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

2. Module 6 Benign Disease

3. 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.

4. 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.

5. 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

6. 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)

7. Mammography of simple cyst

8. 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.

9. Sonography of simple cyst

10. 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.

11. 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

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

13. 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%

14. Complicated fatty cyst (aka Acorn Cyst)

15. Complicated apocrine cyst

16. 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

17. 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

18. 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

19. 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.

20. 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.

21. Complex cyst

22. Septated cyst

23. Calcified cyst

24. 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

25. Clinical Galactocele

26. Galactocele on Sonography

27. 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.

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

30. Sebaceous cyst on Sonography

31. 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.

32. Breast tissue with fibrocystic change

33. 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

34. Cluster of microcysts

35. 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

36. 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

37. 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.

38. Fibroadenoma cartoon

39. Calcified fibroadenoma on mammography

40. 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

41. Classic fibroadenoma on sonography

42. 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.

43. Giant Juvenile fibroadenoma

44. 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

45. Intraductal papilloma

46. Papilloma on Ductoscopy

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

48. Papilloma confirmed by Galactography

49. 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.

50. 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).

51. 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.

52. Papillomatosis

53. Swiss cheese disease

54. 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.

55. 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.

56. Lipoma on Sonography

57. 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

58. Fibroadenolipoma on mammography

59. Fibroadenolipoma (Hamartoma) on Sonography

60. Hamartoma

61. 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

62. Lactating Adenoma

63. 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.

64. 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

65. 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

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

67. Normal Skin thickness

69. 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.

70. 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

71. Nipple Discharge-Galactorrhea

72. 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

73. 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.

74. Fatty Necrosis post breast reduction

75. 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.

76. 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).

77. Hematoma 12 days after breast lift and augmentation

78. 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

79. Seroma following lumpectomy

80. 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

81. 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

82. Sclerosing Adenosis (Mammography)

83. Sclerosing Adenosis – Sonography: Looks bad, but is benign

84. 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

85. Radial scar on mammography

86. Malignancy? NO- Radial Scar

87. 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

88. Mondor’s disease (diagram)

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

90. 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.

91. 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.

92. 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

93. Gynecomastia

94. FIN