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Benign breast disordersBenign breast disorders
““OthersOthers””
Grubstein AhuvaGrubstein AhuvaRabin medical CenterRabin medical Center
PurposePurpose
Introducing the entitiesIntroducing the entities
Tips of how to Tips of how to differentiate from differentiate from
cancercancer
ContentContent GalactoceleGalactocele Mastitis and abscess formationMastitis and abscess formation Duct ectasiaDuct ectasia SeromaSeroma HematomaHematoma Fat necrosisFat necrosis Fat containing lesionsFat containing lesions Intraductal papillomaIntraductal papilloma Skin lesionsSkin lesions Mondor’s diseaseMondor’s disease Hemangiomas and venous malformationsHemangiomas and venous malformations NeurofibromaNeurofibroma
Suggested approachSuggested approachnodulesnodules
Sonography Sonography MammographyMammography
Look for Look for suspicioussuspicious findings findings
If a single finding is present: If a single finding is present: do something moredo something morebiopsybiopsy
Look for Look for suspicioussuspicious findings findings
If a single finding is present: If a single finding is present: do something more--, old do something more--, old films, additional views, films, additional views, ultrasound, biopsyultrasound, biopsy
No suspicious finding, look for No suspicious finding, look for benignbenign findings findings
If benign findings—>follow upIf benign findings—>follow up
No suspiciousNo suspicious finding – finding – routine screeningroutine screening
If no benign findings—If no benign findings—>BIRADS 4>BIRADS 4
BIRADS 3 – short term follow BIRADS 3 – short term follow upup
Patient history
Suggested approachSuggested approachcystscysts
SimpleSimpleComplexComplexAnechoicAnechoicExclude artifactsExclude artifacts
Well circumscribeWell circumscribeLook for BIRADS>4 findingsLook for BIRADS>4 findingsbiopsybiopsy
Thin echogenic wallThin echogenic wallIf not look for BIRADS 3 inflammatory If not look for BIRADS 3 inflammatory findingsfindings
Through Through transmissiontransmission
If not look for strict BIRADS 2 If not look for strict BIRADS 2 findingsfindingsreturn to routine screeningreturn to routine screening
Edge shadowsEdge shadowsIf not look for BIRADS 3If not look for BIRADS 3offer attempt offer attempt aspiration and short term follow upaspiration and short term follow up
BIRADS 2BIRADS 2If notIf notby default consider as BIRADS 4a and by default consider as BIRADS 4a and biopsybiopsy
Patient history
Duct ectasiaDuct ectasia
Large subareolar and intermediate ducts Large subareolar and intermediate ducts become dilated and filled with thick static become dilated and filled with thick static secretions.secretions.
Ducts wall and periductal tissue are Ducts wall and periductal tissue are inflamed.inflamed.
Inflamed ducts may rupture Inflamed ducts may rupture periductal periductal chemical mastitischemical mastitis22ndnd infected infected nonpueperal abscess, mostly in the nonpueperal abscess, mostly in the periareolar area.periareolar area.
Duct evaluation – US Duct evaluation – US techniquetechnique
The nipple will casts a posterior shadow that obscures the intraductal lesion
• Transducer held at an angle
• The ultrasound beam is perpendicular to the long axis of the duct
• Proper contact and pressure
No acoustic shadow from the nipple
Duct ectasiaDuct ectasia
May be associated with May be associated with hyperprolactinemiahyperprolactinemia
Usually asymptomaticUsually asymptomatic
Only 30% have have nipple Only 30% have have nipple discharge – clear-whitish-cheesy-discharge – clear-whitish-cheesy-yellowishyellowish
Duct ectasiaDuct ectasia
GalactoceleGalactocele Cystically dilated terminal Cystically dilated terminal
ductules that are filled with ductules that are filled with milk and lined by double milk and lined by double layer of breast epithelium layer of breast epithelium and myoepithelium.and myoepithelium.
Classically appears as a Classically appears as a painless lump weeks – painless lump weeks – months after cessation of months after cessation of breast feeding. breast feeding.
Galactocele Galactocele USUS
Varies with stage : Varies with stage : cystic – complex cystic – solid cystic – complex cystic – solid appearanceappearance
Fresh milk - anechoicFresh milk - anechoicAs they age - more echogenic.As they age - more echogenic.Eventually usually regress , but may Eventually usually regress , but may
persist for yearspersist for yearsWall may calcified – like oil cyst on Wall may calcified – like oil cyst on
MammoMammo
Mastitis and abscess Mastitis and abscess formationformation
Classic Classic streptococcalstreptococcal infection of infection of breastbreast
1. Cellulitis1. Cellulitis
2. Systemic infection and bacteremia with 2. Systemic infection and bacteremia with localization of abscesslocalization of abscess
StaphylococcalStaphylococcal breast abscesses breast abscesses 1. Localized deeply invasive and suppurative 1. Localized deeply invasive and suppurative
abscessesabscesses
2. Multilocular abscesses2. Multilocular abscesses
Mastitis and abscess Mastitis and abscess formationformationpuerperalpuerperal Acute , during lactation , may progress to Acute , during lactation , may progress to
abscessabscess
Staph, strep.Staph, strep.
Contributing factors: nipple fissures , milk stasisContributing factors: nipple fissures , milk stasis
S&S of infection and inflammationS&S of infection and inflammation
Mammo – usually not helpful, increased density Mammo – usually not helpful, increased density obscuring any underlying pathologyobscuring any underlying pathology
Mastitis and abscess formationMastitis and abscess formation
Puerperal - Puerperal - USUS 11st st choicechoice
Edema – skin and subcutaneous tissue, Edema – skin and subcutaneous tissue, thickening and become hyperechoicthickening and become hyperechoic
Cooper’s ligaments become less Cooper’s ligaments become less echogenicechogenic
Loss of distinction between different Loss of distinction between different types of breast tissuestypes of breast tissues
Mastitis and abscess Mastitis and abscess formationformation
Puerperal - Puerperal - USUS
Difficult to penetrateDifficult to penetrateuse deeper use deeper probes (5MHz), to exclude abscess probes (5MHz), to exclude abscess formationformation
Usually single lobe, but may spreadUsually single lobe, but may spread
Mastitis and abscess formationMastitis and abscess formation
Non puerperalNon puerperal
Usually have underlying duct ectasia, Usually have underlying duct ectasia, rarely cystsrarely cysts
More anaerobesMore anaerobes
Duct ectasia periductal mastitis Duct ectasia periductal mastitis complexcomplex
PerimenopausalPerimenopausal
Late teensLate teens
Mastitis and abscess Mastitis and abscess formationformation
Should be distinguished from Should be distinguished from inflammatory carcinomainflammatory carcinoma
Both causing edema and Both causing edema and inflammation. inflammation.
Both can have hypoechoic masses that Both can have hypoechoic masses that have enhanced acoustic through have enhanced acoustic through transmission.transmission.
Inflammatory breast Inflammatory breast mass in nonlactating mass in nonlactating
femalefemale
1. Abscess1. Abscess
2. Infected cysts2. Infected cysts
3. Duct ectasia3. Duct ectasia
4. Carcinoma4. Carcinoma
SeromaSeroma
Localized collection of serous fluidLocalized collection of serous fluid
Lumpectomy cavities, post– vacuum Lumpectomy cavities, post– vacuum assisted large core needle biopsy, assisted large core needle biopsy, around implants.around implants.
Peri implants seroma is desired. May Peri implants seroma is desired. May complicate, when large can be painful, complicate, when large can be painful, infected.infected.
SeromaSeroma
US: simple or complex cyst/s.US: simple or complex cyst/s.
Angular margin may occur at angular Angular margin may occur at angular lumpectomy margins. lumpectomy margins.
Use Doppler, compressibility, to try Use Doppler, compressibility, to try differentiate from recurrence.differentiate from recurrence.
HematomaHematomaLocalized collection of Localized collection of
extravagated blood within the extravagated blood within the breastbreast
Traumatic, post interventionalTraumatic, post interventional
Gradually completely desorbed, or Gradually completely desorbed, or persist as chronic hematoma, fat persist as chronic hematoma, fat necrosis and lipid cyst.necrosis and lipid cyst.
Hematoma - USHematoma - US Acute: hypoechoic, with echogenic clotted Acute: hypoechoic, with echogenic clotted
bloodblood
Layering- fluid debris level that may Layering- fluid debris level that may change with repositioningchange with repositioning
Mural nodule; use Doppler to distinguish Mural nodule; use Doppler to distinguish from papillomafrom papilloma
Hematoma - USHematoma - US
Chronic: Chronic: Mostly Mostly complex cystscomplex cysts with with
thickened walls and septathickened walls and septa
Enhanced through transmissionEnhanced through transmission
CalcifiedCalcified demonstrating acoustic demonstrating acoustic shadowingshadowing
Fat necrosisFat necrosis
Results from injury to breast fatResults from injury to breast fat Trauma, surgery, biopsy….Trauma, surgery, biopsy…. Causes to focal fibrosis and cicatrix Causes to focal fibrosis and cicatrix
formation.formation.
Early: edema of the fat lobules, Early: edema of the fat lobules,
increased echogenicity.increased echogenicity.
Post surgical scar, hematoma, seromaPost surgical scar, hematoma, seroma
Post lumpectomy fat Post lumpectomy fat necrosisnecrosis
Distinction from recurrenceDistinction from recurrence Early - complex cyst with mural thrombi, Early - complex cyst with mural thrombi, later fibrosis causes angulations, spiculations and later fibrosis causes angulations, spiculations and
significant shadowingsignificant shadowing
indistinctable from carcinoma.indistinctable from carcinoma.
Help:Help:Doppler (two caveats: tumors don’t always demonstrate Doppler (two caveats: tumors don’t always demonstrate
increase vascularity, healing granulation tissue may be increase vascularity, healing granulation tissue may be vascular), vascular),
Spot compression mammogram, Spot compression mammogram,
Fat containing lesionsFat containing lesions
Lymph nodesLymph nodesHamartomasHamartomasLipomasLipomasHemangiomasHemangiomasDD DD Acute hematomaAcute hematomaFocal fibrosisFocal fibrosisMalignancy Malignancy
Fat containing lesionsFat containing lesionslymph nodes – 2lymph nodes – 2ndnd look US look US
Fat containing lesionsFat containing lesionsLipomasLipomas
Lipoma
Angiolipoma
Fat containing lesionsFat containing lesionsHamartomasHamartomas
Localized overgrowth of fibrous epithelial and fatty elements.
““Breast within Breast within Breast”Breast”
Intraductal papillomaIntraductal papilloma
Ductal epithelial proliferations that Ductal epithelial proliferations that grow in a frond like pattern. grow in a frond like pattern.
A central fibrovascular stalk covered A central fibrovascular stalk covered by double layer of epithlium and by double layer of epithlium and myoepithelium.myoepithelium.
Intraductal papillomaIntraductal papilloma
Intraductal papillomaIntraductal papilloma
CentralCentral – – Large duct papilloma, subareolarLarge duct papilloma, subareolar
Nipple discharge, bloodyNipple discharge, bloody
PerimenopausalPerimenopausal
Intraductal papillomaIntraductal papilloma
PeripheralPeripheral – – In the terminal duct of the TDLUIn the terminal duct of the TDLU More often multipleMore often multiple Younger patientsYounger patients More associated with diffuse epithelial More associated with diffuse epithelial
proliferation; ADH, DCIS, proliferation; ADH, DCIS, less often will cause nipple dischargeless often will cause nipple discharge
papillomatosispapillomatosis
Intraductal papillomaIntraductal papilloma
Secrete fluid into the ductsSecrete fluid into the ducts
Causing duct dilatation & and nipple Causing duct dilatation & and nipple dischargedischarge
Intracystic papillomaIntracystic papilloma
Intraductal papillomaIntraductal papillomacentralcentral
Central Central intraductintraductal al papillomapapillomaUS techniqueUS technique
DuctographyDuctography, filling , filling defectdefect
TechniqueTechnique:: Cannulation of the Cannulation of the
offending duct, offending duct, and injection of and injection of iodinated contrastiodinated contrast
CC and MLO CC and MLO mammogramsmammograms
Intraductal papillomaIntraductal papillomacentralcentral
Subtracted T1 T2
Complex cystsComplex cysts
Apocrine metaplasiaApocrine metaplasia Intraductal papilloma
Papillary lesionsPapillary lesionsperipheralperipheral
65 y.o. bloody nipple 65 y.o. bloody nipple dischargedischarge
Papillary lesionsPapillary lesionsperipheralperipheral
Papillary lesionsPapillary lesions
????BIRADSBIRADS????
Skin lesions: Skin lesions: Sebaceous cysts, Montgomery Sebaceous cysts, Montgomery
gland cysts, Epidermal inclusion gland cysts, Epidermal inclusion cystscysts
Lies entirely within the skinLies entirely within the skin
Most of the lesion is in the Most of the lesion is in the subcutaneous tissue (claw sign)subcutaneous tissue (claw sign)
Entirely in the subcutaneous fat tissue, Entirely in the subcutaneous fat tissue, but a neck or a hair follicle can be shown but a neck or a hair follicle can be shown coursing to the skincoursing to the skin
Sebaceous cysts, Sebaceous cysts, Montgomery gland cysts, Montgomery gland cysts, Epidermal inclusion cystsEpidermal inclusion cysts
Sebaceous Sebaceous cyst, cyst,
Epidermal Epidermal inclusion cystinclusion cyst
??
??
Mondor’s disease: acute Mondor’s disease: acute superficial thrombosis of the superficial thrombosis of the
breast veinsbreast veins..RareRareSuperficial veins of the subcutaneous Superficial veins of the subcutaneous
breast thrombosebreast thromboseHx of trauma, pregnancy, CV linesHx of trauma, pregnancy, CV linesPain, tenderness, linear skin Pain, tenderness, linear skin
erythemaerythemaPalpable cordPalpable cord
Mondor’s disease: acute Mondor’s disease: acute superficial thrombosis of the superficial thrombosis of the
breast veinsbreast veins
Thoracoepigastic vein Thoracoepigastic vein
(from inferomedial aspect of the (from inferomedial aspect of the breast to the axilla)breast to the axilla)
Lateral thoracicLateral thoracicwith CVL’s, medial vein that drains with CVL’s, medial vein that drains
into the internal mammary vein.into the internal mammary vein.
Mondor’s disease: acute Mondor’s disease: acute superficial thrombosis of superficial thrombosis of
the breast veinsthe breast veins..
Josep M. Sabaté RadioGraphics
2005; 25: 411-424
Hemangiomas and venous Hemangiomas and venous malformationsmalformations
Microscopic – commonMicroscopic – common
Macroscopic: larger than 4 mm, Macroscopic: larger than 4 mm, usually less than 2 cm, usually less than 2 cm,
(angiosarcoma are usually larger (angiosarcoma are usually larger than 3 cm).than 3 cm).
Hemangiomas and venous Hemangiomas and venous malformationsmalformations
Mammo: nodule, caMammo: nodule, ca++++
US: depends on type - US: depends on type -
Capillary – echogenic nodule, Capillary – echogenic nodule,
Cavernous – hypoechoic nodule (the Cavernous – hypoechoic nodule (the larger the channels the more larger the channels the more hypoechoic)hypoechoic)
HemangiomaHemangioma
Hemangioma
65 y.o. screening mammogram
NeurofibromasNeurofibromas
Subcutaneous benign peripheral nerve Subcutaneous benign peripheral nerve sheath tumorssheath tumors
Neurofibromatosis type 1, Neurofibromatosis type 1, Classically peri-areolar in location.Classically peri-areolar in location.
NeurofibromasNeurofibromas
Mammo : Well-defined benign appearing Mammo : Well-defined benign appearing masses, often multiple. Portions of the masses, often multiple. Portions of the outline may be rimmed by air density outline may be rimmed by air density reflecting their superficial nature reflecting their superficial nature
US: well-defined hypoechoic mass, with US: well-defined hypoechoic mass, with posterior acoustic enhancement, located posterior acoustic enhancement, located in the subcutaneous tissue similar to a in the subcutaneous tissue similar to a fibroadenomafibroadenoma
NeurofibromaNeurofibroma
PurposePurpose
Make acquaintance with the entitiesMake acquaintance with the entities
Know how toKnow how to
differentiate them from cancerdifferentiate them from cancer
Suggested approachSuggested approachnodulesnodules
Sonography Mammography
Look for suspicious findingsIf a single finding is present: do something more--biopsy
Look for suspicious findingsIf a single finding is present: do something more--, old films, additional views, ultrasound, biopsy
No suspicious finding, look for benign findingsIf benign findings—follow up
No suspicious finding – routine screening
If no benign findings—BIRADS 4
BIRADS 3 – short term follow up
Patient history
Patient storyPatient story
Look for findingLook for finding
Suspicious?Suspicious?
Benign?Benign?
Suggested approachSuggested approachcystscysts
SimpleComplex
AnechoicExclude artifacts
Well circumscribeLook for BIRADS>4 findingsbiopsy
Thin echogenic wallIf not look for BIRADS 3 inflammatory findings
Through transmission
If not look for strict BIRADS 2 findingsreturn to routine screening
Edge shadowsIf not look for BIRADS 3offer attempt aspiration and short term follow up
BIRADS 2If notby default consider as BIRADS 4a and biopsy
Patient history
Patient storyPatient story
Look for findingLook for finding
Suspicious?Suspicious?
Benign?Benign?
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