1. SON 2147 Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, LRT(AS)
Sonography of The Breast
Part I Introduction
Lecture Three:
Benign Conditions
Malignant Conditions
Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, LRT(AS)

2. Benign conditions

3. Benign tumors are rubbery, mobile, and well defined (as seen in a fibroadenoma). Malignant tumors are often stone hard.

4. CYSTS Cysts are commonly seen in women 35 to 55 years of age.
Symptoms include history of changing with menstrual cycle, pain, especially when the cyst is growing rapidly, recent lump, and tenderness.
Small cysts may not regress completely and may persist from one cycle to the next.

6. Fibrocystic condition
Fibrocystic changes produce histologic alterations in the terminal ducts and lobules of the breast in both the epithelial and connective tissue.
Fibrocystic changes are usually accompanied by pain or tenderness in the breast and represent normal physilogic processes of breast tissue that fluctuates under the influence of the normal female hormonal cycles.

7. Fibrocystic conditions
Clinical sign and symptoms of FCC include the lumps and pain that the patient feels that fluctuate with every monthly cycle.
Ultrasound of the breast will show round masses which represent multiple cysts.

8. Fibroadenoma The most common benign breast tumors are fibroadenomas.
They occur primarily in young women.
The growth of fibroadenoma is stimulated by estrogen.
Clinically, a fibroadenoma is firm, rubbery, freely mobile, and clearly delineated from the surrounding breast tissue.

9. A fibroadenoma

10. Fibroadenomas are round or ovoid, smooth or lobulated, and usually do not cause loss of contour of the breast, unless it develops into a large size.
Fibroadenomas rarely causes mastodynia (breast pain) and it does not change size during the menstrual cycle.
Sonographically, fibroadenomas have benign characteristics with smooth rounded margins and low-level homogeneous internal echoes.
A fibroadenoma may demonstrate intermediate posterior enhancement.

11. Fibroadenomas are normally hypoechoic, but are occasionally hyperechoic to the fat within the breast or with calcifications.

12. Lipoma-A pure lipoma consists entirely of fatty tissue.

13. Other forms of lipoma consist of fat with fibrous and glandular elements (fibroadenolipoma).
Clinically, on palpation a large, soft poorly demarcated mass is felt that can not be clearly separated from the surrounding parenchyma.
Sonographically, a lipoma may be difficult or impossible to detect within a fatty breast.
A lipoma often demonstrates posterior enhancement and are easily compressible.

14. Fat Necrosis
Fat necrosis may be caused by trauma to the breast, surgery, radiation treatments, or plasma cell mastitis.
Fat necrosis may also be related to an involutional process or other diseases present in the breast, such as cancer.
Fat necrosis is more frequently found in older women.
Sonographically, fat necrosis appears as an irregular complex mass with low-level echoes.
It may mimic a malignant lesion, and may appear as fat.

15. Fat necrosis

16. Acute Mastitis
Acute mastitis may result from infection, trauma, mechanical obstruction in the breast ducts, or other conditions.
Acute mastitis often occurs during lactation, beginning in the lactiferous ducts and spreading via the lymphatics or blood.
Acute mastitis is often confined to one area of the breast.

17. Acute mastitis

18. Chronic Mastitis
Clinically, the patient usually has a nipple discharge, and frequently the nipple has retracted over a period of years.
Palpation reveals some subareolar thickening but no dominant masses.

19. Chronic Mastitis

20. Abscess-An abscess may be single or multiple.

21. Acute abscesses have a poorly defined border, whereas mature abscesses are well-encapsulated with sharp borders.
Clinical findings show pain, swelling, and reddening of the overlying skin. The patient may be febrile, and swollen, painful axillary nodes may be present.

22. Breast abscess diagram

23. Abscess Sonographic findings may show the following:
diffuse, mottled appearance of the breast.
Irregular margins
Posterior enhancement
Low-level internal echoes
Color or power Doppler of the breast may be helpful to document hyperemia (an excess 0f blood accumulation) associated with increased vascularity.

24. Cystosarcoma Phyllodes Cystosarcoma Phyllodes is a rare, predominantly benign breast neoplasm.

25. Although Cystosarcoma Phyllodes is considered a benign lesion, 27% of these tumors are malignant, and 12% metastasize.
Sonographic findings include a large, hypoechoic tumor with well-defined margins and decreased through-transmission.
Internal echoes may be fine or coarse with variable amounts of shadowing.
Think Leaf…

26. Intraductal Papilloma-An intraductal papilloma is a small, benign tumor that grows within the acini of the breast.

27. Intraductal papilloma occurs frequently in middle-aged women.
The predominant symptom is spontaneous nipple discharge arising from a single duct.
Intraductal papillomas consists of simple proliferations of duct epithellum projecting outward into a dilated lumen from one or more focal points.

28. Intraductal Papilloma

29. Malignant conditions

30. It is not unusual for several years to pass from the first appearance of atypical hyperplasia to the final diagnosis of in Situ cancer.
When the carcinoma is contained and has not invaded the basal membrane structure, it is considered in Situ.
Most cancers originate in the terminal ductal lobular units (TDLU) whereas a smaller percentage originate in the glandular tissue.

31. The breast lobules are concentrated in the upper-outer quadrant of the breast. It is then not surprising that a majority of breast cancers (50%) are found there.

32. Cancer of the breast is of two types- Sarcoma and Carcinoma

33. Sarcomas tend to grow rapidly and invade fibrous tissue.

34. Carcinoma refers to breast tumors that arise from the epithelium, in the ductal and glandular tissue, and usually has tentacles.

35. Other malignant diseases affecting the breast are a result of systemic neoplasms, such as leukemia or lymphoma.

36. Breast carcinomas are generally categorized by two factors:
1. Where the cancer cells originate (ductal or lobular)
2. Whether the cancer is prone to spreading (noninvasive or invasive).

37. Most breast carcinomas begin within the ducts of the breast and are called ductal or intraductal carcinomas.

38. Breast cancers that form in the lobules are called lobular carcinomas.

39. Cancers that spread into nearby tissue are said to be invasive or infiltrating.

40. Ductal Carcinoma In Situ (DCIS) AKA intraductal carcinoma

41. DCIS is characterized by cancer cells that are present inside the ducts, but they have not yet spread through the walls of the ducts into the fatty tissue of the breast.
Because these are confined to the duct and they have not spread, DCIS usually has a 100% cure rate.
Calcifications and ductal enlargement with extension within the ducts are common.

42. Invasive Ductal Carcinoma (IDC) IDC accounts for nearly 80% of breast cancers.

43. Like DCIS, IDC cancers begin in the ducts, but unlike DCIS, they invade the fatty tissue of the breast and have the potential to metastasize via the blood-stream or lymphatic system.
It is important to obtain a definitive diagnosis and begin treatment before IDC spreads to other organs.

44. Lobular Carcinoma In Situ LCIS
LCIS is not considered a “cancer” because it has a low malignant potential.
LCIS is confined to the gland and does not penetrate through the wall of the tubule.
LCIS does not usually form a distinct mass and can therefore be difficult to pick up using mammography and ultrasound screening.
Women with LCIS are at a higher risk of developing invasive breast cancer later on.

45. LCIS

46. Invasive Lobular Carcinoma ILC
ILC begins in the lobule, where it extends into the fatty tissue of the breast.
Similar to IDC, invasive lobular carcinoma has the potential to spread to other parts of the body.
ILC is the second most common type of invasive tumor, accounting for 10-15% of all breast cancers.
ILC is often bilateral, multicentric, or multifocal.

47. Invasive Lobular Carcinoma ILC

48. Breast cancers are considered multifocal when more than one tumor is identified and they are located within the same quadrant or ductal system and are within 5 cm of each other.
Breast cancers are considered multicentric when they are located in different quadrants and are located at least 5 cm apart.
Definitive identification of a tumor type can only be made by histologic tissue examination.

49. Comedocarcinoma: Intraductal solid carcinoma in which the lactiferous ducts are filled with a yellow paste-like material that looks like small plugs and classic dot-dash on mammogram.

50. Juvenile breast cancer is similar to ductal carcinoma In Situ and invasive ductal carcinoma found in adults. Generally, it occurs in young females between 8 and 15 years of age and has a good prognosis when treated early. Below: Malignant phyllodes tumor in a 10 yof

51. Papillary Carcinoma
Papillary carcinoma is a tumor that initially arises as an intraductal mass.
It may also take the form of an intra-cystic tumor, which is rare.
The earliest clinical sign of intraductal papillary carcinoma is bloody nipple discharge.
Papillary carcinoma typically has a more favorable prognosis than the other kinds of carcinoma.

52. Papillary Carcinoma

53. Paget’s Disease
Paget’s disease arises in the retro-areolar ducts and grows in the direction of the nipple, spreading into the intra-epidermal region of the nipple and areola.
It has a rash-like appearance that may be confused with a melanoma.
Any ulceration, enlargement, or deformity of the nipple and areola should suggest Paget’s disease.
It is a relatively rare tumor, accounting for 2.5% of all breast cancers.
It typically occurs in women over 50 years of age.

54. Paget’s Disease

55. Scirrhous Carcinoma
Scirrhous carcinoma is a type of intraductal tumor with extensive fibrous tissue proliferation.
It is a common form of breast cancer and often has no specific histologic findings.
The classic clinical signs are
Very firm nodule
Frequently non-movable mass
Fixation and flattening of overlying skin
Nipple retraction

56. Scirrhous Carcinoma

57. Medullary Carcinoma
Medullary carcinoma is a densely cellular tumor containing large, round or oval tumor cells.
It usually is a well-circumscribed mass, with the center frequently necrotic, hemorrhagic, and cystic.

58. Medullary Carcinoma

59. Colloid carcinoma The cells of the tumor produce secretions that fill lactiferous ducts.

60. Tubular Carcinoma
Tubular carcinoma represents an extremely well differentiated form of infiltrating (invasive) ductal carcinoma usually less than 2 cm in dimension.
Death is rare.
Tubular carcinoma typically has poorly circumscribed margins and a hard consistency.

61. Tubular Carcinoma

62. Interventional Breast Procedures
With some suspicious breast lesions, interventional procedures are necessary for a definitive diagnosis.
Ultrasound is an important guide to many diagnostic and interventional procedures in the breast. These include:
Cyst aspiration
Fine-Needle aspiration cytology (FNAC)
Abscess or seroma drainage
Large-core needle biopsy
Ultrasound-guided preoperative needle wire localization
Injection of a sentinel node

63. Cyst aspiration
The two main indications are a symptomatic cyst and hypoechoic lesion on ultrasound that does not meet the criteria for a simple cyst.
Cyst aspiration can be preformed to determine whether the lesion is a complex cyst or truly a solid mass.

64. Cyst Aspiration

65. Fine-Needle Aspiration Cytology (FNAC)
The FNAC procedure uses a fine needle (usually 25 gauge) and an aspiration technique intended to harvest individual cells for diagnosis.
FNAC is fast, easy on the patient, and generally very cost effective.
The single greatest problem in FNAC is an inadequate specimen.

66. Fine-Needle Aspiration Cytology (FNAC)

67. Drainage Procedure
When clinically indicated, most cases of breast abscess, seroma, or hematoma will be easily palpated and drained in a simple office procedure by a breast surgeon or other physician.

68. Preoperative Needle Wire Localization
Ultrasound offers a quick method for placement of a percutaneous wire assembly for preoperative localization of a non-palpable breast lesion for surgical excision.

69. Preoperative Needle Wire Localization

70. Large-Core Needle Biopsy Ultrasound offers a fast and easy method for guiding large-core needle biopsy of solid masses.

71. Sentinel Node Biopsy
In this procedure, the superficial subcutaneous tissues around the tumor bed and or the areola are injected with methylene blue dye and or radioactive-labeled solution.
This helps to identify the Sentinel node for histologic examination to determine if the breast cancer has spread to the lymphatic system.

72. BI-RADS Breast Imaging – Reporting and Data System
BI-RADS 2 - Benign
BI-RADS 3 - Probably Benign
BI-RADS 4 - Suspicious
BI-RADS 5 - Highly Suggestive of Malignancy

73. Homework SDMS webinars- TBA Show images of the following
Normal Lymph nodes
Abnormal Lymph nodes
Describe sonographically how each will look
Obtain 5 BIRADS reports and show ultrasound images of how each would appear in mammography and under ultrasound.

74. The End Part I