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For personal use only; all rights reserved

Mammography
Nipple
Inversion
OBJECTIVE.

Carl L.Kalbhen1
Paula C. Kezdi-Rogus12
Mary P. Dowling1
Michael E. Flisak1

The purpose
of the nipple.

appearances

describe

SUBJECTS

AND

in 595

both with

breasts

and without

RESULTS.
pression;

similarly,

compression.

using

nipple

with

We examined

312 consecutive

women

who

craniocaudal

and mediolateral

oblique

views,

Nipple

position

compression,

(normal

nipple

inversion

was chronic

and

in one (3%)

prior

cancer

known.

Both

mained

inverted

visually
with

23 (7%)

multiple

of 36 breasts,

in one

(3%).

in 33 (92%)

mammographically.

breast

compression,

had

inverted

nursing

In the

and

cysts in one (3%),

the vast majority

causative

other

Also.

with

these

Presented at the annual meeting of the American

on

and axillary

lymphadenopathy

nversion puberty
of
nipple
reported
as the
typically
during
[1-31.

nipples

inversion,

1 Department of Radiology, Loyola University

Medical
Center, 2160 S. First Ave., Maywood, IL 60153. Address

been attributed

to the development

correspondence

tissue

the nipple

Blvd., Albany, NY 12208.

0361-803X/98/1701-117

American

Roentgen

AJR:170, January

normal

1998

inversion

nipple

may

position

between

be a variation

11, 2) and

has

of
also

of fibrous

the process
lacked

normal

patients

breast
from
with

during

in

this

setting

50%

(4J. In

normal

biopsies

findings

have

an occult
pathologic

been

findings

disease

phy

physical

I 1-7].

The

examination
reported

and mammograincidence

of an

un-

on

Because

ex-

random

sub-

recommended

[51.

II

to
The

re-

in nonmalignant

inversion

have included

fibrocystic
, 4.

of accentuated

xeromammograms.

physical

malignancy

and Mondors
faces between
were optimally

two

than

abscess

is

of

adulthood.

carcinoma

fat necrosis,

in adult women
warrants
evaluation

suggestive

5% to greater

duct ectasia,

Acute nipple inversion

less common
and always

and re-

and without

findings

and mammography,

amination

areoiar

Mammographic

was long-standing

that had occurred

ported

[11.

re-

Of the

inversion;
nearly one in
of breast compression.
In

cases of acute nipple

formation

not

nipples

in two (67%)

mammographic

exclude

and the subareolar

in one
were

in position.

in one (3%).
were

parenchyma
[3]. This
condition
impedes
nursing
and may predispose
to mastitis
and

with
Ray Society

nipple

has been
occurring
This
be-

inverted

normal

often failed to reveal nipple

normal
in position
as a result
typically

biopsy
factors

likewise,
of the 595 breasts, 29
Mammographic
findings
in the 33 breasts
in 29 (88%). probably
benign masses in two

inverted

nipple

benign

mammography;

varies

nign

Hospital, 319 S. Manning

became

derlying

Roentgen Ray Society, Boston, May 1997.

AJR1998;170:1 17-121

and acute in the

causative

of 36 clinically

29 (81%)

nipples

women

(89%),

but seven (19%)

Mammography
nipples
became

of women

factors.

after revision July 2, 1997.

3Present address: Department of Radiology, St Peters

visually,

at mammography.

of 36 breasts

in one (3%),

32 breasts

malignancy.
Ofthe
14 patients
with nipple inversion
women (14%) had an underlying
malignancy.

St.. Chicago, IL 60611.

was assessed

the findings

re-

which

prior

pregnancy

CONCLUSION.
five clinically
inverted

250 E. Superior

with

were

were

findings
in the three breasts
with acutely
vealed a suspicious
mass in one (33%).

Hospital,

and

in one (3%) of 36 breasts,

Reported
causative
factors

(6%),

Memorial

or inverted)

and correlated

nipples
(5%) were inverted
on mammography.
with chronically
inverted
nipples were normal

to C. L Kalbhen.

position.

inversion.

Of the 3 12 women, 29 (9%) had visually

inverted nipples without
breast comof the 595 breasts. 36 (6%) had visually
inverted
nipples without
breast

Clinical

3 12 women,

2Present address: Department of Radiology, Northwestern

and mammographic
on nipple

remaining
three breasts (8%). Nipple
inversion
occurred
at birth
during puberty
in 21 (58%). and during adulthood
in 14 (39%).
(3%),

Received June 5, 1997; accepted

the clinical

compression

of

routine

imaged.
breast

of breast

in women

METHODS.

Evaluation

was to correlate

the effects

findings

for mammography

resulted

of this study

determine

the mammographic

ferred

in the

changes,

6, 71.
contrast

at inter-

soft tissue and air. nipples

imaged and easy to assess on
The

nipples

can also

be

117

Kalbhen
on film-screen

evaluated

bright

light

appearance
during

of the nipple

breast

knowledge.

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the

not been

reflects
that

by breast

nipple

has
The

on

nipple

position.

pur-

with

old

(mean.

of 36 breasts
was

breasts.

prospectively
who

our

institution,

fr

diagnostic

were

was
defined

2t-9()

years

old

The

breasts

were

visually

in-

old).

duration

known

causative

dure.

infection.

cancer).

and

Acute
of less

greater

than

Routine
were

Iselin,

supervising
used.

to our

projected

mal.

nipple

tenor

was

renchyrnal

cancer

with

bilum-

2): no causative
32

remaining

sion

bilateral

23

women

years

screening

mal

in one

in 22 (76%).

( 10%),

acute

nipple
(3%

remaining

the

acute

discharge

in one (3%).

). new

axillary

nipple
from

inversion

or

probably

a chronically

palpable
lymphadenopathy
new

in
mass

in

stable

595

illary

ap-

old

lymphadenopathy

with chron-

interpreted
in

in
two

in one (3%),

cysts

63

had a

29 (5%)

findings

masses

These

(mean.

nipple.

were

benign

inver-

six (26%).

breasts.

nipples

mammo-

of 23 women

years

inverted

benign

pected multiple

had

of the 33 breasts

Mammograms
inverted

as-

visual

inversion;

17 (74%)

39-90

mammographically

ically

the

(7%)

nipple

in

in the

Of

and

23

of

were

old).

complete

compression.

unilateral

and

found

mammographic

position

evidence
was

was the same in

mediolateral
ob-

we

the

3 12 women,

graphic

nipple

with

as nor29

(88%),

(6%),

sus-

and new axnormal

breast

or

were

not
on

below

more

the

( Fig.

I ).

skin

flush

with

the

as nor-

the following

were

pseudomass.

an-

posterior

con-

areolar
margin.
The mammograms

abnormalities.

nip-

Nipples

defined

midareola.

fashion

and

light.

of

visual

mammographically
of

subareolar

at the

in routine

The

were

by one
of the

a bright

considered
or

concavity

assessed

during

of the

the

irn-

in profile

unaware

image

on all images:

retraction

pearance

of

mammography

to or were

one

if one

vexity

meno-

The indications
for mammography
in the 29
women
with inverted
nipples
were
routine
three

and

of nipple

benign

position

between

sessment

prior

the

projections.

Of the

during

position

markers

position.

with

anterior

A nipple

present

in

visual

during breast compression

both the craniocaudal
and
agreement

position

3). For each

were ob-

interpreted

were

examined

on at least

inverted

described

the

before

of 36

in

(Fig.

for

technologist

imaged

were
who

of

areola

(Fig.

breasts.

seven

Interpretation

assessment

that

(89%).

and prior
(3%)

(3%)

normal

compression

595

I . Of

nipples.

inverted

became

breast

causative

in one
(3%).

( 19%)

lique

of 36

clinically

on nip-

in Table

image.

radiologists
were

breasts

reported

36

compression

compres-

images
the

were

mammograms

pIes

nipple
breast

standard

nipples

(3%).

were

The

pregnancy

in one

factors

in 21 (58%).
(22%). and after

in one

33
in-

4 years.

(3%)

of breast

are summarized

chronic.
oblique

and

Nipple

in one

pectomy

than

in one

eflects

of a probably
in one (3%).

2 (Siemens,

during
of

nursing

(8%)

fillow-up
mass

as du-

inversion

considered

mammographic

Mammographic
The

proven

was defined

unit,

discretion

normal

one

proce-

nursing.

mediolateral

visually

breasts.

longer

The
the

595

cases. nipple

6-month

pie position

nipple.

in three

). and

mammographic

and any

surgical

on a Mammomat

According

at least

re-

( 17%).

six

were

inverted

The

nipple

was

radiologist.

protocol.

118

inversion
6 months:

sion. Additional

two

pregnancy.

and

areola
below

inverted.

prior

6 months

that

questioned

age at onset.

nipple

the

were

factors

than

p()si-

the

of inversion.

assessed

at

with

considered

NJ) mammography

tamed

nipple

depressed

nipples

obtained

was again

flush

(e.g..

breasts

Nipples

nipples

were

craniocaudal

ages

and

recorded.

to or were

trauma.

ration

of 595

technologist.

inverted

garding

45

A total

margin
with

and

were

as normal:

areolar

patients

for screening

in eight
in

the

in the remaining

for

puberty

Of

(3%

benign

in 22

inverted

acute

at birth

during

factors
opsy
at

women

anterior

were

consecutive

mammography

The

assessed

extended
the

patients

by the same

tion

312

for

examination.

59 years

spected

referred

267

studied.

(mean.

examined

were

was

present

menopause

We

old).

In all chronic

occurred

pause

women

years

and chronic

(92%).

breasts
version

Patients

65

inversion

Onset

and Methods

was unilateral

36 (6%) had a clinically

breasts,

the

pIe inversion.

Subjects

inversion

nip-

29

nip-

describe

in women

years

29 (9% ) had clinical

women and bilateral in the remain(24%). These 29 women were 39-X)

of

Nipple

the clinical

and

findings

mammographic

(76%

ing seven

orien-

compression

was to correlate

one

pIe inversion;

our

and mammographic
appearances
of the nippie. determine
the effects
of breast compression

Results
Of the 3 12 women.

to

in the literature.

addressed

its position
and.

possibility

of this study

pose

but

mammographic

compression.

is altered

tation

examinations,

The

is required.

et al.

and
were

for the presence

gross
then
of pa-

Fig. 1.-68-year-old
woman with clinical inversion of right nipple since birth. Inversion persisted visually during
breast compression.
A and B, Mammograms
of right breast in mediolateral
oblique (A) and craniocaudal
(B) projections
reveal subareolar pseudomass
mediolateral
oblique

(arrow),
representing
mammographically
inverted nipple.
projection
(arrowheads,
A). Breast parenchyma
is normal.

Gross retraction

AJR:170,

can be seen in

January

1998

Mammography

of Nipple

Inversion

One patient
has had a subsequent
gram that showed
normal findings:
has not undergone
The

follow-up

suspicous

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mammography.

mammographic

third case of acute

sequently
palpable.
went a biopsy

nipple
and

followed

mass

by simple

ductal
surgery

tal metastases.

The primary

mastectomy
Metastatic
diffuse skele-

carcinoma.

revealed
breast

malignancy

to be the direct

considered

acute nipple

in the

inversion
was subthis patient
under-

for infiltrating
workup before
was

mammothe other

cause

of her

inversion.

Discussion
To our
version

knowledge,

141.

literature
only

briefly

ease and
Fig. 2.-89-year-old
woman with clinical inversion of right nipple for 12 years. Patient stated that nipple inversion
occurred because of cancer and became more pronounced after lumpectomy. Nipple inversion persisted visually during breast compression.
A, Mammogram
of right breast in craniocaudal
projection,
photographed
to simulate
effects of bright light.
shows nipple inversion, evidenced by gross retraction (arrow) and anterior concavity at midareola (arrowhead).
Breast parenchyma is normal.
B, Xeromammogram of right breast in craniocaudal projection obtained 11 years before A and 1 year after
lumpectomy also shows gross retraction of nipple (arrow) and anterior concavity
at midareola
(arrowhead).
Breast parenchyma is normal.
C, Xeromammogram of right breast in craniocaudal projection, obtained 1 year before B when patient presented
with acute

nipple

inversion

and palpable

lateral

mass,

shows

1.5-cm

lateral

mass (curvedarrow).

Note desmo-

breast

inversion

the actual

in one

up mammograms

(3%).

were

Six-month

at that time.

follow-

recommended

for both

athy

breasts with probably

benign mammographic
masses: One has shown stability for I 8 months
and

the

new

other

axillary

for 6 months.

The

lymphadenopathy
lymph

subsequent

node

breast

chronic

underwent

biopsy

that

cancer

and treated

was

with

diagnosed

modified

2 years

radical
of Breast

and

No

by

revealed

the

earlier

mastectomy
Compression

two

had

malignant

which

been

present

clinicians

with acute

(33%)

(Fig.

either

of

on Nipple
Visually Without

and

4). No biopsy
the

breasts

normal

(n

= 559)

Position

inverted

(n

= 36)

559(100%)

inverted

7(19%)
29 (81%)

559(100%)

Inverted

1998

described

7(19%)
29 (81%)

59

at large.

historic

data

was

on nip-

unilateral

as typically

[ 1-3).

reported

in

onset

more

than

outside

occurring
of

4()C%

our

puberty.

of the skin and nipples during

mammographic
interpretation
is useful

on

routine

and can provide

nancy.

systemic

patients:

evidence

previous

nearly

and

A mammographically
not be confused
with

ina pa-

one

breast

compression.
not be surprised
clinical

subareolar
with

clinical

mass. Nipple
underestimated
in position

inverted

as a result

of

Radiologists,
therefuire.
to find normal-appear-

on mammograms
inversion.

mammographic
nipple

inversion
in our

of five clinically

normal

nipple

malig-

surgery.

became

should

of advanced

disease.

nipples

with

Normal

AJR:170, January

been

puberty

ing nipples

Mammographically

( mean.

population

Inversion

renchymal
subareolar
was mammographically

Breast Compression

for

older

three fourths of women and bifourth.

Although
nipple
inver-

previous
radiation.
verted nipple must

Visually
Normal

findings.

were

Examination

one

performed

was

During Breast Compression

Normal

findings
in

has

cases

Be-

referred

in our patients.
More than 90%
chronic,
and nearly 90% had no
cause.

identifiable

during

of breasts).

were

able to obtain

approximately
lateral in one
sion

three

the mammass

with

years.

of the

as normal

a suspicous

described

inversion;

were interpreted
(67%)

for

were
in any

nipple

to her

had no known

and mammographi-

prevalence
of nipple inwomen
is expected
to be

all

pIe inversion
of cases were

lymphadenop-

to be related

abnormalities

referring

mograms
in

new

inversion.

palpable

breasts

metastatic
adenocarcinoma
from a contralateral primary breast malignancy.
This patients
breast

nipple

cause

with

The

not considered

was

nipple
9% of

less.

We were
parenchyma

finding

population.
clinically
in

the female

among

its prevalence.

(5%

they

old) than

somewhat

data

women

mammography.
Therefore.

dis-

and few numeric

it as a common

of women

these

years

mentioned
breast

of breasts)

(6%
in 7%

cause

is

regarding

present

inin the

of

textbooks

imaging,

was

women
cally

carcinoma

was obtained.

of nipple
recently

inversion

most

I 1-3, 5-71. In our patient

version

days after this image

Nipple

in

have been reported

other than to describe

plastic reaction (open arrows) extending toward nipple. Nipple is less inverted than on A and B. Also note less
pronounced anterior concavity at midareola (arrowhead).
Patient underwent
lumpectomy
for infiltrating
ductal
several

the topic

has not been addressed

inversion

of some women
Conversely.
a
mass
may

in a woman
not

always

119

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Kalbhen

et al.

.p

Fig. 3.-68-year-old
woman with clinical inversion
of
right nipple since puberty.
A, Frontal photograph shows inversion of right nipple.
Left nipple is clinically normal.
B, Lateral photograph
during compression
of right
breast

in craniocaudal

projection

shows

normal

posi-

tion of nipple, which is in profile for photograph and

with respectto mammographic film.
C, Mammogram in craniocaudal projection, photographed to simulate effects of bright light, shows normal position of nipple, which is flush with and slightly
anterior to areola (arrowheads).
Breast parenchyma
is normal.

D, Xeromammogram in craniocaudal projection obtained

9 years before C also shows normal position of nipple,
which projects anteriorto
areola (arrowheads).
Contrast
between skin and air is accentuated by xeromammographic

technique,

which

better reveals findings

seen on

C. Breast parenchyma is normal.

C

represent
significant

the nipple. To prevent

error, we recommend

nologists

notes describe

the nipple

during

We anticipated
inversion-a
would

become

breast

the visual

encountering
clinically

120

nipple

normal

inverted

breasts

position

of

compression.
pseudo-

nipple

as a result

compression-in
a small
tients,
but pseudoinversion
any of the 559

this potentially
that the tech-

that

of breast

number of our
was not identified

with

clinically

pain

normal

nipples.
pie

Our

inversion,

of mammographic

definition

necessitating

that

nip-

findings

be

with

long-standing

ipsilateral

present on all images,

and our imaging
protocol,
requiring at least one image of a normal nipple

thy

to be obtained

adenopathy

partially

least

mammographic

As expected.
not associated
ings

suggestive

in profile,
responsible
nipple

for

of

the

to be at

absence

of

pseudoinversion.

chronic
with

are believed

any

nipple

inversion

mammographic

malignancy.

One

Nipple

nipple

metastatic

from

inversion

axillary

a contralateral

inversion

breast

dence to support

and

a causal

malignancy.

the development

predated

by 9 years,

developed

lymphadenopa-

we

found

relationship

no

of
evi-

between

the two processes.

was
findpatient

The reported association

of acute nipple
version
with an underlying
malignancy
adult

women

varies,

as do

the

inin

recommenda-

AJR:170, January

1998

Downloaded from www.ajronline.org by 202.116.91.2 on 09/08/14 from IP address 202.116.91.2. Copyright ARRS. For personal use only; all rights reserved

Mammography

of Nipple

Inversion

Fig. 4.-76-year-old
woman with clinical inversion of right nipple for 4 months. No palpable abnormalities
were indicated
by referring
clinician.
Nipple inversion persisted
visually during breast compression.
A, Mammogram of right breast in mediolateral oblique projection, photographed to simulate effects of bright light, shows nipple inversion, evidenced by anterior concavity
at midareola (arrowhead).
B, Same mammogram as A, photographed in standard fashion, reveals 2.5-cm central mass (solidarrow).
Note desmoplastic reaction (open arrow) extending toward nippie.
C.Magnified mammogram of mass in mediolateral oblique projection shows spiculated margins and multiple suspicous microcaicifications. Patient was referred to breast surgeon, who was able to palpate mass. Patient underwent biopsy and subsequent simple mastectomy for advanced infiltrating ductai carcinoma several days after mammography.

tions

for evaluating

significance

this

of acute

study population

finding

nipple

is limited

[4,

because

The

ing

malignancy.

in our

this

finding

5].

inversion
only

three

cases presented with underlying

malignancy.
However, if we include
all 14 cases (three
acute,
ring

1 1 chronic)
of nipple
during adulthood,
only

caused

by

malignancy.

caused

by carcinoma

disease

[I

study

were

Nipple

inversion
in our

on mammography,

static

disease

Acute

nipple

rants

further

and this patient

at

the

inversion
evaluation

AJR:170, January

1998

time

and

subareolar
findings

we

biopsies

of

in adult

ad-

in patients

on mammography

and

examination.

to exclude

We wish
sistance

with

to thank

Michele

Graham

for

as-

war2.

Baum M. The breast. In:

Williams
NS, eds. Bailey
tice ofsurgerv.
22nd ed.
Hall Medical. 1995:544-545
Bates B. The breasts and

Mann CV, Russell RCG.

and Love c a short pracNew York: Chapman
&

of

recent

inversion

In: Bates

B. ed. A

the

nipple:

J R Soc Med

apprnac/l.

2nd ed. New York:

McGraw-

Hill. 1997:72-75
6. Tanabe KK. Duct ectasia.
periductal
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