46 THE BREAST

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 46.1 Correct positioning for mediolateral oblique view. a = Nipple in profile. b = Pectoralis muscle visible down to level of the nipple. c = Inframammary fold visible. d = Glandular tissue evenly compressed and adequately penetrated.

• Fig: 46.2. Positioning for the lateral oblique view.

• Fig: 46.3. Positioning for the Craniocaudal view.

• Fig: 46.4. Positioning for a localized compression view

• 46.5. Lateral oblique view: Glandular breasts.

• 46.5. Lateral oblique view: Involuting breast

• 46.5. Lateral oblique view: Adipose breasts

• Fig. 46.7 Normal breast ultrasound: 1 = skin; 2 = subcutaneous fat; 3 = glandular tissue; 4 = retromammary fat; 5 = pectoralis muscle; 6 = rib.

• Fig. 46.8 (A). A typical fibroadenoma with homogeneous internal echoes with an ovoid shape and circumscribed margins. There is posterior acoustic enhancement.

• Fig. 46.8 (B,C) Examples of malignant breast masses with 'benign' ultrasound characteristics. The medullary carcinoma in B has a smooth welldefined margin and is 'wider that tall'. The grade 3 invasive ductal carcinoma in C has marked posterior acoustic enhancement; however its margins are irregular and microlobulated.

• Fig. 46.8 (B,C) Examples of malignant breast masses with 'benign' ultrasound characteristics. The medullary carcinoma in B has a smooth welldefined margin and is 'wider that tall'. The grade 3 invasive ductal carcinoma in C has marked posterior acoustic enhancement; however its margins are irregular and microlobulated.

• Fig. 46.8 (D) A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.

• Fig. 46.8 (E,F) Two examples of fat necrosis mimicking malignant lesions. The case in E shows two hypoechoic areas with irregular outlines. The case in F shows a 'tall' hypoechoic lesion with posterior acoustic shadowing.

• Fig. 46.8 (A). (E,F) Two examples of fat necrosis mimicking malignant lesions. The case in E shows two hypoechoic areas with irregular outlines. The case in F shows a 'tall' hypoechoic lesion with posterior acoustic shadowing.

• Fig. 46.8 (G) An invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation. There is also increased hyperechogenicity of intramammary fat on the right side.

• Fig. 46.8. (H) Inflammatory breast cancer with secondary signs. Note the loss of the normal glandular adipose differentiation due to increased hyperechogenicity of the intramammary fat. Lymphatic dilation is also apparent under the thickened subcutaneous layer.

• Fig. 46.8. (I) A power Doppler image of an invasive grade 3 breast cancer. Note the high density of irregular tortuous and branching vessels penetrating into the centre of the tumour.

• Fig. 46.9 (A) This image shows a focus of high signal corresponding to a fleck of microcalcification lying within an irregular hypoechoic mass with intraductal dilation. (B) The corresponding power Doppler image demonstrates associated neoangiogenesis. This corresponded to a small focus of invasive carcinoma lying within an area of high-grade ductal carcinoma in situ.

• Fig. 46.11 Spiculate mass (arrow) due to an invasive carcinoma on: (A) lateral view; (B) localised compression magnification view.

• Fig. 46.12 A spiculate mass with microcalcification due to a complex sclerosing lesion/radial scar (magnification view).

• Fig. 46.13 Ultrasound showing an echo-poor mass with irregular margins and posterior acoustic shadowing due to a carcinoma.

• Fig. 46.15 Magnification localised compression view showing an architectural distortion (stellate lesion) due to a benign complex sclerosing lesion/radial scar.

• Fig. 46.16 (A) Stellate appearance (arrows) due to summation of overlying stromal shadows. (B) Repeat film shows that no lesion is present.

• Fig. 46.17 Stellate opacity due to a surgical• scar.

• Fig. 46.18 Stellate lesion due to an invasive tubular carcinoma.

Fig. 46.19 Stellate lesion with microcalcification due to a Grade 1 invasive ductal carcinoma. (A) Magnification view. (B) Specimen radiograph.

• Fig. 46.21 A small soft-tissue density with irregular margins due to a carcinoma is present just anterior to the left pectoralis muscle (arrow).

• Fig. 46.22 Lipoma-large circumscribed radiolucent mass with a thin capsule (arrows) and coarse calcification.

• Fig. 46.23 Oil cyst. A round radiolucent lesion is present at the site of a previous surgical excision; clinically a firm lump was present.

• Fig. 46.24 Adenolipoma. A large circumscribed mixed density mass is present (arrows). Clinically only a soft swelling was present.

• Fig. 46.25 Galactocele. A circumscribed mixed density lesion with a capsule (arrows).

• Fig. 46.26 Simple cysts. (A) Multiple circumscribed low soft-tissue density lesions are seen in both breasts. (B) Ultrasound shows the typical features of a simple cyst-a well-defined anechoic lesion with posterior acoustic accentuation.

Fig. 46.27 Intracystic carcinoma in a male presenting with a mass. (A) The mammogram shows a circumscribed soft-tissue-density mass. (B) Ultrasound shows a lobulated intracystic mass (arrow) with calcification. Histology-non-invasive carcinoma.

• Fig. 46.28 Intracystic carcinoma. (A) The mammogram shows a circumscribed soft-tissue mass. (B) Ultrasound shows internal echoes within a cyst. Needle aspiration-blood-stained fluid containing malignant cells. Histology-non-invasive carcinoma.

• Fig. 46.29 Fibroadenoma. (A) Mammogram-a circumscribed soft tissue- density lesion. (B) Ultrasound-a circumscribed solid low reflectivity mass with posterior acoustic shadowing. A focus of calcification is seen.

• Fig. 46.30 Fibroadenomas. (A) First screening mammogram. (B) Second round screening mammogram. Two circumscribed lobulated masses are present. The superior lesion shows progressive coarse calcification.

• Fig. 46.31 Fibroadenoma. Growth while on hormone replacement therapy. (A) First screening mammogram. (B) Second round screening mammogram.

• Fig. 46.32 Phyllodes tumour-mammogram. A circumscribed soft-tissue mass with a lobulated outline.

• Fig. 46.33 Mutinous carcinoma and invasive ductal carcinoma. (A) Mammogram shows a poorly defined spiculate mass: (1) due to invasive ductal carcinoma and a circumscribed soft-tissue mass; (2) due to a mucinous carcinoma. (B) Ultrasound shows a typical low reflectivity mass: (1) due to invasive ductal carcinoma, and a circumscribed mass with posterior acoustic accentuation due to the mutinous carcinoma (2).

• Fig. 46.34 Non-invasive intracystic carcinoma. Mammogram magnified localised compression views shows a circumscribed mass with irregular microcalcification.

• Fig. 46.35 Invasive ductal carcinoma. (A) Mammogram a circum- scribed retroareolar mass with poorly defined posterior margins. (B) Ultrasound a circumscribed mass with a homogeneous internal echo l pattern and through transmission of sound.

• Fig. 46.36 Sarcoma. A round soft-tissue mass with homogeneous internal echoes and normal glandular tissue anteriorly.

• Fig. 46.37 Fibroadenoma-an oval well-defined low reflectivity lesion with posterior acoustic accentuation.

• Fig. 46.38 Giant fibroadenoma. Ultrasound shows a well-defined mass with a homogeneous internal echo pattern and normal glandular tissue anteriorly.

• Fig. 46.43 Keloid. A lobulated soft-tissue opacity is demonstrated overlying the upper part of the breast (arrows).

• Fig. 46.45 Ductal carcinoma in situ-comedo type. Transverse section through a duct showing central necrosis and calcification. (Courtesy of Dr S. Humphreys.)

• Fig. 46.46 Ductal carcinoma in situ-high-grade comedo type. (A-C) Irregular linear branching microcalcification.

• Fig. 46.7: Ductal carcinoma in situ. Intermediate/low grade. Magnification view irregular polymorphic particles of microcalcification.

• Fig. 46.48 Ductal carcinoma in situ. Irregular pleomorphic microcalcification.

• Fig. 46.49 Ductal carcinoma in situ. Cribriform architecture. The particles of calcification are in the small spaces within the thickened duct wall. (Courtesy of Dr S. Humphreys.)

• Fig. 46.50 Ductal carcinoma in situ. Low-grade, cribriform architecture. (A) Multiple clusters of punctate microcalcification distributed throughout one quadrant. (B, C) Solitary clusters of slightly pleomorphic microcalcifications.

• Fig. 46.51 Well-defined calcifications associated with secretory change.

• Fig. 46.52 Lobular calcifications. (A) Adenosis. (B) Sclerosing adenosis. (C) Microcystic change.

• Fig. 46.53 Microcystic change. Calcifications in enlarged lobular spaces.

• Fig. 46.54 Microcystic change. Multiple rounded calcifications of similar density.

• Fig. 46.55 Sclerosing adenosis. (A,B) Clusters of fine granular pleomorphic calcifications. (C) The calcifications are coarser and are associated with a soft tissue opacity.

• Fig. 46.56 Milk of calcium in benign cystic change. On the craniocaudal view the calcifications appear as round 'smudge' shadows (A). On the lateral view the calcifications show a straight upper border, the 'tea cup‘ sign (B).

• Fig. 46.57 Skin calcification. Multiple small ring-shaped calcifications.

• Fig. 46.61 Renal failure. Extensive stromal and vascular calcification.

• Fig. 46.63 Oedematous right breast due to right heart failure.

• Fig. 46.64 Ultrasound of a 48-year-old woman with a palpable left breast mass. The mammogram did not demonstrate a mass. Ultrasound shows a solid mass. FNAC - malignant cells. Final diagnosis - invasive breast carcinoma.

• Fig. 46.65 Localised compression magnification view of a 56-year-old woman with a palpable left subareolar mass. The standard views showed no subareolar abnormality. The localised compression view, however, shows a spiculate mass (arrows) due to an invasive carcinoma.

• Fig. 46.66 Breast MRI: time-signal intensity curves following IV contrast. In type I, enhancement continues through the duration of the study. In type II, there is a plateau, whereas in type III, signal intensity diminishes (washout).

• Fig. 46.67 Sagittal T 1 -weighted gradient-echo images with fat saturation pre (A) and post (B) intravenous gadolinium-DTPA. Two malignant masses are demonstrated. Note typical heterogeneous and rim enhancement of the larger mass and clear demonstration of involvement of the prepectoral fascia, pectoralis major muscle and skin by the inferior mass.

• Fig. 46.68 Axial T1 -weighted (A) and T2 -weighted (B) i mages in a patient with bilateral single lumen silicon implants. Note extracapsular rupture of the right breast implant, with a collection of silicon lying in the lateral aspect of the breast. There is intracapsular rupture of the left breast implant, with a classical linguine sign.

• Fig. 46.69 (A) Implant with silicomoma formation. A firm mass was palpable adjacent to the lateral aspect of the implant. The craniocaudal view shows a soft-tissue opacity with irregular margins adjacent to the lateral aspect of the implant. There are several small round nodules in the adjacent breast tissue. (B) Ultrasound at the site of the mass shows acoustic shadowing only.

• Fig. 46.72 1 4G needle and automated biopsy device used for ultrasound and stereotactic core breast biopsy.

• Fig. 46.73 Ultrasound-guided 14G core biopsy of a solid mass. (A) The tip of the needle is positioned just proximal to the lesion prior to firing the biopsy device. (B) The needle is demonstrated within the lesion after firing the biopsy device. Note that the needle is parallel to the chest wall.

• Fig. 46.75 Stereotactic-guided fine needle aspiration. The check pair of films shows the tip of the needle positioned within the small cluster of microcalcification on both views.

• Fig. 46.77 Stereotactic core biopsy. Stereo film pair showing 'post fire‘ position of needle during biopsy of microcalcification.

• Fig. 46.78 (A) Core biopsy specimen radiograph demonstrating microcalcification within the core samples. (B) Core biopsy showing ductal carcinoma in situ with calcification.

• Fig. 46.79 Vacuum-assisted core biopsy. (A) Probe showing biopsy port with holes leading to vacuum-producing apparatus. (B) Biopsy probe and driver unit.

Fig. 46.80 Wire localization and surgical excision of a non palpable carcinoma. (A) The position of a spiculate mass in the upper part of the left breast is marked with a localizing wire. (B) Preoperative specimen radiography confirms that the mass has been excised.

• Fig. 46.81 A ductogram showing small filling defects due to an intraductal carcinoma (arrows).