Transcript Benign Masses in Breast Ultrasound

BENIGN MASSES IN
BREAST ULTRASOUND
Dr. Mona Rozin
Director of Breast Imaging
Assuta Medical Centers
mrozin md
Benign Masses
I. Fibroadenoma
II. Fibroadenoma variants : complex FA
tubular adenoma, lactating adenoma
III. Phylloides Tumor
IV. Hamartoma
V. Lipoma
VI. Focal Fibrosis
VII. Diabetic mastopathy
VIII.Fibrocystic change
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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
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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
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FA – sonographic appearance
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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
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oval
lobulated
irregular
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hypoechogenic
isoechogenic
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Calcifications in FA
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Ca++
FA in pathology
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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
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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.
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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;190:214-218
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cysts & sclerosis
Complex FAs
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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
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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
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spindle shaped
microlobulated
Tubular adenomas
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hypo
IDC-Grade 3
hyper
Lactating adenomas
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III. Phylloides Tumor
• Rare – peak at 40-50 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”
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Phylloides with cystic clefts
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The faces of phylloides
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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
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Classic hamartoma
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Hamartoma on mammo & CT
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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
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fat necrosis
hyper
iso
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VI. Focal Fibrosis
• FIBROUS MASTOPATHY
• Can cause tender/non-tender
palpable lump
• May see focal asymmetry on mammo
– UOQ
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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 !!!
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MUST have mammographic correlation
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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
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VII. Diabetic Mastopathy
• Mammo: non specific asymmetry
• U/S: VERY SCARY !!!!!!
Ill-defined, angular, microlobulated,
hypoechoic, not parallel, intense
shadowing
• ALL go to Bx.
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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
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adenosis with amorphous ca++
adenosis with cysts
hypoechoic adenosis in
hyper glandular tissue
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Adenosis and
blunt duct adenosis
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adenosis
blunt duct adenosis
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“starry night” of sclerosing adenosis
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The faces of sclerosing adenois
branching
central fibrosis
distended terminal lobule
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Sclerosing adenosis with spiculation & halo
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Sclerosing adenosis with ca++
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• Remember algorithm and technique
• Know your anatomy
• Must correlate with mammo & clinical
presentation
• Huge overlap of findings
• Better than doing mammograms all day!
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mrozin md