1 Summary of management of palpable breast lumps [4]
All palpable breast abnormalities must undergo a complete imaging
evaluation prior to biopsy
Women aged 40 years or older are initially evaluated with
diagnostic mammography or DBT
Women younger than 30 years should be initially evaluated with a
breast ultrasound targeted to the site of the palpable abnormality
Women in the age group of 30–39 years may be evaluated with
either ultrasound or diagnostic mammography or DBT
Correlation between imaging and the area of palpable abnormality
is important
A clinically suspicious mass must be biopsied despite a negative
imaging evaluation
of tissue in the inframammary regions are symmetrical. In
augmented breasts, the fill valve of the implant may provoke
concern for presence of a breast lump. Malignant masses
tend to be firm, with indistinct margins, with possible attach-
ment to the skin or deep fascia. Lack of tenderness is charac-
teristic. Benign masses tend to have discrete regular margins
and are generally mobile [4, 5]. Table 2.1 summarizes the
management of palpable breast lumps.
A palpable abnormality of the breast is the most clinically
significant breast symptom, with a higher probability of
malignancy than other symptoms with which women present
for a breast imaging evaluation (Fig. 2.1). A study of perfor-
mance measures for 401,548 diagnostic digital mammogra-
phy examinations among 265,360 women from 2007 to 2013
reported a cancer detection rate of 6.45% for patients with a
palpable lump compared to 2.49% for patients being evalu-
ated for other symptoms. The sensitivity and specificity of
mammography for detection of cancer in women with a pal-
pable lump was 92.3% and 86.8%, respectively [6]. In a
study of 935 breast lumps in women 30 or older, who under-
went combined evaluation with mammography and ultra-
sound, the malignancy rate was 8.2%. The incidence
increased with age from 2.5% in the 30–39 age group to
13.6% in women over the age of 50 years. Ultrasound identi-
fied 97.4% (75/77) of malignant lumps, mammography iden-
27
28 M. K. Shetty

a b

c d

Fig. 2.1 (a) Mediolateral and (b) craniocaudal views of the right breast
with spot compression in a 41-year-old female with a palpable breast
lump demonstrate a hyperdense focal asymmetry corresponding to the
lump. (c, d) Ultrasound shows two solid masses (arrowhead) side by
side, one is hyperechoic (c) with indistinct margins and (d) the second
solid mass is round and heterogeneous and with posterior acoustic
enhancement. (e) Histological diagnosis was mucinous carcinoma.
Photomicrograph of the mucinous breast carcinoma (and, H&E ×10).
Shows carcinoma cells (arrowhead) arranged in small groups sur-
rounded by lakes of extracellular mucin (M)
2 Imaging of the Symptomatic Breast
e Table 2.2 Palpable lump in women under the age of 30 years
Fig. 2.1 (continued)
tified 85.7% of malignant lumps, and 2 of 77 malignancies
were occult on both mammogram and ultrasound, both of
which were invasive lobular cancer that was subsequently
identified on a breast MRI [7]. Superior accuracy of a com-
bined mammography and ultrasound has been previously
reported [8]. The added value of mammography is to define
extent of cancer and screening of the symptom-free portions
of both breasts especially in older postmenopausal women in
whom the incidence of breast cancer is higher. In 35%
(27/77) of cases, mammography aided in better delineating
the extent of the disease, and 7 incidental malignancies in
non-palpable areas among 52 patients with incidental find-
ings [1]. Mammography also aids in definitive diagnosis of
benignity in 10% of cases thereby avoiding biopsy. Presence
of characteristic benign calcifications or fat was the feature
most commonly resulting in a benign assessment. Most of
the palpable cancers that are not detected on a mammogram
are in heterogeneously dense or dense breast with the palpa-
ble cancer being obscured by fibroglandular tissue.
The American College of Radiology Appropriateness
Criteria are evidence-based guidelines for specific clinical
conditions; recommendations vary based on the age group of
women presenting with a palpable lump (Tables 2.2, and 2.3).
In women over the age of 40, recommended initial examina-
tion is a diagnostic mammogram. If a suspicious finding is
seen, the next imaging modality is ultrasound and if there is a
benign finding such as a lipoma, no further imaging may be
needed; a probably benign finding or a suspicious finding
warrants additional evaluation with ultrasound. A negative
mammogram also needs further evaluation with a targeted
ultrasound of the area of concern. Exceptionally a palpable
cancer may be missed even in a predominantly fat replaced
29
1. Ultrasound is negative No further imaging is appropriate. If
finding is clinically suspicious,
biopsy
2. Ultrasound shows Diagnostic mammogram
suspicious finding
3. Ultrasound shows a No further imaging
benign finding (cyst)
4. Ultrasound shows a Ultrasound follow-up
probably benign finding
Table 2.3 Palpable lump in women over the age of 40 years
1. Diagnostic Targeted ultrasound
mammogram/DBT is
negative
2. Diagnostic No further imaging is needed
mammogram shows
benign findings
3. Diagnostic Ultrasound is done for correlation of
mammogram shows a clinical finding with imaging and for
probably benign finding lesion characterization
4. Diagnostic Ultrasound for lesion characterization
mammogram shows a and as a modality for biopsy
suspicious finding
breast as in cases of the extremely rare angiosarcoma of the
breast or in cases of small superficial palpable cancers
(Figs. 2.2, and 2.3). In women younger than 30 years, several
factors dictate initial and often use only of ultrasound and not
diagnostic mammography. A low incidence of breast cancer
(<1%), a theoretically increased radiation risk from mam-
mography, and a relatively denser breast tissue in younger
women that is associated with decreased mammographic sen-
sitivity are the reasons why ultrasound is recommended as the
initial imaging modality in women under the age of 30 years.
However, when a suspicious finding is encountered on ultra-
sound in these women, diagnostic mammography is war-
ranted to better delineate disease and identify features of
malignancy [9]. Core needle biopsy is superior to fine-needle
aspiration biopsy in terms of sensitivity and specificity and
histological grading of palpable cancers. Image-guided
biopsy is the preferred method to obtain tissue samples of
palpable masses identified on imaging, due to better sampling
possible and allowing placement of a tissue marker within the
sampled abnormality. It is prudent to use color Doppler on all
breast masses primarily to assess vascular flow and to avoid
biopsy of the extremely uncommon arteriovenous fistula or
an aneurysmal dilatation of an artery in the breast presenting
as a cystic mass (Fig. 2.4). Ultrasound guidance is the pre-
ferred method of guidance for percutaneous minimally inva-
30 M. K. Shetty

a b

c d

Fig. 2.2 (a, b) Left breast mammogram in a fatty breast, shows no
abnormality in a 62-year-old patient presenting with a large palpable
mass with no history of exposure to radiation, and a family history of
breast cancer in mother and personal history of dermal scleroderma. (c,
d) Ultrasound shows a hyperechoic mass (arrowhead) with ill-defined
borders corresponding to the palpable lump. Ultrasound-guided biopsy
showed an angiosarcoma of the breast. (e) Photomicrograph of the
angiosarcoma shows vascular structures lined by atypical cells with
hyperchromatic nucleus and cytoplasm (hematoxylin-eosin-safran ×40)
2 Imaging of the Symptomatic Breast 31

e may serve to reinforce benignity by demonstrating a cyst that

will not require imaging follow-up or show a solid mass with
benign characteristics that can then be placed in a BI-RADS
3 category and managed by short interval imaging follow-up
[2]. Alternatively, ultrasound may demonstrate fine irregular-
ity of margins in a mass that appeared circumscribed on the
mammogram leading to a BI-RADS assessment category
upgrading prompting a biopsy. Probably benign findings on
imaging can only be placed in the follow-up category if the
clinical findings are not suspicious. For those findings that
are followed up, biopsy is indicated if the palpable mass
increases in size by >20% in volume or diameter in a 6-month
period. Clinical evaluation by breast surgeons have similar
diagnostic accuracy in recommending further imaging in
clinically suspicious breast lumps [3].
Fig. 2.2 (continued)

Management of a Palpable Lump with a Negative

sive image-guided biopsy whenever the abnormality is seen
Mammogram and Ultrasound In this subset of patients, in
on ultrasound (Table 2.4). Surgical biopsy is not the preferred
the presence of a clinically suspicious finding, a biopsy must
method because of more complications, scarring, longer
be performed regardless of the imaging findings. This may
recovery time, and more cost, all of which are seen for a simi-
be percutaneous biopsy by palpation or an open surgical
lar accuracy [10]. In pregnancy and lactation, ultrasound is
biopsy. The negative predictive value of a combined mam-
the initial modality of choice for investigation of a palpable
mographic and sonographic evaluation of a palpable breast
lump. However, women with a suspicious finding on ultra-
lump is high and over 97% in several studies [4]. There is no
sound and in whom biopsy is being considered, or if malig-
established role for advanced breast imaging using positron
nancy is suspected, should undergo a diagnostic mammogram.
emission mammography, contrast enhanced digital mam-
Mammography is not a contraindication during pregnancy or
mography, or Tc-99m sestamibi MBI in such patients. MRI
during breastfeeding. Mammography is effective in detecting
may have value in problem solving in the setting of a post
microcalcifications and subtle architectural distortion, which
lumpectomy patient with a palpable lump at the surgical site
are not well seen on ultrasound and for defining extent of dis-
and inconclusive findings at conventional imaging. In
ease. For the same reasons in this subset of women with nega-
patients with negative findings on mammography and ultra-
tive findings on ultrasound, mammography should be
sound, MRI does not have a proven role. In a retrospective
considered particularly in those patients with a clinically sus-
series of 77 MRI exams performed on this subset of patients,
picious palpable lump [9].
a sensitivity of 100% was reported with a low specificity of
70%; the cancer yield was low with 2 cancers identified in 22
Management of a Palpable Lump with a Probably Benign
patients undergoing biopsy. There is no proven benefit for
Assessment at Imaging A palpable solid mass identified on
the use of additional imaging with breast MRI in patients
ultrasound and exhibiting benign features such as an oval or
with a negative finding after imaging with mammography
round shape with circumscribed well-defined margins and
and ultrasound. Another study of 29 palpable masses with an
homogenous echogenicity and in an orientation parallel to
incomplete assessment following conventional imaging
the chest wall and no posterior acoustic shadowing may be
reported a sensitivity of 100% but a low specificity of 74%.
managed by ultrasound surveillance. The incidence of malig-
MRI is hence not recommended due to cost effectiveness and
nancy of such solid masses is 0–2% [11, 12]. In women
low specificity. In patients with negative mammographic and
where a mammogram demonstrates a probably benign find-
sonographic evaluation and in the absence of a clinically sus-
ing, additional characterization with ultrasound is useful and
Another random document with
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second when her foolish husband, with cards and horses, succeeded
in losing the family estate. When he is killed in France, and the sixth
Earl of Clarehaven at last arrives, the impoverished countess still has
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detriment of the writer. Nevertheless, in spite of these handicaps,
there is acute analysis in Professor Mackenzie’s book. In its parts his
book is good; as a whole it lacks coherence and smoothness.”

+ − N Y Times 25:296 Je 6 ’20 1100w

Reviewed by Archibald MacMechan

Review 2:546 My 22 ’20 1300w

− + Sat R 130:319 O 16 ’20 820w
 “It is an entertaining book.”

+ Spec 124:215 F 14 ’20 160w

“With such fair promise it is the more regrettable that we should

be compelled, as we are, to admit that the performance is not
answerable to the high intent of the author. Not once nor twice, but
repeatedly throughout the book, we are confronted with a looseness
of thought, a disinclination to get to the heart of his subject which is
certainly surprising in an emeritus professor of logic.”

− + The Times [London] Lit Sup p207 Ap 1

’20 1950w

MACKENZIE, KENNETH JAMES JOSEPH.

Cattle and the future of beef-production in England.
*$2.50 (3c) Putnam 636.2

Agr20–243

A British work growing out of the necessity of conserving and

increasing the food supply. The author is reader in agriculture in the
University of Cambridge, and late editor of the Journal of the Royal
Agricultural Society of England, and the preface and one of the
chapters are contributed by F. H. A. Marshall, lecturer in agricultural
physiology, Cambridge. Contents: Introduction; Store cattle; Grass
beef; Winter beef; Beeflings; Dual-purpose cattle; Pedigree breeding;
Possibilities of the future; Physiological (by F. H. A. Marshall);
Breeds of cattle (four chapters); Index.
 “There are many signs that the line of reorganisation which Mr
Mackenzie indicates is the one which British agriculture is most
likely to follow, and it is sincerely to be hoped that his book will
circulate widely amongst the leaders of agricultural opinion and the
farming community generally.” C. C.

+ Nature 105:62 Mr 18 ’20 850w

“Mr Mackenzie’s book is all the more stimulating because he does

not profess to deliver a final opinion on any matters.”

+ Spec 124:278 F 28 ’20 1200w

“Mr Mackenzie is original and daring in some of his suggestions.”

+ The Times [London] Lit Sup p549 O 9

’19 200w

MACKIE, RANSOM A. Education during

adolescence. *$2 Dutton 373

20–4028

“Basing his arguments very largely on Stanley Hall’s ‘Educational

problems,’ the author proceeds to describe what are the essentials of
a high school curriculum.” (Cleveland) “In the introduction, Dr Hall
states that interest is the very Holy Ghost of education and so-called
formal studies and methods of discipline are largely a delusion and a
snare. They make degenerate mental tissue. In chapter I the author
states that the purpose of education, based not only on the needs of
society but also on the needs of the adolescent, are, according to Dr
Hall, ‘to train character, to suggest, to awaken, to graft interest, to
give range and loftiness of sentiment of view, to broaden knowledge,
and to bring everything into touch with life.’ During this age every
effort possible should be made to ‘fill and develop mind, heart, soul,
and body,’ especially with a view to vocational training. Such training
demands vitalized and humanized materials of education and
methods of instruction.” (School R)

“A good summary written with forceful simplicity.”

+ Booklist 17:54 N ’20

Cleveland p91 S ’20 50w
El School J 21:158 O ’20 200w

Reviewed by Paul Shorey

− Review 2:433 Ap 24 ’20 1600w

“Taken as a whole, this book is quite suggestive and inspirational.

Those persons who find the original works of G. Stanley Hall a little
weighty will have their minds refreshed with some of his doctrines by
reading Mr Mackie’s book, in which Dr Hall’s philosophy is
presented in a very readable style, yet with less tonnage than is found
in his own works.” J: B. Clark

+ School R 28:717 N ’20 820w

 MCKIM, WILLIAM DUNCAN. Study for the
times. *$2.50 Putnam 150

20–21213

The author calls his study “an inquiry into thought and motive,”
and this he considers imperative in these post-war times of
restlessness and impatience, of fads and crazes, of hasty formulation
of rights and noisy demand for their concession. Although much in
this mad onward rush may be of lasting value and help towards a
rejuvenation of the race, the latter, he holds, can only be
accomplished through careful patient thought and a study of the
limitations and frailties of our own individual natures. The book
deals largely with human psychology and the findings of psycho-
pathology. Contents: Introduction; Social influences; The individual
mind; The knowing function; The feeling function; Conclusion;
Index.

MACKINNON, ALBERT GLENTHORN. Guid

auld Jock. *$1.75 (2c) Stokes

19–18839

Jock had a keen relish for other people’s affairs, especially those of
Scotchmen. At the military hospital he ferreted out all such and
became their father confessor, their lawyer and general confidant.
The book is a collection of such confessions, of wrongs committed, of
secret sins, of weighted consciences. And every story had its
complement. The other man always turned up and in his turn made a
confession, and, thanks to Jock’s discretion, quick wit and sense of
humor, there was always a righting and a smoothing over. Some of
the titles are: Jock’s neebors; How Jock healed his comrade’s worst
wound; The barbed wires of misunderstanding; A prank o’ the post;
A maitter o’ conscience.

MCKISHNIE, ARCHIE P. Son of courage. il

*$1.75 (2c) Reilly & Lee

20–17187

Billy Wilson was one of the boys in a small settlement on the north
coast of Lake Erie. He was full of fun, always ready for some boyish
deviltry and the leader among his chums. The other side of his
character was love of nature and animals, undaunted courage and
love of fair dealing. He was afraid only of ghosts and even against
those he felt secure with his rabbit’s-foot charm. His exploits are
many and exasperating but he wins the heart of his stepmother and
of the prettiest girl in the settlement and becomes instrumental in
solving several mysteries and discovering a treasure.

“A satisfying story of outdoor life.”

+ Springf’d Republican p9a O 31 ’20 70w

[2]
MCKOWAN, EVAH. Graydon of the
Windermere. *$1.90 (2½c) Doran

20–21188
 Kent Graydon of the Windermere is a young Canadian engineer
who has gone West and made good. Since his schoolboy days he has
cherished the memory of Alleyne Milburne as his ideal of
womanhood. Then one summer he meets her again in his own
western country. He woos her ardently and it is not until he loses out
to his rival of earlier days that he realizes that it is not she who
embodies his ideals, but her cousin Claire, who is “honourable and
generous, sportsmanlike and fair, sympathetic and womanly.”

MCLACHLAN, HERBERT. St Luke, the man

and his work. *$3 (*7s 6d) Longmans 226

20–14133

“In a dozen chapters, Mr McLachlan, lecturer in Hellenistic Greek

in the University of Manchester, discusses St Luke, the man of
letters, the linguist, the editor, the theologian, the humorist, the
letter writer, the reporter, the diarist, etc. The work gives in brief the
views of German and English Protestants and Rationalists on every
phase of the Lucan problem—authenticity, language, accuracy,
doctrine and the like.”—Cath World

“This is a book from which the student of the Lucan writers will
learn much, whether he is among the conservatives or the
revolutionaries in textual criticism.”

+ Ath p540 Ap 23 ’20 800w

+ − Cath World 111:686 Ag ’20 320w
 “This scholarly book is to be commended to the notice of New
Testament students.”

+ The Times [London] Lit Sup p111 F 12

’20 290w

[2]
MCLAUGHLIN, ANDREW CUNNINGHAM.
Steps in the development of American democracy.
*$1.50 Abingdon press 342.7

20–8377

“A small volume comprising the lectures delivered by Professor

McLaughlin at Wesleyan university. This series of lectures was the
first to be given on the George Slocum Bennett foundation ‘for the
promotion of a better understanding of national problems and of a
more perfect realization of the responsibilities of citizenship.’ The
author tells us in the preface that his purpose ‘is simply to recount a
few salient experiences which helped to make America what it is, ...
as also to describe certain basic doctrines and beliefs, some of which
may have had their day, while others have not yet reached
fulfillment.’”—Am Hist R

“In a work of this character, the presentation of new historical

facts is not to be expected, but rather a new and fresh treatment of
them and of their significance. This latter task is what Mr
McLaughlin essayed in this series of lectures and this he has most
successfully achieved. Mr McLaughlin’s firm grasp upon the history
of the country is apparent throughout his treatment, and his
discussion is characterized by brilliant exposition and frequently
enlivened by flashes of wit and even restrained sarcasm.” H. V. Ames
 + Am Hist R 26:344 Ja ’21 540w
+ Am Pol Sci R 14:739 N ’20 50w

“Necessarily, the treatment of the subject is broad but it is marked

by a sense of proportion and by genuine insight.”

+ Bookm 52:368 D ’20 120w

MCLELLAN, ELEANOR. Voice education.

*$1.75 (7½c) Harper 784.9

20–16097

The author claims to have discovered a system of scientific vocal

technique through many years of practical research work by
beginning with correcting abnormalities of speech and voice action.
“This means rectifying conditions such as hoarseness, thickness of
the vocal cords and surrounding muscles, nodules, paralyzed vocal
cords, loss of high or low notes, stuttering, and all allied phonation
and action troubles.” (Preface) The contents are: Breath; Tone versus
vowel; Attack and poise of tone; Consonants; Interpretation;
Requirements of a great career; Emotions and characteristics of
singers.

“Every teacher and singer—and just people—would do well to take

the chapter on ‘Emotions and characteristics of the singer’ in this
book to heart. But there the practical help of the book to a singer or
teacher ends.”
 + − N Y Evening Post p27 O 23 ’20 150w

MACMANUS, SEUMAS. Top o’ the mornin’.

*$1.90 (3c) Stokes

20–17081

A collection of old and new tales in the Irish dialect. Some of the
copyright dates go back to 1899. Others belong to the present year.
The titles are: The lord mayor o’ Buffalo; The Widow Meehan’s
Cassimeer shawl; The cadger-boy’s last journey; The minister’s
racehorse; The case of Kitty Kildea: Billy Baxter’s holiday; Wee
Paidin; When Barney’s trunk comes home; Five minutes a
millionaire; Mrs Carney’s sealskin; The capture of Nelly Carribin;
The bellman of Carrick; Barney Brian’s monument; All on the brown
knowe; The heartbreak of Norah O’Hara.

“Splendid for reading aloud and full of fun and good Irish wit.”

+ Booklist 17:118 D ’20

“Mr MacManus has a certain delicate whimsicality of utterance

that transforms his somewhat sordid characters into beings of real
interest. They provide a volume of extremely pleasant little stories,
all quite indelibly branded with the mark of the shamrock.”

+ Boston Transcript p5 N 20 ’20 220w

 “Mr MacManus makes potent use of the folk-flavour: he draws his
inspiration from the touchstone of common humanity; but he never
hesitates to take what liberties he chooses with his material.” L. B.

+ − Freeman 3:238 N 17 ’20 170w

+ Outlook 126:378 O 27 ’20 60w

Reviewed by H. W. Boynton

Review 3:422 N 3 ’20 380w

+ Springf’d Republican p8 D 28 ’20 130w
Wis Lib Bul 16:195 N ’20 90w

MCMASTER, JOHN BACH. United States in

the world war (1918–1920). v 2 *$3 Appleton
940.373

20–12608

This is the second volume of Professor McMaster’s history of the

war. It deals with the work of the American troops in France and
ends with the peace conference and the rejection of the peace treaty
by the United States senate. Contents: Submarines off our coast; War
work at home; Fighting in France; Peace offensives; The armistice;
The president goes abroad; The peace conference; The treaty of
peace; The treaty rejected; Appendices; Index.
 + Booklist 17:25 O ’20

“The arrangement may be registered at once as both logical and,

within the scope of logic, rhetorical, even dramatic. He did not make
as good use as he might have done of the reports of Pershing and
March. When the chapter ‘War work at home’ is so well written it is a
pity that no attention should be paid to the efforts the enemy was
making to render that work futile.” Walter Littlefield

+ − N Y Times p22 Ag 29 ’20 2500w

+ Outlook 126:202 S 29 ’20 100w

“The second volume is a distinct disappointment. Even

considering the haste with which it must have been prepared, the
single chapter devoted to the military phase of the war is almost
absurdly inadequate and our naval participation is snubbed still
more severely. The chapter headed ‘War work at home,’ however, is
well done, and the one entitled ‘The treaty rejected,’ considering all
the difficulties of the topic, is also handled with considerable skill.”

− + Review 3:508 N 24 ’20 220w

R of Rs 62:445 O ’20 160w

“We do not observe that Professor McMaster has utilized any

sources of information which are not readily accessible; he seems
indeed to have relied largely upon the reports in the newspapers. The
book is disfigured by some careless mistakes.”

− + Spec 125:643 N 13 ’20 170w