Breast Pathology

Shape and orientation of benign disease

Round, oval, ellipsoide

Horizontal in orientation (wider than tall)

Benign disease margins

Smoot, well defined or circumscribed

Macrolobularions- large, gentle lobulations

Benign disease border thickness

Thin, Echogenic pseudocapsule- rim of tissue around lesion

Echogenicity of benign disease

Anechoic, hyperechoic, homogeneous

Benign disease artifacts

Acoustic enhancements

Edge shadowing

Benign disease doppler

None - little flow

Benign disease fibrous planes

Tend to grow within or along the tissue plane

Benign disease ducts

Generally measure 2-3

Dilation or ectasia due to mastitis, fibrocystic changes, or papillomas

Benign disease calcifications

Large that cause shadowing

Diffuse pattern

Malignant disease shape and orientation

Irregular shape, usually with angles and straight lines

Spiculated (mammo)

Vertical orientation (taller than wide)

Malignant disease margins

Microlobulations

Ill-defined

Angular

Malignant disease radial extensions

Must be scanning in radial plane

Duct extension- tumor into duct coursing toward nipple

Branch pattern- tumor extension into a duct coursing away from nipple

Malignant disease border thickness

Thick, Echogenic halo

Desmoplasia

Desmoplasia

Thick, Echogenic halo with fibrotic host response surrounding a breast cancer

Malignant disease spechogenicity

Mildly to markedly Hypoechoic, almost anechoic

Heterogenous

Malignant disease artifacts

Shadowing, typically sharp

Malignant disease doppler

Angiogenesis- ability of malignancy to develop new blood vessels

Tend to be more peripheral than internal

Malignant disease fibrous planes

Invade tissue planes and disrupt adjacent tissue

Skin dimpling, skin thickening, nipple retraction

Malignant disease ducts

May invade ducts causing dilation and internal echoes

Malignant disease calcifications

Small, micro calcifications

Clustered micro calcifications

Benign or malignant lesions often Hypervascular?

Malignant

Doppler commonly used for

Detect presence of flow

Distinguish solid vs cystic

Distinguish inflamed vs non inflamed

Distinguish complex cyst vs intraductal papilloma

Cysts

Fluid filled masses that form at the TDLU or from an obstructed duct

Cysts most common in

Women 40-50

Where are cysts frequently found

Perimenopausal women, and fluctuate with menstrual cycle

Cysts signs and symptoms

Say,ptomatic, palpable mass, single or multiple, may be painful, varying size

Simple cyst

Very common

Result of an obstructed duct

35-50 yrs

Variable in presentation

STAR criteria

STAR criteria

Smooth

Through transmission

Anechoic

Round

Complex cyst

Contain internal echoes, or changes in cyst wall

Could be due to infection, hemorrhage, mass, abscess

Galactocele

Complex cyst

Milk

Sebaceous cyst

Complex cyst

Sebum (greasy substance)

Sebaceous cyst aka

Epidermal inclusion cyst

Oil cyst

Complex cyst

Oil cells

Fibrocystic changes

Collective term used to describe a variety of benign changes occurring in the breast

20-40 years

Most common disorder of the breast

Fibrocystic changes

Fibrocystic change outcomes

Cyst formation, fibrosis, possible epithelial hyperplasia

Fibrocystic changes signs and symptoms

Asymptomatic, palpable lumps, cyclic pain due to hormonal influence, tender breasts

Fibrocystic Changes Ultrasound

Variable;

Cluster of cells, diffuse highly Echogenic fibroglandular tissue with increased shadowing

Most common solid benign mass in premenopausal women, typically under age 30

Fibroadenoma

Fibroadenoma

Increased incidence in African American women

Estrogen stimulated- may grow rapidly during pregnancy and decrease in size after menopause

True or false: Fibroadenoma should be highly suspicious for cancer

True

Tissue diagnosis though biopsy is essential

Fibroadenoma signs and symptoms

Painless, palpable lump

Firm, moveable, rubbery

Upper outer quadrant

Single or multiple

Fibroadenoma ultrasound

Round, oval, or lobulated

Smooth or macrolobulated

Wider than tall

Well marginated

Homogeneous with low level internal echoes

Typically measure less than 3 cm

Lipoma

Nodules of adipose tissue encased by a thin layer of connective tissue

Typically found in superficial/subcutaneous layer

Middle aged- older patients

Lipoma is difficult to distinguish from:

Redundant fatty or axillary lymph nodes

Lipoma signs and symptoms

Soft, compressible, mobile mass

Lipoma ultrasound

Oval, well defined, variable echogenicity, homogeneous, superficial locations, compressible

Mastitis

Inflammation of breast- most cases occur during lactation

Mastitis usually caused by

Bacterial infection and responds to antibiotic treatment

Mastitis signs and symptoms

Firm, tender, swollen breast; warmth or redness, fever and elevated WBC; tender axillary nodes

Mastitis ultrasound

Increased echogenicity, blurred tissue planes, skin thickening, cellulitis, increased doppler flow

Abscess

Typically complication of mastitis, can also be byproduct of infested cyst

Localized area of pus that forms within breast tissue

Abscess usually loacted

Retroareolar

Abscess signs and symptoms

Palpable lump, tender or enlarged lymph nodes, swollen and tender breast

Abscess ultrasound

Complex or cystic mass, irregular borders, localized edema or skin thickening, reactive lymph nodes

Mondors disease

Acute thrombophlebitis of the superficial veins of the chest wall and breast

Mondor’s disease may be result of

Breast injury, recent surgery, infection, pregnancy, dehydration

Mondor’s disease signs and symptoms

Palpable tender cord like structure, fever, thickened or red skin

Mondor’s disease ultrasound

Superficial, tortuous, tubular lesion

can breast cancer occur concurrently?

Yes, 2 different cancers can occur at same time

Most breast cancer arises from

TDLU

Terminal ductal lobar unit

Where are majority breast cancer located

Upper outer quadrant

Breast cancer progression

Normal- hyperplasia- DCIS- invasive- mets

Breast cancer signs and symptoms

Typically asymptomatic or have new, hard, immobile lump

Pain is rare

May have skin discolorations- redness, edema, thickening

Breast cancer risk factors

Gender

Advancing age

Family history

Personal history

Radiation therapy

Menstrual periods (onset)

Nulliparity or late pregnancy

Biopsy findings

Breast cancer characteristics

Speculations

Taller than wide

Irregular shape

Duct extension

Microlobulations

Disrupts tissue planes

BI-RADS

Breast imaging- reporting and data system

0 Bi-rads

Incomplete

Likelihood of malignancy- NA

Recall for additional imaging

1 bi-rads

Negative

Essentially 0% likelihood for malignancy

Routine screening

2 bi-rads

Benign

Essentially 0% likelihood of malignancy

Routine screening

3 bi-rads

Probably benign

>0% - <2% malignancy

Short interval follow up

4 bi-rads

Suspicious

>2% - <95% malignancy

Tissue diagnosis

5 bi-rads

Highly suggestive of malignancy

>90%

Tissue diagnosis

6 bi-rads

Proven malignancy

Surgical excision

Non invasive carcinomas

Ductal carcinoma in situ

Lobular carcinoma in situ

Ductal carcinoma in situ aka

Intraductal carcinoma

Most common non invasive carcinoma

Ductal carcinoma in situ

70%

Ductal carcinoma in situ

Malignant changes in ductal epithelium without extension past basement membrane

Stage 0 disease

Ducts, carcinoma in situ ultrasound

Often undiagnosed by US

Ductal dilation

Most common breast cancer

Invasive ductal carcinoma

70-80% of all breast cancers

Peak age 50

Invasive ductal carcinoma

Malignant changes in ductal epithelium with invasion through the basement membrane

Ability to metastasize through blood stream and lymphatic system

Invasive ductal carcinoma signs and symptoms

Solitary, hard, fixed palpable masses

Focal breast tenderness, nipple discharge, skin changes

Invasive ductal carcinoma ultrasound

Irregular, speculated, Hypoechoic, sharp angulations, posterior shadowing, heterogeneous

Second most common type of invasive breast cancer

Invasive lobular carcinoma

55-70 years

Most frequent missed breast cancer

Invasive lobular carcinoma

Invasive lobular carcinoma

Second most common invasive breast cancer

Most frequently missed breast cancer

Likely bilateral, multicentric, multifocal

Invasive lobular carcinoma signs and symptoms

Rarely a discrete palpable masses Focal, breast thickening or tenderness

Invasive lobular carcinoma ultrasound

Often more effective at demonstrating this cancer

Speculated, ill defined borders, Hypoechoic with posterior shadowing

Medullary carcinoma

Women 35 years

More common among Asian and African American women

Most commonly mistaken cancer for benign Fibroadenoma

Highly cellular and fast growing tumors that may become large and stretch the skin

Which cancer is most commonly mistaken for Fibroadenoma

Medullary carcinoma

Medullary carcinoma signs and symptoms

Discrete, soft, mobile mass

Non tender

Compressible

Medullary carcinoma ultrasound

Large solid mass, Hypoechoic, round or oval, well marginated, homogeneous or mildly heterogeneous, posterior enhancement

Metastases

Spread to and from breast through lymphatic system, bloodstream, direct invasion

Common Mets from primary breast cancer

Lymph nodes- axillary most common

Bone

Lung

Liver

Opposite breast

Mets to breast from another primary cancer

Uncommon-

Melanoma

Lymphoma

Lumping

Sarcoma

Ovary

Opposite breast

Gynecomastia

Most common male breast abnormality

Non-neoplastic enlargement of the male breast

Increased fat and stromal elements, duct enlargement, and possible glandular development

Most common male breast abnormality

Gynecomastia

Gynecomastia usually associated with

Increase in estrogen or a decrease in testosterone

Gynecomastia signs and symptoms

Unilateral or bilateral, breast enlargement, palpable subareolar nodule, tenderness, skin spthickening

Gynecomastia ultrasound

Normal appearing fibroglandular tissue without extension past triangular shaped pattern, increased fat