Teaching Atlas of Mammography (RÖFO-Ergänzungsbände) PDF
Preview Teaching Atlas of Mammography (RÖFO-Ergänzungsbände)
Teaching Atlas of Mammography László Tabár, MD Professor Department of Mammography Central Hospital, Falun, Sweden University of Uppsala School of Medicine Uppsala, Sweden Peter B. Dean, MD Professor Department of Diagnostic Radiology University of Turku Director of Breast Imaging Turku University Hospital Turku, Finland With the contribution of Tibor Tot, MD, PhD Associate Professor of Pathology and Chairman Department of Pathology and Clinical Cytology Central Hospital Falun, Sweden 4th edition 669 illustrations Thieme Stuttgart · New York IV LibraryofCongressCataloging-in-PublicationDataisavailablefrom Important note: Medicine is an ever-changing science undergoing thepublisher. continual development. Research and clinical experience are con- tinuallyexpanding our knowledge, inparticular ourknowledgeof proper treatment and drug therapy.Insofarasthisbook mentions any dosage or application, readers may rest assured that the au- thors,editors,andpublishershavemadeeveryefforttoensurethat 1stEnglishedition1983 such references are in accordance with the state of knowledge at 2ndEnglishedition1985 thetimeofproductionofthebook. 1stGermanedition1985 Nevertheless,thisdoesnotinvolve,imply,orexpressanyguarantee 1stSpanishedition1985 or responsibility on the part of the publishers in respect to any 1stItalianedition1986 dosage instructions and forms of applications stated in the book. 1stPortugueseedition1994 Every user is requested to examine carefully the manufacturers’ 3rdEnglishedition2001 leafletsaccompanyingeachdrugandtocheck,ifnecessaryincon- 2ndItalianedition2002 sultationwithaphysicianorspecialist,whetherthedosagesched- 1stFrenchedition2002 ulesmentionedthereinorthecontraindicationsstatedbytheman- 2ndSpanishedition2002 ufacturers differ from the statements made in the present book. 2ndPortugueseedition2002 Such examination is particularly important with drugs that are eitherrarelyusedorhavebeennewlyreleasedonthemarket.Every dosagescheduleoreveryformofapplicationusedisentirelyatthe user’s own risk and responsibility. The authors and publishers re- quest every user to report to the publishers any discrepancies or inaccuraciesnoticed.Iferrorsinthisworkarefoundafterpublica- tion, errata will be posted at www.thieme.com on the product descriptionpage. ©2012GeorgThiemeVerlag, Someoftheproductnames,patents,andregistereddesignsreferred Rüdigerstrasse14,70469Stuttgart,Germany to in this book are in fact registered trademarks or proprietary http://www.thieme.de names even though specific reference to this fact is not always ThiemeNewYork,333SeventhAvenue, made in the text. Therefore, the appearance of a name without NewYork,NY10001,USA designationasproprietaryisnottobeconstruedasarepresentation http://www.thieme.com bythepublisherthatitisinthepublicdomain. Thisbook,includingallpartsthereof,islegallyprotectedbycopy- Coverdesign:ThiemePublishingGroup right.Anyuse, exploitation, or commercialization outsidethenar- TypesettingbyprimustypeRobertHurlerGmbH,Notzingen, rowlimitssetbycopyrightlegislation,withoutthepublisher’scon- Germany sent,isillegalandliabletoprosecution.Thisappliesinparticularto PrintedinGermanybyOffizinAndersenNexö,Leipzig photostat reproduction, copying, mimeographing, preparation of microfilms,andelectronicdataprocessingandstorage. ISBN978-3-13-640804-9 123456 V Preface to the Second Edition This atlas consists of a systematic collection of mammograms of This book was written to help radiologists fill the anticipated breastlesions,manyintheearlyandsomeintheearliestdetectable need for many skilled mammographers. We expect that this need phasesofdevelopment.Thesereflectthetypesoflesionstobefound willcontinuetogrowaspopulationscreeningwithmammography inamammographyscreening population. Smallmalignantlesions becomesmorewidelyadopted. are presumed to be the precursors of large, metastasizing lesions, This edition contains no major revisions and no additional fig- and their removal at a sufficiently early stage should prevent the ures. We are grateful to many of our colleagues for constructive developmentofbreastcancertothestagewhereitkillsthepatient. criticism, and with the publication of this second editionwehave There is no question that mammography screening, when per- endeavoredtorespondtotheircomments. formed to high standards and repeated at sufficiently frequent intervals,leadstothedetectionofmostbreastcancersatapreclin- icalstage.Theresultisalowermortalityfrombreastcancerand,in LászlóTabár,Falun,Sweden manycases,lessmutilatingandtraumatictherapythanpreviously PeterB.Dean,Turku,Finland possible. Preface to the Third Edition Thepassageoftimehasprovidedtheopportunityforaddingalong- upon fifteen years further experience in teaching breast imaging termfollow-upforthosewomenwhowerediagnosedwithbreast whenrevisingthetext.Thesefactorsincombinationwillexplainto cancer twodecadesagoand whosemammogramsareincludedin thereaderwhysomuchofthetexttothisbookhasbeenrewritten thisedition.Severalcaseshavebeenreplacedtoemphasizeimpor- forthisedition. tantteachingpoints. Closecooperationwithaskilledpathologistisessentialifaradi- Our understandingof thevariationsinnormaland pathological ologist is to learn from his/her own patients. We are pleased to breast anatomyasrepresented onthemammogramhasincreased acknowledgethecontributionofTiborTot,MD,whohasprovided greatly during the intervening years, thanks largely to knowledge uswiththehistopathologicalimages. gainedfromtheanalysisofthick-section,three-dimensionalhistol- ogy. There have also been a few changes in nomenclature, which LászlóTabár,Falun,Sweden havebeenintroducedtothisedition.Theauthorshavealsodrawn PeterB.Dean,Turku,Finland VI Preface to the Fourth Edition Theconversiontodigitalmammography,adramaticimprovement disease will be more precisely described, particularly with multi- in breast ultrasonography, and the ascendance of breast magnetic focal and diffuse breast cancers, and patient management can be resonance imaging (MRI) during the past decade serve to confirm morefullyindividualized. theneedforradiologiststobefullyconversantwiththeradiologic These advancements serve all women, who first and foremost anatomy of the normal breast and its distortion by benign and want to be assured that they do not havebreast cancer. For those malignantbreastlesions.Allthesemajorimprovementsinimaging whodevelopthedisease,earlydetectionandaccuratediagnosiswill bringuseverclosertotheactualsubgross(3D)imageofthebreast ensurethebestachievablelong-termoutcome,whileinmanycases tissue. less radical, custom-tailored treatment will minimize the side ef- The subgross, thick-section histologic images of normal and fectsoftherapy. pathologic breast tissue serve as an intermediary between the Long-term (25–30 years) follow-up of breast cancer screening imperfectresolutionofanyimagingmethodandthecellulardetails trialscontinuestoconfirmthebenefitsofearlydiagnosisandcom- seen under themicroscope.Furthermore, studying thesesubgross pletesurgicalremovalofbreastcancer,whichcontinuetoimprove images assists in comprehending the pathophysiologic processes withfollow-uptime,whilemanypurported”harms”fadeaway.The leading to specific changes in the breast tissue. Breast imagers significant improvement in the spectrum of tumor characteristics who are familiar with these alterations at the subgross level will obliges health-care professionals involved in the diagnosis and have a great advantage in the interpretation of breast images, re- treatmentof breast cancer patients to re-evaluatetheir diagnostic gardlessofthemethodologyused. and therapeutic approaches to the disease. We have revised this Asbreast-imagingmethodologyimprovesbyquantumleaps,and Atlaswiththesethoughtsinmind. asbreastimagersbecomemoreknowledgeablefromstudyingsub- grosshistologyimagescorrelateddirectlywiththeimagingmeth- ods, the preoperative diagnoses will become ever more accurate, LászlóTabár,Falun,Sweden smallertumorswillbedetectedmorereliably,thefullextentofthe PeterB.Dean,Turku,Finland VII Introduction The purpose of this Atlas is to teach radiologists how to analyze Ratherthanstarting withthediagnosisanddemonstratingtyp- mammograms and arrive at the correct diagnosis through proper icalfindings,theapproachofthisAtlasistoteachthereaderhowto evaluationofthefindings.Theillustratedcasescoverpracticallythe analyzetheimageand reachthecorrectdiagnosisthrough proper entire spectrum of breast abnormalities. They are based upon re- evaluation of the mammographic signs. Prerequisites for the per- ferredpatientmaterialaswellasuponalargenumberofmammo- ceptionandevaluationofthemammographicfindingsareoptimum graphicscreeningexaminations.Thiseditionincludestheoutcome technique,knowledgeofanatomy,andunderstandingofthepatho- ofscreen-detectedcasesfollowedforupto25years. logicalprocessesleadingtothemammographicappearances. Therearetwobasicstepsintheinterpretationofmammograms: Breast lesionsareextremely heterogeneous.It is an oversimpli- perceptionandanalysis. fication to expect that one single imaging method can image all Sincethegreatestbenefitofmammographyliesinthedetection breastdiseasesubtypeswithequalproficiency. of breast carcinoma in its earliest possible stages, every mammo- Consequently, ancillary imaging and interventional methods grammustbesystematicallysurveyedforthesubtlehintsofmalig- have been developed during the past few decades to increase the nancy.PerceptionistaughtinthisAtlasbydescribingamethodfor sensitivityanddiagnosticaccuracyofbreastimaging.Theprolifer- systematicviewing(Chapter2).Thereaderisthenprovidedwitha ation and refinementof these methodshasnot decreased the im- series of mammograms, many with obscure lesions, to encourage portanceofathoroughmammographicworkup.Onthecontrary,a practicewiththismethod.Withthehelpofacoordinatesystem,the careful analysis of the subtle mammographic signs will help the lesions can be precisely located. Practice in perception continues radiologist choose the ancillary imaging and interventional meth- throughouttheAtlas.Afterdetectinganabnormalityonthemam- od(s)bestsuitedforreachinganaccuratediagnosisanddescribing mogram,thediagnosiscanbereachedthroughacarefulanalysisof thetrueextentofthedisease. themammographictumorfeatures.Additionalprojections,coned- downcompression,andmicrofocusmagnificationviewsareneces- saryfortheanalyticworkup,priortotheuseofotherimagingtools. VIII Contents I AnatomyoftheBreast . . . . . . . . . . . . . . . . . . . . . . 1 II MethodforSystematicViewingofMammograms. . . 5 III ApproachtoViewingMammographicImagesand InterpretingtheFindings . . . . . . . . . . . . . . . . . . . . 15 IV Circular/OvalLesions . . . . . . . . . . . . . . . . . . . . . . . 17 SignsofPrimaryImportanceinDiagnosing Circular/OvalLesions . . . . . . . . . . . . . . . . . . . . . . . . 18 SignsofSecondaryImportanceinDiagnosing Circular/OvalLesions . . . . . . . . . . . . . . . . . . . . . . . . 19 Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 PracticeinAnalyzingCircular/OvalTumors(Cases1–56) 21 V Stellate/SpiculatedLesionsandArchitectural Distortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 PracticeinAnalyzingStellate/SpiculatedLesionsand ArchitecturalDistortionontheMammogram (Cases58–85). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 VI CalcificationsontheMammogram. . . . . . . . . . . . . . 169 Malignant-TypeCalcificationswithinDuctsand/or inTerminalDuctalLobularUnits. . . . . . . . . . . . . . . . . 170 PracticeinCalcificationAnalysis(Cases86–109). . . . . . 173 Benign-typeCalcificationswithinDuctsorLobules . . . . 239 MiscellaneousCalcifications. . . . . . . . . . . . . . . . . . . . 242 PracticeinCalcificationAnalysis(Cases112–152). . . . . 243 VII ThickenedSkinSyndromeoftheBreast . . . . . . . . . . 289 PhysicalExamination . . . . . . . . . . . . . . . . . . . . . . . . 291 MammographicAppearance . . . . . . . . . . . . . . . . . . . 291 VIII OverallStrategy. . . . . . . . . . . . . . . . . . . . . . . . . . . 295 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 FurtherReading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 I Anatomy of the Breast
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