Abid Irshad, MD Director Breast Imaging Medical University of South Carolina Charleston
Cases
Financial disclosure: I or my family have no financial interest related to the material discussed in this presentation
Case
30 yo F with h/o recent breast reduction presents with new right breast thickening and swelling.
What is the differential diagnosis? Seroma? Abscess? Hematoma? Large cyst? Necrotic cancer? Implant?
Fluid aspiration performed 300 cc of clear fluid aspirated
Recent plain chest film
Diagnosis: CSF collection within the breast The VP shunt pulled up during the breast reduction surgery
Old plain films (Prior to breast reduction)
Case
81 year old female presents with right nipple inversion Old Old
US retro-areolar US
Core needle biopsy Invasive Lobular Cancer
MRI Invasive lobular carcinoma
Patient elected mastectomy with implant reconstruction 2015 Replaced with double lumen implant 2013
Recently presented with hardness and warmth of the right breast.
US Differential diagnosis Recurrent ILC Abscess Granulation tissue Hematoma Implant leak Lymphoma
Core needle biopsy
Why is the outer surface of mass very smooth?
Diagnosis: Spindle cell neoplasm / Metaplastic carcinoma
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
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
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
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)
Case
History 51 year old female presents with breast masses seen on CT scan
Mammogram shows two masses with indistinct margins
Ultrasound shows two hypoechoic masses which are non-parallel and have indistinct margins
Differential Diagnosis: Multifocal cancer Mucinous carcinoma High grade IDC Medullary carcinoma Fibroadenomas Phyllodes tumor Hematomas Metastasis
Core needle biopsy done Diagnosis: Plasmacytoma / Myeloma
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%
Plasmacytoma The needle core biopsy specimen consist of sheets of mature and immature plasma cells
Plasmacytoma Tumor cells are immunoreactive for plasma cell marker CD 138
Case
53 year old female presented with palpable lump
Ultrasound D/D IDC? ILC? Less common types (mucinous, medullary etc.) Benign: Lactating adenoma? PASH? Fat necrosis? Hematoma? Phyllodes?
Core needle biopsy performed Diagnosis: Neuroendocrine tumor (Small cell / Oat cell cancer)
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
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
Case
History 61 y o female with mass in the right breast seen on CT
Right CC Left CC
Right CC Right MLO
Differential diagnosis 1. Abscesses 2. Metastasis 3. Fat necrosis 4. Hematomas 5. Lymphoma 6. Multifocal primary breast cancer
Core needle biopsy performed Diffuse Large B-cell lymphoma
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
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
Case
History 60 year old male with palpable mass right upper breast for 6 months
Right CC Left CC
R MLO L MLO
Differential diagnosis 1. Breast carcinoma 2. PASH (pseudoangiomatous stromal hyperplasia) 3. Fat necrosis 4. Hemangioma 5. Hematoma 6. Fibroadenoma 7. Lactating adenoma
Diagnosis Benign Cavernous hemangioma
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
Tubular cavernous channels formed within the mass
Case
History 44 y o white female with palpable lump H/O previous benign excision
Right MLO Right CC
Differential diagnosis 1. Fibroadenoma 2. Breast carcinoma 3. Granuloma 4. Nodular PASH (pseudo-angiomatous stromal hyperplasia) 5. Epidermal inclusion cyst Benign or malignant?
Diagnosis: Suture granuloma Pathology on CNB: Necrotic debris with foreign material on core needle biopsy with organizing granulomatous inflammation on excision
Suture granuloma Uncommon, foreign body reaction to suture material Granulomatous inflammation Macrophages and multinucleated giant cells are typical
Case
History 69 y o white female found to have a large breast mass
R CC R MLO
T 2 Post contrast
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
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
Case
History 59 y o AA male with palpable right breast mass
Right MLO Left MLO
Right CC Left CC
Differential diagnosis 1. Invasive ductal cancer 2. Dense stromal fibrosis 3. Complex sclerosing lesion or radial scar 4. Granular cell tumor 5. Desmoid tumor
Diagnosis: Granular cell tumor
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
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
A different Patient
Case
History 64 yo female with new palpable lump left breast
DDX for new solid circumscribed mass: Malignant Benign Breast carcinoma Invasive ductal Medullary Mucinous Papillary Malignant phyllodes Adenoma Papilloma PASH Lymphoma Benign phyllodes
RCC Patient complained of pain on the other side
DDx for multiple circumscribed masses Cysts Fibroadenomas Metastasis Lymphoma Multiple primary breast CA s PASH Granulomas
Biopsied right axillary tail and left breast lesions Diagnosis: Metastatic melanoma (poorly differentiated) Remote history of melanoma leg in 2003
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
Case
History 47 year old female with new masses in the left breast
Differential diagnosis Cysts Fibroadenomas Metastatic lesions Lymphoma Granulomas Fat necrosis Multi-centric cancer PASH
US of the left breast
3 most suspicious masses were biopsied Diagnosis: PASH Pseudo angiomatous stromal hyperplasia
Few years later
Few years later
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
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
Case
History 15 year old girl presents with palpable lump in the right upper outer quadrant
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
Core needle biopsy performed Diagnosis: Cystosarcoma Phyllodes
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
Phylloides Tumor-Malignant Marked cytologic atypia and abundant mitosis (>10/HPF) Malignant stroma showing fibrosarcomatous appearance
Thank You
67 yo F on screening mammogram
Adenoid cystic carcinoma
33 yo F with palpable lump
Mass-like Radial Scar (RSL)
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
Adenomyoepithelioma Ultrasound reveals a hypoechoic, solid mass with slightly lobulated borders
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
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
Tubular Adenoma
Case
17 year old female presents with right breast swelling