Role of sono-mammography in the evaluation of clinically palapble breast masses during pregnancy & lactation with differentaition between true patholgical & false physiological lobular hyperlpasia.sudanese experience. Poster No.: C-007 Congress: ECR 205 Type: Scientific Exhibit Authors: A. F. I. Moustafa, O. M. M. Shetat, A. H. O. Yousif, H. Fadl ; 2 2 3 3 Cairo/EG, Khartoum/SD, London/UK Keywords: Biological effects, Diagnostic procedure, Ultrasound, Mammography, Breast DOI: 0.594/ecr205/C-007 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. www.myesr.org Page of 2
Aims and objectives During pregnancy and lactation the breasts undergoes significant changes in the breast parenchyma representing unique physiologic states. Considerable hypertrophy of the ductal-lobular-alveolar system occurs. These physiologic changes start at pregnancy, continue through lactation & persists for approximately three months after cessation of breast-feeding. Most of the breast masses presenting during pregnancy and lactation are benign, however, any breast mass that occurs during this time requires thorough assessment to exclude the possibility of pregnancy-associated breast cancer. 2 Physiologic changes also manifest clinically with increased breast size, firmness, and nodularity which make the physical examination more difficult. On ultrasound, lactational change occasionally is visible as a homogeneous to 3 heterogeneous mass. The goal of this study is to evaluate the role of the sono-mammography in the characterization of clinically palpable breast lumps during pregnancy and lactation and rule out pregnancy associated breast cancer which represent the most ominous entity and also to highlight the radiologic features of lactational breast changes/lobular hyperplasia. Images for this section: Page 2 of 2
Fig. : (A & B) 28 years old lactating for 9 months presented with right breast lump felt. A Bilateral mammogram (cranio-caudal & medio-lateral oblique views) showing marked diffuse increase in parenchymal density more dense in right breast UOQ. B US images of the clinically palpable lump at 9 to O`clock revealed diffuse enlargement of the glandular component with hyperechogenicity, yet no definite masses consistent with lactational changes /lobular hyperplasia confirmed by histopathology showing active breast tissue. Page 3 of 2
Fig. 2: 28 years old lactating woman presented with right breast palpable non painful lump. US showing marked echogenic breast tissue with no underlying masses consistent with lactational changes /lobular hyperplasia. These findings are normal in lactating patients & are due to engorged milk filled breast. Page 4 of 2
Methods and materials This study was carried on 00 female patients with clinically palpable lumps during pregnancy & lactation. Patients were referred from the outpatient clinics. Patients' ages ranged from 8 to 4 years with a mean age 29 years. Patients were submitted to the following: I-Clinical history & examination: Full history taking including clinical presentation (complaint), age, family and past medical history with dedicated examination. II- Imaging procedures: All 00 patients underwent B-mode ultrasound examination using ultrasound device of GE Healthcare (LOGIQ E5 with XDclear premium ultrasound) with a superficial linear 2 MHz probe. When Ultrasound revealed a benign lesion, no further diagnostic evaluation was necessary. In patients over 35 years old & when Ultrasound demonstrated a suspicious lesion, a dedicated mammogram in craniocaudal & mediolateral oblique view was done using the digital mammography system (using GE Senographe 2000D fullfield digital mammography system from GE Healthcare; Chalfont St-Giles, UK). Only 23 patients underwent conventional digital mammography. III- Pathologic Diagnosis: Samples of breast lesions were attained in 22 patients by core biopsy under US guidance using true cut needle biopsy (via 4 -gauge needles).specimens were evaluated and analyzed by the well-trained expert pathologists. Lesions were classified on B-mode sonography & mammography according to BIRADS criteria of the American College of Radiology. Images for this section: Page 5 of 2
Fig. 3: (A & B) 2 years old lactating woman presented with left UOQ breast lump. A Bilateral mammogram (cranio-caudal & medio-lateral oblique views) showing bilateral extremely dense breast parenchyma with left UOQ well defined lobulated isodense mass lesion. B images of US guided biopsy showing at 0 O`clock a welldefined homogenously isoechoic mass lesion consistent with fibroadenoma confirmed by histopathology. Page 6 of 2
Fig. 4: 26 years old pregnant woman last trimester presented with right upper outer quadrant palpable non painful lump. US showing well defined homogenous iso to hypoechoic mass lesion consistent with fibroadenoma. Page 7 of 2
Results 85 of the patients presented during lactation & 5 patients during pregnancy. The clinically palpable lumps were 5 in the left breast & 49 in the right breast. Radiographic findings are demonstrated at the following tables:table U/S findings of the 00 cases U/S category BIRADS BIRADS 2 BIRADS 3 Number cases 20 52 of 3 BIRADS 4 BIRADS 5 3 2 (invasive parenchymal duct (lactational (3 cysts, 6 (35 fibro- distortion carcinoma) breast galactocele adenoma, changes/ & intra- (2 proven to lobular mammary abscesses, be invasive hyperplasia) lymph node) duct? 4 lactating carcinoma adenoma, & granulomatous? mastitis) papilloma, mastitis) Table 2 Mammographic findings of the 23 cases MammographyBIRADS category BIRADS 2 Number cases 2(galactoceles)4(3 2(parenchymal2 (invasive fibroadenoma distortionduct & mastitis) proven to be carcinoma) invasive duct carcinoma) of 4 BIRADS 3 BIRADS 4 BIRADS 5 Table 3 True cut biopsy pathological results of 22 cases. Page 8 of 2
Pathology Number cases Active breast Papilloma tissue of 5 GranulomatousDuctal mastitis carcinoma Fibroadenoma 4 Images for this section: Fig. 5: (A & B) 35 years old lactating woman presented with left UOQ breast lump. 5A Bilateral mammogram (cranio-caudal & medio-lateral oblique views) showing bilateral extremely dense breast parenchyma with left UOQ scattered micro-calcific foci with ductal extension pointing towards the nipple. 5B US images showing at 2 to 3 O`clock diffuse hypoechoic parenchymal infiltration.(birads 5). U/S guided core biopsy was done & histopathology revealed invasive duct carcinoma grade III. Page 9 of 2
Fig. 6: (A, B, C & D) 40 years old lactating woman presented with palpable hard nonpainful lump of the upper outer quadrant of the left breast. 6A Bilateral mammogram (cranio-caudal & medio-lateral oblique views) showing bilateral heterogeneously dense breast parenchyma with left UOQ partly obscured ill-defined highly suspicious mass lesion. 6B US images showing at 2 O`clock an ill-defined hypoechoic suspicious mass lesion measuring 2.6X3X4.2 cm along its maximal dimensions. (BIRADS 5) 6C US images showing left axillary pathological lymph nodes with cortical thickening & effaced hilum. 6D US images of U/S guided core biopsy from the suspicious mass. Histopathology revealed invasive duct carcinoma grade III. Page 0 of 2
Conclusion The majority of pregnancy-associated breast masses are benign; still, a thorough and prompt evaluation of any lesion during this time is required, in order to rule out malignancy & to avoid misdiagnosis of lactational breast changes/lobular hyperplasia as a pathology. Ultrasound constitutes the most appropriate radiologic method for evaluating breast disorders in women during pregnancy and lactation. In older patients & when the imaging results are suspicious mammography is to be done with further biopsy performed to obtain a pathologic diagnosis. Images for this section: Fig. 7: (A & B) 3 years old lactating woman presented with palpable non-painful lump of the upper outer quadrant of the left breast. 7A Bilateral mammogram (cranio-caudal & medio-lateral oblique views) showing bilateral marked diffuse increase in parenchymal density, no definite masses. 7B US images of the clinically palpable lump at to 3 O`clock revealed diffuse area of parenchymal hyperechogenicity, yet no definite masses consistent with lactational changes /lobular hyperplasia. Page of 2
Personal information References. Vashi R, Hooley R, Butler R, Geisel J, Philpotts L. Breast imaging of the pregnant and lactating patient: Physiologic changes and common benign entities. AJR. American journal of roentgenology 203;200:329-336 2. Hogge JP, Paredes D, Shaw E, Magnant CM, Lage J. Imaging and management of breast masses during pregnancy and lactation. The breast journal 999;5:272-283 3. Joshi S, Dialani V, Marotti J, Mehta TS, Slanetz PJ. Breast disease in the pregnant and lactating patient: Radiological-pathological correlation. Insights into imaging 203;4:527-538 Page 2 of 2