Atlas of mammography

1032 Pages·2006·21.203 MB·English

by  Ellen Shaw de Paredes

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Table of Contents
1. Cover ............................................................................................................................................... 2
2. Authors .......................................................................................................................................... 90
3. Dedication ..................................................................................................................................... 91
4. Preface to the 3rd Edition ............................................................................................................. 91
5. Preface to the 1st Edition ............................................................................................................. 93
6. Foreword from the 2nd Edition .................................................................................................... 95
7. Contents ........................................................................................................................................ 96
8. 1 - Anatomy of the Breast ............................................................................................................. 97
9. 2 - Techniques and Positioning in Mammography ..................................................................... 125
10. 3 - An Approach to Mammographic Analysis ........................................................................... 188
11. 4 - Circumscribed Masses ......................................................................................................... 259
12. 5 - Indistinct and Spiculated Masses ......................................................................................... 379
13. 6 - Analysis of Calcifications ...................................................................................................... 454
14. 7 - Prominent Ductal Patterns .................................................................................................. 609
15. 8 - Asymmetry and Architectural Distortion ............................................................................. 647
16. 9 - The Thickened Skin Pattern ................................................................................................. 715
17. 10 - The Axilla ............................................................................................................................ 758
18. 11 - The Male Breast ................................................................................................................. 798
19. 12 - The Postsurgical Breast ...................................................................................................... 817
20. 13 - The Augmented Breast ...................................................................................................... 879
21. 14 - Galactography .................................................................................................................... 935
22. 15 - Needle Localization ............................................................................................................ 967
23. 16 - Percutaneous Breast Biopsy .............................................................................................. 998
24. 17 - The Roles of Ultrasound and MRI in the Evaluation of the Breast .................................. 1051
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2. Authors
Author
Ellen Shaw de Paredes MD, FACR
Founder and Director
Ellen Shaw de Paredes Institute for Women's Imaging, Glen Allen,
Virginia
Clinical Professor of Radiology, University of Virginia, School of
Medicine, Charlottesville, Virginia
Clinical Professor of Medicine, Virginia Commonwealth University,
Richmond, Virginia
Secondary Editors
Lisa McAllister
Acquisitions Editor
Kerry Barrett
Managing Editor
Leanne McMillan
Developmental Editor
Angela Panetta
Marketing Manager
Nicole Walz
Project Manager
Ben Rivera
Manufacturing Coordinator
Stephen Druding
Design Coordinator
Cathleen Elliott
Cover Designer
Aptara, Inc.
Production Services
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Maple Press—York
Printer
3. Dedication
To Victor, for his tremendous encouragement, support, advice, and
dedication.
and
To my parents, George and Julia Shaw, who inspired me to achieve
my goals.
I am forever grateful.
4. Preface to the 3rd Edition
“The heights by great men reached and kept Were not attained
by sudden flight But they, while their companions slept Were
toiling upward in the night”
—Longfellow
Mammography is a well established technique that has been proven
to reduce the death rate for breast cancer in screened populations
of women. Since the last edition of this book, major changes have
occurred in breast imaging. Mammography has been well
established and is utilized as a screening and diagnostic tool.
Breast ultrasound and MRI are also used frequently in the
evaluation of abnormalities. Breast interventional procedures are
more varied and serve to diagnose breast lesions. Digital
mammography has been developed, approved by the Food and Drug
Administration and is utilized in the United States and abroad. The
Mammography Quality Standards Act was passed by Congress and
implemented, and is an important mechanism for standardizing and
improving the quality of mammography services. The training of
radiologists in breast imaging is now a well established component
of radiology residency programs. Even with improved techniques,
tools and training, the challenge for the radiologist remains to
identify breast cancer when it is small and curable.
The focus of this book is to present via mammographic images, the
patterns of normal and abnormal breasts so that radiologists may
be better equipped to identify breast cancers. The Atlas of
Mammography serves as a primary training tool as well as a
reference source when one is faced with a diagnostic dilemma. The
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book is organized based on a pattern-recognition format, thereby
facilitating its use as a reference source.
Chapters on anatomy, techniques and positioning and an approach
to mammographic analysis are once again included as well as a
series of chapters on masses, calcifications, dilated ducts, the
edema pattern and asymmetries. The male breast, the axilla, the
post surgical and augmented breast are covered as well as a series
of chapters on breast interventions and the roles of ultrasound and
MRI. New chapters in this book are those on asymmetries and
distortions, the augmented breast, galactography, needle
localization, percutaneous breast biopsy, ultrasound and MRI. In
each chapter, comprehensive differential diagnoses are presented
with cases demonstrating the various entities.
Images were acquired on Siemens analog and full field digital
units. All mammographic images are presented with the patient's
left to the reader's left. I prefer to read film screen images in this
orientation so that the surface glare from the non emulsion side of
the film is reduced.
There are many individuals I wish to thank for their contributions
to this book. First, my technologists, Diane Loudermilk, Chrystal
Sullivan, Robyn Ost, Deborah Smith, and Lanea Bare are
responsible for the excellent radiography that served as the source
material for this book. Dr. Ami Trivedi was instrumental in case
collection and organization. Image production and graphics were
carefully prepared by Whitney Shank and who was assisted by
Mariel Santos. The photographs were prepared by Carlos Chavez.
The editorial assistance provided by my mother, Julia Shaw was
invaluable. The pathology images were provided by Dr. Michael
Kornstein to whom I am most thankful. Some of the unusual cases
were provided by former fellows including Drs. Neeti Goel, Thomas
Poulton, Thomas Langer, Deanna Lane, Patricia Abbitt, and Lindsay
Cheng.
I gratefully thank my secretary, Ms. Louise Logan who tirelessly
worked on the manuscript preparation, giving attention to all the
details. I also thank Kerry Barrett at Lippincott Williams & Wilkins
for her editorial assistance.
The Ellen Shaw de Paredes Research Foundation provided support
through a grant for book production and preparation of materials,
and I am most grateful for the unwavering support of the Board.
Several individuals who are extremely important to me helped to
guide my career into the subspecialty of breast imaging, a field
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that has so much meaning and importance in improving patients'
lives. My parents, George and Julia Shaw, encouraged me to be a
physician and taught me the value of education and the importance
of self discipline. My selection of the field of radiology was
suggested by my husband, Dr. Victor Paredes, who encouraged me
to write the first Atlas and has been incredibly supportive and
encouraging of this endeavor. I thank Dr. Theodore Keats, who was
the first radiology chair under whom I worked, and who directed
me into breast imaging, giving me the opportunity to develop the
section at the University of Virginia.
As I write this preface, I reflect on the many nights that I sat up
late until the early morning hours, working on the book. As life has
become busier with clinical work, the effort to produce this book
has been far greater than that for the earlier editions. This effort
was energized by the kind support and constant encouragement of
my husband, the loyalty of my dear dog Sam, who warmed my feet
as I wrote every word, and the powerful self discipline that my
mother has taught me. But most importantly so many of my former
residents and fellows have taught me how much their training in
mammography and their knowledge has changed their own
patients' lives. I hope that this work will provide the reader with
greater insight into the complexities of mammography.
Ellen Shaw de Paredes M.D.
5. Preface to the 1st Edition
“People see only what they are prepared to see.”
--(Ralph Waldo Emerson, Journals, 1863)
The early detection of breast cancer depends primarily on
mammography. With the increasing emphasis on screening
mammography by organizations such as the American Cancer
Society, there is rapidly expanding utilization of mammography
services, and there is a concomitant need for increased training of
radiologists and radiology residents.
High-quality images are absolutely necessary for the detection of
subtle abnormalities. There are tremendous differences in patterns
of the breast parenchyma among women. Although the number of
diseases that affect the breast is not vast, the perception and
analysis of an abnormality can make mammography seem difficult.
The purpose of this book is to present through images the various
manifestations of breast diseases, so that the reader may use it
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not only as a reference source, but also as a tool for developing
pattern recognition skills in mammography. The book will be useful
to practicing radiologists or to radiology residents in the process of
learning mammography.
Each chapter is introduced with a brief review of the various
processes that are manifested as a specific pattern, and is followed
by a series of radiographs demonstrating the lesions. Correlation of
clinical findings, mammographic findings, and histologic diagnosis
is made. In some cases, not only mammography but also
ultrasound images and histopathologic sections are correlated.
The initial sections discuss the anatomy and physiology of the
breast, the proper techniques for performing film-screen
mammography, and the analysis of a mammogram. The body of the
text deals with chapters divided by patterns—well-defined masses,
ill-defined masses, calcifications, prominent ducts, and thickened
skin. The remainder of the text covers the axilla, the male breast,
and interventional procedures in mammography.
The recent technical trends are towards film-screen mammography.
This book covers only film-screen techniques, and all images are
film radiographs. The images were produced almost entirely at the
University of Virginia on either an Elscint Mam-II unit, which does
not utilize a grid, or newer Siemens Mammomat B and the
Mammomat-2 units with grids. The higher contrast and improved
image quality on the radiographs from the equipment with grids
are apparent on the reproductions. Film-screen systems that have
been utilized are Kodak Ortho M film and Min-R screens and Kodak
T-Mat M film with Min-R Fast screens.
I wish to acknowledge the fine work of my dedicated technologists.
Deborah Smith, Diane Loudermilk, Mary Owens, Bonnie Mallan,
Marie Bickers, Theresa Breeden, and Lisa Elgin, who are
responsible for the radiographs. My special thanks go to Deborah
Smith for assisting in writing the section on patient positioning.
Manuscript preparation was carried out by Joy Bottomly and Patsie
Cutright. Esther Spears, Catherine Payne, Kim Nash, Adair
Crawford, Susan Bywaters, Tracy Bowles, and Lisa Crickenberger
assisted in the collection of cases and other production work. The
line drawings were produced by Craig Harding, and the
reproductions of radiographs were done by Ursula Bunch, Connie
Gardner, and Patricia Pugh of the Biomedical Communications
Division. I wish to thank Dr. Sana Tabbarah for her assistance with
the pathology slides and descriptions. My postresidency fellows,
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Drs. Patricia Abbitt and Thomas Langer, have assisted greatly with
clinical work, leaving me time to work on this project. My
appreciation also goes to other physicians who have sent me
interesting cases: Drs. Luisa Marsteller, George Oliff, Jay Levine,
Alexander Girevendulis, A.C. Wagner, Bernard Savage, M.C.
Wilhelm, Melvin Vinik, and James Lynde. Lastly, I wish to thank my
husband, Dr. Victor Paredes, for his assistance with the production
and editing of the book. Without their help, this work would not
have been possible.
Ellen Shaw de Paredes M.D.
6. Foreword from the 2nd Edition
Although many years of effort have been spent in improving
surgical and radiotherapeutic techniques, the mortality rate from
breast cancer remains appalling. It is commonly conceded that
early detection is the best means of reducing this mortality.
Fortunately, mammography has finally evolved as a means of
achieving this purpose. At last we have an opportunity to improve
significantly the cure rate for patients with breast cancer.
Mammography today is far different from what it was when I
became involved with it more than 25 years ago. Progress has
resulted from the dedicated efforts of the pioneers in this field,
such as Egan and Wolfe and their associates. Today, this progress
continues with further improvement in image quality, techniques
for localizing lesions, and biopsy procedures. These advances have
led to greatly improved detection rates. They have also made it
necessary for the radiologist constantly to modify his or her
patterns of practice and to become a perennial student in the field.
Dr. Ellen Shaw de Paredes has been tireless in the pursuit of
excellence in her mammographic program at the University of
Virginia. Her work exemplifies the enlightened state of modern
mammography. This book reflects her clinical experience and
contains a wealth of teaching axioms gleaned from working with
many residents, fellows, and surgical colleagues. Her new edition
includes additional case material to amplify her teaching points.
Also included are discussions of interventional procedures and a
valuable chapter on the postoperative breast. These additions
should further enhance the scope of this valuable work.
Theodore E. Keats M.D.
Professor and Chairman
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Department of Radiology, University of Virginia School of Medicine,
Charlottesville, Virginia
7. Contents
Front of Book
[+]
Authors
[+]
Editors
-
Dedication
-
PREFACE to the THIRD EDITION
-
PREFACE to the FIRST EDITION
-
FOREWORD from the SECOND EDITION
↑
Table of Contents
[+]
Chapter 1 - Anatomy of the Breast
[+]
Chapter 2 - Techniques and Positioning in Mammography
[+]
Chapter 3 - An Approach to Mammographic Analysis
[+]
Chapter 4 - Circumscribed Masses
[+]
Chapter 5 - Indistinct and Spiculated Masses
[+]
Chapter 6 - Analysis of Calcifications
[+]
Chapter 7 - Prominent Ductal Patterns
[+]
Chapter 8 - Asymmetry and Architectural Distortion
[+]
Chapter 9 - The Thickened Skin Pattern
[+]
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Chapter 10 - The Axilla
[+]
Chapter 11 - The Male Breast
[+]
Chapter 12 - The Postsurgical Breast
[+]
Chapter 13 - The Augmented Breast
[+]
Chapter 14 - Galactography
[+]
Chapter 15 - Needle Localization
[+]
Chapter 16 - Percutaneous Breast Biopsy
[+]
Chapter 17 - The Roles of Ultrasound and Magnetic Resonance Imaging
in the Evaluation of the Breast
8. 1 - Anatomy of the Breast
Chapter 1
Anatomy of the Breast
The breast or mammary gland is a modified sweat gland that has
the specific function of milk production. An understanding of the
basic anatomy, physiology, and histology is important in the
interpretation of mammography. With an understanding of the
normal breast, one is better able to correlate radiologic-pathologic
entities.
Development
The development of the breast begins in the fifth-week embryo
with the formation of the primitive milk streak from axilla to groin.
The band develops into the mammary ridge in the thoracic area
and regresses elsewhere.
If there is incomplete regression or dispersion of the milk streak,
there is accessory mammary tissue present in the adult, which
occurs in 2% to 6% of women (1). Accessory breast tissue,
particularly in the axillary area, that is separate from the bulk of
the parenchyma may be identified on mammography in these
women (2) (Fig. 1.1). The orientation of the milk streak is slightly
lateral to the nipple above the nipple line and medial to the nipple
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