Pictorial Essay pissn J Korean Soc Radiol 2012;66(1):69-76 Breast Findings on Computed Tomography: Correlation with Mammography and Breast U

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1 Pictorial Essay pissn J Korean Soc Radiol 2012;66(1):69-76 reast Findings on Computed Tomography: Correlation with Mammography and reast Ultrasonography 1 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 : 유방촬영및유방초음파의비교 1 Jae Hyun Kim, MD 1, Yun-Woo Chang, MD 1, Jung Hwa Hwang, MD 1, Yoo Na Kim, MD 1, Hye Shin hn, MD 1, Kui Hyang Kwon, MD 1, Hyung Hwan Kim, MD 2 1 Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea 2 Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea Chest CT often provides images of the breast when scanning is performed for pulmonary and cardiac disease or metastasis work up, and can allow for a confident diagnosis of breast lesions. This study is an exhibit with an introductory section for the usefulness of a chest CT and how to accurately describe breast lesions found on CT. In addition, a review of the benign and malignant lesions on chest CT with correlation of breast images was made. Index terms Multi-Detector Computed Tomography Chest reast Imaging Received ugust 26, 2011; ccepted October 4, 2011 Corresponding author: Yun-Woo Chang, MD Department of Radiology, Soonchunhyang University Hospital, 22 Daesagwan-gil, Yongsan-gu, Seoul , Korea. Tel Fax ywchang@schmc.ac.kr Copyrights 2012 The Korean Society of Radiology 서론 양성유방병변 흉부전산화단층촬영 (computed tomography; 이하 CT) 은폐나심장질환의평가를위해시행되거나암전이를평가하기위해시행되나종종유방질환에대한진단에도움이되는소견들을제공한다 (1, 2). CT의사용이증가되면서유방조직이포함되는흉부 CT에서발견되는유방병변이증가하고있고흉부 CT에서처음발견되는유방병변들도늘고있다. 그러므로이들병변들을유방촬영이나초음파검사와비교하여아는것이 CT에서발견되는유방병변들을감별하는데도움이된다. CT는양성과악성질환을발견하는데민감하나우연히발견된유방병변에서는진단이과장될수있고양성과악성을구분하는것이쉽지않다 (1, 2). 몇몇연구에서 CT에서우연히발견된유방병변중 0.4~2% 에서유방암이었다고보고하고있다 (3, 4). 그러므로유방질환에대한정확한임상정보가필요하며유방검사방법과의비교가필요하다. 저자들은흉부 CT에서발견된유방영상에대해유방촬영술과유방초음파검사를비교하여양성과악성질환들을보여주고자한다. 양성유방병변에대한 CT 소견은몇몇질환에서는특징적인소견을보인다. 과오종 (Hamartoma) 지방과유선조직을가지는드문종양으로만져지는경우가많으며 유방내유방 으로칭해지기도한다. CT에서는잘그려지는경계를가지며지방을포함하는혼합음영의병변으로나타난다. 유방촬영술에서얇은고음영의가성피막으로둘러싸인경계가좋은종괴로보이며초음파에서경계가잘그려지는비균질한혼합에코의종괴로보인다 (Fig. 1)(1, 5). 섬유선종섬유선종은유방의가장흔한종양으로 15세 ~40대여성에서흔하며다발성혹은양측성으로나타날수있다. 유방소엽내에결합조직의증식으로발생하며중년이후의여성에서기질세포의유리질화가되면석회화를동반할수있다 (1, 2). submit.radiology.or.kr 대한영상의학회지 2012;66(1):

흉부전산화단층촬영에서보이는다양한유방질환의영상소견 C Fig. 1. 61-year-old female.

. Mammography shows well-defined, fat containing, heterogeneous mass in right breast, representing

. Sonography shows well-defined, round, hypoechogenic mass on right breast.

14-year-old male with gynecomastia in both breast.

Chest CT scan shows soft tissue density in both subareloar regions (arrows), representing

2 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 C Fig year-old female.. CT scan shows well-defined fat containing soft tissue density mass in right breast (arrows).. Mammography shows well-defined, fat containing, heterogeneous mass in right breast, representing hamartoma. C. Sonography shows large circumscribed, ovoid mass with mixed internal echogenicity. Fig year-old woman.. Chest CT scan shows well-defined, round, homogeneous enhancing mass on right breast (arrow).. Sonography shows well-defined, round, hypoechogenic mass on right breast. This lesion was confirmed as fibroadenoma at biopsy. CT 에서경계가잘그려지는둥글거나난원의종양으로보인 다 (Fig. 2). Fig year-old male with gynecomastia in both breast. Chest CT was performed due to evaluation of asthma. Chest CT scan shows soft tissue density in both subareloar regions (arrows), representing gynecomastia. 남성유방 (Gynecomastia) 남성유방이비종양성증식을보이는것으로단측혹은양측성으로올수있다. 청소년기와 50대, 두번의호발연령을가지며호르몬의불안정한상태를유발할수있는내적혹은외적호르몬의불균형에서생긴다. 내인성요인으로간경화, 호르몬분비고환종양, 폐암이나신장암의종양부수증후군혹은갑상선기능항진증이있으며외인성요인으로는알코올이나마리화나, 단백동화스테로이드 (anabolic steroid) 나향정신성약물들이다 (2, 6). CT에서화염상 (flame shape) 의연부조직감쇠 (soft tissue attenuation) 로나타난다 (Fig. 3). 70 대한영상의학회지 2012;66(1):69-76 submit.radiology.or.kr

김재현외 이물질주입에따른육아종 (Granuloma due to Foreign ody Injections) 실리콘이나파라핀을미용목적으로유방내에주입한경우에석회화나육아종이형성된다. CT에서주입된실리콘들은다발성의둥글고밀도가높은결절로보인다.

수술초기의혈종이나장액종은조직변성을보이는종양으로보여남아 있는악성종양과감별해야한다 (2). 혈종은시간이지남에따라점차흡수되어크기가작아지므로다른종양과구별하는데도움이된다. CT에서혈종은장액종에비해상대적인고음영의액체저류로보이며 (Fig. 5) 혈액은흡수되면서장액종을형성한다.

58-year-old female with incidental breast lesions.. High resolution CT (HRCT) was performed to evaluation of fever and upper respiratory tract infection.

5. 77-year-old female with contusion of breast due to traffic accident.. Chest CT scan shows non-enhancing, huge, soft tissue density mass in left breast.

3 김재현외 이물질주입에따른육아종 (Granuloma due to Foreign ody Injections) 실리콘이나파라핀을미용목적으로유방내에주입한경우에석회화나육아종이형성된다. CT에서주입된실리콘들은다발성의둥글고밀도가높은결절로보인다. 파라핀의경우높은줄무늬모양음영의기이한구조적왜곡으로결절성의연부조직음영보다는거친석회화로나타난다 (Fig. 4). 혈종과장액종 (Hematoma and Seroma) 외상, 수술혹은조직검사후에혈종이나장액종이생길수있으며진단은임상적인병력과연관하여얻어진다. 수술초기의혈종이나장액종은조직변성을보이는종양으로보여남아 있는악성종양과감별해야한다 (2). 혈종은시간이지남에따라점차흡수되어크기가작아지므로다른종양과구별하는데도움이된다. CT에서혈종은장액종에비해상대적인고음영의액체저류로보이며 (Fig. 5) 혈액은흡수되면서장액종을형성한다. 조영증강후주변부조영증강이보일수있어농양과도유사하나고열과백혈구상승등의임상소견이구별에도움이된다 (1). 악성유방병변 CT의역동적조영증강기법을사용하면유방악성종양은불규칙한경계, 불규칙한모양, 환형조영증강을보인다는보고 Fig year-old female with incidental breast lesions.. High resolution CT (HRCT) was performed to evaluation of fever and upper respiratory tract infection. HRCT scan shows multiple high density foreign bodies mainly in pectoralis muscle (arrows).. Mammography shows injection foreign bodies in right breast. Fig year-old female with contusion of breast due to traffic accident.. Chest CT scan shows non-enhancing, huge, soft tissue density mass in left breast.. Sonography was performed after 10 days, irregular, ill-defined, low echogenic cyst with septa and debris are seen in left breast, possible of liquefaction of hematoma correlation with history. submit.radiology.or.kr 대한영상의학회지 2012;66(1):

흉부전산화단층촬영에서보이는다양한유방질환의영상소견 가있으며침상또는불규칙한경계가악성진단에정확한소견으로알려져있다 (7). CT의역동적조영증강에서배출 (washout) 되는소견이나소엽분포를따르는부분적조영증강은악성진단에높은양성예측도를보인다고보고되었다 (8).

악성엽상종은섬유선종과유사하게상피와결합조직기질을가지는종양으로 35~55 세의여성에서호발하며병리적으로침습적종양경계, 현저한정도의과세포기질과증식 (hy- percellular stromal overgrowth), 현미경소견에서유사분열수가 10 high-power fields 에

CT에서경계가잘그려지는다양한조영증강의종양으로보인다 (Fig. 6). 점액암종은많은양의점액를포함하는종양으로서서히자라는비교적예후가좋은종양으로나이든여성에서호발한다 (11).

. Multi-detector CT scan shows huge, relatively well-defined, mild enhancing mass with calcifications in left breast.

4 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 가있으며침상또는불규칙한경계가악성진단에정확한소견으로알려져있다 (7). CT의역동적조영증강에서배출 (washout) 되는소견이나소엽분포를따르는부분적조영증강은악성진단에높은양성예측도를보인다고보고되었다 (8). 경계가잘그려지는악성종양경계가잘그려지는유방종양의 10~20% 는악성종양으로악성엽상종, 점액암종, 수질성암종, 유두상암종, 화생성암종등이있다 (9). 이들종양들은양성종양처럼보이는악성종양으로유방영상검사로감별하기가쉽지않다. 악성엽상종은섬유선종과유사하게상피와결합조직기질을가지는종양으로 35~55 세의여성에서호발하며병리적으로침습적종양경계, 현저한정도의과세포기질과증식 (hy- percellular stromal overgrowth), 현미경소견에서유사분열수가 10 high-power fields 에 5개이상, 기질세포다형태성 (stromal cellular pleomorphism) 을가지는경우악성엽상종으로분류한다 (10). 유방영상소견은경계가잘그려지는섬유선종과유사한종양으로낭성성분은양성엽상종보다악성엽상종에서더잘동반된다. CT에서경계가잘그려지는다양한조영증강의종양으로보인다 (Fig. 6). 점액암종은많은양의점액를포함하는종양으로서서히자라는비교적예후가좋은종양으로나이든여성에서호발한다 (11). 유방초음파검사시경계가잘그려지는둥글고난원의종양으로낭성과고형성분이혼합되어보이므로 CT에서양성종양과유사하게보일수있으며 (Fig. 7) 수질암종도드문유방종양으로 35세이하젊은여성에서생기는경우가많고유 Fig. 6. Malignant phyllodes tumor.. Multi-detector CT scan shows huge, relatively well-defined, mild enhancing mass with calcifications in left breast.. Sonography shows circumscribed mass with hyperechogenic internal septums. Fig year-old female with mucinous carcinoma.. CT scan shows well-defined, non/poorly enhancing mass in right inner breast (arrows).. Sonography shows well-defined, isoechoic mass in right breast (arrows). 72 대한영상의학회지 2012;66(1):69-76 submit.radiology.or.kr

김재현외 방초음파검사에서경계가잘그려지는둥글거나난원형의종양으로내부에괴사나출혈을유발하여낭성성분을가질수있다 (12). CT 소견으로도경계가잘그려지는종괴로보이며균질하지않은조영증강을보일수있다 (Fig. 8).

CT에서도유방촬영이나초음파소견과같이경계가잘그려지는둥글거나난원의유방종양으로보이며내부에낭성성분을가지는경우내부에조영증강이되지않을수있다 (Fig. 9).

CT에서는치밀한침상형의종괴로조기조영증강그리고 / 또는주변의환형조영증강을보인다. CT는피부의두꺼워짐, 임파절침윤, 흉벽침윤등을확인하는데도움이되며양측성병변을발견할수도있다 (Fig. 10). 유방촬영과는달리미세석회화는 0.

염증유방암염증유방암은초기진피림프계침윤을보이는예후가좋지않은공격적인종괴로임상적으로열감, 유방피부의발적, 오렌지껍질같은피부 (erysipeloid edge, peau d orange), 유두뒤당김 (nipple retraction) 의소견에기초하여진단한다.

. Multi-detector CT scan shows round, relatively well-defined, subtle enhancing mass in right breast (arrow).

5 김재현외 방초음파검사에서경계가잘그려지는둥글거나난원형의종양으로내부에괴사나출혈을유발하여낭성성분을가질수있다 (12). CT 소견으로도경계가잘그려지는종괴로보이며균질하지않은조영증강을보일수있다 (Fig. 8). 침습유두암종은유방암의 2% 를차지하며유관내형 (intraductal type) 과낭내형 (intracystic type) 으로나타날수있다 (13). CT에서도유방촬영이나초음파소견과같이경계가잘그려지는둥글거나난원의유방종양으로보이며내부에낭성성분을가지는경우내부에조영증강이되지않을수있다 (Fig. 9). 침윤유방암침윤유방암의 80~90% 를차지하는가장흔한악성종양으로유방촬영에서불규칙, 침상경계의치밀한종괴로초음파에서도불규칙, 원형또는침상형의종괴로보인다. 유방촬영에서다형태성미세석회화를포함하는경우는유관상피내암 (DCIS) 이동반되어있음을의미한다 (1, 5). CT에서는치밀한침상형의종괴로조기조영증강그리고 / 또는주변의환형조영증강을보인다. CT는피부의두꺼워짐, 임파절침윤, 흉벽침윤등을확인하는데도움이되며양측성병변을발견할수도있다 (Fig. 10). 유방촬영과는달리미세석회화는 0.5 mm 이하의크기를가지므로공간분해능이떨어지는 CT에서발견하기어렵다 (2). 염증유방암염증유방암은초기진피림프계침윤을보이는예후가좋지않은공격적인종괴로임상적으로열감, 유방피부의발적, 오렌지껍질같은피부 (erysipeloid edge, peau d orange), 유두뒤당김 (nipple retraction) 의소견에기초하여진단한다. 유방염이나농양과구분이어려울수있다 (1). CT에서공격적인현저한피부두꺼워짐과주변부조영증강을보이며종종명확히구분되는종괴가보이지않을수도있다 (Fig. 11). 병변의범위를 Fig. 8. Medullary carcioma.. Multi-detector CT scan shows round, relatively well-defined, subtle enhancing mass in right breast (arrow).. Sonography shows a microlobulated, round, isoechogenic mass with posterior enhancement (arrows). C Fig. 9. Papillary carcinoma.. Multi-detector CT shows lobulated, round, cystic mass with solid enhancing component in right breast.. lobulated, oval mass with well-circumscribed margins is seen on mammogramphy. C. Sonography shows a well-circumscribed, oval, solid and cystic complex echoic mass. submit.radiology.or.kr 대한영상의학회지 2012;66(1):

흉부전산화단층촬영에서보이는다양한유방질환의영상소견 C D Fig. 10. ilateral invasive ductal carcinoma.,.

spiculated, irregular, enhancing mass in left breast (arrow). C, D.

Pathology confirmed bilateral invasive ductal carcinoma. Fig. 11.

Physical examination revealed erythema and flaking of nipple.

6 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 C D Fig. 10. ilateral invasive ductal carcinoma.,. Contrast-enhanced CT scan shows irregular, round, enhancing mass in right breast (arrow) and spiculated, irregular, enhancing mass in left breast (arrow). C, D. These masses are well correlated with multi-detector CT, and ultrasonography. Pathology confirmed bilateral invasive ductal carcinoma. Fig year-old female with invasive ductal carcinoma and paget disease. Physical examination revealed erythema and flaking of nipple.. CT scan shows multiple irregular, ill-defined, heterogeneous enhancing masses with skin thickening in left breast and nipple.. Mammography shows irregular, ill-defined mass with thickening of nipple and periareolar region. 파악하는데있어유방촬영술보다도움이된다 (14). 유방전이 유방전이는반대측유방에서다른쪽으로의전이는볼수있 으나유방외의장기에서유방으로의전이는드물며유방암의 2% 를차지한다. 가장흔한유방전이는악성흑생종이며림프종, 폐암과유암종의순으로알려져있다 (15). 난소암, 신장암, 대장암이나자궁경부암에서유방으로전이될수도있다. 전이 74 대한영상의학회지 2012;66(1):69-76 submit.radiology.or.kr

김재현외 C Fig. 12. Melanoma metastasis.,. Contrast enhanced CT scan shows multiple, well-defined, round masses with homogeneous or heterogeneous enhancement in both breasts (arrow). C. Sonography shows well-defined heterogeneous low echoic masses.

결론 CT에서발견되는유방질환들은진단에도움이되는올바른정보들을제공할수있다. CT는액와부전이를평가하고피부나흉곽의병변을평가하는데있어유방촬영이나초음파보다유용한정보를제공할수있다. 그러나 CT에서보이는유방질환들은종종과대평가되거나과소평가될수있으므로유방병변에대한정확한임상정보하에유방촬영이나유방초음파를통한정확한진단이요구된다. 참고문헌 1.

Yi JG, Kim SJ, Marom EM, Park JH, Jung SI, Lee MW. Chest CT of incidental breast lesions. J Thorac Imaging 2008;23: 148-155 3. Swensen SJ, Jett JR, Hartman TE, Midthun DE, Sloan J, Sykes M, et al.

7 김재현외 C Fig. 12. Melanoma metastasis.,. Contrast enhanced CT scan shows multiple, well-defined, round masses with homogeneous or heterogeneous enhancement in both breasts (arrow). C. Sonography shows well-defined heterogeneous low echoic masses. Melanoma is confirmed by core needle biopsy. This patient with a history of a malignant cutaneous melanoma of nasal cavity had been surgically excised. 암은다발성으로양측성의표재성위치를보인다 (Fig. 12). 결론 CT에서발견되는유방질환들은진단에도움이되는올바른정보들을제공할수있다. CT는액와부전이를평가하고피부나흉곽의병변을평가하는데있어유방촬영이나초음파보다유용한정보를제공할수있다. 그러나 CT에서보이는유방질환들은종종과대평가되거나과소평가될수있으므로유방병변에대한정확한임상정보하에유방촬영이나유방초음파를통한정확한진단이요구된다. 참고문헌 1. Harish MG, Konda SD, MacMahon H, Newstead GM. reast lesions incidentally detected with CT: what the general radiologist needs to know. Radiographics 2007;27 Suppl 1:S37-S51 2. Yi JG, Kim SJ, Marom EM, Park JH, Jung SI, Lee MW. Chest CT of incidental breast lesions. J Thorac Imaging 2008;23: Swensen SJ, Jett JR, Hartman TE, Midthun DE, Sloan J, Sykes M, et al. Lung cancer screening with CT: Mayo Clinic experience. Radiology 2003;226: Lin WC, Hsu HH, Li CS, Yu JC, Hsu GC, Yu CP, et al. Incidentally detected enhancing breast lesions on chest computed tomography. Korean J Radiol 2011;12: Marsteller LP, Shaw de Paredes E. Well defined masses in the breast. Radiographics 1989;9: Kopans D. The male breast. In Kopans D. reast Imaging. Philadelphia: Lippincott-Raven, 1998: Inoue M, Sano T, Watai R, shikaga R, Ueda K, Watatani M, et al. Dynamic multidetector CT of breast tumors: diagnostic features and comparison with conventional techniques. JR m J Roentgenol 2003;181: Miyake K, Hayakawa K, Nishino M, Nakamura Y, Morimoto T, Urata Y, et al. enign or malignant?: differentiating breast lesions with computed tomography attenuation values on dynamic computed tomography mammography. J Comput ssist Tomogr 2005;29: Yoo JL, Woo OH, Kim YK, Cho KR, Yong HS, Seo K, et al. Can MR Imaging contribute in characterizing well-circumscribed breast carcinomas? Radiographics 2010;30: Liberman L, onaccio E, Hamele-ena D, bramson F, Cohen M, Dershaw DD. enign and malignant phyllodes tumors: mammographic and sonographic findings. Radiology 1996;198: Memis, Ozdemir N, Parildar M, Ustun EE, Erhan Y. Mucinous (colloid) breast cancer: mammographic and US features with histologic correlation. Eur J Radiol 2000;35: Meyer JE, min E, Lindfors KK, Lipman JC, Stomper PC, Genest D. Medullary carcinoma of the breast: mammographic and US appearance. Radiology 1989;170: Lam WW, Tang P, Tse G, Chu WC. Radiology-Pathology conference: papillary carcinoma of the breast. Clin Imaging 2005;29: Kim SM, Park JM. Computed tomography of the breast. submit.radiology.or.kr 대한영상의학회지 2012;66(1):

8 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 bnormal findings with mammographic and sonographic correlation. J Comput ssist Tomogr 2003;27: Kopans D. Pathologic, mammographic, and sonographic correlation. In Kopans D. reast Imaging. Philadelphia: Lippincott-Raven, 1998: 흉부전산화단층촬영에서보이는다양한유방질환의영상소견 : 유방촬영및유방초음파의비교 1 김재현 1 장윤우 1 황정화 1 김유나 1 안혜신 1 권귀향 1 김형환 2 흉부전산화단층촬영은폐나심장질환을평가하거나암의전이를찾기위해시행하나예상치않은유방의이상소견을 발견할수있다. 저자들은흉부전산화단층촬영에서보이는다양한유방질환의영상소견들을양성및악성병변으로나 누어유방촬영및유방초음파검사와비교하여보여주고자한다. 1 순천향대학교병원영상의학과, 2 순천향대학교천안병원영상의학과 76 대한영상의학회지 2012;66(1):69-76 submit.radiology.or.kr

Kbcs002.hwp

Kbcs002.hwp Does Real-time Compound Imaging Improve Evaluation of reast Cancer Compared to Conventional Sonography? o Kyoung Seo, M.D., Yu Whan Oh, M.D., Kyu Ran Cho, M.D., Young Hen Lee, M.D., Hyung Joon Noh, M.D.,