Mrozin md BENIGN MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers.

mrozin md

BENIGN MASSES IN BREAST ULTRASOUND

Dr. Mona RozinDirector of Breast Imaging

Assuta Medical Centers

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Benign MassesI. FibroadenomaII. Fibroadenoma variants : complex FA

tubular adenoma, lactating adenoma

III. Phylloides TumorIV. HamartomaV. LipomaVI. Focal FibrosisVII. Diabetic mastopathyVIII.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

• 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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isoechogenic

hypoechogenic

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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 breastno need to Bx all of themnew ones will almost always developneed 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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Complex

FAs

cysts & sclerosis

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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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hyper

hypo

IDC-Grade 3

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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hyper

iso

fat necrosis

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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 numbernormal lobules – 2 mmadenosis – 5 mm

• Mammo: focal asymmetry, masses, “starry night” calcifications

• U/S: extremely varied

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adenosis with cysts

hypoechoic adenosis in hyper glandular tissue

adenosis with amorphous ca++

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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

distended terminal lobule

branching

central fibrosis

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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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