Benign breast disorders “Others” Grubstein Ahuva Rabin medical Center.

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


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

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


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


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.


CentralCentral – – Large duct papilloma, subareolarLarge duct papilloma, subareolar

Nipple discharge, bloodyNipple discharge, bloody

PerimenopausalPerimenopausal


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


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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Benign breast disorders “Others” Grubstein Ahuva Rabin medical Center.

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Transcript of Benign breast disorders “Others” Grubstein Ahuva Rabin medical Center.