Abid Irshad, MD Director Breast Imaging. Medical University of South Carolina Charleston

Transcription

1 Abid Irshad, MD Director Breast Imaging Medical University of South Carolina Charleston

2 Cases

3 Financial disclosure: I or my family have no financial interest related to the material discussed in this presentation

4 Case

5 30 yo F with h/o recent breast reduction presents with new right breast thickening and swelling.

6 What is the differential diagnosis? Seroma? Abscess? Hematoma? Large cyst? Necrotic cancer? Implant?

7 Fluid aspiration performed 300 cc of clear fluid aspirated

8 Recent plain chest film

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10 Diagnosis: CSF collection within the breast The VP shunt pulled up during the breast reduction surgery

11 Old plain films (Prior to breast reduction)

12 Case

13 81 year old female presents with right nipple inversion Old Old

14 US retro-areolar US

15 Core needle biopsy Invasive Lobular Cancer

16 MRI Invasive lobular carcinoma

17 Patient elected mastectomy with implant reconstruction 2015 Replaced with double lumen implant 2013

18 Recently presented with hardness and warmth of the right breast.

19 US Differential diagnosis Recurrent ILC Abscess Granulation tissue Hematoma Implant leak Lymphoma

20 Core needle biopsy

21 Why is the outer surface of mass very smooth?

22 Diagnosis: Spindle cell neoplasm / Metaplastic carcinoma

23 Wargotz and Norris proposed Classification System Metaplastic carcinoma subdivided into: Spindle cell type Squamous cell type Carcinosarcoma Matrix producing type Metaplastic carcinoma with osteoclastic giant cells

24 Metaplastic Carcinoma of the Breast Uncommon form of breast cancer (<5%) Heterogeneous group of neoplasms with glandular and non glandular components Mixed epithelial and mesenchymal differentiation Often sporadic development

25 Spindle cell neoplasm Often presents palpable mass Women often greater than 50 years old Larger tumor size Complete surgical excision necessary Variable axillary lymph node involvement reported ranging from 8% to 40% High hematogenous metastatic rather than lymphatic spread

26 Metaplastic Carcinoma- Spindle Cell Type Higher magnification: Elongated spindle cells Squamous cell nest (arrow) portrays differentiation Positive cytokeratin stain marker for epithelial differentiation (sarcoma not reactive to cytokeratin stain)

27 Case

28 History 51 year old female presents with breast masses seen on CT scan

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30 Mammogram shows two masses with indistinct margins

31 Ultrasound shows two hypoechoic masses which are non-parallel and have indistinct margins

32 Differential Diagnosis: Multifocal cancer Mucinous carcinoma High grade IDC Medullary carcinoma Fibroadenomas Phyllodes tumor Hematomas Metastasis

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35 Core needle biopsy done Diagnosis: Plasmacytoma / Myeloma

36 Plasmacytoma Breast plasmacytoma is extremely rare (<100 cases since 1928) Majority 66% were unilateral Most (77%) have occurred in patients with multiple myeloma Imaging features similar to primary breast carcinoma Very radiosensitive, with success rates of 79% 90% 10-year survival rate of 50% 100%

37 Plasmacytoma The needle core biopsy specimen consist of sheets of mature and immature plasma cells

38 Plasmacytoma Tumor cells are immunoreactive for plasma cell marker CD 138

39 Case

40 53 year old female presented with palpable lump

41 Ultrasound D/D IDC? ILC? Less common types (mucinous, medullary etc.) Benign: Lactating adenoma? PASH? Fat necrosis? Hematoma? Phyllodes?

42 Core needle biopsy performed Diagnosis: Neuroendocrine tumor (Small cell / Oat cell cancer)

43 Neuroendocrine tumor / Small Cell Carcinoma Very Rare tumors which vary from less aggressive lesions, such as carcinoid to very aggressive such as oat cell cancer Important to rule out breast metastasis from a primary elsewhere in the body, as this is more common than primary breast lesion

44 Small Cell Carcinoma Tumor cells are small with scant cytoplasm, finely granular chromatin and high mitotic rate Necrosis is present Infiltrating tumor cells show organoid pattern of growth

45 Case

46 History 61 y o female with mass in the right breast seen on CT

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49 Right CC Left CC

50 Right CC Right MLO

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53 Differential diagnosis 1. Abscesses 2. Metastasis 3. Fat necrosis 4. Hematomas 5. Lymphoma 6. Multifocal primary breast cancer

54 Core needle biopsy performed Diffuse Large B-cell lymphoma

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56 Breast Lymphoma 1-2% of all lymphomas occur in the breast Secondary More common than primary lesions (S>P) Most of primary lymphomas are large B-cell type Usually present as non-calcified circumscribed masses or indistinctly marginated spherical or ovoid masses On US, usually show hypoechoic masses with posterior enhancement but may have mixed echogenicity Managed by systemic chemotherapy +/- local excision +/- radiation

57 Large B-Cell Lymphoma The tumor cells are immunoreactive for B-cell marker CD 20 The needle core biopsy specimen consists of diffuse infiltrate of monotonous population of cells with large vesicular nuclei and scant cytoplasm

58 Case

59 History 60 year old male with palpable mass right upper breast for 6 months

60 Right CC Left CC

61 R MLO L MLO

62 Differential diagnosis 1. Breast carcinoma 2. PASH (pseudoangiomatous stromal hyperplasia) 3. Fat necrosis 4. Hemangioma 5. Hematoma 6. Fibroadenoma 7. Lactating adenoma

63 Diagnosis Benign Cavernous hemangioma

64 Cavernous hemangioma Variable appearance on mammogram, often an oval or lobulated mass with circumscribed or microlobulated margins Calcification secondary to phlebolith formation Often located superficially, may have bluish skin Variable echogenicity and margination on US Management in the literature varies from surgical excision to imaging surveillance

65 Tubular cavernous channels formed within the mass

66 Case

67 History 44 y o white female with palpable lump H/O previous benign excision

68 Right MLO Right CC

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71 Differential diagnosis 1. Fibroadenoma 2. Breast carcinoma 3. Granuloma 4. Nodular PASH (pseudo-angiomatous stromal hyperplasia) 5. Epidermal inclusion cyst Benign or malignant?

72 Diagnosis: Suture granuloma Pathology on CNB: Necrotic debris with foreign material on core needle biopsy with organizing granulomatous inflammation on excision

73 Suture granuloma Uncommon, foreign body reaction to suture material Granulomatous inflammation Macrophages and multinucleated giant cells are typical

74 Case

75 History 69 y o white female found to have a large breast mass

76 R CC R MLO

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79 T 2 Post contrast

80 Differential diagnosis Benign or malignant? 1. Breast abscess 2. Mucinous or colloid cancer 3. Papillary cancer 4. Large organizing hematoma 5. Invasive ductal cancer 6. Phyllodes tumor

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82 Diagnosis: Invasive ductal carcinoma grade III/III ER, PR negative, HER 2 Neu unamplified (triple negative) 22 of 22 nodes positive with adenocarcinoma cells in pleural and ascites fluid

83 Case

84 History 59 y o AA male with palpable right breast mass

85 Right MLO Left MLO

86 Right CC Left CC

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88 Differential diagnosis 1. Invasive ductal cancer 2. Dense stromal fibrosis 3. Complex sclerosing lesion or radial scar 4. Granular cell tumor 5. Desmoid tumor

89 Diagnosis: Granular cell tumor

90 Granular cell tumor of the breast More common in AA females Relative incidence of about 1-6 per1000 breast cancers Mostly benign but rare malignant reports May be locally invasive, wide surgical excision is recommended Mammographically, non-calcified, many times spiculated masses Great mimickers of breast carcinoma On US, hypoechoic masses with posterior shadowing On MR, may show strong homogeneous or rim enhancement

91 Granular Cell Tumor Cells contain abundant granular eosinophilic cytoplasm and small nuclei Infiltrating nests and cords of large polygonal cells, separated by prominent fibrous septae

92 A different Patient

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94 Case

95 History 64 yo female with new palpable lump left breast

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98 DDX for new solid circumscribed mass: Malignant Benign Breast carcinoma Invasive ductal Medullary Mucinous Papillary Malignant phyllodes Adenoma Papilloma PASH Lymphoma Benign phyllodes

99 RCC Patient complained of pain on the other side

100 DDx for multiple circumscribed masses Cysts Fibroadenomas Metastasis Lymphoma Multiple primary breast CA s PASH Granulomas

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104 Biopsied right axillary tail and left breast lesions Diagnosis: Metastatic melanoma (poorly differentiated) Remote history of melanoma leg in 2003

105 Metastatic Disease to the Breast If multiple solid lesions present, consider metastasis Frequently round and fairly well circumscribed; single or multiple, vary in size, non-ductal pattern Melanoma is the most common cancer to metastasize to breast; followed by lung and lymphoma. Others-Ovarian, Cervical and Renal Cell Carcinoma

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107 Case

108 History 47 year old female with new masses in the left breast

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110 Differential diagnosis Cysts Fibroadenomas Metastatic lesions Lymphoma Granulomas Fat necrosis Multi-centric cancer PASH

111 US of the left breast

112 3 most suspicious masses were biopsied Diagnosis: PASH Pseudo angiomatous stromal hyperplasia

113 Few years later

114 Few years later

115 Pseudoangiomatous Stromal Hyperplasia (PASH) Uncommon benign lesion likely related to hormones, as it is only seen in premenopausal women Benign overgrowth of fibrous connective tissue stroma that separates into lobules and ducts that resemble vascular spaces. Must distinguish from angiosarcoma On mammography, lesions usually well defined with smooth border and no calcifications, but partially circumscribed borders and even spiculated margins have been reported On ultrasound, usually well defined hypoechoic or mixed echogenicity, solid mass with variable posterior sound properties

116 Pseudoangiomatous Stromal Hyperplasia (PASH) Complex, anastomosing, and empty slit-like spaces in dense collagenous stroma Empty spaces are lined by monomorphic spindle cells resembling endothelial cells

117 Case

118 History 15 year old girl presents with palpable lump in the right upper outer quadrant

119 Differential diagnosis 1. Breast Abscess 2. Breast carcinoma (IDC, papillary etc.) 3. Lactating adenoma 4. Phyllodes tumor 5. Hematoma 6. Acute fat necrosis 7. Galactocele

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121 Core needle biopsy performed Diagnosis: Cystosarcoma Phyllodes

122 Cystosarcoma Phyllodes (Malignant Phyllodes) Malignant high grade phyllodes tumor (sarcomatous features) Usually presents as a rapidly enlarging mass Represents <1% of breast neoplasms Related to fibroadenoma group May recur locally if not completely excised Up to 10% may metastasize, usually hematogeneously to lung or bone

123 Phylloides Tumor-Malignant Marked cytologic atypia and abundant mitosis (>10/HPF) Malignant stroma showing fibrosarcomatous appearance

124 Thank You

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126 67 yo F on screening mammogram

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129 Adenoid cystic carcinoma

130 33 yo F with palpable lump

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132 Mass-like Radial Scar (RSL)

133 Adenomyoepithelioma Rare breast tumor which arises from myoepithelial and epithelial cells that are present in normal breast. Most are benign and characterized by biphasic proliferation of epithelial and myoepithelial elements Non specific imaging features Prone to locally recur and may recur several years after surgical removal

134 Adenomyoepithelioma Ultrasound reveals a hypoechoic, solid mass with slightly lobulated borders

135 Adenomatous Lesions Tubular adenomas Pure adenomas without significant fibrous stroma Variant of pericanalicular fibroadenoma, but usually do not calcify Seen in young females Similar imaging features to fibroadenoma, but may mimic malignancy Lactating adenomas Uncommon tumor seen in pregnant or lactating females Variant of fibroadenoma and tubular adenomas and cannot be distinguished by imaging alone Tend to be well circumscribed, hypoechoic masses with posterior enhancement, but occasionally have irregular margins or heterogeneous appearance Many regress spontaneously

136 Tubular Adenoma Lactating Adenoma Ultrasound shows a lobulated oval hypoechoic mass which is indistinguishable from a fibroadenoma Ultrasound shows a well circumscribed, slightly lobulated hypoechoic mass, which is indistinguishable from a fibroadenoma

137 Tubular Adenoma

138 Case

139 17 year old female presents with right breast swelling