Lonie Sall<owsl<i I Thieme RadCases Breast Imaging Edited by Lonie Salkowski, MD, MS Professor of Radiology, Breast Imaging University of Wisconsin School of Medicine & Public Health Madison, Wisconsin Series Editors jonathan Lorenz, MD Associate Professor of Radiology Department of Radiology The University of Chicago Chicago, Illinois Hedor Ferra I, MD Senior Clinical Educator lnterventional Radiology NorthShore University HealthSystem Evanston, Illinois Thieme New York • Stuttgart • Delhi • Rio Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Executive Editor: Timothy Hiscock Managing Editor: ]. Owen Zurhellen IV Editorial Assistant: Sohini Das Senior Vice President, Editorial and Electronic Product Development: Cornelia Schulze Production Editor: Teresa Exley, Maryland Composition International Production Director: Andreas Schabert Senior Vice President and Chief Operating Officer: Sarah Vanderbilt President: Brian D. Scanlan Compositor: MPS limited Printer: Sheridan Books, Inc. library of Congress catalogiog-in-Publication Data Breast imaging I edited by Lonie Salkowski. p.; cm.-(RadCases) Includes bibliographical references. ISBN 978-1-60406-191-8 I. Salkowski, Lonie.II. Series: RadCases. IDNLM: 1. Breast Diseases-radiography-case Reports. 2. Diagnosis, Differential-Case Reports. 3. Mammography-Case Reports. WP 815] 618.1 '90754-dc23 2012033626 Copyright Cl2014 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher's consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translat ing, preparation of microfilms, and electronic data processing and storage. Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowl edge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designa tion as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Printed in the United States of America ISBN 978-1-60406-191-8 Also available as an e-book: eiSBN 978-1-60406-192-5 First and foremost, I want to thank my patients. You are my best teachers, and I am grateful for the faith you entrusted in me. Thank you for allowing me to care for you. I also thank my colleagues and staff for championing me as I took on this project. Thank you for your assistance in providing me with interesting case material. And, of course, this book would not have been possible without the encouragement and support of my parents, family, and friends. Thank you all for helping me to achieve my goal. To students of all ages, I hope this book helps you understand more about the complexity of breast imaging and that you find the same enthusiasm and success in helping your patients that I have found with mine. To access additional material or resources available with this e-book, please visit http:J/www.thieme.com/bonuscontent. After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content. RadCases Series Preface The ability to assimilate detailed information across the review books, we removed the guesswork by providing clear entire spectrum of radiology is the Holy Grail sought by annotations and descriptions for all images. In our opinion, those preparing for the American Board of Radiology there is nothing worse than being unable to locate a subtle examination. As enthusiastic partners in the Thieme Rad finding on a poorly reproduced image even after one knows Cases Series who formerly took the examination, we under the final diagnosis. stand the exhaustion and frustration shared by residents The electronic cases expand on the printed book and and the families of residents engaged in this quest. It has provide a comprehensive review of the entire subspedalty. been our observation that despite ongoing efforts to improve Thousands of cases are strategically designed to increase the Web-based interactive databases, residents still find them resident's knowledge by providing exposure to additional selves searching for material they can review while preparing case examples-from basic to advanced-and by exploring for the radiology board examinations and remain frustrated ~Aunt Minnie's," unusual diagnoses, and variability within by the fact that only a few printed guidebooks are available, a single diagnosis. The search engine gives the resident a which are limited in both format and image quality. Perhaps fighting chance to find the Holy Grail by creating individual their greatest source of frustration is the inability to easily ized, daily study lists that are not limited by factors such as locate groups of cases across all subspecialties of radiology radiology subsection. For example, tailor today's study list that are organized and tailored for their immediate study to cases involving tuberculosis and include cases in every needs. Imagine being able to immediately access groups of subspecialty and every system of the body. Or study only high-quality cases to arrange study sessions, quickly extract thoracic cases, including those with links to cardiology, nu and master information, and prepare for theme-based radi clear medicine, and pediatrics. Or study only musculoskel ology conferences. Our goal in creating the RadCases Series etal cases. The choice is yours. was to combine the popularity and portability of printed As enthusiastic partners in this project, we started small books with the adaptability, exceptional quality, and inter and, with the encouragement, talent, and guidance of Tim active features of an electronic case-based format. Hiscock at Thieme, we have continued to raise the bar in The intent of the printed book is to encourage repeated our effort to assist residents in tackling the daunting task of priming in the use of critical information by providing a por assimilating massive amounts of information. We are pas table group of exceptional core cases that the resident can sionate about continuing this journey, hoping to expand the master. The best way to determine the format for these cas cases in our electronic series, adapt cases based on direct es was to ask residents from around the country to weigh in. feedback from residents, and increase the features intended OVerwhelmingly, the residents said that they would prefer a for board review and self-assessment. As the American concise, point-by-point presentation of the Essential Facts of Board of Radiology converts its certifying examinations to each case in an easy-to-read, bulleted format. This approach an electronic format, our series will be the one best suited is easy on exhausted eyes and provides a quick review to meet the needs of the next generation of overworked and of Pearls and Pitfalls as information is absorbed during re exhausted residents in radiology. peated study sessions. We worked hard to choose cases that could be presented well in this format, recognizing the jonathan Lorenz, MD limitations inherent in reproducing high-quality images Hector Ferral, MD in print. Unlike the authors of other case-based radiology Chicago, IL Preface Breast imaging is a continuously evolving specialty expe the reader with some quick facts and also some management riencing many changes over a relatively short period of aspects related to the case. Whole mammogram images of time. The technology and the imaging guidelines are al a case are provided when possible. Although this approach ways being updated. Staying up-to-date within the field may include some normal images, the idea is to present it can be challenging. The underlying disease processes, as a case rather than as findings. The findings are presented both benign and malignant, have not greatly changed over later in the case, demonstrating the specific nuances of the the years; however, our understanding and classification finding that should yield a specific diagnosis. of the diseases has evolved. With this in mind, the cases Building the RlldCases Breast Imaging series book has presented in this text and online material reflect the ar been a labor of love. I have truly enjoyed the experience and ray of diseases that one could expect to experience over a learned a great deal about different aspects of the breast im career in breast imaging, both in general practice and as aging field and the publication process. I hope that you will a specialist. As new understandings of disease processes gain as much or more from the cases than I have in putting and new technology are developed, it is expected that them together. Constructive feedback is always welcome to the management of breast diseases and how we approach assist in improving and updating the material. This book was them from an imaging and management standpoint are published prior to the release of BI-RADS version 5, thus I bound to change. It is important to remain open to the am sure that any significant updates will be made to the in constant changes. teractive material as information is provided. It has been very humbling and gratifying to be part of Thieme's RadCases series. The goal of the cases is to provide Lonie Salkowski, MD, MS Acknowledgments I wish to thank Wally Peppler, PhD, for his technical assistance with image processing for the manuscript. Walter W. Peppler, PhD UW School of Medicine 81 Public Health Department of Medical Physics and Radiology Technical image support Enterprise Imaging UW Hospital 81 Clinics Image acquisition from PACs 1 Case 1 A B c D • Clinical Presentation A3 2-year-old woman presents for baseline mammogram. Her mother had breast cancer at age 59. • Further Wortc:-up E F