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Questions and Answers
What characteristic is indicative of invasion when evaluating angular margins in breast lesions?
What characteristic is indicative of invasion when evaluating angular margins in breast lesions?
What do microlobulations of size 1-2mm typically indicate regarding the grade of cancer?
What do microlobulations of size 1-2mm typically indicate regarding the grade of cancer?
Which of the following ultrasound findings may indicate the presence of a breast abscess?
Which of the following ultrasound findings may indicate the presence of a breast abscess?
What does a 'stepladder' sign on an ultrasound usually indicate?
What does a 'stepladder' sign on an ultrasound usually indicate?
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In evaluating breast lesions, which finding corresponds with spiculation?
In evaluating breast lesions, which finding corresponds with spiculation?
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When evaluating duct extension in breast lesions, what pattern is typical?
When evaluating duct extension in breast lesions, what pattern is typical?
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What is a common characteristic of calcifications in breast cancer lesions?
What is a common characteristic of calcifications in breast cancer lesions?
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Which of the following is a sign of breast implant rupture?
Which of the following is a sign of breast implant rupture?
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What is an important measurement criterion when documenting breast lesions?
What is an important measurement criterion when documenting breast lesions?
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In the context of mastitis, which clinical symptom is commonly observed?
In the context of mastitis, which clinical symptom is commonly observed?
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What should be done before palpating a lesion during sonographic evaluation?
What should be done before palpating a lesion during sonographic evaluation?
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What distinguishes complex cysts from simple cysts in breast imaging?
What distinguishes complex cysts from simple cysts in breast imaging?
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What does acoustic shadowing in breast lesions usually correspond to?
What does acoustic shadowing in breast lesions usually correspond to?
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What is the most common appearance of a fibroadenoma on ultrasound?
What is the most common appearance of a fibroadenoma on ultrasound?
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What does being 'taller than wide' indicate in breast lesions?
What does being 'taller than wide' indicate in breast lesions?
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Which type of breast cancer is characterized by localized tissue invasion and commonly occurs in ducts?
Which type of breast cancer is characterized by localized tissue invasion and commonly occurs in ducts?
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Which region is commonly affected by breast cancer metastases?
Which region is commonly affected by breast cancer metastases?
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Which feature is NOT considered a suspicious finding on ultrasound?
Which feature is NOT considered a suspicious finding on ultrasound?
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What does echogenicity indicate about a lesion's composition?
What does echogenicity indicate about a lesion's composition?
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When should a patient with a simple cyst typically not require further US follow-up?
When should a patient with a simple cyst typically not require further US follow-up?
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Which type of lesion typically occurs in women who are pregnant or recently lactating and is filled with milk?
Which type of lesion typically occurs in women who are pregnant or recently lactating and is filled with milk?
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What is the sonographic appearance of infected cysts?
What is the sonographic appearance of infected cysts?
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What is a characteristic feature of spiculated lesions on ultrasound?
What is a characteristic feature of spiculated lesions on ultrasound?
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What distinguishes lobular carcinoma from ductal carcinoma?
What distinguishes lobular carcinoma from ductal carcinoma?
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Which type of cyst may demonstrate echogenic ‘fluid’ without actually containing milk?
Which type of cyst may demonstrate echogenic ‘fluid’ without actually containing milk?
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What characteristic can help differentiate malignant from benign lesions on ultrasound?
What characteristic can help differentiate malignant from benign lesions on ultrasound?
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Study Notes
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.
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Description
Explore the critical aspects of breast pathology, focusing on the sonographic evaluation of breast lesions. This quiz covers essential techniques such as capturing images in multiple planes and assessing palpable lesions. Understand the importance of measurement and documentation for accurate diagnosis.
