The Breast Pathology PDF - Dalhousie School of Health Sciences

The Breast Pathology Dalhousie School of Health Sciences DMUT 2050 – Topic 11 Documentation of Breast Lesions ⚫ Record images of lesion in 2 planes ⚫ Capturing maximum diameter of lesion is important  Key diagnostic feature  May require: ⚫ LG – TR...

The Breast Pathology Dalhousie School of Health Sciences DMUT 2050 – Topic 11 Documentation of Breast Lesions ⚫ Record images of lesion in 2 planes ⚫ Capturing maximum diameter of lesion is important  Key diagnostic feature  May require: ⚫ LG – TR ⚫ RAD – ANTIRAD ⚫ Oblique - 90 to Oblique ⚫ Record images with and without calipers  Especially for small lesions ⚫ Color Doppler of image ⚫ Demonstrate compressibility of lesion ⚫ Demonstrate mobility of contents (if necessary) Palpable Lesions ⚫All lesions palpable by the patient should be palpated by the sonographer during sonographic evaluation ⚫Ask permission to palpate prior to doing so ⚫Simultaneous scanning and palpation To ensure palpable lesion is the same lesion being evaluated on US ⚫Label lesion as palpable Rumack Fig 20-16, 20-17 Measuring Lesions ⚫Outer to outer Include capsule surrounding lesion ⚫Maximum diameter ⚫Lesions on mammo tend to appear more round then on US US may demonstrate more elliptical shape Due to compression by mammo  ANDIs Aberrations of Normal Development and Involution ANDIs ⚫ Normal breast tissue and variations of normal breast tissue Cause palpable, mammo and US imaging “abnormalities” ⚫ Account for many “false positive” results at biopsy ⚫ May cause a spectrum of appearances from BIRADS 1 to BIRADS 4 Include fibrocystic change, duct ectasia, benign proliferative disease Fibrocystic Changes Simple Cysts Complex Cysts Simple Cysts ⚫ Common ⚫ Occur in women of all ages ⚫ May cause palpable abnormalities ⚫ Demonstrate simple cyst criteria ⚫ BI-RADS 2 No US follow-up or biopsy needed Aspiration only if large and symptomatic Rumack Fig 20-40 Complex Cysts ⚫ Complexities Internal debris, septations, mural nodules, eggshell calcifications ⚫ Must demonstrate enhancement to be a cyst ⚫ Often due to infection of simple cyst or “functional” cyst ⚫ Malignant breast cysts are rare Intracystic carcinoma is possible Thick septations, mural nodules, Doppler in nodule and clustered complex cysts are most worrisome ⚫ May require follow-up US, biopsy or aspiration Complex Cysts Thin, benign appearing septations Thick, worrisome septations Rumack Fig 20-41, 20-42, 20-43, 20-44 Proven carcinoma on biopsy Types of Complex Cysts ⚫ Infection of a cyst ⚫ Clustered macrocysts ⚫ Milk of calcium cyst ⚫ Sebaceous cysts ⚫ Galactoceles ⚫ Foam cysts ⚫ Lipid cysts ⚫ Acorn cysts Most complex cysts will be given a BI-RADS classification of 2 or 3 Infected Cyst ⚫ Often painful ⚫ Sonographic Appearance Thick isoechoic wall Fluid-debris levels ⚫ Mobile with change in patient position Hyperemia of cyst wall ⚫ Fluid may be aspirated and sent for gram stain and cultures Aspiration often removes entirety of cyst content ⚫ Treated with antibiotics Rumack Fig 20-46 Milk of Calcium Cysts ⚫Do not contain milk “Milk” refers to tiny stones ⚫Sonographic Appearance Highly echogenic “fluid” ⚫Mobile with change in patient position ⚫May demonstrate shadowing Rumack Fig 20-48. 20-49, 20-50 Galactoceles ⚫ Milk-filled cysts ⚫ Occur in women who are pregnant, lactating or history of lactating in the last 2-3 years ⚫ Sonographic Appearance Fat-fluid level ⚫ Mobile with change in patient position ⚫ Echogenic fat is typically “on top” ⚫ May take up to 5 minutes for shift to be complete Galactoceles Lipid layer moves with a change in patient position Rumack Fig 20-51 Lipid Cysts ⚫ Usually the result of chronic seromas or hematomas Fat necrosis in these lesions History of recent surgery or intervention (lumpectomy) ⚫ Sonographic Appearance May demonstrate ⚫ Mural nodules ⚫ Thick septations ⚫ Thick walls ⚫ Fluid-debris levels More worrisome appearance on US than on Mammo,  Mammo is more heavily relied upon Lipid Cysts Rumack Fig 20-53 Internal debris and mural nodularity in 2 lipid cysts Clustered Macrocysts ⚫Clusters of benign simple cysts ⚫Gives appearance of septated cysts ⚫Usually the result of dilated ductules Sebaceous Cysts of the Skin ⚫Occur in skin and/or subcutaneous layer ⚫Sonographic Appearance Rumack Fig 20-55 Usually complex or solid appearing ⚫Due to debris Often demonstrates a tract to skin surface ⚫Inflamed hair follicle Sebaceous Cysts of the Skin May require use of a stand-off pad Foam Cysts ⚫Cyst whose lumen is completely filled with echoes ⚫May appear to be a solid lesion ⚫Often appears similar to a fibroadenoma Debris in cyst Enhancement demonstrated Rumack Fig 20-56 Acorn Cysts ⚫Cysts who have a thickened wall or mural nodule that mimics fat-fluid level Will not move with a change in patient position Did not move with a Rumack Fig 20-54, 20-56 change in position Benign Solid Lesions Fibroadenoma Intraductal Papilloma Lipoma Fibroadenomas ⚫Benign solid lesion ⚫Most common in young women ⚫Fluctuate with hormonal changes Often enlarge with pregnancy ⚫After menopause may involute or calcify Fibroadenomas Sonographic Appearance ⚫ BI-RADS 3 ⚫ Most common appearance Elliptical ⚫ Wider than tall Hypoechoic Complete, thin, echogenic capsule ⚫ May demonstrate Lobulated contour ⚫ ≤ 3 lobulations Calcification Rumack Fig 20-39 Intraductal Papillomas ⚫ Benign lesion of the duct ⚫ Most commonly seen posterior to the areola ⚫ Often causes bloody discharge ⚫ Sonographic Appearance Duct ectasia ⚫ Anechoic, tubular Isoechoic nodules within duct May see irregularities of the duct walls ⚫ DDx Intraductal carcinoma Intraductal Papillomas Dilated duct at nipple Rumack Fig 20-57, 20-58 Isoechoic mass in dilated duct Lipomas ⚫Benign fatty lesion ⚫Usually mobile on palpation ⚫More common in elderly women ⚫Sonographic Appearance Well-defined Often hyperechoic to surrounding fat Breast Cancer and Metastases Types of Breast Cancer Suspicious Findings Metastases Breast Cancer ⚫ Most common type of cancer in women ⚫ Risk Factors Female gender ⚫ May occur in males Increasing age Personal or family history ⚫ Especially first-order relatives Early menarche, late menopause Nulliparity History of benign breast disease Most women with breast cancer have no identifiable risk factors Breast Cancer ⚫ Hereditary Link ⚫ Clinical Symptoms May be tested for the “breast Palpable mass cancer genes” ⚫ Painless BRCA1 ⚫ Fixed BRCA2 ⚫ Solitary ⚫ Firm Known carriers should do self- Focal skin retraction exams at age 18 and mammos at Erythema age 25 Most breast cancers occur in the UOQ of the breast Breast Cancer Types ⚫ IDC ⚫ ILC Infiltrating Ductal Carcinoma Infiltrating Lobular Carcinoma Most common type of breast 2nd most common type of breast cancer cancer ⚫ ~80% ⚫ ~10% Originates in ducts Originates in lobules Both types often invade adjacent tissues, therefore lymph nodes should be tested Both are usually treated with lumpectomy or mastectomy, radiation and chemotherapy Breast Cancer Types ⚫ DCIS ⚫ Inflammatory Breast Ca  Ductal Carcinoma In Situ  Rare and aggressive  Most common non-invasive form of  Presents with symptoms of breast cancer inflammation  Originates in the ducts ⚫ Redness  Better prognosis but high recurrence ⚫ Swelling rate ⚫ Heat  Usually treated with lumpectomy and ⚫ Orange peel appearance radiation therapy Pitted skin  Inversion of the nipple  Treatment usually includes other methods (chemo, radiation) before surgery Solid Lesions ⚫Differentiating benign from malignant is impossible on US Requires biopsy ⚫Not prudent to biopsy all lesions ⚫Look for “suspicious” sonographic findings Solid Lesions Suspicious US Findings ⚫Spiculation or thick, echogenic halo ⚫Angular margins ⚫Microlobulations ⚫Taller than wide ⚫Duct extension and branch pattern ⚫Acoustic shadowing ⚫Calcification ⚫Hypoechoic Similar to suspicious findings on mammo, however hypoechoic, shadowing and taller than wide are specific to US Suspicious US Findings Spiculation or Thick, Echogenic Halo ⚫ Spiculation ⚫ Thick, Echogenic Halo Corresponds to local invasion and Corresponds to tiny spiculations, desmoplastic host response to the indistinguishable on US lesion ⚫ Sonographic Appearance ⚫ Sonographic Appearance Echogenic halo Hyperechoic lines radiating out Thicker along edges from lesion ⚫ Than ant. and post. walls Hypoechoic “fingers” ⚫ Due to perpendicular incidence May be co-existent Depends on background echogenicity Suspicious US Findings Spiculation or Thick, Echogenic Halo Hypoechoic “fingers”, echogenic halo, and echogenic radiating lines Rumack Fig 20-23 and 20-24 Suspicious US Findings Angular Margins ⚫Indicative of invasion ⚫Acute, right angle or obtuse margins ⚫As little as 1 angle causes suspicion BI-RADS 4 and up Rumack Fig 20-27 Suspicious US Findings Microlobulations ⚫1-2mm lobulations Size of lobulation usually corresponds to grade of cancer ⚫ (small lobulation = low grade, large lobulation = high-grade) ⚫May correspond to: “Fingers” of spiculated lesions (invasive) ⚫Look for echogenic halo Ducts extended with tumor (DCIS) Cancerized lobules Suspicious US Findings Microlobulations Rumack Fig 20-28 Suspicious US Findings Taller Than Wide ⚫Larger in A-P dimension than horizontal dimension ⚫Becomes unreliable as lesion size increases Suspicious US Findings Duct Extension and Branch Pattern ⚫ Duct Extension ⚫ Branch Pattern Usually a single projection of solid Usually a projection of solid growth in a duct towards the growth into multiple small ducts nipple away from the nipple Usually larger Usually smaller Rumack Fig 20-31, 20-32 Many benign ductal lesions can grow in this pattern as well If malignant, corresponds to DCIS lesions Suspicious US Findings Acoustic Shadowing ⚫Corresponds to spiculation and desmoplastic host response ⚫Can occur throughout or within portions of lesion Rumack Fig 20-33 Suspicious US Findings Calcification ⚫Usually correspond to necrotic debris in the lesion ⚫Appear as bright echoes Microcalcifications Often too small to demonstrate shadowing ⚫Smaller than beam width  volume averaging Rumack Fig 20-35 Suspicious US Findings Hypoechogenicity ⚫More hypoechoic than surrounding fat ⚫Harmonics is useful for isoechoic lesions Malignancy Normal fat Rumack Fig 20-36, 20-37 Breast Cancer Metastases ⚫ Common sites of metastases Lymph nodes Liver Adrenals Same breast ⚫Or the area where the breast used to be Chest wall Bones Lungs Brain Rumack Fig 20-67, 20-68, 20-69, 20-70, 20-71, 20-72, 20-73 Axillary lymph nodes Inflammation of the Breast Mastitis Abscess Mastitis and Breast Abscess ⚫ Inflammation of the breast ⚫ Usually occurs when patient is breast-feeding  Puerperal mastitis ⚫ Clinical symptoms  Hard, inflamed breast  Redness, swelling  Tender  Fever  Increased WBC ⚫ Appears as decreased echogenicity and skin thickening ⚫ Mastitis may progress to abscess Breast Abscess ⚫ Hypoechoic ⚫ Ill-defined ⚫ Often contain internal echoes, thick walls and septations ⚫ Usually demonstrate posterior acoustic enhancement ⚫ May see echogenic foci of gas with posterior ringdown artifact Rumack Fig 20-60, 20-61 Breast Implants and Pathology Rupture Breast Implants ⚫AKA – Breast augmentation ⚫For reconstructive or cosmetic purposes ⚫Saline or silicone filled ⚫May be folds or wrinkles ⚫Sonographic Appearance Anechoic Highly echogenic anterior “shell” Often see reverberation artifact in the anterior portion Breast Implants Sonographic Appearance Normal folds Normal reverberation artifact Rumack Fig 20-62 Breast Implant Rupture ⚫All implants are foreign to the body ⚫The body will form a capsule around the foreign body Must differentiate the capsule from the implant shell ⚫Rupture can be intracapsular or extracapsular Breast Implant Rupture ⚫ Intracapsular ⚫ Extracapsular Capsule remains intact Tear in shell and capsule Fluid is contained by capsule Fluid extravasates into ⚫ Becomes echogenic breast tissues “Stepladder” sign Silicone granuloma ⚫ Linear, horizontal echoes ⚫ Inflammatory reaction to Represent collapsed shell silicone ⚫ Appears highly echogenic ⚫ “Snowstorm” sign Posterior dirty shadow ⚫ May appear as a complex mass Breast Implant Rupture Intracapsular Extracapsular Rumack Fig 20-63, 20-64, 20-65, 20-66 “Stepladder sign” “Snowstorm sign” References ⚫ Author unknown (2010) Types of breast cancer, Retrieved from http://www.breastcancer.org/ ⚫ Harvey, J. (2006). Sonography of palpable breast masses [Electronic version]. Seminars in Ultrasound, CT and MRI, 27:4, 284-297. ⚫ Mittelstaedt, C. A. (Ed.). (1992). General ultrasound. New York, NY: Churchill Livingstone Inc. ⚫ Porth, C.M. (2004). Essentials of pathophysiology: Concepts of altered health states. Philadelphia, PA: Lippincourt Williams & Wilkins. ⚫ Rumack, C. M. & Levine, D. (Eds.). (2018). Diagnostic ultrasound (5th ed.). Philadelphia, PA: Elsevier Inc.