Mimickers of breast malignancy

Transcription

1 Mimickers of breast malignancy Poster No.: C-0477 Congress: ECR 2010 Type: Educational Exhibit Topic: Breast Authors: S. H. Park, H.-Y. Choi; Incheon/KR Keywords: mimickers, breast malignancy, ultrasound DOI: /ecr2010/C-0477 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives To identify benign lesions that share malignant features in imaging findings To describe the various causes of benign breast lesions that may mimic carcinoma in imaging findings To get to the correct diagnosis and to avoid unnecessary surgical intervention To be familiar with these benign lesions for more appropriate diagnostic approach Background This exhibit aims to do a pictorial review of the imaging findings of carcinoma-mimicking benign breast lesions. These presentation include fatty necrosis, diabetic mastopathy, adenosis, sclerosing adenosis, ruptured inflammed cyst, inflammation with abscess, granulomatous mastitis, fibroadenoma, fibroadenomatous mastopathy, apocrine metaplasia. Page 2 of 16

3 Imaging findings OR Procedure details CASE 1. F/27 PALPABLE MASS in LLMQ Fig.: 1.F/27 PALPABLE MASS in LLMQ - Fatty necrosis Irregular shape Partially indistinct margin Taller than wide Lack of vascularity 1. FATTY NECROSIS Asymptomatic or palpable Usually result of injury to breast fat US findings Acute phase: increased echogenicity d/t edema Subacute phase: complex cystic phase Late phase (after 18months): calcified wall, thick walled or even solid Color Doppler - Internal flow increases concern for recurrent tumor - May see flow in granulation tissue within 6months Page 3 of 16

4 CASE 2. F/47 PALPABLE MASS WITH SKIN THICKENING Fig.: 2. F/47 PALPABLE MASS WITH SKIN THICKENING -Diabetic mastopathy Partially indistinct margin Extending into subareolar Skin thickening Pathologic lymph node in axilla 2. DIABETIC MASTOPATHY Clinical features A variant of stromal fibrosis occurring in diabetis Clinically hard breast 20yrs average interval between DM onset and mass US Page 4 of 16

5 Large poorly-defined heterogeneously hypoechoic region with indistinct margins No hypervascularity on color doppler Posterior shadowing Differential diagnosis Carcinoma Focal or stromal fibrosis CASE 3. F/54 SCREENING Fig.: 3. F/54 SCREENING - Fibrocystic change Spiculated or microlobulated margin Taller than wide Irregular shap 3. FIBROCYSTIC CHANGE Histopathology Histopathologic Dx : Constellation of cysts, fibrosis and adenosis Spectrum of normal variation Clinical features Page 5 of 16

6 Most common Sx: mastalgia, particularly in outer portions of breasts Most common in pre-menopausal women; changes usually lessen in postmenopausal women Focal, regional or diffuse Increase in cyst formation in postmenopausal woman on HRT, especially estrogen alone Radiologic findings Scattered echogenic foci due to calcifications Simple cysts Complicated cysts Clustered microcysts Complex cystic and solid masses -Often difficult to distinguish from malignancy Discrete masses due to fibrosis -Can appear irregular with shadowing -Often require biopsy CASE 4. F/36 NONPALPABLE MASS on US Fig.: 4. F/36 NONPALPABLE MASS on US - Adenosis Angular margin Heterogeneous echogenicity 4. ADENOSIS, SCLEROSING ADENOSIS Proliferation of glandular elements (lobules and ductules) Hyperplastic lobules contain numerous acini Page 6 of 16

7 may represent failure of involution of lactational changes Focal or diffuse M/C in pre- and perimenopausal women Sclerosing adenosis: fibrosis of surrounding supportive stromal tissue may trap galnds Distorted, narrowed glandular elements Radiologic findings Best diagnostic clue: microcalcifications -Clustered or scattered, amorphous or punctate Less common: oval circumscribed mass with or w/o calcifications -Size: usually small (12-25mm) -Indistinguishable from malignancy -Spiculated or indistinct margins, distortion Radiologic-pathologic discordance may necessitate excision CASE 5. F/42 PALPABLE LESION Fig.: 5. F/42 PALPABLE LESION - Ruptured inflammed cyst Clusterd cystic lesions with internal echogenicity 5. RUPTURED INFLAMMAED CYSTS Histologic Dx: inflammatory cells surrounding cyst wall and /or cyst contents US findings Indistinct cyst wall in context of multiple simple cysts Page 7 of 16

8 Thick walled cystic mass : complex cystic mass Contents : anechoic - hypoechoic tumefactive debris Posterior enhancment Indistinct margin: most common Fluid-debris level Rim enhancing cyst MR CASE 6. F/44 with RMRM Fig.: 6. F/44 RMRM - Chronic inflammation Elongated tubular structure CASE 7. F/46 PALPABLE MASS Fig.: 7. F/46 PALPABLE MASS - Chronic inflammation Page 8 of 16

9 Lobulated margined, mixed-echoic nodule CASE 8. F/32 LT.PALPABLE MASS Fig.: F/32 LT.PALPABLE MASS - Acute inflammation with abscess Irregular mass with ill defined margin extending into the periareolar ducts Surrounding tissue is edematous with increased vascularity 6-8. INFLAMMATION WITH ABSCESS Localized pus collection within the breast tissue Tender palpable mass near nipple US findings Hypoechoic mass with heterogeneous texture Complex cystic solid mass with thick wall or septation Fluid-debris level Movement of echogenic prulent materilas Hyperemia in surrounding tissue CASE 9. F/36 HARD PALPABLE MASS in LT.BREAST Page 9 of 16

10 Fig.: 9. F/36 HARD PALPABLE MASS in LT.BREAST - Granulomatous mastitis CASE 10. F/32 NIPPLE DISCHARGE Fig.: 10. F/32 NIPPLE DISCHARGE - Granulomatous mastitis Large irregular shape hypoechoic mass Track to the skin Increased vascularity in surrounding tissue GRANULOMATOUS MASTITIS Idiopathic mastitis, nonspecific mastitis Diagnosis of exclusion Idiopathic, probably autoimmune etiology Page 10 of 16

11 Inflammatory mass with discharging sinuses Noncaseating granulomas Vast majority a/w lactation Typically postpartum Resolve on steroid therapy Radiologic findings Often retroareolar Multiple, irregular, clustered, often contiguous, tubular hypoechoic lesions May be confluent Hypoechoic linear track to skin(cutaneous sinuses) Surrounding increased echogenicity due to edema Color doppler: hypervascularity in surrounding parenchyma CASE 11. F/32 PALPBLE MASS in LT.BREAST Fig.: 11. F/32 PALPBLE MASS in LT.BREAST - Fibroadenoma Lateral indistinct and microlobulated margin Hypoehoic mass with posterior shadowing 11. FIBROADENOMA Benign fibroepithelial tumor with mixed stromal and epithelial elements Most common solid mass in women under 35 yrs Anywhere in breast parenchyma Hormonally influenced growth and involution Vast majority self limited, involute spontaneously Page 11 of 16

12 Develop on chronic cyclosporin A therapy after renal transplantation Highly mobile palpable painless firm mass Radiologic findings Circumscribed oval or gently lobulated hypo-iso echoic mass Homogeneous, low internal echogenicity 2-4%: contain small cystic foci Associated calcifications Variable posterior enhancement Color doppler: Peripheral feeding vessels often visible Annual F/U after core biopsy showed FA Growth >20% in diameter in 6 months suggests possible phylloides, recommend excision CASE 12. F/54 PALPABLE MASS NEAR AXILLA Fig.: 12. F/54 PALPABLE MASS NEAR AXILLA - Fibroadenomatous mastopathy Well circumscribed palpable mass with heterogeneous internal echogenicity Suspicious of well circumscribed malignancy or metastatic lymph node 12. FIBROADENOMATOUS MASTOPATHY Benign proliferative lesions Intermediate step(or arrested at intermediate stage) during histogenesis of fibroadenoma Page 12 of 16

13 Differ from fibroadenoma as the stromal hyperplasia may not have welldefined borders and usually involves several lobules When palpable, mean diameter: 4cm Circumscribed lobulated mass with internal echogenic septation US CASE 13. F/43 PALPABLE MASS in RT.BREAST, s/p RECTAL CANCER Fig.: 13. F/43 PALPABLE MASS in RT.BREAST, s/p RECTAL CANCER - Apocrine metaplasia Complex cystic lesion (cystic-solid) Irregularly thick wall US-guided biopsy targeting for solid portion 13. APOCRINE METAPLASIA Dilated acini lined by columnar type secretary epithelium with granular, eosinophilic cytoplasm Not premalignant itself (apocrine metaplasia) Atypical apocrine metaplasia a/w 5.5 x relative risk of cancer Often associated with FCC Radiologic findings Incidental new or enlarging microlobulated mass on mammography Incidental clustered microcysts on US Page 13 of 16

14 Best diagnostic clue: clustered microcysts on US, especially if fuzzy border internally Size: microscopic to several centimeters Clustered microcyst Complete overlap with FCC Complicated microcyst Microcyst with milk-of calcium Clustered microcysts without a solid component do not require biopsy US Page 14 of 16

15 Conclusion Benign breast lesions somtimes have malignant features in imaging and to be familiar with these benign lesions mimicking breast malignancy can be helpful for radiologists to plan appropriate diagnostic approach. Personal Information Sung Hee Park M.D. Department of Diagnostic Radiology Gachon University Gil Hospital Incheon, South Korea shpark@gilhospital.com pshee11@medimail.co.kr References Berg WA et al. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology. 227:183-91,2003 Gatta G et al: Clinical, mammographic and ultrasonographic features of blunt breast trauma. Eur J Radiol.2006 Page 15 of 16

16 Crystal P et al: Sonographic findings of palpable isoechoic breast fat necrosis. J Umtrasound Med. 24(1):105-7,2005 Bassett LW et al: Diagnosis of Diseases of the Breast. Philadelphia,Elsevier Saunders Page 16 of 16