Breast Pathology DMUT 2050

Breast Pathology

• This is a study of breast pathology, specifically focused on the sonographic evaluation of breast lesions.
• The Dalhousie School of Health Sciences and DMUT 2050 course material is used for the information.

Documentation of Breast Lesions

• Images of lesions should be recorded in two planes.
• Capturing the maximum diameter of the lesion is critical for diagnosis.
• Additional views (like LG-TR and RAD-ANTIRAD) may be needed.
• Oblique views at 90° obliques are frequently used.
• Images should be taken with and without calipers, particularly for smaller lesions.
• Color Doppler imaging is used to assess lesion compressibility and content mobility.

Palpable Lesions

• All palpable breast lesions should be palpated by the sonographer during the sonographic evaluation.
• Permission should be sought from the patient before palpation.
• Simultaneous scanning and palpation help ensure the same lesion is evaluated.
• Label the lesion as palpable.

Measuring Lesions

• Lesions are measured from outer edge to outer edge, including the capsule.
• Maximum diameter is used for measurement.
• Mammograms often show round lesions while ultrasound may show elliptical shapes due to compression during mammogram.

Aberrations of Normal Development and Involution (ANDIS)

• Normal breast tissue can cause palpable, mammographic and sonographic abnormalities.
• This accounts for many "false positives" detected during biopsy.
• They can range from BIRADS 1 to BIRADS 4, encompassing fibrocystic change, duct ectasia, and benign proliferative disease.

Fibrocystic Changes

• Simple cysts are common in women of all ages.
• Simple cysts might cause palpable abnormalities.
• Simple cysts are classified as BIRADS 2, requiring no further follow-up or intervention unless large and symptomatic.
• Complex cysts include internal debris, septations, mural nodules and eggshell calcifications.
• These cysts necessitate enhancement demonstration to be deemed a cyst.
• Often caused by infection or functional simple cyst.
• Malignant breast cysts are rare; intracystic carcinoma might be present.
• Appearance with thick septations, mural nodules, Doppler in a nodule or clustered complex cysts are usually worrisome and could require follow-ups, biopsies or aspiration.

Types of Complex Cysts

• Infection of a cyst, Milk of calcium cyst, Galactoceles, Lipid cysts, Clustered macrocysts, Sebaceous cysts, Foam cysts and Acorn cysts fall into this category.
• Most complex cysts are generally classified as BIRADS 2 or 3.

Infected Cyst

• Infected cysts are often painful.
• Sonography reveals a thick, isoechoic wall, fluid-debris levels, and mobile contents that change with patient position.
• Hyperemia is also observed from the cyst wall.
• Fluid is aspirated and sent for gram stain and cultures for treatment with antibiotics.

Milk of Calcium Cysts

• These cysts do not contain milk, instead small stones are present.
• Sonography reveals a highly echogenic "fluid," mobile with changes in patient position and potential shadowing.

Galactoceles

• These milk-filled cysts occur in pregnant, lactating women, or those with a history of lactation within the last 2-3 years.
• Sonography shows a fat-fluid level that is mobile with patient position changes.
• Echogenic fat may be on top.
• Shifting may take up to 5 minutes to complete.

Lipid Cysts

• Result from chronic seromas or hematomas, exhibiting fat necrosis in these lesions.
• These lesions sometimes follow recent surgery or intervention, like lumpectomy.
• Sonography might reveal mural nodules, thick septations, thick walls, and fluid-debris levels.
• Mammograms are more important than ultrasounds for determining this.

Clustered Macrocysts

• Composed of benign simple cysts that appear septated.
• These often arise from dilated ductules.

Sebaceous Cysts of the Skin

• Found within skin and subcutaneous layers.
• Sonography shows complex or solid appearances due to debris.
• Often exhibit a tract to the skin, potentially originating from an inflamed hair follicle.
• Stand-off pads may be required during imaging.

Foam Cysts

• These cysts fill with echoes, giving a solid appearance that somewhat resembles fibroadenomas.

Acorn Cysts

• Characterized by a thickened wall or mural nodule reminiscent of a fat-fluid level.
• Unlike other cysts, they do not change positions when the patient does.

Benign Solid Lesions

• Include fibroadenomas, intraductal papillomas, and lipomas.

Fibroadenomas

• They are benign solid lesions prevalent in young women.
• Their size fluctuates with hormonal changes, often enlarging during pregnancy.
• After menopause they might involute or calcify.
• Common sonographic appearance is BI-RADS 3, elliptical and wider than tall, hypoechoic.
• A thin, echogenic capsule and lobular contour are common features.
• Calcification might be observed.

Intraductal Papillomas

• Benign lesions primarily develop in the duct posterior to the areola.
• Intraductal papillomas commonly cause bloody nipple discharge.
• Sonographically, duct ectasia, anechoic tubular and isoechoic masses within the duct, and possible duct wall irregularities may be observable.
• Differentiation from intraductal carcinoma might necessitate further assessment.

Lipomas

• Benign fatty lesions are usually movable during palpation.
• Lipomas appear more commonly in elderly women.
• Sonography reveals well-defined hyperechoic structures that stand out from surrounding fat.

Breast Cancer and Metastases

• Breast cancer is a prevalent cancer in women
• Risk factors include gender (predominantly female, though males can be effected), increasing age, family history (especially first-degree relatives), early menarche, late menopause, nulliparity, and a history of benign breast disease.
• Most women with breast cancer do not illustrate any identifiable risk factor.

Clinical Symptoms of Breast Cancer

• Common symptoms include palpable masses, painlessness, fixed qualities, solitary locations, firmness, focal skin retraction, and erythema.
• Breast cancers frequently develop in the upper outer quadrant (UOQ) area of the breast.

Breast Cancer Types

• Infiltrating Ductal Carcinoma (IDC) is the most common, comprising about 80% of breast cancers.
• Originating in the ducts. and infiltrating surrounding tissues.
• Infiltrating Lobular Carcinoma (ILC) is the second most common accounting for roughly 10% of all breast cancers, arising in the lobules.
• It infiltrates encompassing tissues as well.
• Both types necessitate lymph node testing.
• Treatments include lumpectomy, mastectomy, chemo, and radiation.
• Ductal Carcinoma In Situ (DCIS) is considered a non-invasive form of breast cancer.
• Originates in the ducts.
• While it has a favourable prognosis, recurrence rates are notably higher.
• Inflammatory breast cancer is rare and aggressive.
• Patients may exhibit redness, swelling, heat, and skin changes such as an orange peel appearance or pitting.
• Usually treated with a series of multidisciplinary methods including chemo and radiation before surgery if possible.

Differentiating Benign from Malignant in Solid Breast Lesions

• Distinguishing between benign and malignant lesions using ultrasound alone is not possible, a biopsy is required.
• Screening all lesions for biopsy is not recommended; focus instead on those with suspicious sonographic findings.

Breast Lesion Suspicious US Findings

• Spiculation and Thick, Echogenic Halo, Angular Margins, Microlobulations, Duct Extension and Branch Pattern, Acoustic Shadowing, Calcification, Hypoechogenicity - all offer indication and clues to further investigate and evaluate possible malignancy.

Common Metastasis Sites in Breast Cancer

• Common metastasis sites encompass lymph nodes, liver, adrenals, the breast itself, chest wall, bones, lungs, and the brain.

Mastitis and Breast Abscess

• Mastitis and breast abscesses are inflammatory conditions of the breast frequently observed in patients who are breast-feeding (puerperal mastitis).
• Symptoms for mastitis include a hard, inflamed breast, redness, swelling , tenderness, and fever.
• An increased number of WBCs might also be present.
• Appearances on ultrasound include decreased echogenicity and thickening of the rind.
• Mastitis may lead to breast abscess.

Breast Abscess Sonographic Appearance

• Breast abscesses exhibit hypoechoic features and poorly defined margins.
• Internal echoes, thick walls, and septations are frequent findings.
• Posterior acoustic enhancement is often observed.
• Echogenic foci of gas are sometimes seen, accompanied by posterior ringdown artifacts.

Breast Implants and Pathology

• Breast implants (either saline or silicone) are placed for cosmetic or reconstructive purposes.
• The body forms a surrounding capsule.
• Sonography reveals an anechoic structure with a highly echogenic anterior "shell."
• Reverberation artifacts might appear in the anterior portion.

Breast Implant Rupture

• All implants are perceived as foreign bodies by the body, and therefore a capsule is formed.
• Rupture can be intracapsular (capsule remains intact, fluid contained) or extracapsular (tear in shell, fluid extravasates).
• Extracapsular ruptures manifest as a highly echogenic "snowstorm" or "stepladder" sign.