Transcript DMSM 111 Superficial Structures Part I

Sonography of The Breast
Part I Introduction
Lecture Three:
Benign Conditions
Malignant Conditions
Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, LRT(AS)
Benign conditions
Benign tumors are rubbery, mobile, and well defined (as seen in
a fibroadenoma). Malignant tumors are often stone hard.
CYSTS
 Cysts are commonly seen in women 35 to 55 years of
age.
 Symptoms include history of changing with menstrual
cycle, pain, especially when the cyst is growing rapidly,
recent lump, and tenderness.
 Small cysts may not regress completely and may
persist from one cycle to the next.
Fibrocystic condition
 Fibrocystic changes produce histologic alterations in
the terminal ducts and lobules of the breast in both
the epithelial and connective tissue.
 Fibrocystic changes are usually accompanied by pain
or tenderness in the breast and represent normal
physilogic processes of breast tissue that fluctuates
under the influence of the normal female hormonal
cycles.
Fibrocystic conditions
 Clinical sign and symptoms of FCC include the lumps
and pain that the patient feels that fluctuate with
every monthly cycle.
 Ultrasound of the breast will show round masses
which represent multiple cysts.
Fibroadenoma
 The
most common benign breast tumors are
fibroadenomas.
 They occur primarily in young women.
 The growth of fibroadenoma is stimulated by estrogen.
 Clinically, a fibroadenoma is firm, rubbery, freely
mobile, and clearly delineated from the surrounding
breast tissue.
A fibroadenoma
 Fibroadenomas are round or ovoid, smooth or
lobulated, and usually do not cause loss of contour of
the breast, unless it develops into a large size.
 Fibroadenomas rarely causes mastodynia (breast pain)
and it does not change size during the menstrual cycle.
 Sonographically,
fibroadenomas
have
benign
characteristics with smooth rounded margins and lowlevel homogeneous internal echoes.
 A fibroadenoma may demonstrate intermediate
posterior enhancement.
Fibroadenomas are normally hypoechoic, but are occasionally
hyperechoic to the fat within the breast or with calcifications.
Lipoma-A pure lipoma consists entirely of fatty
tissue.
 Other forms of lipoma consist of fat with fibrous and
glandular elements (fibroadenolipoma).
 Clinically, on palpation a large, soft poorly demarcated
mass is felt that can not be clearly separated from the
surrounding parenchyma.
 Sonographically, a lipoma may be difficult or
impossible to detect within a fatty breast.
 A lipoma often demonstrates posterior enhancement
and are easily compressible.
Fat Necrosis
 Fat necrosis may be caused by trauma to the breast,
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surgery, radiation treatments, or plasma cell mastitis.
Fat necrosis may also be related to an involutional
process or other diseases present in the breast, such as
cancer.
Fat necrosis is more frequently found in older women.
Sonographically, fat necrosis appears as an irregular
complex mass with low-level echoes.
It may mimic a malignant lesion, and may appear as
fat.
Fat necrosis
Acute Mastitis
 Acute mastitis may result from infection, trauma,
mechanical obstruction in the breast ducts, or other
conditions.
 Acute mastitis often occurs during lactation,
beginning in the lactiferous ducts and spreading via
the lymphatics or blood.
 Acute mastitis is often confined to one area of the
breast.
Acute mastitis
Chronic Mastitis
 Clinically, the patient usually has a nipple discharge,
and frequently the nipple has retracted over a period
of years.
 Palpation reveals some subareolar thickening but no
dominant masses.
Chronic Mastitis
Abscess-An abscess may be single or multiple.
 Acute abscesses have a poorly defined border, whereas
mature abscesses are well-encapsulated with sharp
borders.
 Clinical findings show pain, swelling, and reddening of
the overlying skin. The patient may be febrile, and
swollen, painful axillary nodes may be present.
Breast abscess diagram
Abscess
 Sonographic findings may show the following:
 diffuse, mottled appearance of the breast.
 Irregular margins
 Posterior enhancement
 Low-level internal echoes
 Color or power Doppler of the breast may be helpful to
document hyperemia (an excess 0f blood
accumulation) associated with increased vascularity.
Cystosarcoma Phyllodes Cystosarcoma
Phyllodes is a rare, predominantly benign breast neoplasm.
 Although Cystosarcoma Phyllodes is considered a
benign lesion, 27% of these tumors are malignant, and
12% metastasize.
 Sonographic findings include a large, hypoechoic
tumor with well-defined margins and decreased
through-transmission.
 Internal echoes may be fine or coarse with variable
amounts of shadowing.
 Think Leaf…
Intraductal Papilloma-An intraductal
papilloma is a small, benign tumor that grows within the acini
of the breast.
 Intraductal papilloma occurs frequently in middle-
aged women.
 The predominant symptom is spontaneous nipple
discharge arising from a single duct.
 Intraductal papillomas consists of simple
proliferations of duct epithellum projecting outward
into a dilated lumen from one or more focal points.
Intraductal Papilloma
Malignant conditions
 It is not unusual for several years to pass from the first
appearance of atypical hyperplasia to the final
diagnosis of in Situ cancer.
 When the carcinoma is contained and has not invaded
the basal membrane structure, it is considered in Situ.
 Most cancers originate in the terminal ductal lobular
units (TDLU) whereas a smaller percentage originate
in the glandular tissue.
The breast lobules are concentrated in the upper-outer
quadrant of the breast. It is then not surprising that a majority
of breast cancers (50%) are found there.
Cancer of the breast is of
two types- Sarcoma and
Carcinoma
Sarcomas tend to grow rapidly and
invade fibrous tissue.
Carcinoma refers to breast tumors that arise from the
epithelium, in the ductal and glandular tissue, and usually has
tentacles.
Other malignant diseases affecting the breast are a result of
systemic neoplasms, such as leukemia or lymphoma.
Breast carcinomas are generally
categorized by two factors:
 1. Where the cancer cells originate (ductal or lobular)
 2. Whether the cancer is prone to spreading
(noninvasive or invasive).
Most breast carcinomas begin within the ducts of the
breast and are called ductal or intraductal carcinomas.
Breast cancers that form in the lobules are called
lobular carcinomas.
Cancers that spread into nearby tissue
are said to be invasive or infiltrating.
Ductal Carcinoma In Situ (DCIS)
AKA intraductal carcinoma
 DCIS is characterized by cancer cells that are present
inside the ducts, but they have not yet spread through
the walls of the ducts into the fatty tissue of the breast.
 Because these are confined to the duct and they have
not spread, DCIS usually has a 100% cure rate.
 Calcifications and ductal enlargement with extension
within the ducts are common.
Invasive Ductal Carcinoma (IDC)
IDC accounts for nearly 80% of breast cancers.
 Like DCIS, IDC cancers begin in the ducts, but unlike
DCIS, they invade the fatty tissue of the breast and
have the potential to metastasize via the blood-stream
or lymphatic system.
 It is important to obtain a definitive diagnosis and
begin treatment before IDC spreads to other organs.
Lobular Carcinoma In Situ
LCIS
 LCIS is not considered a “cancer” because it has a low
malignant potential.
 LCIS is confined to the gland and does not penetrate
through the wall of the tubule.
 LCIS does not usually form a distinct mass and can
therefore be difficult to pick up using mammography
and ultrasound screening.
 Women with LCIS are at a higher risk of developing
invasive breast cancer later on.
LCIS
Invasive Lobular Carcinoma ILC
 ILC begins in the lobule, where it extends into the fatty
tissue of the breast.
 Similar to IDC, invasive lobular carcinoma has the
potential to spread to other parts of the body.
 ILC is the second most common type of invasive
tumor, accounting for 10-15% of all breast cancers.
 ILC is often bilateral, multicentric, or multifocal.
Invasive Lobular Carcinoma ILC
 Breast cancers are considered multifocal when more
than one tumor is identified and they are located
within the same quadrant or ductal system and are
within 5 cm of each other.
 Breast cancers are considered multicentric when they
are located in different quadrants and are located at
least 5 cm apart.
 Definitive identification of a tumor type can only be
made by histologic tissue examination.
Comedocarcinoma: Intraductal solid carcinoma in which
the lactiferous ducts are filled with a yellow paste-like material
that looks like small plugs and classic dot-dash on mammogram.
Juvenile breast cancer is similar to ductal carcinoma In
Situ and invasive ductal carcinoma found in adults.
Generally, it occurs in young females between 8 and 15
years of age and has a good prognosis when treated
early. Below: Malignant phyllodes tumor in a 10 yof
Papillary Carcinoma
 Papillary carcinoma is a tumor that initially arises as an
intraductal mass.
 It may also take the form of an intra-cystic tumor,
which is rare.
 The earliest clinical sign of intraductal papillary
carcinoma is bloody nipple discharge.
 Papillary carcinoma typically has a more favorable
prognosis than the other kinds of carcinoma.
Papillary Carcinoma
Paget’s Disease
 Paget’s disease arises in the retro-areolar ducts and
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grows in the direction of the nipple, spreading into the
intra-epidermal region of the nipple and areola.
It has a rash-like appearance that may be confused
with a melanoma.
Any ulceration, enlargement, or deformity of the
nipple and areola should suggest Paget’s disease.
It is a relatively rare tumor, accounting for 2.5% of all
breast cancers.
It typically occurs in women over 50 years of age.
Paget’s Disease
Scirrhous Carcinoma
 Scirrhous carcinoma is a type of intraductal tumor
with extensive fibrous tissue proliferation.
 It is a common form of breast cancer and often has no
specific histologic findings.
 The classic clinical signs are
 Very firm nodule
 Frequently non-movable mass
 Fixation and flattening of overlying skin
 Nipple retraction
Scirrhous Carcinoma
Medullary Carcinoma
 Medullary carcinoma is a densely cellular tumor
containing large, round or oval tumor cells.
 It usually is a well-circumscribed mass, with the center
frequently necrotic, hemorrhagic, and cystic.
Medullary Carcinoma
Colloid carcinoma The cells of the tumor
produce secretions that fill lactiferous ducts.
Tubular Carcinoma
 Tubular carcinoma represents an extremely well
differentiated form of infiltrating (invasive) ductal
carcinoma usually less than 2 cm in dimension.
 Death is rare.
 Tubular carcinoma typically has poorly circumscribed
margins and a hard consistency.
Tubular Carcinoma
Interventional Breast Procedures
 With some suspicious breast lesions, interventional
procedures are necessary for a definitive diagnosis.
 Ultrasound is an important guide to many diagnostic
and interventional procedures in the breast. These
include:
 Cyst aspiration
 Fine-Needle aspiration cytology (FNAC)
 Abscess or seroma drainage
 Large-core needle biopsy
 Ultrasound-guided preoperative needle wire localization
 Injection of a sentinel node
Cyst aspiration
 The two main indications are a symptomatic cyst and
hypoechoic lesion on ultrasound that does not meet
the criteria for a simple cyst.
 Cyst aspiration can be preformed to determine
whether the lesion is a complex cyst or truly a solid
mass.
Cyst Aspiration
Fine-Needle Aspiration Cytology
(FNAC)
 The FNAC procedure uses a fine needle (usually 25
gauge) and an aspiration technique intended to
harvest individual cells for diagnosis.
 FNAC is fast, easy on the patient, and generally very
cost effective.
 The single greatest problem in FNAC is an inadequate
specimen.
Fine-Needle Aspiration Cytology
(FNAC)
Drainage Procedure
 When clinically indicated, most cases of breast
abscess, seroma, or hematoma will be easily palpated
and drained in a simple office procedure by a breast
surgeon or other physician.
Preoperative Needle Wire
Localization
 Ultrasound offers a quick method for placement of a
percutaneous wire assembly for preoperative
localization of a non-palpable breast lesion for surgical
excision.
Preoperative Needle Wire
Localization
Large-Core Needle Biopsy Ultrasound offers a fast and easy
method for guiding large-core needle biopsy of solid masses.
Sentinel Node Biopsy
 In this procedure, the superficial subcutaneous tissues
around the tumor bed and or the areola are injected
with methylene blue dye and or radioactive-labeled
solution.
 This helps to identify the Sentinel node for histologic
examination to determine if the breast cancer has
spread to the lymphatic system.
BI-RADS
Breast Imaging – Reporting and Data System
 BI-RADS 2 - Benign
 BI-RADS 3 - Probably Benign
 BI-RADS 4 - Suspicious
 BI-RADS 5 - Highly Suggestive of Malignancy
Homework
 SDMS webinars- TBA
 Show images of the following
 Normal Lymph nodes
 Abnormal Lymph nodes
 Describe sonographically how each will look
 Obtain 5 BIRADS reports and show ultrasound images
of how each would appear in mammography and
under ultrasound.
The End Part I