Transcript MALIGNANT MASSES IN BREAST ULTRASOUND

MALIGNANT MASSES IN
BREAST ULTRASOUND
Dr. Mona Rozin
Director of Breast Imaging
Assuta Medical Centers
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Usual Breast Cancers
I.
II.
III.
IV.
V.
VI.
VII.
DCIS
IDC
Medullary
Mucinous
Tubular
Papillary
ILC
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I. DCIS
• Precursor of IDC
• Become IDC after 5-8 yrs
• “dirty borders” – 30% will have a
recurrence and 50% of these will be IDC
• 30% of mammographically detected
cancer in women aged 40-49 yrs.
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DCIS - Prognosis
• Most important feature is GRADE
• Necrosis brings calcifications
• Most are multifocal and 12%
multicentric
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DCIS - Mammo
•
•
•
•
Calcifications alone
70%
Calcifications in a mass or density 15%
Mass without calcifications
15%
Calcifications are “tip of the iceberg”
especially in Low Grade DCIS
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DCIS - Ultrasound
• Mass – most common finding
may see any of the entire BIRADS
descriptors
• Calcifications – may be seen with high
frequency transducers
increased vascularity on Doppler
may have associated mass
• Check mammo
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DCIS - Ultrasound
• May be mixed solid and cystic
• Clustered “microcysts” –rare but these
are usually vascular (Doppler), with
thick walls and irregular shape & size
• Abnormal size and branching of ducts
THE GREAT PRETENDER
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perpendicular
parallel
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microcysts
perpendicular
parallel
max
max
min
min
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IDC
DCIS
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RT. normal
LT. necrosis & calcs,
desmoplasia, inflammatory
infiltrates
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2
1
adenosis with microcysts
5
DCIS with calcs
4
3
PURE DCIS
microcysts
DCIS
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II. IDC
• 75-80% of all CA
• Host reaction: desmoplastic, inflammatory
• Necrois: 30% - may be liquid, hemorrhagic,
or fibrotic !!!!!!!
• Intraductal component – 85%
• Multifocal – 25-50% muticentric – 15-20%
and bilateral – 5-8%
• Invasion of Cooper’s ligaments – skin
dimpling
• Lymph node metastasis
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I
II
III
echogenic rim
III
II
branch size
I
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I
III
Size of microlobulations
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necrosis with central scar
cystic necrosis
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duct extension
calcifications
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III. Medullary CA
• 5% of all CA, younger than 40yr, rapidly
growing – therefore can be 3-4 cm, DCIS
• US: hypo, circumscribed, enhancement !!!!
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echogenic halo
microloblulation
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IV. Mucinous CA
• 2% of all CA, older than 60 yrs, tumor cell
mixed with mucin, DCIS – 75%
• US: iso - “salt and pepper”, circumscribed,
normal to enhanced transmission
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taller than wide
enhancement
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V. Tubular
• 2% of all CA, 40-50 yrs, DCIS - 75%
• US: spiculation, thick echogenic rim, hypo,
shadowing
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VI. Papillary CA
• 1-2% of all CA, 60-70 yrs, 50% arise in
intraductal papillomas, bleeding nipple –
20-35%, may be intracystic, mixed with
DCIS, abnormal ducts with enlarged TDLU
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VII. ILC
• 5-15% of all CA
• “Indian files” on pathology
• May not be detected on mammo, us, or
physical exam (vague thickening)
• Therefore may be found only when large!
• Multifocal, multicentric, bilateral – MRI !
• Unusual metastasis – peritoneum,
stomach, ovaries, meninges
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ILC - Mammo
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•
•
•
•
High false negative
May have no desmoplastic reaction
Isodense with few if any ca++
May be seen on 1 view only (CC)
Spiculated mass, arch. distortion,
asymmetric density, nipple & skin
retraction
• “Shrinking breast” !!!!
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ILC - Ultrasound
•
•
•
•
•
Irregular shape
Ill defined margins
Shadowing
Hypoechoic
Wider than tall
88%
94%
84%
92%
77%
• May also be iso or hyperechoic
• Up to 10% not seen on US !!!
• US is INVALUABLE in the staging of ILC
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ILC
Smaller
left breast
Indian files
Diffuse enhancement
Panoramic view
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ILC
Asymmetry
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ILC
Left shrunken breast
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ILC
“Golden Gate Sign”
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Other Malignancies
• Lymphoma
• Metastasis
• Sarcomas
- angio SA
- fibro SA
- carcino SA
• Inflammatory
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Primary Lymphoma
• 0.1 – 0.5% of all breast masses, 50-60
yrs, LYM:IDC 1:1000
• Mammo: increased density with skin
thickening, large mass, path. ax.
nodes-50%
• US: diffuse hypoechogenicity, edema,
dilated lymph channels, skin thickening
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Primary Lymphoma
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Metastasis to the Breast
• Rare
• Melanoma, lung, ovary, thyroid
• Mammo/US:
multiple bilateral nodules
circumscribed or ill defined margins
hypoechoic
NO desmoplastic reation
NO calcifications
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Angio SA
•
•
•
•
33% with negative mammo
33% non-calcified mass
Purplish – blue skin discoloration
Hematogenic metastasis to lungs
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Carcinosarcoma = Metaplastic CA
• Rarest primary malignancy of the breast –
less than 0.1%
• Contains BOTH carcinomatous and
sarcomatous components
• Large and palpable – up to 5 cm, poor
prognosis !
• Mammo: oval mass with circumscribed or
ill defined margins, +/- calcifications
• US: oval, ill defined margins, hypo, very
vascular, enhancement, mixed solid/cystic
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Carcinosarcoma = Metaplastic CA
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2001
2002
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mag
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Inflammatory CA
• 1% of all CA, pregnancy & lactation
• Erythema, warmth, edema in more than 1/3
of the breast associated with a high grade
IDC, poor prognosis – 55% survival with
chemo and rad Tx, 80% have tumor emboli
in skin lymphatics
• Mammo: edema, thick skin, thick C.L.
• U/S: as in mammo, may need 5 MHz to
penetrate and see hypoechoic mass
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Inflammatory CA
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