CRITERIA OF BENIGNITY AND MALIGNANCY OF CICUMSCRIBED BREAST MASS: ABOUT A SERIE OF 55 CASES Z.OUERGHI; N.DALI; A.MANAMANI A; A. BEN TEKAYA; I.MARZOUK; L.BEN FARHAT; L.HENDAOUI DEPARTMENT OF DIAGNOSTIC IMAGING MONGI SLIM HOSPITAL. LA MARSA BR5

Introduction A circumscribed breast mass is defined as a round or oval breast lesion well demarcated It may correspond to different diagnosis - Benign lesion dominated by cyst and fibroadenoma - Malignant lesion such as medullary, papillary or mucinous carcinoma or well circumscribed ductal carcinoma…

Introduction The aim of our work is to analyze the mammographic and ultrasonographic criteria of benignity and malignancy of circumscribed breast masses through a serie of 55 observations

Materials and methods This is a serie of 55 women The age is ranging from 28 to 76 old years All patients have received a mammogram and a breast ultasound 43 of them underwent biopsy under ultrasound guidance, the others 12 patients were monitored ( followed up ) by breast ultrasound

Result (1) On mammography : The masses density was : - high in 25 cases - low in 26 cases - Radiolucent in one case - Mixed in three cases Calcifications were present in 10 cases which two were benign « popcorn » like in fibroadenoma and eight were malignant in invasive ductal carcinoma

Result (1) On mammography : The halo sign was present in 19 cases The margin was: - regular in 17 cases - lobulated in 21 cases - spiculated in 17 cases

FIBROADENOMA with « popcorn » like calcifications CYST FIBROADEMA WELL DEMARCATED AND SLIGHTLY DENSE MASSES FIBROADENOMA with « popcorn » like calcifications CYST FIBROADEMA

HAMARTOMA with calcifications HAMARTOMA WELL DEMARCATED MASSES CONTAINING FAT DENSITY LIPOMA HAMARTOMA with calcifications HAMARTOMA

LOBULATED AND STRONGLY DENSE MASSES INFILTRATING DUCTAL CARCINOMA

SPICULATED MASSES WITH BRANCHED AND VERMICULAR CALCIFICATIONS INFILTRATING DUCTAL CARCINOMA

WELL DEMARCATED MASS ILL DEMARCATED MASSES INFILTRATING DUCTAL CARCINOMA

Result (2) In ultrasound : The lesions echogenecity was : - Hypoechoic in 47 cases in whoum 20 were homogenous and 27 were heteregenous - Hyperechoic in 7 cases - Anechoic in one case The long axis was : - Wider then tall in 28 cases - Taller then wide 27 cases

Result (2) Posterior acoustic feature was : - A shadowing in 15 cases - An enhancement in 15 cases - Unaffected in 13 cases

FIBROADENOMA WELL DEFINED HOMOGENOUS MASSES WITH POSTERIOR ACOUSTIC ENHANCEMENT AND WIDER THEN TALL LONG AXIS

FIBROADENOMA CONTAINING LITTLE CYSTS CONTAINING POP CORN  LIKE CALCIFICATIONS

FIBROADENOMA STRONGLY CALCIFICATED LOBULATED

FIBROCYSTIC MASTOPATHY HAMARTOMA WELL DEFINED HETEROGENOUS MASS ISOECHOIC TO THE MAMMARY GLAND LOBULATED HYOECHOIC MASS CONTAINING LITTLE CYSTS

INFILTRATING DUCTAL CARCINOMA LOBULATED HETEROGENOUS MASSES WITH TALLER THAN WIDE LONG AXIS

INFILTRATING DUCTAL CARCINOMA SPICULATED MASSES WITH POSTERIOR SHADOWING

Result (3) Of the 43 patients who underwent biopsy the pathology result shows : - Infiltrating ductal carcinoma in 24 cases - A metastasis of melanoma in one case - A fibroadenoma in 11 cases - A fibrocystic mastopathy in 8 cases - A lipoma in one case - An hamartoma in 2 cases

Discussion The large number of biopsies performed for benign breast abnormalities has long been recognized as a serious problem. the mammographic and ultrasonographic features for differentiating benign from malignant solid mass can help to decrease the number of biopsies performed for benign solid masses.

Discussion In order to detect small cancers in breast screening, it is essential to have high quality images. Radiologists reading mammograms shoud be trained in the recognition of the malignant and benign signs of breast masses, because breast cancer may not show typical malignant features.

Discussion The mammograhic features of a breast mass are essentially: - the shape - the margin - the mass density - the calcifications Skin thikening, nipple retraction and architectural distorsion associated to a breast mass can be malignant signs

BENIGN MALIGNANT DIFFERENCIATION mammography Shape Margin Mass density Round / oval with light center stellar Margin circumscribed Spiculated/ microlobulated/ indistinct/ obscured Mass density Low/ fat containing High/ dense center calcifications annular/ regular/ clear centre as an eggshell/lucent centred/ Coarse or popcorn like/ large rod like Skin or dermal and vascular one Size : uniform Distribution : any Density : sparse Vermicular/ irregular/ polyhedral/ pleomorphic/ Fine/ branched and numerous Size : heterogenous Distribution : clustered/ segmental Density : high

Discussion Ultrasonography does contribuate the differentiation of benign versus malignant if the mass is not visible at mammography. In women youger than 30 years, in whom mammography is less useful, ultrasonography is often considered the modality of choice to initiate the evaluation of a breast mass.

Discussion The ultrasonographic features of a breast mass are essentially: - the shape - the margin - the orientation or long axis - the echotexture - the posterior acoustic features - the lesion boundary

US DIFFERENCIATION BENIGN MALIGNANT Shape Round / oval++ Three or fewer lobulation Irregular More than three lobulation Margin Circumscribed Well defined Spiculated/angular/ microlobulated Orientation Wider than taller : long axis parallel to skin Taller than wide : long axis perpendicular to skin Echotexture homogenous heterogenous Echo pattern Markedly hypoechoic Puer and intesely hyperechoic anechoic Posterior acoustic feature Enhancement Shadowing ++ Lesion boundary Thick echogenic rim Abrupt interface

Benign breast masses mammography ultrasound CYST Circular or oval low-density mass with smooth margins Well defined shaped lesion without internal echoes and with posterior acoustic enhancement SEBACEOUS CYST Cyst like mass under the skin A mass lieing entirely within the skin surrounded by a hyperechoic band « clow sign » FIBROADENOMA Well defined or lobulated mass wicth can contain « pop corn » like calcifications An isoechoic mass with wider than tall orientation and distal acoustic enhancement LIPOMA A fat density mass with a thin capsula Isoechoic or mildly hyperechoic mass HAMARTOMA Well defined heterogenous mass with halo sign and fat density Well defined mass with a same echotexture than the mammary gland INTRAMAMMARY LYMPH NODE Well limited low density mass with fatty hilum Hypoechoic nodule with an echogenic hilum

Conclusion The radiologist must be informed about the radiological criteria of benignity and malignancy of circumscribed breast mass. Given the frequency of breast cancer, which affects one in ten women, in any doubt a biopsy should be indicated to give the definitive diagnosis.

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