1. 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

2. 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…

3. 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

4. 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

5. 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

6. 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

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

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

9. LOBULATED AND STRONGLY DENSE MASSES
INFILTRATING DUCTAL CARCINOMA

10. SPICULATED MASSES WITH BRANCHED AND VERMICULAR CALCIFICATIONS
INFILTRATING DUCTAL CARCINOMA

11. WELL DEMARCATED MASS
ILL DEMARCATED MASSES
INFILTRATING DUCTAL CARCINOMA

12. 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

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

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

15. FIBROADENOMA CONTAINING LITTLE CYSTS
CONTAINING POP CORN  LIKE CALCIFICATIONS

16. FIBROADENOMA
STRONGLY CALCIFICATED
LOBULATED

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

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

19. INFILTRATING DUCTAL CARCINOMA
SPICULATED MASSES WITH POSTERIOR SHADOWING

20. 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

21. 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.

22. 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.

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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.

30. References
Stephen A. feig, MD.Breast masses-mammographic and sonographic evalution Radio Clin North Am 30:67-90,1992 
Lowerence W. Bassett, MD. Mammographic analysis of calcifications Radio Clin North Am 30:93-105,1992
Stavros AT, Thickman D. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995;196(1):123–134
Sughra Raza, MD • Allison L. US of Breast Masses Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing Clinical Management RadioGraphics 2010; 30(5): 1199 – 1213
Breast calcifications: which are malignant Muttarak M, Kongmebhol P, Sukhamwang Singapore Med J 2009; 50(9) : 907
N Shah, SB Patell Well circumscribed breast carcinoma : Mammographic and sonographic finding report of fine cas 2005
Linda Moy, MD, Priscilla J.Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review