RADIOLOGICAL FEATURES OF BREAST DX

DISCUSS THE RADIOLOGICAL FEATURES OF COMMON BENIGN AND MALIGNANT BREAST LESIONS ON ULTRASOUND AND

MAMMOGRAPHY

BYDR MAIMUNA A. HALLIRU

DEPARTMENT OF RADIOLOGYAMINU KANO TEACHING HOSPITAL, KANO.

SYNOPSIS• INTRODUCTION• ROLE OF IMAGING (MAMMO & USS) IN

DIAGNOSIS• OVERVIEW OF ACR BIRADS• RADIOLOGICAL FEATURES OF COMMON

BENIGN & MALIGNANT LESIONS• ASSOCIATED LYMPHADENOPATHY• CONCLUSION/SUMMARY

INTRODUCTION

• The breasts are a pair of glandular organs

• Function: lactation.

• Dynamic structure ; undergoes changes throughout a woman’s reproductive life.

INTRODUCTION

INTRODUCTION

• Breast diseases : variety of conditions .

• Benign or Malignant.

• Most common presentation: a palpable lump.

ROLE OF IMAGING IN DIAG.

• For patients attending breast clinics with symptoms of breast disease, mainstay of diagnosis is triple assessment.

• Imaging plays an important role in the evaluation of breast diseases.


• Accurate imaging is vital: -Identify cancers-Avoid false positives-Avoid False negatives


• The principal imaging modalities: mammography and ultrasound.

• Sensitivity of mammography alone = 45-90% (age, parity and breast density).

• Sensitivity of ultrasound = 80-90%.


• The Royal College of Radiologists and the American College of Radiology guidelines:

• <35years, USS• >35years, Mammo.


• Also, ultrasound an adjunct to mammo in patients of all ages.

• Mammography: masses, assessment of calcifications and other features which raise suspicion of breast cancer.


• USS method of choice in differentiating between cystic and solid lesions and in providing guidance for interventional procedures.

BENIGN NON-INFLAMMATORY LESIONS

• Fibroadenoma• Fibrocystic change• Lipoma of the breast• Gynaecomastia• Intraductal papilloma

BENIGN INFLAMMATORY LESIONS

• Breast Abscess• Galactocele• Fat Necrosis

MALIGNANT LESIONS

• Invasive Ductal Carcinoma• Invasive Lobular Carcinoma• Inflammatory Breast Carcinoma

BENIGN NON-INFLAMMATORY

LESIONS

FIBROADENOMA

• Fibroadenoma is an oestrogen-induced benign breast tumour .

• Arises from the terminal duct lobular unit (TDLU) .

FIBROADENOMA

• Most common benign solid tumour among women of child-bearing age.

• Peak incidence: 3rd decade, second peak 5th decade.

FIBROADENOMA

• Grow rapidly but rarely exceed 2-3cm in size.

• Giant fibroadenomas and juvenile fibroadenomas often measure >5cm.

• Lesions up to 10cm may be encountered.

FIBROADENOMA

• Due to hormonal influence on this tumour;

-Slight enlargement at the end of the menstrual cycle.

-During pregnancy.-Regression after menopause.

FIBROADENOMA• Sonographically:

Classically oval or elliptical mass with long axis parallel to the chest wall.

Usually mildly hypoechoic or isoechoic with respect to fat.

Mixed echogenic masses may also be encountered.

FIBROADENOMA

Show a smooth or gently lobullated contour.

An echogenic pseudocapsule is usually demonstrated.

FIBROADENOMA

Represents normal, compressed adjacent breast tissue, indicating that the leading edge is pushing rather than infiltrating.

Sound transmission normal / increased with bilateral edge shadowing.

FIBROADENOMA

• Mammographically,tumours surrounded by dense breast tissue

may not be appreciated.

visible tumours are classically circular, oval or gently lobulated in shape.

FIBROADENOMA

Isodense lesions, smooth, discrete margins.

Margins may be lobular in larger tumours.

Degenerated fibroadenomas usually contain calcifications:

coarse or popcorn-like pathognomonic.

FIBROADENOMA

FIBROADENOMA

FIBROADENOMA

FIBROADENOMA

FIBROCYSTIC CHANGE

• Formerly : fibrocystic breast disease.

• Fibrocystic change (FCC) of the breast: benign alteration in the terminal ductal lobular unit of the breast

• ± associated fibrosis.

FIBROCYSTIC CHANGE

• Now known: exaggerated response of normal breast tissue to the cyclical variations in oestrogen and progesterone.

• Commoner in women of child-bearing age; 35-55years but can occur at any age.

FIBROCYSTIC CHANGE

• On ultrasound these lesions may appear as:

-duct ectasia with a ductal pattern; -multiple cysts of varying size, or -ill-defined focal echogenic lesions with or

without posterior attenuation.

FIBROCYSTIC CHANGE

• Ductal ectasia sonographically seen as tubular anechoic structures radiating in a centripetal fashion towards the nipple in a non-lactating woman usually above 40years of age.

FIBROCYSTIC CHANGE

• Breast cysts appear as rounded or oval shaped well defined sonolucent lesions with imperceptible walls and posterior acoustic enhancement.

FIBROCYSTIC CHANGE

• Mammographically, fibrocystic change of the cystic type appears as individual round or ovoid lesions of low density with discrete, smooth margins.

FIBROCYSTIC CHANGE

• Teacup-like calcifications on horizontal beam

• Rounded smudged calcifications on craniocaudal projections depicting the

• Classic milk of calcium pathognomonic.

FIBROCYSTIC CHANGE

• Involutional type: fine punctuate calcifications evenly distributed within one or more lobes against a fatty background.

• In such cases; percutaneous biopsy is usually required to exclude DCIS.

FIBROCYSTIC CHANGE

FIBROCYSTIC CHANGE

FIBROCYSTIC CHANGE

FIBROCYSTIC CHANGE

FIBROCYSTIC CHANGE

FIBROCYSTIC CHANGE

INTRA-DUCTAL PAPILLOMA

• Benign tumours of mammary duct epithelium.

• Arise anywhere in the ductal system, central >>peripheral.

• Papillomas are the most common cause ofbloody nipple discharge.


• Mammographically; mass or asymmetry.

• Microcalcifications may be seen


• Sonographically;

hyperechoic or hypoechoic masses within dilated retro-areolar duct surrounded by anechoic fluid.

If no fluid, seen as round/irregular hyperechoic or hypoechoic mass lesion usually retroareolar in location.


• A hypervascular stalk may be seen on Doppler interrogation.



LIPOMA OF THE BREAST

• Benign mesenchymal tumours composed of mature adipose tissue.

• Mostly asymptomatic and coincidentally discovered on routine mammography.


• Patients may present with a painless palpable breast lump which is soft and mobile.

• In these cases the diagnosis is clinically obvious.

LIPOMA OF THE BREAST• Mammographically, Typically seen as radiolucent mass with no

calcification.

May have a thin, fluid density capsule.

Mammographic detection easier in a dense breast.

LIPOMA OF THE BREAST• Sonographically, Seen as rounded isoechoic or slightly

hyperechoic lesion in comparison to surrounding fat. Occasionally hypoechoic.

Multiple thin echogenic septations may be seen running parallel to the skin surface.

These lesions are also found in males.



GYNAECOMASTIA

• Enlargement of the male breast benign ductal and stromal proliferation.

• Imbalance between oestrogen action relative to androgen action at the breast tissue level is the key aetiological factor.

GYNAECOMASTIA

AETIOLOGY:• Physiological

• Pathological -Drugs-Systemic diseases-Tumours

GYNAECOMASTIA

• Subtypes:-Nodular -Dendritic -Diffuse

GYNAECOMASTIA

• Mammographically;i. Nodular pattern: seen in patients with

gynaecomastia for less than 1 year.

• Seen as a nodular subareolar density.

GYNAECOMASTIA

• Mammographically;ii. Dendritic pattern: a flame-shaped subareolar

density with posterior linear projections radiating into the surrounding tissue.

GYNAECOMASTIA

• Is seen in patients with gynaecomastia for longer than 1 year.

• Fibrosis becomes the dominant process and is irreversible.

GYNAECOMASTIA

• Mammographically;iii. Diffuse Glandular pattern: commonly seen in

patients receiving exogenous oestrogen.

• There is enlargement of the breast and diffuse density with both dendritic and nodular features.

GYNAECOMASTIA

• Sonographically;i. Nodular gynaecomastia: can be subareolar fan

or disc shaped hypoechoic nodule surrounded by normal fatty tissue.

GYNAECOMASTIA

• Sonographically; ii. Dendritic gynaecomastia: subareolar

hypoechoic lesion with anechoic star-shaped posterior border, described as finger-like projections or "spider legs" insinuating into the surrounding echogenic fibrous breast tissue.

GYNAECOMASTIA

• Sonographically; iii. Diffuse glandular gynaecomastia shows both

nodular and dendritic features surrounded by diffuse hyperechoic fibrous breast tissue.

GYNAECOMASTIA

• A hallmark of gynaecomastia is its central symmetric location under the nipple.

• Imaging differential is male breast cancer which is usually eccentrically located with respect to the nipple. Other features like surrounding distortion, lymphadenopathy etc will be present.

GYNAECOMASTIA

GYNAECOMASTIA

GYNAECOMASTIA

GYNAECOMASTIA

GYNAECOMASTIA

GYNAECOMASTIA

?GYNAECOMASTIA

?GYNAECOMASTIA

BENIGN INFLAMMATORY

LESIONS

BREAST ABSCESS• Relatively common complication of mastitis.

• May occur during breastfeeding, particularly in primiparous women.

• Clinical context is key to diagnosis as imaging appearances (particularly ultrasound) can mimic many other entities such as breast carcinoma.

BREAST ABSCESS

• The predominant infectious organism: Staphylococcus aureus, often the penicillinase-producing type.

• Other common types include Staphylococcus epidermidis and Proteus mirabilis.

BREAST ABSCESS• Classification:

Puerperal abscesses: seen in primiparous mothers.

Non-puerperal central abscesses: commonest non-breastfeeding abscess.

• Seen mostly in young women; especially smokers.

BREAST ABSCESS• Classification:Non-puerperal peripheral abscesses: less

commonly seen. • Seen in older women with underlying chronic

medical conditions like diabetes, rheumatoid arthritis; women taking steroids or underwent a recent breast intervention

BREAST ABSCESS• Ultrasound considered most useful initial

imaging modality when a breast abscess is suspected.

• Imaging method of choice to monitor progress, response to therapy and to ensure resolution.

BREAST ABSCESS• For the purpose of follow up 3-D

measurement of the abscess and the volume should be given.

BREAST ABSCESS• Sonographic features suggestive of a breast

abscess include:

Hypoechoic collection, mostly multiloculated with no vascularity within the collection.

Posterior acoustic enhancement due to fluid content.

Echogenic, vascular rim.Axillary lymphadenopathy

BREAST ABSCESS

• On ultrasound, breast abscess can easily mimic other entities such as a breast malignancy or a breast haematoma on imaging grounds alone.

• In practice, the most difficult differentiation is from a galactocoele.

BREAST ABSCESS

• Mammography is very rarely indicated or useful.

• Mammography is recommended to exclude the possibility of malignancy in non-puerperal abscesses, in ladies over 30 years and in puerperal abscesses with a prolonged clinical course.

BREAST ABSCESS• Mammographic appearances are often non

specific and in the age group where breast abscesses are most often found, mammography is rarely done.

• Findings which may be demonstrated are skin thickening and an asymmetric density, mass or distortion.

BREAST ABSCESS

• These findings are not specific for abscess or malignancy; however presence of suspicious microcalcifications is more specific for malignancy and a biopsy to rule out carcinoma should be carried out.

BREAST ABSCESS

BREAST ABSCESS

BREAST ABSCESS

FAT NECROSIS

• A pathological process that occurs when there is saponification of local fat.

• A benign inflammatory process and is becoming increasingly common with greater use of breast conserving surgery and mammoplasty procedures.

FAT NECROSIS

• Most at risk are middle-aged women with pendulous breasts.

• Aetiologically, in everyday practice, trauma and surgery are the most common cause.

FAT NECROSIS

• Trauma includes seat belt injury, contact sports.

• Surgical procedures include implant removal breast biopsy, prior reconstruction.

• There is no relationship between fat necrosis and subsequent breast carcinoma.

FAT NECROSIS• Mammographically,

An ill-defined and irregular, spiculated mass-like area.

Associated calcification can be seen, which can mimic that of more malignant entities such as DCIS.

FAT NECROSIS• The changes are often seen and correlated

with the position of surgical scarring on the breast itself.

• The calcification of fat necrosis is typically peripheral with a stippled curvilinear appearance creating the appearance of lucent "bubbles" in the breast parenchyma.

FAT NECROSIS• With time, it becomes more defined and well-

circumscribed giving rise to an oil cyst.

• Oil cysts can have very fine curvilinear calcification of the walls.

• The centre of the lesion becomes increasingly homogenous with fat-density. The cyst wall calcify in about 5%.

FAT NECROSIS• Sonographically,

Fat necrosis may be seen as a hypoechoic mass with well defined margins with/without mural nodule(s).

Aspiration of an oil cyst shows typically a milky, emulsified fat appearance.

FAT NECROSIS

• On ultrasound, the lesion may occasionally represent an intracystic carcinoma and mammographic correlation and biopsy are recommended in these circumstances.

FAT NECROSIS

FAT NECROSIS

FAT NECROSIS

FAT NECROSIS

GALACTOCELE

• Most common benign breast lesion typically occurring in young lactating women.

• They mostly occur on cessation of lactation.

GALACTOCELE

• Essentially a retention cyst resulting from lactiferous duct occlusion.

• There is a predilection towards the retroareolar region.

GALACTOCELE

• Mammographic appearance of galactocoele can be varied depending on the fat and protein content and the consistency of the fluid.

Due to significant fat content the mass may appear radiolucent; i.e. PSEUDOLIPOMA.

GALACTOCELE

When the milk is in fresh liquid state, a characteristic fat fluid level is seen due to viscosity difference.

• This can be demonstrated on mediolateral view with the beam horizontal to the upright patient; i.e. Fat-fluid level within a cyst.

GALACTOCELE

When contents are old milk and water, due to highly viscous old milk, gives a hamartoma-like appearance on mammogram.

GALACTOCELE• On ultrasound appearances can be widely

variable. Thin-walled cystic mass with low level internal

echoes 50%.

Complex cystic-solid mass 37%.

Solid mass 13%.

GALACTOCELE

GALACTOCELE

GALACTOCELE

GALACTOCELE

COMMON MALIGNANT

LESIONS

INVASIVE DUCTAL CARCINOMA• Commonest histologically diagnosed breast

malignancy accounting for 50-70% of invasive breast cancers.

• Most tumours are believed to arise from the ducts within the terminal ductal lobular unit (TDLU).

INVASIVE DUCTAL CARCINOMA

• In a study conducted in this department, peak presentation of IDC was in the age groups 31-45 years.

• Patients are much older in the West. Generally in 5th – 6th decade.

INVASIVE DUCTAL CARCINOMA• Mammographically,

Findings vary greatly and reflect gross tumour morphology and histological heterogeneity.

Include irregular masses with or without microcalcifications and architectural distortion.


• Masses usually show spiculated or indistinct margins.

• Rarely however, a mass with circumscribed margins may be seen.


• Extensive intraductal component is not uncommon and may manifest mammographically as linearly arranged calcifications .

INVASIVE DUCTAL CARCINOMA• Sonographically,

Appear as irregular, microlobullated, hypoechoic masses.

Widest diameter of the tumour perpendicular to the skin surface.

Hyperechoic margins and Posterior shadowing = Desmoplasia.


• However, in high grade variants that are highly cellular with little desmoplasia, posterior enhancement may be observed.

• Axillary lymphadenopathy is a prominent feature.








INVASIVE LOBULAR CARCINOMA• 2ND most common invasive breast malignancy

accounting for about 5-15% of all invasive breast tumours.

• Arise from the terminal ductules of the breast lobules and are more common in elderly women; 2% <35years.

INVASIVE LOBULAR CARCINOMA

• Mammographically,

Non-specific.

Commonest abnormality an ill-defined isodense mass with obscured, spiculated margins.


ILC may only be a one view finding; usually the CC view which is typically better compressed than the MLO view.

Subtle mammographic findings such as asymmetric densities and architectural distortion commoner in ILC >> IDC.


“Shrinking breast phenomenon” may be seen where in a large tumour, the affected breast appears mammographically smaller compared to the normal breast due to decreased compliance and compressibility.

INVASIVE LOBULAR CARCINOMA• Sonographically,

An irregular, angular hypoechoic mass.

Heterogenous internal echoes with ill-defined or spiculated margins and posterior acoustic shadowing.

Axillary lymphadenopathy


In some cases, no abnormality may be detected.

The only abnormality might be suspicious shadowing with no obvious mass.






INFLAMMATORY BREAST Ca.

• A relatively uncommon but aggressive form of invasive breast carcinoma.

• Any pathological sub-type of breast cancer may be involved.


• Account for 1-4% of all breast cancers, typically occurring in women between 4th to 5th decades.


• Mammographic findings include:

Tumour mass MicrocalcificationsFeatures of inflammation: skin thickening

coarsened trabeculae, increased densityAxillary lymphadenopathy


• Ultrasound may be helpful to locate a hypoechoic shadowing mass, which can be obscured on mammography by diffusely increased breast density.





ASSOCIATED LYMPHADENOPATHY

• Normal lymph nodes: short axis diameter < 10mm.

• Oval shaped

• Smooth regular contour

• Central hilum: echogenic on USS; lucent on mammogram.

NORMAL AXILLARY LN: MAMMO

NORMAL AXILLARY LN: USS


• Abnormal lymph nodes: inflammatory / malignant, short axis diameter > than 10mm.


• Inflammatory enlargement: proportionate in all directions elliptical-shaped enlargement.

• Neoplastic enlargement: disproportionate in its shortest plane abnormal “rounding” of the node.

ASS LYMOCIATEDPHADENOPATHY• Sonographic features suggestive of malignant

infiltration include:-Eccentric cortical thickening.-Eccentric mediastinal compression.-Focal inward convex compression of the

mediastinum (rat bites). -Mediastinal obliteration.-Loss of the thin echogenic outer capsule. -Presence of angular margins.


• Mammographically; -Loss of the normal fatty hilum,-Loss of the normal oval or reniform shape,-Poorly circumscribed margins,-Increased size and opacity






SUMMARY/CONCLUSION• Many of the commonly encountered breast

lesions have classic imaging features.

• There are a few exceptions.

• Knowledge of imaging features enables the radiologist to make proper diagnosis and contribute towards effective management.

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RADIOLOGICAL FEATURES OF BREAST DX