1. Benign breast disorders
“Others”
Grubstein Ahuva
Rabin medical Center

2. Introducing the entities Tips of how to differentiate from cancer
Purpose
Introducing the entities
Tips of how to differentiate from cancer

3. Content Galactocele Mastitis and abscess formation Duct ectasia Seroma
Hematoma
Fat necrosis
Fat containing lesions
Intraductal papilloma
Skin lesions
Mondor’s disease
Hemangiomas and venous malformations
Neurofibroma

4. Suggested approach nodules
Mammography
Sonography
Look for suspicious findings
If a single finding is present: do something more--, old films, additional views, ultrasound, biopsy
If a single finding is present: do something morebiopsy
No suspicious finding – routine screening
No suspicious finding, look for benign findings
If benign findings—>follow up
BIRADS 3 – short term follow up
If no benign findings—>BIRADS 4
Patient history

5. Suggested approach cysts
Complex
Simple
Exclude artifacts
Anechoic
Look for BIRADS>4 findingsbiopsy
Well circumscribe
If not look for BIRADS 3 inflammatory findings
Thin echogenic wall
If not look for strict BIRADS 2 findingsreturn to routine screening
Through transmission
If not look for BIRADS 3offer attempt aspiration and short term follow up
Edge shadows
If notby default consider as BIRADS 4a and biopsy
BIRADS 2
Patient history

6. Duct ectasia
Large subareolar and intermediate ducts become dilated and filled with thick static secretions.
Ducts wall and periductal tissue are inflamed.
Inflamed ducts may rupture  periductal chemical mastitis2nd infected  nonpueperal abscess, mostly in the periareolar area.

7. Duct evaluation – US technique
Transducer held at an angle
The ultrasound beam is perpendicular to the long axis of the duct
Proper contact and pressure 
No acoustic shadow from the nipple
The nipple will casts a posterior shadow that obscures the intraductal lesion

8. Duct ectasia May be associated with hyperprolactinemia
Usually asymptomatic
Only 30% have have nipple discharge – clear-whitish-cheesy-yellowish

9. Duct ectasia

10. Galactocele
Cystically dilated terminal ductules that are filled with milk and lined by double layer of breast epithelium and myoepithelium.
Classically appears as a painless lump weeks – months after cessation of breast feeding.

11. Galactocele US Varies with stage :
cystic – complex cystic – solid appearance
Fresh milk - anechoic
As they age - more echogenic.
Eventually usually regress , but may persist for years
Wall may calcified – like oil cyst on Mammo

12. Mastitis and abscess formation
Classic streptococcal infection of breast
1. Cellulitis
2. Systemic infection and bacteremia with localization of abscess
Staphylococcal breast abscesses
1. Localized deeply invasive and suppurative abscesses
2. Multilocular abscesses

13. Mastitis and abscess formation puerperal
Acute , during lactation , may progress to abscess
Staph, strep.
Contributing factors: nipple fissures , milk stasis
S&S of infection and inflammation
Mammo – usually not helpful, increased density obscuring any underlying pathology

14. Mastitis and abscess formation Puerperal - US
1st choice
Edema – skin and subcutaneous tissue, thickening and become hyperechoic
Cooper’s ligaments become less echogenic
Loss of distinction between different types of breast tissues

15. Mastitis and abscess formation Puerperal - US
Difficult to penetrateuse deeper probes (5MHz), to exclude abscess formation
Usually single lobe, but may spread

16. Mastitis and abscess formation Non puerperal
Usually have underlying duct ectasia, rarely cysts
More anaerobes
Duct ectasia periductal mastitis complex
Perimenopausal
Late teens

17. Mastitis and abscess formation
Should be distinguished from inflammatory carcinoma
Both causing edema and inflammation.
Both can have hypoechoic masses that have enhanced acoustic through transmission.

18. Inflammatory breast mass in nonlactating female
1. Abscess
2. Infected cysts
3. Duct ectasia
4. Carcinoma

19. Seroma Localized collection of serous fluid
Lumpectomy cavities, post– vacuum assisted large core needle biopsy, around implants.
Peri implants seroma is desired. May complicate, when large can be painful, infected.

20. Seroma US: simple or complex cyst/s.
Angular margin may occur at angular lumpectomy margins.
Use Doppler, compressibility, to try differentiate from recurrence.

21. Hematoma Localized collection of extravagated blood within the breast
Traumatic, post interventional
Gradually completely desorbed, or persist as chronic hematoma, fat necrosis and lipid cyst.

22. Hematoma - US Acute: hypoechoic, with echogenic clotted blood
Layering- fluid debris level that may change with repositioning
Mural nodule; use Doppler to distinguish from papilloma

23. Hematoma - US
Chronic:
Mostly complex cysts with thickened walls and septa
Enhanced through transmission
Calcified demonstrating acoustic shadowing

24. Fat necrosis Results from injury to breast fat
Trauma, surgery, biopsy….
Causes to focal fibrosis and cicatrix formation.
Early: edema of the fat lobules,
increased echogenicity.
Post surgical scar, hematoma, seroma

25. Post lumpectomy fat necrosis
Distinction from recurrence
Early - complex cyst with mural thrombi,
later fibrosis causes angulations, spiculations and significant shadowing
indistinctable from carcinoma.
Help:
Doppler (two caveats: tumors don’t always demonstrate increase vascularity, healing granulation tissue may be vascular),
Spot compression mammogram,

26. Fat containing lesions
Lymph nodes
Hamartomas
Lipomas
Hemangiomas DD
Acute hematoma
Focal fibrosis
Malignancy

27. Fat containing lesions lymph nodes – 2nd look US

28. Fat containing lesions Lipomas
Angiolipoma
Lipoma

29. Fat containing lesions Hamartomas
Localized overgrowth of fibrous epithelial and fatty elements.
“Breast within Breast”

30. Intraductal papilloma
Ductal epithelial proliferations that grow in a frond like pattern.
A central fibrovascular stalk covered by double layer of epithlium and myoepithelium.

31. Intraductal papilloma

32. Intraductal papilloma
Central –
Large duct papilloma, subareolar
Nipple discharge, bloody
Perimenopausal

33. Intraductal papilloma
Peripheral –
In the terminal duct of the TDLU
More often multiple
Younger patients
More associated with diffuse epithelial proliferation; ADH, DCIS,
less often will cause nipple discharge
papillomatosis

34. Intraductal papilloma
Secrete fluid into the ducts
Causing duct dilatation & and nipple discharge
Intracystic papilloma

35. Intraductal papilloma central

36. Central intraductal papilloma US technique

37. Ductography, filling defect
Technique:
Cannulation of the offending duct, and injection of iodinated contrast
CC and MLO mammograms

38. Intraductal papilloma central
Subtracted T1 T2

39. Complex cysts
Apocrine metaplasia
Intraductal papilloma

40. Papillary lesions peripheral
65 y.o. bloody nipple discharge

41. Papillary lesions peripheral

42. Papillary lesions

43. ?? BIRADS??

44. Skin lesions: Sebaceous cysts, Montgomery gland cysts, Epidermal inclusion cysts
Lies entirely within the skin
Most of the lesion is in the subcutaneous tissue (claw sign)
Entirely in the subcutaneous fat tissue, but a neck or a hair follicle can be shown coursing to the skin

45. Sebaceous cysts, Montgomery gland cysts, Epidermal inclusion cysts

46. Sebaceous cyst, Epidermal inclusion cyst

47. ?

48. ?

49. Mondor’s disease: acute superficial thrombosis of the breast veins.
Rare
Superficial veins of the subcutaneous breast thrombose
Hx of trauma, pregnancy, CV lines
Pain, tenderness, linear skin erythema
Palpable cord

50. Mondor’s disease: acute superficial thrombosis of the breast veins
Thoracoepigastic vein
(from inferomedial aspect of the breast to the axilla)
Lateral thoracic
with CVL’s, medial vein that drains into the internal mammary vein.

51. Mondor’s disease: acute superficial thrombosis of the breast veins.
Josep M. Sabaté RadioGraphics 2005; 25:

52. Hemangiomas and venous malformations
Microscopic – common
Macroscopic: larger than 4 mm, usually less than 2 cm,
(angiosarcoma are usually larger than 3 cm).

53. Hemangiomas and venous malformations
Mammo: nodule, ca++
US: depends on type -
Capillary – echogenic nodule,
Cavernous – hypoechoic nodule (the larger the channels the more hypoechoic)

54. Hemangioma

55. Hemangioma
65 y.o. screening mammogram

56. Neurofibromas Subcutaneous benign peripheral nerve sheath tumors
Neurofibromatosis type 1,
Classically peri-areolar in location.

57. Neurofibromas
Mammo : Well-defined benign appearing masses, often multiple. Portions of the outline may be rimmed by air density reflecting their superficial nature
US: well-defined hypoechoic mass, with posterior acoustic enhancement, located in the subcutaneous tissue similar to a fibroadenoma

58. Neurofibroma

59. Purpose Make acquaintance with the entities Know how to
differentiate them from cancer

60. Suggested approach nodules
Patient story
Look for finding
Suspicious?
Benign?
Mammography
Sonography
Look for suspicious findings
If a single finding is present: do something more--, old films, additional views, ultrasound, biopsy
If a single finding is present: do something more--biopsy
No suspicious finding – routine screening
No suspicious finding, look for benign findings
If benign findings—follow up
BIRADS 3 – short term follow up
If no benign findings—BIRADS 4
Patient history

61. Suggested approach cysts
Patient story
Look for finding
Suspicious?
Benign?
Complex
Simple
Exclude artifacts
Anechoic
Look for BIRADS>4 findingsbiopsy
Well circumscribe
If not look for BIRADS 3 inflammatory findings
Thin echogenic wall
If not look for strict BIRADS 2 findingsreturn to routine screening
Through transmission
If not look for BIRADS 3offer attempt aspiration and short term follow up
Edge shadows
If notby default consider as BIRADS 4a and biopsy
BIRADS 2
Patient history

62. תודה רבה