Breast lesions related to pregnancy and lactation - a diagnostic challenge

Transcription

1 Breast lesions related to pregnancy and lactation - a diagnostic challenge Award: Certificate of Merit Poster No.: C-2185 Congress: ECR 2017 Type: Educational Exhibit Authors: M. Szep, A. R. Chiorean, M. A. Chiorean, M. M. Duma; Cluj Napoca/RO Keywords: Cancer, Biopsy, Ultrasound, MR, Mammography, Radioprotection / Radiation dose, Breast DOI: /ecr2017/C-2185 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 24

2 Learning objectives To highlight the selection of the appropriate imaging workup and intervention for evaluating the breast during pregnancy and lactation. Describe radiologic manifestations of the most common disorders. Discuss the most common and relevant clinical and radiologic manifestations of pregnancy-associated breast carcinoma. Background Pregnancy and lactation represent physiologic states that induce changes in the mammary glands in response to hormonal stimulation (estrogen, progesterone and prolactin). These changes begin early in the the 1st trimester of pregnancy and lead to a diffuse and marked increase in parenchymal density [1]. Tumors or disorders affecting the breasts in pregnant or lactating women are the same as those found in non-pregnant women. However, there are some breast diseases specific to pregnancy and lactation. Breast lesions detected during pregnancy and lactation are generally benign, but the possibility of breast cancer must also be considered to avoid any delays in diagnosis [1,2]. At mammography, the gland appears enlarged and very dense. Given these features, the sensitivity severely decrease (30 % for dense breast compared with 80 % for fatty breast), and cancer detection may be difficult [3]. It is recommended to avoid mammography during the 1st trimester, due to exposure to ionizing radiation. However, mammography with abdominal shielding can be performed if necessary during pregnancy, with minimal or no risk to the fetus [1]. Ultrasound has a better sensitivity in pregnant and lactating patients, ranging from 86.7 to 100 %. On ultrasound, the breast predominantly appears diffusely hypoechoic during pregnancy due to enlargement of the non-fatty fibroglandular component (Fig.1), whereas during lactation there is diffuse hyperechogenicity with prominent ducts and vascularity during lactation. (Fig.2) [4] The routine use of contrast-enhanced MRI in the evaluation of pregnant patients is not appropriate and is recommended only in situations where the risk-benefit ratio is clear [2]. There is some controversy regarding the fetal effects of gadolinium-based contrast agents. The European Society of Radiology reported that gadolinium based contrast could be safely utilized during pregnancy, because it would be less absorbed into placenta and also, it would be rapidly excreted to kidney [5]. Page 2 of 24

3 Contrast enhanced MRI can be safely performed in lactating women. Nevertheless, lactating parenchyma present increased vascularity and consequently rapid enhancement of contrast material, followed by an early plateau of enhancement. Given this feature similar to that seen in invasive malignancy, the detection of malignancy is difficult [6,7]. Ultrasound guided core biopsy is the accepted cost-effective standard procedure for assessing breast masses during pregnancy and lactation. However, the decision to use core biopsy requires caution because of increased risk of bleeding, milk fistula formation and infection. These risks can be minimised by cessation of breastfeeding before core biopsy, paying close attention to haemostasis, and maintaining strict asepsis [1,8]. Images for this section: Fig. 1: Ultrasound changes during pregnancy. Breast US image obtained during gestation shows diffuse enlargement of the nonfatty glandular component and global hypoechogenicity (a). Color Doppler image shows diffuse incresed vascularity (b). Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 3 of 24

4 Fig. 2: Ultrasound changes during lactation. US image shows diffuse enlargement of the glandular component with diffuse hyperechogenicity due to milk production (a) and prominent ductal system (b). Color Doppler image demonstrates increased vascularity (c). Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 4 of 24

5 Findings and procedure details A retrospective study was performed including all those pregnant and lactating women investigated for palpable masses during a 3-year period. Radiographic findings, pathology results, and clinical notes were reviewed. Aspects were assessed according to BI-RADS and Tsukuba elasticity score [9,10]. Imaging modalities used for examination (according to case peculiarities and ACR recommendations): Ultrasound (US)/ Sonoelastography (USE): Hitachi 8500 EUB, Vision Avius machines. Examinations were performed and interpreted by two Consultant Radiologists with several years experience in breast imaging including ultrasound elastography. Means of diagnostic: percutaneous biopsies for BI-RADS 4 and 5 lesions; short term follow up BI-RADS 3 lesions no further assessment for lesions categorized as BI-RADS 2 lesions with no suspicious clinical signs. Findings: Fifty-five lesions were analyzed and the current analysis showed similar findings with those already published in literature regarding the age of the patients, size, location of the lesions and imaging features the mean age was 31,67 (19-44) years old; the maximum diameter of the lesions varied from 7 mm to 110 mm; lesions were located in every quadrant of the breast The most frequent were fibroadenomas (twenty-eight; 3 of these were growing fibroadenomas), followed by galactoceles (eleven), lactating adenoma (three), lactational breast abscess (one), physiologic changes during pregnancy (three) and physiologic changes during lactation (six). Three pregnancy-associated breast cancers were identified (ductal carcinoma in situ, II grade and III grade invasive ductal carcinoma). Fibroadenoma is the most common benign solid breast lesion, and results from proliferation of connective tissue, both stromal and epithelial cells. These lesions are hormone sensitive and the increased hormone levels associated with pregnancy and lactation can induce morphologic and physiologic changes: growing #broadenoma (Fig. 3, Fig. 4), #broadenoma with spontaneous infarction or #broadenoma with secretory hyperplasia or lactational change [1,11]. The ultrasound appearance is often similar to Page 5 of 24

6 a fibroadenoma in a non-pregnant or non-lactating woman. Typically appears as a wellcircumscribed, round to ovoid, or macrolobulated mass with generally homegeneous hypoechogenicity [12]. Fibroadenoma may show hypoechoic "pseudocapsule" or echogenic septation. Peripheral and feeding vessels are often visible on color Doppler examination. Occasionally, due to rapid growth, a fibroadenoma may have complex features such as cystic spaces and increased vascularity [11,13]. Galactoceles are the most common benign breast lesion in lactating women, although they more frequently occur after a few weeks or months from the time the patient stopped breast feeding, when milk is retained and becomes stagnant within the breast [1,8]. Galactoceles represent retention cyst resulting from lactiferous duct occlusion. They are often accompanied by in#ammatory or necrotic debris. Frequently they are located subareolar but may be anywhere in the breast [13,14]. Needle aspiration biopsy is both diagnostic and therapeutic, however, milk-like liquid during lactation and thickened milk #uid after lactation, are found in aspiration [8]. The imaging appearance is variable, depending on the amount of fat, protein and water content, as well as the density and viscosity of the #uid. Based on these the galactocoeles could appear on mammography like a: pseudolipoma (completely radiolucent mass), cystic mass with fat-fluid level (this sign can be depicted only on the mediolateral view with the beam horizontal to the upright patient), pseudohamartoma (mixed content closely resembling the imaging features of hamartoma) [1,4]. Sonographic findings of galactoceles may also have different aspects: cystic/multicystic (Fig.5), mixed (cystic + solid) (Fig.6, Fig.7) or solid (Fig.8) [14]. Infection represents a relatively common complication of galactoceles due to their rich nutrient content. This finding is usually clinically suspected (painful, palpable breast mass and reddish skin) and well observed in the ultrasound. The diagnosis is confirmed with fine-needle aspiration when purulent material is extracted [8] (Fig. 9). Puerperal Mastitis/Abscess Disease Infection is uncommon during pregnancy but occurs relatively often during breastfeeding. Breast abscesses are thought to develop in 5-11% of lactating women with infectious mastitis [15]. The organism that most commonly causes infection is Staphylococcus aureus, followed by Streptococcus [16]. Ultrasound is considered the best imaging tool which can confirm the diagnosis, provide a means to drain the collection and can be safely used for regular follow-up of abscess [16]. Abscesses usually appear as irregular heterogeneous hypoechoic (Fig.10) or anechoic masses, sometimes with #uid-debris levels and posterior acoustic enhancement [1,15]. Page 6 of 24

7 Lactating adenoma is a benign stromal tumour which typically occur in the peripartum period and presents as a painless palpable mobile mass with rapid growth during pregnancy. Lactating adenomas resolve or decrease in size spontaneously after pregnancy and lactation [17]. Sonographic features of a lactating adenoma can be variable. Usually, the features are benign that are indistinguishable from #broadenomas (Fig.11); however, some characteristics can mimic malignancy: irregular masses, microlobulated margins, posterior acoustic shadowing, pronounced hypoechogenicity, and structural heteroechogenicity [13,17] (Figs.12, 13). The coexistence of lactating adenoma and malignancy has been reported [18]. Pregnancy-associated breast cancer (PABC) is de#ned the breast cancer diagnosed during pregnancy, one year post-partum or anytime during lactation [1] and represent approximately 3% of all breast malignancies. Typically patients with PABC present painless palpable lump [19]. Patients with PABC tend to have larger, more advanced neoplasms at diagnosis and a poorer outcome, more than 50% of patients present with high-grade tumors and with lymph node involvement [3]. The radiologic features of PABC do not differ from those of non-pabc. Mammographic sensitivity for PABC is lower in pregnant or lactating patients due to increased glandular density [20]. During pregnancy, ultrasound remains the optimal tool for imaging. However, if a suspicious finding is seen on the ultrasound in a pregnant patient, mammography should be performed. Nevertheless, mammography plays a complementary role demonstrating features such as malignant microcalcification, multifocality, multicentricity, or bilaterality that may not be suspected at US alone [1,3]. US is also useful in assessing axillary nodes and monitoring the response to neoadjuvant chemotherapy [21]. We identified three cases of PABC in our study with different imaging appearances: Case no1: 44-year-old women, 8 weeks pregnant, with family history of breast cancer (grandmother and aunt) presented with bilateral palpable nodules in the left inferior outer quadrant and in the right superior-outer quadrant. Breast US demonstrated bilateral suspicious lesions. Ultrasound also revealed round lymph nodes with moderate vascularity in the left axilla. The percutaneous biopsies of breast nodules were performed and the result was II grade and III grade invasive ductal carcinoma. (Figs. 14,15) Case no2: 32-year-old women, 33 weeks pregnant, presented with palpable left mass and breast edema. Breast US showed a diffuse heterogeneous mass with angular margins and calci#cations in the left superior inner quadrant. Percutaneous biopsy shows grade III IDC. (Fig. 16) Case no3: 33-year-old woman, 9 weeks pregnant, presented with bloody nipple discharge. Ultrasound, color Doppler examination and Strain elastography demonstrated multiple hyperechogenic foci visible in the left upper-outer quadrant asociated with moderat vascularity and rigid areas. Page 7 of 24

8 The percutaneous biopsy of described area was performed and the result was DCIS. (Fig. 17) Ultrasound combined with core needle biopsy established the final diagnosis in these cases. All three cases underwent treatment during pregnancy and had favorable maternal and fetal outcomes. Images for this section: Fig. 3: Growing #broadenoma. 32-year-old pregnant woman (Gestatonal age: 8 weeks). Ultrasound, Doppler examination and Strain elastography reveal a hypoechoic,, circumscribed mass with increased vascularity. Elastography shows non-rigid mass with Tsukuba score 1. BI-RADS 4A. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 8 of 24

9 Fig. 4: Growing #broadenoma 32-year-old pregnant woman (Gestational age: 28 weeks) with family history of breast cancer (mother). US image demonstrates homogeneous hypoechoic mass with circumscribed margins. Color Doppler US image reveals moderate vascularity and strain elastography shows Tsukuba score 2. BIRADS 4A. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 9 of 24

10 Fig. 5: Galactocele. Ultrasound, Doppler examination and Strain elastography obtained in a 27-year-old lactating woman show a galactocel with cystic appearance, well-circumcribed, non-vascularized at Doppler examination and BGR pattern at elastography. BIRADS 2 Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 10 of 24

11 Fig. 6: Galactocele Ultrasound, Doppler examination and Strain elastography obtained in a 26-year-old lactating woman show a galactocel in the left upper-outer guadrant with appearance of complex cyst, minimal marginal Doppler signal and Tsukuba score BGR (anechoic component) and 2 (hypoechoic component). Lesion recurred after a previous ultrasound guided fine-needle aspiration. BIRADS 3. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 11 of 24

12 Fig. 7: Galactocele 35-year-old lactating woman. US image reveal a circumscribed mixed lesion, cystic and solid, with lack of blood flow at Doppler interogation and Tsukuba score 2 at elastography. BIRADS 2 Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 12 of 24

13 Fig. 8: Galactocele 35 -year-old lactating woman. Ultrasound and Strain elastography showing a predominantly solid, circumscribed, hypoechoic and soft mass (Tsukuba score 1). BIRADS 2. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 13 of 24

14 Fig. 9: Infected galactocele 28-year-old lactating woman who presented with a painful, palpable breast mass and discrete clinical signs of in#ammation. Ultrasound, Doppler examination and Strain elastography revealing an irregular, heterogeneous, hypoechoic mass, with adjacent vascular tracts. Strain elastography image demonstrates a BGR pattern. Ultrasound guided fine-needle aspiration revealed purulent material, thereby con#rming infected galactocele. Courtesy of Dr. A.R. Chiorean, Medimages, ClujNapoca, Romania Page 14 of 24

15 Fig. 10: Lactational breast abscess in a 28-year-old lactating woman who presented with discreet erythema and pain in the upper-inner quadrant of the right breast. US image reveal a diffuse, irregular and heteregeneous mass with impur fluid areas included. Lesion present incresed vascularity at Doppler interogation and benign appearance at elastography. Intralesional fluid areas were evacuated and extracted purulent material. BI-RADS 3. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 15 of 24

16 Fig. 11: Lactating adenoma. 30 -year-old woman. Ultrasound, Doppler examination and Strain elastography: lobulated, hypoechoic lesion with parallel orientation, minimal Doppler signal and non-rigid pattern at elastography (Tsukuba score 2). BI-RADS 4A. The percutaneous biopsy was performed and the result was lactating adenoma. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 16 of 24

17 Fig. 12: Lactating adenoma. Ultrasound, Doppler examination and Strain elastography obtained in a 33-year-old lactating woman show a irregular, microlobulated, heterogeneous mass with minimal Doppler signal and benign pattern at elastography (Tsukuba score 2,3). BI-RADS 4B. Percutaneous biopsy shows lactating adenoma, ductal ectasia and inflamation. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 17 of 24

18 Fig. 13: Lactating adenoma. 34-year-old lactating woman. Ultrasound, Doppler examination and Strain elastography: Heterogeneous round mass partially circumscribed, partially indistincted, asociated with incresed vascularity. Elastography shows non-rigid mass with Tsukuba score 2 and BGR. BI-RADS 4B. Histopathology on core biopsy: lactating adenoma. Courtesy of Dr. A.R. Chiorean, Medimages, ClujNapoca, Romania Page 18 of 24

19 Fig. 14: 44 -year-old pregnant women (Gestational age: 8 weeks) with family history of breast cancer (grandmother and aunt). Ultrasound and color Doppler US shows a 7 cm nodule with suspicious features of malignancy in the inferior outer quadrant of the left breast (irregular, hypoechoic and heterogeneous mass with angular margins and posterior shadowing)(a). Lesion present minimal marginal vascularity at Doppler examination (b). Percutaneous biopsy shows grade III IDC (c). Ultrasound showing round lymph nodes with moderat evascularity in the left axilla (d, e). Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 19 of 24

20 Fig. 15: 44 -year-old pregnant women - Same patient as in Fig. 14 Ultrasound, Doppler examination and Strain elastography show another suspicious nodule in the superiorouter quadrant of the right breast. Percutaneous biopsy shows grade II IDC Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 20 of 24

21 Fig. 16: 32-year-old pregnant woman (Gestational age at diagnosis: 33 weeks). Palpable left mass and breast edema. Ultrasound, Power Doppler examination and Strain elastography show a diffuse heterogeneous mass with angular margins in the left superior inner quadrant. The hyperechogenic punctate areas represent calci#cations. Note also the posterior acoustic shadowing and minimal breast edema. Lesion presents increased vascularity at Doppler examination and rigid aspect (Tsukuba score 5) at elastography. BI-RADS 5. The histopathological result: grade III IDC Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 21 of 24

22 Fig. 17: 33-year-old pregnant woman (Gestational age at diagnosis: 9 weeks) who presented with bloody nipple discharge. Ultrasound, color Doppler examination and Strain elastography demonstrate multiple hyperechogenic foci, which represent intraductal calci#cations in the left upper-outer quadrant asociated with moderat vascularity and rigid areas. The percutaneous biopsy was performed and the result was DCIS. Courtesy of Dr. A.R. Chiorean, Medimages, Cluj-Napoca, Romania Page 22 of 24

23 Conclusion Knowledge of the entities that are specifically related to pregnancy and lactation and of their imaging appearances are essential for an accurate diagnosis. The standard method for assessing these breast disorders is ultrasound combined, if needed, with core needle biopsy. The possibility of breast cancer must be considered to avoid any delays in diagnosis Personal information References 1. Sabate JM et al. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics Oct;27 Suppl 1:S Ayyappan A.P. et al. Pregnancy-associated breast cancer: spectrum of imaging appearances. The British Journal of Radiology, 83 (2010), Vashi et al. Breast Imaging of the Pregnant and Lactating Patient: Imaging Modalities and PregnancyAssociated Breast Cancer. AJR Am J Roentgenol Feb;200(2): Joshi S et al. Breast disease in the pregnant and lactating patient: radiologicalpathological correlation. Insights Imaging Oct;4(5): Webb JA, Thomsen HS, Morcos SK. The use of iodinated and gadolinium contrast media during pregnancy and lactation. Eur Radiol 2005;15: Espinosa LA, Daniel BL, Vidarsson L, Zakhour M, Ikeda DM, Herfkens RJ. The lactating breast: contrast-enhanced MR imaging of normal tissue and cancer. Radiology 2005;237: Talele AC, Slanetz PJ, Edmister WB, Yeh ED, Kopans DB. The lactating breast: MRI findings and literature review. Breast J 2003;9: Ji Hoon Yu et al. Breast diseases during pregnancy and lactation. Obstet Gynecol Sci 2013;56(3): Page 23 of 24

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