Sonography of the Breast Part III Module 6 Harry H. Holdorf PhD, MPA, RDMS (Ab, Ob/Gyn, Br), RVT, LRT(AS)

Module 6 Benign Disease

Breast Cysts Simple Cyst A simple cyst of the breast is very common and generally occurs in women between the ages of 35 and 50. Simple cysts will typically regress after menopause, but may persist in women taking HRT.

Hormone Replacement Therapy HRT for menopause is based on the idea that the treatment may prevent discomfort caused by diminished circulating estrogen and progesterone hormones. Or, in the case of surgical or premature menopause, that it may prolong life and may reduce the incidence of dementia. It involves the use of one or more of a group of medications designed to artificially boost hormone levels. The main types of hormones involved are estrogens, and sometimes testosterone. It is often referred to a “treatment” rather than a therapy.

Cysts result from obstructed lactiferous ducts (usually the TDLU) due to fibrosis or proliferative changes in the duct epithelium. Cysts also result from hormonal dilation

Cysts can be: Single or multiple Unilateral or bilateral Variable in size Palpable or non-palpable Silent or painful Moveable Compressible On Mammography, simple cysts appear: Round or Oval smooth (circumscribed) margins Radiopaque (Water density) Halo sign (lucent rim of fat)

Mammography of simple cyst

On Sonography, simple cysts appear: Round or Oval Anechoic* Well circumscribed* Acoustic Enhancement* May have edge shadowing Occasionally lobulated Compressible No internal Doppler signal * Three criteria required for a cyst to be classified as SIMPLE.

Sonography of simple cyst

Sonography can accurately diagnosis simple cyst of the breast Sonography can accurately diagnosis simple cyst of the breast. No further intervention is required unless the cyst is large and painful for the patient. If needed, aspiration can be both therapeutic and diagnostic. Only 11% of breast cysts are simple.

Artifacts within a cyst may be due to: Improper TGC Overall Gain too high Improper focal position Small cyst size Superficial location (Use a standoff pad) Deep location Side or grating lobe artifact Slice (section) thickness artifact Volume averaging artifact

Artifact within a cyst-Reverberation near field artifact- left straight arrow

Non-Simple Cysts Non-simple cyst include: Complicated cysts Complex cysts Clustered microcysts Septated cysts Calcified cysts Complicated cysts contain homogeneous low-level internal echoes with fluid-fluid or fluid-debris levels which react to gravity. The malignancy rate of a complicated cyst is 0-1.4%

Complicated fatty cyst (aka Acorn Cyst)

Complicated apocrine cyst

Non-malignant fibrocystic disease Apocrine metaplasia of the breast A common non-neoplastic condition as part of fibrocystic changes. Common in women greater than 30 years of age but most common in post-menopausal women

Types of complicated cysts Debris-filled, foam cyst Cellular debris, epithelial cells, apocrine cells, foam cells, and cholesterol crystals Fatty cyst Fat and protein cells Hemorrhagic cyst Blood cells Inflammatory cyst Inflammatory cells and purulent fluid, may have thick walls Galactocele Milk Milk of calcium cyst Calcium in dependent portion Sebaceous cyst (Epidermal inclusion cyst) Sebum (greasy substance) Oil Cyst Oil cells

Non-Simple cysts On sonography, complicated cysts may demonstrate: Low to medium level echoes Heterogeneous internal appearance Gravity dependent fluid-fluid levels Septations Wall thickening Total or partial wall calcifications Partial enhancement or shadowing

It may be difficult to differentiate a complicated cyst from a complex cyst, intraductal papilloma, or papillary carcinoma. Color Doppler may be helpful in the assessment of complicated cysts. No Doppler flow will be detected within the debris of a complicated cyst. If complicated cysts are painful, reoccur several times, associated with inflammation, or appear suspicious, aspiration may be required. Cytology can reveal the true nature of the cyst. Complicated cysts will show a change in debris location (gravity dependence) if the patient is examined in both supine and upright positions.

Complex cysts Clustered microcysts Septated cysts Calcified cysts Contain a solid component. Complex cysts are managed differently than complicated cyst. The malignancy rate of a complex cyst is 23%. Clustered microcysts Are commonly seen as fibrocystic changes on mammography and sonography. It may be difficult to distinguish a cluster of microcysts from a hypoechoic mass. Septated cysts Contain one or several internal septations. Calcified cysts Have partial or total wall calcification.

Complex cyst

Septated cyst

Calcified cyst

Galactocele A Galactocele is a milk-filled cyst caused by the obstruction of a lactiferous duct. It is usually associated with childbirth, affecting both breast-feeding and non-breast feeding mothers. The cyst is typically located in the subareolar region. Sonography reveals: Round, oval, or lobulated well-defined mass Hypoechoic to isoechoic Homogenous internal appearance Acoustic enhancement No internal Doppler signal May also see dilated ducts, mastitis, abscess

Clinical Galactocele

Galactocele on Sonography

Sebaceous Cyst A sebaceous cyst (also known as epidermal inclusion cyst) results from an obstructed sebaceous gland associated with the skin (dermis) of the breast. The cyst contains sebum, an oily substance. It is commonly associated with the Montgomery glands of the areola or found at the inframammary fold. Sebaceous cysts are found within the skin, just under the skin (demonstrating the CLAW sign: hyperechoic skin around the edge of the lesion), or within the subcutaneous fat layer.

Sonography reveals: Round, well-defined mass Hypoechoic to Isoechoic (oily sebum) Superficial location (stand-off pad) Acoustic Enhancement No internal Doppler signal

Sebaceous cyst on Sonography

Fibrocystic changes A wide range of benign changes occurring in the female breast is collectively called “fibrocystic Changes”. They are the most common disorder of the breast accounting for nearly half of all surgical procedures. Fibrocystic changes are extremely common, affecting 60 to 90% of females between the ages of 20 to 40. These changes may produce no symptoms, palpable lumps, and/or cyclic pain. Often, the condition is bilateral.

Breast tissue with fibrocystic change

Sonography may reveal: Fibrocystic changes are caused by a battle between proliferation and resorption of epithelial and stromal tissues of the breast. The outcome is cyst formation, fibrosis, and possible epithelial hyperplasia. Mammography may identify fibrocystic changes as an increased density of the fibroglandular tissue in comparison to a previous study. Sonography may reveal: Cysts of various sizes, simple and complex Cluster of cysts Increased fibrosis of the parenchymal layer (hyperechoic fibroglandular tissue) Dilated ducts

Cluster of microcysts

Characteristics of fibrocystic changes: Fibrocystic changes are significant clinically because they produce masses in the breast that must be differentiated from carcinoma. Biopsy is the only certain way to distinguish a benign change from cancer. Characteristics of fibrocystic changes: Bilaterally, multiple nodules, pain prior to menses

Fibroadenoma Fibroadenomas are the most common benign solid tumor of the breast. These estrogen-related tumors typically affect women between the ages of 20 and 40. They arise from the epithelial (glandular) and stromal tissue of the breast. Common Characteristics: Arise from the TDLU < 3cm in size Increased incidence in African-American females Pregnancy may influence rapid growth Single or multiple Presents as painless, palpable mass Firm or rubbery Moveable, not fixed Pseudo-encapsulated Capsule-like structure due to compression of adjacent tissues May undergo changes Necrosis Calcification

On Mammography, a fibroadenoma appears: Round, oval or lobulated Circumscribed Radiopaque-water density May have halo May have calcifications Unable to differentiate from a cyst Fibroadenoma is the most common solid, benign tumor of the breast.

Fibroadenoma cartoon

Calcified fibroadenoma on mammography

On Sonography, a fibroadenoma appears: Round, oval or lobulated Well-defined borders Mildly hypoechoic or isoechoic Homogeneous Thin, echogenic pseudocapsule Wider than tall May compress (due to soft nature) Edge shadowing No significant enhancement or shadowing Peripheral and internal flow may be detected by Doppler

Classic fibroadenoma on sonography

Juvenile (Giant) Fibroadenoma Juvenile fibroadenomas seen in adolescent girls is a highly cellular type of benign fibroadenoma. These tumors grow rapidly and may measure beyond 5cm Doppler could be increased due to vascularity required to accommodate growth. They can grow large enough to impinge on breast development, so they are usually surgically removed.

Giant Juvenile fibroadenoma

Papilloma Intraductal Papilloma A benign tumor growing from the ductal epithelium projecting into the lumen of the duct. Intraductal papilloma occurs most often in women age 30 to 55. The most common cause of blood nipple discharge. Common Characteristics: Typically located in the subareolar region May be single or multiple (papillomatosis) Usually < 2cm Non-palpable May have a “raspberry” appearance Tumor may cause duct obstruction Most frequent symptom is nipple discharge – serous or bloody Ductography may be helpful in diagnosis

Intraductal papilloma

Papilloma on Ductoscopy

Ductogram (Galactogram) Injection of contrast into the lactiferous duct demonstrates a “filling defect”. This confirms an intraductal papilloma or papillary carcinoma.

Papilloma confirmed by Galactography

On sonography, an intraductal papilloma appears: Small, solid lesion within the duct Hypoechoic or isoechoic Round, oval or tubular Associated duct dilatation Radial scanning is optimal for duct visualization Doppler signal within the solid component confirms papilloma or papillary carcinoma (no signal generally confirms complicated cyst.

Intracystic papilloma Intracystic papilloma is the focal dilatation of a duct caused by an obstructing papilloma. It generally represents a type of intraductal papilloma, now presenting as a papilloma within a cyst. The cyst could be clear of hemorrhagic. The lesion is usually small, but can become large. Clinical symptoms are the same as intraductal papilloma. On sonography, an intracystic papilloma will appear: Round or oval cyst containing a solid, mural tumor Cyst could be anechoic or complex Papilloma will appear hypoechoic or isoechoic Doppler signal within the solid component confirms papilloma or papillary carcinoma (no signal generally confirms a complicated cyst).

Juvenile Papillomatosis Juvenile papillomatosis is also known as the “Swiss Cheese Disease”. It is a rare condition affecting females less than 30 years of age. It is characterized by cysts, duct ectasia, intraductal hyperplasia, and Sclerosing Adenosis. It usually presents as a mass located in the periphery of the breast resembling a fibroadenoma. Unfortunately, 25% of patients have a positive family history of breast cancer which arises the suspicion of increased risk. On sonography, Juvenile papillomatosis may appear: Hypoechoic Heterogeneous appearance May have visible cysts and or duct ectasia.

Papillomatosis

Swiss cheese disease

Lipoma A lipoma is an encapsulated tumor of mature adipose tissue. It typically arises from the subcutaneous fat layer, anywhere in the body. In the breast, lipomas are usually located superficially but may also arise from the retromammary layer. Clinically, lipomas are soft, compressible, mobile masses.

On mammography, a lipoma will appear: Radiolucent Circumscribed Thin capsule On sonography, a lipoma will appear: Oval and well-defined Isoechoic (although hyperechoic and hypoechoic lesions are seen) Homogenous Compressible Usually superficial May be mistaken for a fat lobule Lipomas are the only breast lesion with a true capsule.

Lipoma on Sonography

Fibroadenolipoma A fibroadenolipoma, also known as a Hamartoma, is a rare type of fatty tumor occurring in the breast. The non-encapsulated tumor is composed of fat, fibrous and glandular tissues. It is thought to develop due to an overgrowth of normal breast tissues. It usually occurs in women over 35 years of age. On sonography, a fibroadenolipoma may appear: Well-defined, pseudocapsule Oval or lobulated Echogenicity depends on amounts of fat, fibrous, and glandular tissue. Possible shadowing May be quite large

Fibroadenolipoma on mammography

Fibroadenolipoma (Hamartoma) on Sonography

Hamartoma

Lactating Adenoma A lactating adenoma typically arises as a rapidly enlarging palpable mass during pregnancy. It is benign, but is usually surgically removed due to its large size and aggressive growth. On sonography, a lactating adenoma may appear: Large, well-defined mass Lobulated margins Multiple septations within the mass

Lactating Adenoma

Inflammation Mastitis Mastitis (breast inflammation) often causes marked pain, swelling, and redness of the breast. The most common form of inflammation is lactational (puerperal – following childbirth) mastitis. A cracked nipple, common from breast-feeding, allows bacteria to invade the ducts. The ducts become inflamed and plugged causing milk statsis.

These infections usually respond to antibiotic therapy. Non-lactational (non-puerperal ) forms of mastitis include infected cysts, subareolar abscess, post-surgical inflammation, plasma cell (periductal mastitis) tuberculosis, and inflammatory carcinoma. These infections usually respond to antibiotic therapy. Severe mastitis may be hard to distinguish form inflammatory carcinoma. Acute mastitis presents with: Firm, tender, swollen breast Localized skin thickening and redness Purulent nipple discharge Tender axillary lymph nodes Leukocytosis and fever

Miscellaneous Benign Disease Skin thickening The thickness of the skin of the breast is usually 0.5 to 2.0 mm. An increase in the thickness of the skin may correlate with both benign and malignant processes. Interruption of the dermis layer is suspicious for carcinoma. Skin thickening may be caused by: Trauma Benign Inflammation Mastitis Abscess Plasma cell mastitis Fat necrosis Post-Surgical Scarring Malignancy Tumor invasion Inflammatory Carcinoma (peau d’orange) Cross lymphatic metastasis Lymphoma Radiation Therapy Treatment Restriction of venous return Congestive heart failure Obstruction of Superior vena cava

Stand-off Pad is extremely useful in evaluating skin thickness.

Normal Skin thickness

Nipple Discharge Nipple discharge may be incidental or due to underlying disease. Fluid secretion from the breast may be seen in the non-lactating and non-pregnant female. Galactorrhea is bilateral, milk discharge from a non-lactating and non-pregnant female. It is usually endocrine-induced (caused by a pituitary adenoma) or medication-induced (oral contraceptives, antihypertensive, etc.) Purulent discharges have the characteristic appearance of pus as a result of breast inflammation. These discharges are usually unilateral and arise from multiple ducts.

Breast tumors causing nipple discharge include: Nipple discharge from breast tumors usually arises from a single duct and are associated with one breast lobe. Breast tumors causing nipple discharge include: Benign Intraductal papilloma Malignant Intraductal papillary carcinoma DCIS Invasive Ductal carcinoma Types of discharges that may indicate Breast cancer are: Serous-clear, yellow fluid Serosanguineous – pink color, both serous and bloody fluid Sanguineous – Red, bloody fluid Watery- clear, pale yellow fluid

Nipple Discharge-Galactorrhea

Trauma Several benign conditions may occur of the breast following trauma including: Fat necrosis, Hematoma, Seroma, Lymphocele, and Post-Operative Scarring. Fat Necrosis is a thickening or scarring in the fatty tissue that is caused by an injury to the breast. In most cases, fat necrosis is secondary to biopsy, surgery, radiation therapy, or other latrogenic causes. It can occur at any age. In some cases, there is no known trauma. It may simply occur in obese women with fatty, pendulous breasts

Fat Necrosis typically presents in one or two ways: Oil cyst Firm, fixed, spiculated mass Because it resembles breast cancer, careful clinical correlation is required.

Fatty Necrosis post breast reduction

Trauma A hematoma is a blood-filled tumor of the breast following direct trauma (accidental or latrogenic). Hematomas usually demonstrate bruising of the skin. On sonography, the echogenicity of a hematoma depends on the amount of coagulation present. Hematomas may appear anechoic, complex, or hyperechoic.

Hematoma. (A) Mammogram of a firm, palpable mass that arose at a recent biopsy site shows a dense lesion associated with skin thickening (arrows). (B) Three months later, there has been almost complete resolution of the hematoma with only minimal residual architectural distortion (arrows).

Hematoma 12 days after breast lift and augmentation

Seroma A seroma is a localized collection of serous fluid within the breast. It typically arises following a surgical or invasive procedure. A seroma may develop within cavities such as mammotomy cavity, lumpectomy cavity, or explanation (implant removal) cavity. It may also appear as a perimplant effusion. Seromas typically resolve spontaneously. However, they may persist long-term or become complicated by infection. A variety of sonographic appearances may be seen: Simple cyst Free fluid appearance with angular margins. Low level internal echoes Thick walled with septations

Seroma following lumpectomy

A lymphocele may occur following breast surgery. It represents a cystic tumor filled with lymph fluid. Imaging features are similar to a simple or complex cyst. Post-operative Scarring may present as a palpable mass following breast surgery. These scars usually do not pose a problem unless they have associated fat necrosis. This type of lesion may appear similar to a cancer, so careful clinical correlation is required. Sonography may reveal: A thin shadow from the skin surface A spiculated, fixed, hypoechoic mass with shadowing Doppler demonstrates no increase in flow

Sclerosing Adenosis Sclerosing Adenosis is a benign enlargement of a breast lobule due to epithelial and stromal hyperplasia. The acini of the TDLU increase in number and produce a distorted, spiking, infiltrative appearance. The enlarged lobule occasionally presents as a palpable mass and may have calcifications. The primary significance of Sclerosing Adenosis is its ability to mimic cancer. Biopsy is suggested. On mammography, Sclerosing Adenosis may appear as: Architectural distortion Spiculated appearance Micorcalcifications Sonography may reveal: Irregular, spiculated, or lobulated mass Hypoechoic Possible shadowing No increased Doppler signal

Sclerosing Adenosis (Mammography)

Sclerosing Adenosis – Sonography: Looks bad, but is benign

Radial Scar A radial scar is the invasion of ductal epithelium into the surrounding stromal tissues. It results in a scar formation but may present as a suspicious mass. It is a benign process not associated with trauma. Radial scars are usually less than 1cm and are non-palpable. Its importance is that it may simulate a cancer on mammography, Sonography, and microscopic examination. In 20% of the cases, a radial scar is associated with tubular carcinoma. Therefore, local excision is the suggested treatment. On mammography, a radial scar may appear: Spiculated May have calcifications On sonography, a radial scar may appear: Irregular, spiculated lesion Possible shadowing No increased Doppler signal

Radial scar on mammography

Malignancy? NO- Radial Scar

Mondor’s Disease Mondor’s disease is a rare thrombophlebitis of a superfical vein of the breast. It was first describe in 1939 by French surgeon Henry Mondor. It is usually associated with the internal thoracic vein and therefore, causes pain in the lateral half of the breast. Mondor’s disease may be idiopathic, but it is most often caused by trauma (including blunt trauma, repetitive exercise, aspiration, or biopsy technique). There have been some cases associated with breast cancer. Mondor’s disease may present clinically as a palpable, tender , cord-like, superficial mass. The patient may also have a fever. With hot compress therapy, the phlebitis usually resolves in 2 to 8 weeks. Sonography reveals: Superficial, tortuous, tubular lesion Anechoic, or hypoechoic Stand-off pad may be useful

Mondor’s disease (diagram)

Mondor’s disease (sonography) Thrombophlebitis of a breast vein

Precocious Puberty Breast enlargement during puberty in females usually occurs between ages 9 and 16. The onset of breast enlargement before age 8 is known as Precocious Puberty. This generally benign condition is caused by an endocrine disorder. Careful consideration of the cause is essential for proper treatment. Several causes may include: Ovarian Ovarian enlargement Ovarian cyst Adrenal Gland Adrenal gland tumor Adrenal cortex hyperplasia Adrenogenital syndrome Thyroid Primary hypothyroidism Pituitary Early production of gonadotropin Ovarian Enlargement and/or hyperstimulation is the most common cause.

Gyneocomastia Gyneomastia is the non-neoplastic enlargement of the male breast. It is usually associated with an increase in estrogen and/or a decrease in testosterone. The condition may be unilateral or bilateral. Gyneocomastia is clinically significant and must be differentiated from male breast cancer, endocrine and hormonal disorders. The male breast normally consists of stroma, rudimentary ducts, and fat. TDLUs are usually not evident. Gynecomastia results in increased fat and stromal elements, duct enlargement, and possible glandular development.

Gyneocomastia may present as: Breast enlargement Palpable subareolar nodule Breast tenderness/soreness Skin thickening Possible nipple discharge Causes of Gyneocomastia: Hormonal changes in the male (neonate, puberty, after 50) Estrogen treatment of prostate cancer Testicular failure Neoplasms: testicular, adrenal, and lung Chronic disease: Liver, renal, and pulmonary Medications: antidepressant, antihypertensive, estrogen Marijuana Klinefelter’s Syndrome: xxy sex chromosomes Idiopathic Sonography may reveal Presence of glandular tissue Possible dilated ducts Increased fat

Gynecomastia

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