1. BENIGN MASSES IN BREAST ULTRASOUND
Dr. Mona Rozin
Director of Breast Imaging
Assuta Medical Centers

2. Benign Masses Fibroadenoma
Fibroadenoma variants : complex FA tubular adenoma, lactating adenoma
Phylloides Tumor
Hamartoma
Lipoma
Focal Fibrosis
Diabetic mastopathy
Fibrocystic change

3. I. Fibroadenoma
Arise from a single TDLU and contain both stromal (fibroma) & epithelial (adenoma) elements
Edge is “pushing” not infiltrating & becomes “encapsulated” by compressed breast tissue
FAs with cysts, apocrine metaplasia, or sclerosing adenosis are called COMPLEX

4. FA – cont. Peak incidence – 20-30 yr & again 40-50 yr
Usually 2-3 cm but giant FA & juvenile FA can grow to 10 cm
Estrogen stimulation is important so most common when unopposed (anovulatory) i.e.. in adolescence and perimenopause
Multiple in 25% also bilateral

5. FA – sonographic appearance
Oval, lobulated
Circumscribed with echogenic capsule
Parallel
Iso or hypoechoic
Normal or enhanced transmission with edge shadows
Tiny ones (<1cm) may be round & can’t DD from a complex cyst
May mimic duct extension

6. oval
lobulated
irregular

7. hypoechogenic
isoechogenic

8. Calcifications in FA

9. Ca++
FA in pathology

10. FA – cont. Wide variability in histologic composition
Wide variability in sonographic appearance
Bilateral multiple FAs up to 10 nodules in each breast no need to Bx all of them new ones will almost always develop need 6 mo. F/U

11. II. FA variants – Complex FA
The epithelial components undergo proliferative change and we may see: sclerosing adenosis, cysts, apocrine metaplasia, amorphous calcifications
About 20% of all FAs are complex ! (-) FHx increases risk for CA 3x (+) FHx increases risk for CA 4x
Risk is generalized for the whole of both breasts.

12. II. FA variants – Complex FA
The diagnosis is histological
U/S: may see internal cysts or heterogeneous echo pattern
Seen at older age – median age 47 yrs
Only 1.5% contained a CA
AJR:2008;190:

13. cysts & sclerosis
Complex FAs

14. II. FA variants – Tubular Adenoma & Lactating Adenoma
Almost pure epithelial growth with very little or NO stromal component
Tubular adenoma is very rare
Lactating adenoma is common during pregnancy (mainly 3rd trimester) and lactation

15. II. FA variants – Tubular Adenoma & Lactating Adenoma
Lactating adenoma may arise de novo, from a FA or from a tubular adenoma
U/S: oval, spindle shaped, parallel, hypo-hyperechoic, enhancement, Doppler (+), microlobulated

16. spindle shaped
microlobulated
Tubular adenomas

17. hypo
IDC-Grade 3
hyper
Lactating adenomas

18. III. Phylloides Tumor
Rare – peak at yr but can occur in teenagers
Very rapid growth – up to 15 cm
2/3 benign 1/3 malignant
Mix of very cellular stromal and epithelial elements
U/S: oval, well circumscribed, capsule, hypo, enhancement, “cystic slits”

19. Phylloides with cystic clefts

20. The faces of phylloides

21. IV. Hamartoma
Localized overgrowth of fibrous, epithelial and fatty elements = normal breast tissue
Other names: adenolipofibroma, lipoadenofibroma, fibroadenolipoma
U/S: oval, very heterogeneous, capsule, parallel

22. Classic hamartoma

23. Hamartoma on mammo & CT

24. V. Lipoma Overgrowth of fatty tissue
They are actually in the skin NOT in the breast
May grow up to 20 cm !!!!
U/S: completely isoechoic with the other fat lobules or mildly hyperechoic, soft and compressible

25. fat necrosis
hyper
iso

27. VI. Focal Fibrosis FIBROUS MASTOPATHY
Can cause tender/non-tender palpable lump
May see focal asymmetry on mammo – UOQ

28. VI. Focal Fibrosis
Pathology: dense stromal fibrous tissue without cells
U/S: purely hyperechoic & homogeneous, no capsule tapers into Cooper’s ligaments so can be teardrop or spindle shaped BEWARE: DD with echogenic rim !!!

29. MUST have mammographic correlation

30. VII. Diabetic Mastopathy
Occurs in premenopausal women
Most have Type I diabetes before the age of 20 yr
Usually a very hard palpable lump
May be multifocal, multicentric and bilateral

31. VII. Diabetic Mastopathy
Mammo: non specific asymmetry
U/S: VERY SCARY !!!!!! Ill-defined, angular, microlobulated, hypoechoic, not parallel, intense shadowing
ALL go to Bx.

34. VIII. Fibrocystic Change
Huge spectrum from all the types of cystic change to benign proliferation forming a solid nodule
Adenosis & Sclerosing Adenosis: TDLUs enlarge and increase in number normal lobules – 2 mm adenosis – 5 mm
Mammo: focal asymmetry, masses, “starry night” calcifications
U/S: extremely varied

37. adenosis with amorphous ca++
adenosis with cysts
hypoechoic adenosis in hyper glandular tissue

38. Adenosis and blunt duct adenosis

39. adenosis
blunt duct adenosis

40. “starry night” of sclerosing adenosis

41. The faces of sclerosing adenois
central fibrosis
branching
distended terminal lobule

42. Sclerosing adenosis with spiculation & halo

43. Sclerosing adenosis with ca++

44. Remember algorithm and technique
Know your anatomy
Must correlate with mammo & clinical presentation
Huge overlap of findings
Better than doing mammograms all day!

45. Thank You !