{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:40:08Z","timestamp":1760060408490,"version":"build-2065373602"},"reference-count":31,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T00:00:00Z","timestamp":1756166400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: The normal pattern of nipple enhancement on magnetic resonance imaging (MRI) is defined based on healthy individuals, as it correlates with the structural anatomy of the nipple\u2013areola complex (NAC). Understanding the normal range of nipple morphology and enhancement on MRI allows radiologists to better identify abnormalities. Some authors have previously detailed the morphology and characteristics of nipple\u2013areola complex enhancement, both in normal and pathologically infiltrating conditions. Our aim is to present a case series involving a population of women with breast cancer infiltrating the NAC, retrospectively evaluated at our institution. Furthermore, based on previously published literature and our own experience, we intend to propose potential standardized language to describe tumor-infiltrating NAC enhancement on MRI and compare it with CT and PET findings. Methods: Our study included 110 breast cancer patients with NAC infiltration, who were referred to our hospital from August 2023 to July 2024. All patients were candidates for neoadjuvant chemotherapy and therefore underwent MRI and CT; 33 of them also underwent PET\/CT. We distinguished the MRI enhancement pattern based on morphology and intensity. There were three types of morphology: SLE (superficial linear enhancement) at the skin level, NEZ (non-enhancing area immediately below the SLE), and INE (nipple enhancement below the NEZ but above the nipple base). In INE, the pattern could be linear or patchy. Depending on the intensity, the enhancement could be minimal, mild, moderate, or marked. The enhancement on CT depended on the distribution of pathological tissue in the infiltrated NAC and could be present or absent; it could involve the nipple base, the nipple body, or both. For quantitative analysis, we used the maximum standardized uptake value (SUV) measured in early-stage PET\/CT images, obtained by delineating a three-dimensional volume of interest (VOI) on the NAC. Results: In our population, the most represented enhancement pattern was INE (110), while slightly less than half of the patients showed invasion of the NEZ (49). Approximately one quarter of the patients presented linear ductal INE (36), while the majority presented patchy INE (74). On CT and PET\/CT, NAC enhancement was detectable in almost all patients (102), mainly involving the base and the body together. Correlation analysis in the following pairs of variables showed a high association, with a Kendall\u2019s tau value greater than 0.7 (p &lt; 0.001): (1) involvement of the NEZ on ce-MR and pattern of nipple involvement on ce-CT (CT score); (2) morphological pattern of INE on ce-MR (INE score) and intensity of INE enhancement on MR; and (3) pattern of nipple involvement on ce-CT (CT score) and intensity of INE enhancement on MR. The calculated mean SUV of pathological NACs on PET\/CT for early-stage images was 3.59, while the mean SUV of contralateral normal NACs was 2.12. The calculated mean NAC-SUV ratio was 1.7. Conclusions: Although pathological involvement of the NAC cannot always be assessed in the final surgical specimen due to the effects of neoadjuvant chemotherapy, so the \u201cgold standard\u201d of histological reference is missing, MRI and CT with morphology and enhancement descriptors, and additionally PET\/CT with SUV measurement can, in our opinion, provide valuable information on the infiltrated nipple. Standardized language for describing breast tumors infiltrating the NAC is desirable to ensure consistent interpretation across different radiologists.<\/jats:p>","DOI":"10.3390\/diagnostics15172155","type":"journal-article","created":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T14:18:49Z","timestamp":1756217929000},"page":"2155","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Towards Standardized Language to Describe the Pathological Enhancement of the Nipple in NAC-Infiltrating Breast Tumors: A Retrospective Case Series Study"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0309-034X","authenticated-orcid":false,"given":"Cristiana","family":"Boldrini","sequence":"first","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Silvia","family":"Amodeo","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-9142-8015","authenticated-orcid":false,"given":"Angelica","family":"Marra","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Micol","family":"Bottalico","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-0003-9181","authenticated-orcid":false,"given":"Roberta","family":"Dattoli","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4972-9500","authenticated-orcid":false,"given":"Riccardo","family":"Manfredi","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology-Diagnostic Imaging Area, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"20","DOI":"10.21037\/cco-24-140","article-title":"Oncoplastic surgery in the treatment of breast cancer: A review of evolution and surgical training","volume":"14","author":"Cavalcante","year":"2025","journal-title":"Chin. Clin. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1148\/rg.2019180039","article-title":"An Analysis of Nipple Enhancement at Breast MRI with Radiologic-Pathologic Correlation","volume":"39","author":"Gao","year":"2019","journal-title":"Radiographics"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"739","DOI":"10.3348\/kjr.2022.0846","article-title":"Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis","volume":"24","author":"Byon","year":"2023","journal-title":"Korean J. Radiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1148\/radiol.2021204136","article-title":"Diagnostic Accuracy of Nonmass Enhancement at Breast MRI in Predicting Tumor Involvement of the Nipple: A Prospective Study in a Single Institution","volume":"301","author":"Bae","year":"2021","journal-title":"Radiology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s12957-023-02898-x","article-title":"Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features","volume":"21","author":"Lai","year":"2023","journal-title":"World J. Surg. Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1007\/s12282-018-0845-9","article-title":"Preoperative breast MRI: Reproducibility and significance of findings relevant to nipple-areolar complex involvement","volume":"25","author":"Machida","year":"2018","journal-title":"Breast Cancer"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2183","DOI":"10.1111\/tbj.14088","article-title":"Nipple-sparing mastectomy: A review of outcomes at a single institution","volume":"26","author":"Woodward","year":"2020","journal-title":"Breast J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3115","DOI":"10.1245\/s10434-019-07560-z","article-title":"Outcomes of \u22651300 nipple-sparing mastectomies with immediate reconstruction: The impact of expanding indications on complications","volume":"26","author":"Young","year":"2019","journal-title":"Ann. Surg. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1016\/j.clbc.2023.01.003","article-title":"Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy","volume":"23","author":"Loreti","year":"2023","journal-title":"Clin. Breast Cancer"},{"key":"ref_10","first-page":"761","article-title":"Surgical management of nipple areola complex in central breast cancer","volume":"44","author":"Zhang","year":"2022","journal-title":"Chin. J. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"S82","DOI":"10.1016\/j.breast.2017.06.034","article-title":"Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications","volume":"34","author":"Galimberti","year":"2017","journal-title":"Breast"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S13","DOI":"10.1093\/asj\/sjaa139","article-title":"Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy","volume":"40","author":"Choi","year":"2020","journal-title":"Aesthet. Surg. J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"20201013","DOI":"10.1259\/bjr.20201013","article-title":"Magnetic resonance imaging in the evaluation of pathologic nipple discharge: Indications and imaging findings","volume":"94","author":"Samreen","year":"2021","journal-title":"Br. J. Radiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3241","DOI":"10.1245\/s10434-015-4739-1","article-title":"Overall survival, disease-free survival, local recurrence, and nipple-areolar recurrence in the setting of nipple-sparing mastectomy: A meta-analysis and systematic review","volume":"22","author":"Moody","year":"2015","journal-title":"Ann. Surg. Oncol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e2963","DOI":"10.1097\/GOX.0000000000002963","article-title":"Tumor-to-Nipple Distance in Selecting Patients for Nipple-sparing Mastectomy","volume":"8","author":"Allweis","year":"2020","journal-title":"Plast. Reconstr. Surg. Glob. Open."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"9654741","DOI":"10.1155\/2022\/9654741","article-title":"Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis","volume":"2022","author":"Harish","year":"2022","journal-title":"Breast J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1016\/j.amjsurg.2020.01.002","article-title":"Evidence-based nipple-sparing mastectomy in patients with higher body mass index: Recommendations for a successful standardized surgery","volume":"220","author":"Franceschini","year":"2020","journal-title":"Am. J. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1318","DOI":"10.1245\/s10434-019-08159-0","article-title":"Workload Differentiates Breast Surgical Procedures: NSM Associated with Higher Workload Demand than SSM","volume":"27","author":"Hallbeck","year":"2020","journal-title":"Ann. Surg. Oncol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1186\/s12957-023-02949-3","article-title":"How to accurately preoperative screen nipple-sparing mastectomy candidate-a nomogram for predicting nipple-areola complex involvement risk in breast cancer patients","volume":"121","author":"Xu","year":"2023","journal-title":"World J. Surg. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1e","DOI":"10.1097\/PRS.0000000000003414","article-title":"Tumor-to-nipple distance as a predictor of nipple involvement: Expanding the inclusion criteria for nipple-sparing mastectomy","volume":"140","author":"Dent","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1016\/j.anplas.2023.06.003","article-title":"The star approach, a surgical approach for skin sparing mastectomy and central lumpectomies","volume":"69","author":"Fraisse","year":"2024","journal-title":"Ann. Chir. Plast. Esthet."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"612","DOI":"10.1111\/tbj.13289","article-title":"Oncologic safety of nipplesparing mastectomy in patients with short tumor-nipple distance","volume":"25","author":"Balci","year":"2019","journal-title":"Breast J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1882","DOI":"10.1016\/j.ejca.2015.07.001","article-title":"MRI and intraoperative pathology to predict nipple-areola complex (NAC) involvement in patients undergoing NAC-sparing mastectomy","volume":"51","author":"Ponzone","year":"2015","journal-title":"Eur. J. Cancer"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e458","DOI":"10.1016\/j.clbc.2020.02.005","article-title":"Significance of Non-Mass Enhancement in the Subareolar Region on Preoperative Breast Magnetic Resonance Imaging for Nipple-Sparing Mastectomy","volume":"20","author":"Jun","year":"2020","journal-title":"Clin. Breast Cancer"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"3543","DOI":"10.21873\/anticanres.14343","article-title":"Tumor-to-nipple Distance Should Not Preclude Nipple-sparing Mastectomy in Breast Cancer Patients. Personal Experience and Literature Review","volume":"40","author":"Fregatti","year":"2020","journal-title":"Anticancer Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1016\/j.ejso.2020.08.010","article-title":"A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery","volume":"47","author":"Seki","year":"2021","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Yoo, J., Kim, B.S., Chung, J., and Yoon, H.J. (2018). Clinical value of delayed 18F-FDG PET\/CT for predicting nipple-areolar complex involvement in breast cancer: A comparison with clinical symptoms and breast MRI. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0203649"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1016\/j.jss.2022.04.063","article-title":"Comparison of Magnetic Resonance Imaging with Positron Emission Tomography\/Computed Tomography in the Evaluation of Response to Neoadjuvant Therapy of Breast Cancer","volume":"278","author":"Baysal","year":"2022","journal-title":"J. Surg. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"3709","DOI":"10.1007\/s00259-024-06815-6","article-title":"Baseline [18F]FDG PET\/CT and MRI first-order breast tumor features do not improve pathological complete response prediction to neoadjuvant chemotherapy","volume":"51","author":"Oliveira","year":"2024","journal-title":"Eur. J. Nucl. Med. Mol. Imaging."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1186\/s13058-023-01722-4","article-title":"Multimodal prediction of neoadjuvant treatment outcome by serial FDG PET and MRI in women with locally advanced breast cancer","volume":"25","author":"Kazerouni","year":"2023","journal-title":"Breast Cancer Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1186\/s13058-020-01350-2","article-title":"Prognostic value of 18F-FDG PET and PET\/CT for assessment of treatment response to neoadjuvant chemotherapy in breast cancer: A systematic review and meta-analysis","volume":"22","author":"Han","year":"2020","journal-title":"Breast Cancer Res."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/15\/17\/2155\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:33:04Z","timestamp":1760034784000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/15\/17\/2155"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,26]]},"references-count":31,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2025,9]]}},"alternative-id":["diagnostics15172155"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics15172155","relation":{},"ISSN":["2075-4418"],"issn-type":[{"type":"electronic","value":"2075-4418"}],"subject":[],"published":{"date-parts":[[2025,8,26]]}}}