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DISCUSS THE RADIOLOGICAL FEATURES
OF COMMON BENIGN AND MALIGNANT
BREAST LESIONS ON ULTRASOUND AND
MAMMOGRAPHY
BY
DR MAIMUN...
SYNOPSIS
• INTRODUCTION
• ROLE OF IMAGING (MAMMO & USS) IN
DIAGNOSIS
• OVERVIEW OF ACR BIRADS
• RADIOLOGICAL FEATURES OF C...
INTRODUCTION
• The breasts are a pair of glandular organs
• Function: lactation.
• Dynamic structure ; undergoes changes
t...
INTRODUCTION
INTRODUCTION
• Breast diseases : variety of conditions .
• Benign or Malignant.
• Most common presentation: a palpable lum...
ROLE OF IMAGING IN DIAG.
• For patients attending breast clinics with
symptoms of breast disease, mainstay of
diagnosis is...
ROLE OF IMAGING IN DIAG.
• Accurate imaging is vital:
-Identify cancers
-Avoid false positives
-Avoid False negatives
ROLE OF IMAGING IN DIAG.
• The principal imaging modalities:
mammography and ultrasound.
• Sensitivity of mammography alon...
ROLE OF IMAGING IN DIAG.
• The Royal College of Radiologists and the
American College of Radiology guidelines:
• <35years,...
ROLE OF IMAGING IN DIAG.
• Also, ultrasound an adjunct to mammo in
patients of all ages.
• Mammography: masses, assessment...
ROLE OF IMAGING IN DIAG.
• USS method of choice in differentiating
between cystic and solid lesions and in
providing guida...
BENIGN NON-INFLAMMATORY LESIONS
• Fibroadenoma
• Fibrocystic change
• Lipoma of the breast
• Gynaecomastia
• Intraductal p...
BENIGN INFLAMMATORY LESIONS
• Breast Abscess
• Galactocele
• Fat Necrosis
MALIGNANT LESIONS
• Invasive Ductal Carcinoma
• Invasive Lobular Carcinoma
• Inflammatory Breast Carcinoma
BENIGN
NON-INFLAMMATORY
LESIONS
FIBROADENOMA
• Fibroadenoma is an oestrogen-induced benign
breast tumour .
• Arises from the terminal duct lobular unit
(T...
FIBROADENOMA
• Most common benign solid tumour among
women of child-bearing age.
• Peak incidence: 3rd decade, second peak...
FIBROADENOMA
• Grow rapidly but rarely exceed 2-3cm in size.
• Giant fibroadenomas and juvenile
fibroadenomas often measur...
FIBROADENOMA
• Due to hormonal influence on this tumour;
-Slight enlargement at the end of the menstrual
cycle.
-During pr...
FIBROADENOMA
• Sonographically:
Classically oval or elliptical mass with long
axis parallel to the chest wall.
Usually m...
FIBROADENOMA
Show a smooth or gently lobullated contour.
 An echogenic pseudocapsule is usually
demonstrated.
FIBROADENOMA
Represents normal, compressed adjacent
breast tissue, indicating that the leading edge
is pushing rather tha...
FIBROADENOMA
• Mammographically,
tumours surrounded by dense breast tissue
may not be appreciated.
visible tumours are c...
FIBROADENOMA
Isodense lesions, smooth, discrete margins.
Margins may be lobular in larger tumours.
Degenerated fibroade...
FIBROADENOMA
FIBROADENOMA
FIBROADENOMA
FIBROADENOMA
FIBROCYSTIC CHANGE
• Formerly : fibrocystic breast disease.
• Fibrocystic change (FCC) of the breast: benign
alteration in...
FIBROCYSTIC CHANGE
• Now known: exaggerated response of normal
breast tissue to the cyclical variations in
oestrogen and p...
FIBROCYSTIC CHANGE
• On ultrasound these lesions may appear as:
-duct ectasia with a ductal pattern;
-multiple cysts of va...
FIBROCYSTIC CHANGE
• Ductal ectasia sonographically seen as tubular
anechoic structures radiating in a centripetal
fashion...
FIBROCYSTIC CHANGE
• Breast cysts appear as rounded or oval shaped
well defined sonolucent lesions with
imperceptible wall...
FIBROCYSTIC CHANGE
• Mammographically, fibrocystic change of the
cystic type appears as individual round or
ovoid lesions ...
FIBROCYSTIC CHANGE
• Teacup-like calcifications on horizontal beam
• Rounded smudged calcifications on
craniocaudal projec...
FIBROCYSTIC CHANGE
• Involutional type: fine punctuate calcifications
evenly distributed within one or more lobes
against ...
FIBROCYSTIC CHANGE
FIBROCYSTIC CHANGE
FIBROCYSTIC CHANGE
FIBROCYSTIC CHANGE
FIBROCYSTIC CHANGE
FIBROCYSTIC CHANGE
INTRA-DUCTAL PAPILLOMA
• Benign tumours of mammary duct epithelium.
• Arise anywhere in the ductal system, central >>
peri...
INTRA-DUCTAL PAPILLOMA
• Mammographically; mass or asymmetry.
• Microcalcifications may be seen
INTRA-DUCTAL PAPILLOMA
• Sonographically;
hyperechoic or hypoechoic masses within
dilated retro-areolar duct surrounded b...
INTRA-DUCTAL PAPILLOMA
• A hypervascular stalk may be seen on Doppler
interrogation.
INTRA-DUCTAL PAPILLOMA
INTRA-DUCTAL PAPILLOMA
LIPOMA OF THE BREAST
• Benign mesenchymal tumours composed of
mature adipose tissue.
• Mostly asymptomatic and coincidenta...
LIPOMA OF THE BREAST
• Patients may present with a painless palpable
breast lump which is soft and mobile.
• In these case...
LIPOMA OF THE BREAST
• Mammographically,
Typically seen as radiolucent mass with no
calcification.
May have a thin, flui...
LIPOMA OF THE BREAST
• Sonographically,
Seen as rounded isoechoic or slightly
hyperechoic lesion in comparison to
surroun...
LIPOMA OF THE BREAST
LIPOMA OF THE BREAST
GYNAECOMASTIA
• Enlargement of the male breast benign
ductal and stromal proliferation.
• Imbalance between oestrogen acti...
GYNAECOMASTIA
AETIOLOGY:
• Physiological
• Pathological
-Drugs
-Systemic diseases
-Tumours
GYNAECOMASTIA
• Subtypes:
-Nodular
-Dendritic
-Diffuse
GYNAECOMASTIA
• Mammographically;
i. Nodular pattern: seen in patients with
gynaecomastia for less than 1 year.
• Seen as ...
GYNAECOMASTIA
• Mammographically;
ii. Dendritic pattern: a flame-shaped subareolar
density with posterior linear projectio...
GYNAECOMASTIA
• Is seen in patients with gynaecomastia for
longer than 1 year.
• Fibrosis becomes the dominant process and...
GYNAECOMASTIA
• Mammographically;
iii. Diffuse Glandular pattern: commonly seen in
patients receiving exogenous oestrogen....
GYNAECOMASTIA
• Sonographically;
i. Nodular gynaecomastia: can be subareolar fan
or disc shaped hypoechoic nodule surround...
GYNAECOMASTIA
• Sonographically;
ii. Dendritic gynaecomastia: subareolar
hypoechoic lesion with anechoic star-shaped
poste...
GYNAECOMASTIA
• Sonographically;
iii. Diffuse glandular gynaecomastia shows both
nodular and dendritic features surrounded...
GYNAECOMASTIA
• A hallmark of gynaecomastia is its central
symmetric location under the nipple.
• Imaging differential is ...
GYNAECOMASTIA
GYNAECOMASTIA
GYNAECOMASTIA
GYNAECOMASTIA
GYNAECOMASTIA
GYNAECOMASTIA
?GYNAECOMASTIA
?GYNAECOMASTIA
BENIGN
INFLAMMATORY
LESIONS
BREAST ABSCESS
• Relatively common complication of mastitis.
• May occur during breastfeeding, particularly
in primiparous...
BREAST ABSCESS
• The predominant infectious organism:
Staphylococcus aureus, often the penicillinase-
producing type.
• Ot...
BREAST ABSCESS
• Classification:
Puerperal abscesses: seen in primiparous
mothers.
Non-puerperal central abscesses: comm...
BREAST ABSCESS
• Classification:
Non-puerperal peripheral abscesses: less
commonly seen.
• Seen in older women with under...
BREAST ABSCESS
• Ultrasound considered most useful initial
imaging modality when a breast abscess is
suspected.
• Imaging ...
BREAST ABSCESS
• For the purpose of follow up 3-D
measurement of the abscess and the volume
should be given.
BREAST ABSCESS
• Sonographic features suggestive of a breast
abscess include:
Hypoechoic collection, mostly multiloculate...
BREAST ABSCESS
• On ultrasound, breast abscess can easily
mimic other entities such as a breast
malignancy or a breast hae...
BREAST ABSCESS
• Mammography is very rarely indicated or
useful.
• Mammography is recommended to exclude
the possibility o...
BREAST ABSCESS
• Mammographic appearances are often non
specific and in the age group where breast
abscesses are most ofte...
BREAST ABSCESS
• These findings are not specific for abscess or
malignancy; however presence of suspicious
microcalcificat...
BREAST ABSCESS
BREAST ABSCESS
BREAST ABSCESS
FAT NECROSIS
• A pathological process that occurs when there
is saponification of local fat.
• A benign inflammatory proce...
FAT NECROSIS
• Most at risk are middle-aged women with
pendulous breasts.
• Aetiologically, in everyday practice, trauma
a...
FAT NECROSIS
• Trauma includes seat belt injury, contact
sports.
• Surgical procedures include implant removal
breast biop...
FAT NECROSIS
• Mammographically,
An ill-defined and irregular, spiculated mass-
like area.
Associated calcification can ...
FAT NECROSIS
• The changes are often seen and correlated
with the position of surgical scarring on the
breast itself.
• Th...
FAT NECROSIS
• With time, it becomes more defined and well-
circumscribed giving rise to an oil cyst.
• Oil cysts can have...
FAT NECROSIS
• Sonographically,
Fat necrosis may be seen as a hypoechoic
mass with well defined margins with/without
mura...
FAT NECROSIS
• On ultrasound, the lesion may occasionally
represent an intracystic carcinoma and
mammographic correlation ...
FAT NECROSIS
FAT NECROSIS
FAT NECROSIS
FAT NECROSIS
GALACTOCELE
• Most common benign breast lesion typically
occurring in young lactating women.
• They mostly occur on cessat...
GALACTOCELE
• Essentially a retention cyst resulting from
lactiferous duct occlusion.
• There is a predilection towards th...
GALACTOCELE
• Mammographic appearance of galactocoele
can be varied depending on the fat and
protein content and the consi...
GALACTOCELE
When the milk is in fresh liquid state, a
characteristic fat fluid level is seen due to
viscosity difference....
GALACTOCELE
When contents are old milk and water, due to
highly viscous old milk, gives a hamartoma-like
appearance on ma...
GALACTOCELE
• On ultrasound appearances can be widely
variable.
Thin-walled cystic mass with low level internal
echoes 50...
GALACTOCELE
GALACTOCELE
GALACTOCELE
GALACTOCELE
COMMON
MALIGNANT
LESIONS
INVASIVE DUCTAL CARCINOMA
• Commonest histologically diagnosed breast
malignancy accounting for 50-70% of invasive
breast ...
INVASIVE DUCTAL CARCINOMA
• In a study conducted in this department, peak
presentation of IDC was in the age groups 31-
45...
INVASIVE DUCTAL CARCINOMA
• Mammographically,
Findings vary greatly and reflect gross tumour
morphology and histological ...
INVASIVE DUCTAL CARCINOMA
• Masses usually show spiculated or indistinct
margins.
• Rarely however, a mass with circumscri...
INVASIVE DUCTAL CARCINOMA
• Extensive intraductal component is not
uncommon and may manifest
mammographically as linearly ...
INVASIVE DUCTAL CARCINOMA
• Sonographically,
Appear as irregular, microlobullated,
hypoechoic masses.
Widest diameter of...
INVASIVE DUCTAL CARCINOMA
• However, in high grade variants that are highly
cellular with little desmoplasia, posterior
en...
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE LOBULAR CARCINOMA
• 2ND most common invasive breast malignancy
accounting for about 5-15% of all invasive
breast ...
INVASIVE LOBULAR CARCINOMA
• Mammographically,
Non-specific.
Commonest abnormality an ill-defined
isodense mass with obs...
INVASIVE LOBULAR CARCINOMA
ILC may only be a one view finding; usually the
CC view which is typically better compressed
t...
INVASIVE LOBULAR CARCINOMA
“Shrinking breast phenomenon” may be seen
where in a large tumour, the affected breast
appears...
INVASIVE LOBULAR CARCINOMA
• Sonographically,
An irregular, angular hypoechoic mass.
Heterogenous internal echoes with i...
INVASIVE LOBULAR CARCINOMA
In some cases, no abnormality may be
detected.
The only abnormality might be suspicious
shado...
INVASIVE LOBULAR CARCINOMA
INVASIVE LOBULAR CARCINOMA
INVASIVE LOBULAR CARCINOMA
INVASIVE LOBULAR CARCINOMA
INVASIVE LOBULAR CARCINOMA
INFLAMMATORY BREAST Ca.
• A relatively uncommon but aggressive form of
invasive breast carcinoma.
• Any pathological sub-t...
INFLAMMATORY BREAST Ca.
• Account for 1-4% of all breast cancers,
typically occurring in women between 4th to
5th decades.
INFLAMMATORY BREAST Ca.
• Mammographic findings include:
 Tumour mass
 Microcalcifications
Features of inflammation: sk...
INFLAMMATORY BREAST Ca.
• Ultrasound may be helpful to locate a
hypoechoic shadowing mass, which can be
obscured on mammog...
INFLAMMATORY BREAST Ca.
INFLAMMATORY BREAST Ca.
INFLAMMATORY BREAST Ca.
INFLAMMATORY BREAST Ca.
ASSOCIATED LYMPHADENOPATHY
• Normal lymph nodes: short axis diameter
< 10mm.
• Oval shaped
• Smooth regular contour
• Cent...
NORMAL AXILLARY LN: MAMMO
NORMAL AXILLARY LN: USS
ASSOCIATED LYMPHADENOPATHY
• Abnormal lymph nodes: inflammatory /
malignant, short axis diameter > than 10mm.
ASSOCIATED LYMPHADENOPATHY
• Inflammatory enlargement: proportionate in
all directions elliptical-shaped
enlargement.
• Ne...
ASS LYMOCIATEDPHADENOPATHY
• Sonographic features suggestive of malignant
infiltration include:
-Eccentric cortical thicke...
ASSOCIATED LYMPHADENOPATHY
• Mammographically;
-Loss of the normal fatty hilum,
-Loss of the normal oval or reniform shape...
ASSOCIATED LYMPHADENOPATHY
ASSOCIATED LYMPHADENOPATHY
ASSOCIATED LYMPHADENOPATHY
ASSOCIATED LYMPHADENOPATHY
ASSOCIATED LYMPHADENOPATHY
SUMMARY/CONCLUSION
• Many of the commonly encountered breast
lesions have classic imaging features.
• There are a few exce...
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RADIOLOGICAL FEATURES OF BREAST DX

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RADIOLOGICAL FEATURES OF BREAST DX

  1. 1. DISCUSS THE RADIOLOGICAL FEATURES OF COMMON BENIGN AND MALIGNANT BREAST LESIONS ON ULTRASOUND AND MAMMOGRAPHY BY DR MAIMUNA A. HALLIRU DEPARTMENT OF RADIOLOGY AMINU KANO TEACHING HOSPITAL, KANO.
  2. 2. SYNOPSIS • INTRODUCTION • ROLE OF IMAGING (MAMMO & USS) IN DIAGNOSIS • OVERVIEW OF ACR BIRADS • RADIOLOGICAL FEATURES OF COMMON BENIGN & MALIGNANT LESIONS • ASSOCIATED LYMPHADENOPATHY • CONCLUSION/SUMMARY
  3. 3. INTRODUCTION • The breasts are a pair of glandular organs • Function: lactation. • Dynamic structure ; undergoes changes throughout a woman’s reproductive life.
  4. 4. INTRODUCTION
  5. 5. INTRODUCTION • Breast diseases : variety of conditions . • Benign or Malignant. • Most common presentation: a palpable lump.
  6. 6. ROLE OF IMAGING IN DIAG. • For patients attending breast clinics with symptoms of breast disease, mainstay of diagnosis is triple assessment. • Imaging plays an important role in the evaluation of breast diseases.
  7. 7. ROLE OF IMAGING IN DIAG. • Accurate imaging is vital: -Identify cancers -Avoid false positives -Avoid False negatives
  8. 8. ROLE OF IMAGING IN DIAG. • The principal imaging modalities: mammography and ultrasound. • Sensitivity of mammography alone = 45-90% (age, parity and breast density). • Sensitivity of ultrasound = 80-90%.
  9. 9. ROLE OF IMAGING IN DIAG. • The Royal College of Radiologists and the American College of Radiology guidelines: • <35years, USS • >35years, Mammo.
  10. 10. ROLE OF IMAGING IN DIAG. • Also, ultrasound an adjunct to mammo in patients of all ages. • Mammography: masses, assessment of calcifications and other features which raise suspicion of breast cancer.
  11. 11. ROLE OF IMAGING IN DIAG. • USS method of choice in differentiating between cystic and solid lesions and in providing guidance for interventional procedures.
  12. 12. BENIGN NON-INFLAMMATORY LESIONS • Fibroadenoma • Fibrocystic change • Lipoma of the breast • Gynaecomastia • Intraductal papilloma
  13. 13. BENIGN INFLAMMATORY LESIONS • Breast Abscess • Galactocele • Fat Necrosis
  14. 14. MALIGNANT LESIONS • Invasive Ductal Carcinoma • Invasive Lobular Carcinoma • Inflammatory Breast Carcinoma
  15. 15. BENIGN NON-INFLAMMATORY LESIONS
  16. 16. FIBROADENOMA • Fibroadenoma is an oestrogen-induced benign breast tumour . • Arises from the terminal duct lobular unit (TDLU) .
  17. 17. FIBROADENOMA • Most common benign solid tumour among women of child-bearing age. • Peak incidence: 3rd decade, second peak 5th decade.
  18. 18. FIBROADENOMA • Grow rapidly but rarely exceed 2-3cm in size. • Giant fibroadenomas and juvenile fibroadenomas often measure >5cm. • Lesions up to 10cm may be encountered.
  19. 19. FIBROADENOMA • Due to hormonal influence on this tumour; -Slight enlargement at the end of the menstrual cycle. -During pregnancy. -Regression after menopause.
  20. 20. FIBROADENOMA • Sonographically: Classically oval or elliptical mass with long axis parallel to the chest wall. Usually mildly hypoechoic or isoechoic with respect to fat. Mixed echogenic masses may also be encountered.
  21. 21. FIBROADENOMA Show a smooth or gently lobullated contour.  An echogenic pseudocapsule is usually demonstrated.
  22. 22. FIBROADENOMA Represents normal, compressed adjacent breast tissue, indicating that the leading edge is pushing rather than infiltrating. Sound transmission normal / increased with bilateral edge shadowing.
  23. 23. FIBROADENOMA • Mammographically, tumours surrounded by dense breast tissue may not be appreciated. visible tumours are classically circular, oval or gently lobulated in shape.
  24. 24. FIBROADENOMA Isodense lesions, smooth, discrete margins. Margins may be lobular in larger tumours. Degenerated fibroadenomas usually contain calcifications: coarse or popcorn-like pathognomonic.
  25. 25. FIBROADENOMA
  26. 26. FIBROADENOMA
  27. 27. FIBROADENOMA
  28. 28. FIBROADENOMA
  29. 29. FIBROCYSTIC CHANGE • Formerly : fibrocystic breast disease. • Fibrocystic change (FCC) of the breast: benign alteration in the terminal ductal lobular unit of the breast • ± associated fibrosis.
  30. 30. FIBROCYSTIC CHANGE • Now known: exaggerated response of normal breast tissue to the cyclical variations in oestrogen and progesterone. • Commoner in women of child-bearing age; 35-55years but can occur at any age.
  31. 31. FIBROCYSTIC CHANGE • On ultrasound these lesions may appear as: -duct ectasia with a ductal pattern; -multiple cysts of varying size, or -ill-defined focal echogenic lesions with or without posterior attenuation.
  32. 32. FIBROCYSTIC CHANGE • Ductal ectasia sonographically seen as tubular anechoic structures radiating in a centripetal fashion towards the nipple in a non-lactating woman usually above 40years of age.
  33. 33. FIBROCYSTIC CHANGE • Breast cysts appear as rounded or oval shaped well defined sonolucent lesions with imperceptible walls and posterior acoustic enhancement.
  34. 34. FIBROCYSTIC CHANGE • Mammographically, fibrocystic change of the cystic type appears as individual round or ovoid lesions of low density with discrete, smooth margins.
  35. 35. FIBROCYSTIC CHANGE • Teacup-like calcifications on horizontal beam • Rounded smudged calcifications on craniocaudal projections depicting the • Classic milk of calcium pathognomonic.
  36. 36. FIBROCYSTIC CHANGE • Involutional type: fine punctuate calcifications evenly distributed within one or more lobes against a fatty background. • In such cases; percutaneous biopsy is usually required to exclude DCIS.
  37. 37. FIBROCYSTIC CHANGE
  38. 38. FIBROCYSTIC CHANGE
  39. 39. FIBROCYSTIC CHANGE
  40. 40. FIBROCYSTIC CHANGE
  41. 41. FIBROCYSTIC CHANGE
  42. 42. FIBROCYSTIC CHANGE
  43. 43. INTRA-DUCTAL PAPILLOMA • Benign tumours of mammary duct epithelium. • Arise anywhere in the ductal system, central >> peripheral. • Papillomas are the most common cause of bloody nipple discharge.
  44. 44. INTRA-DUCTAL PAPILLOMA • Mammographically; mass or asymmetry. • Microcalcifications may be seen
  45. 45. INTRA-DUCTAL PAPILLOMA • Sonographically; hyperechoic or hypoechoic masses within dilated retro-areolar duct surrounded by anechoic fluid. If no fluid, seen as round/irregular hyperechoic or hypoechoic mass lesion usually retroareolar in location.
  46. 46. INTRA-DUCTAL PAPILLOMA • A hypervascular stalk may be seen on Doppler interrogation.
  47. 47. INTRA-DUCTAL PAPILLOMA
  48. 48. INTRA-DUCTAL PAPILLOMA
  49. 49. LIPOMA OF THE BREAST • Benign mesenchymal tumours composed of mature adipose tissue. • Mostly asymptomatic and coincidentally discovered on routine mammography.
  50. 50. LIPOMA OF THE BREAST • Patients may present with a painless palpable breast lump which is soft and mobile. • In these cases the diagnosis is clinically obvious.
  51. 51. LIPOMA OF THE BREAST • Mammographically, Typically seen as radiolucent mass with no calcification. May have a thin, fluid density capsule. Mammographic detection easier in a dense breast.
  52. 52. LIPOMA OF THE BREAST • Sonographically, Seen as rounded isoechoic or slightly hyperechoic lesion in comparison to surrounding fat. Occasionally hypoechoic. Multiple thin echogenic septations may be seen running parallel to the skin surface. These lesions are also found in males.
  53. 53. LIPOMA OF THE BREAST
  54. 54. LIPOMA OF THE BREAST
  55. 55. GYNAECOMASTIA • Enlargement of the male breast benign ductal and stromal proliferation. • Imbalance between oestrogen action relative to androgen action at the breast tissue level is the key aetiological factor.
  56. 56. GYNAECOMASTIA AETIOLOGY: • Physiological • Pathological -Drugs -Systemic diseases -Tumours
  57. 57. GYNAECOMASTIA • Subtypes: -Nodular -Dendritic -Diffuse
  58. 58. GYNAECOMASTIA • Mammographically; i. Nodular pattern: seen in patients with gynaecomastia for less than 1 year. • Seen as a nodular subareolar density.
  59. 59. GYNAECOMASTIA • Mammographically; ii. Dendritic pattern: a flame-shaped subareolar density with posterior linear projections radiating into the surrounding tissue.
  60. 60. GYNAECOMASTIA • Is seen in patients with gynaecomastia for longer than 1 year. • Fibrosis becomes the dominant process and is irreversible.
  61. 61. GYNAECOMASTIA • Mammographically; iii. Diffuse Glandular pattern: commonly seen in patients receiving exogenous oestrogen. • There is enlargement of the breast and diffuse density with both dendritic and nodular features.
  62. 62. GYNAECOMASTIA • Sonographically; i. Nodular gynaecomastia: can be subareolar fan or disc shaped hypoechoic nodule surrounded by normal fatty tissue.
  63. 63. GYNAECOMASTIA • Sonographically; ii. Dendritic gynaecomastia: subareolar hypoechoic lesion with anechoic star-shaped posterior border, described as finger-like projections or "spider legs" insinuating into the surrounding echogenic fibrous breast tissue.
  64. 64. GYNAECOMASTIA • Sonographically; iii. Diffuse glandular gynaecomastia shows both nodular and dendritic features surrounded by diffuse hyperechoic fibrous breast tissue.
  65. 65. GYNAECOMASTIA • A hallmark of gynaecomastia is its central symmetric location under the nipple. • Imaging differential is male breast cancer which is usually eccentrically located with respect to the nipple. Other features like surrounding distortion, lymphadenopathy etc will be present.
  66. 66. GYNAECOMASTIA
  67. 67. GYNAECOMASTIA
  68. 68. GYNAECOMASTIA
  69. 69. GYNAECOMASTIA
  70. 70. GYNAECOMASTIA
  71. 71. GYNAECOMASTIA
  72. 72. ?GYNAECOMASTIA
  73. 73. ?GYNAECOMASTIA
  74. 74. BENIGN INFLAMMATORY LESIONS
  75. 75. BREAST ABSCESS • Relatively common complication of mastitis. • May occur during breastfeeding, particularly in primiparous women. • Clinical context is key to diagnosis as imaging appearances (particularly ultrasound) can mimic many other entities such as breast carcinoma.
  76. 76. BREAST ABSCESS • The predominant infectious organism: Staphylococcus aureus, often the penicillinase- producing type. • Other common types include Staphylococcus epidermidis and Proteus mirabilis.
  77. 77. BREAST ABSCESS • Classification: Puerperal abscesses: seen in primiparous mothers. Non-puerperal central abscesses: commonest non-breastfeeding abscess. • Seen mostly in young women; especially smokers.
  78. 78. BREAST ABSCESS • Classification: Non-puerperal peripheral abscesses: less commonly seen. • Seen in older women with underlying chronic medical conditions like diabetes, rheumatoid arthritis; women taking steroids or underwent a recent breast intervention
  79. 79. BREAST ABSCESS • Ultrasound considered most useful initial imaging modality when a breast abscess is suspected. • Imaging method of choice to monitor progress, response to therapy and to ensure resolution.
  80. 80. BREAST ABSCESS • For the purpose of follow up 3-D measurement of the abscess and the volume should be given.
  81. 81. BREAST ABSCESS • Sonographic features suggestive of a breast abscess include: Hypoechoic collection, mostly multiloculated with no vascularity within the collection. Posterior acoustic enhancement due to fluid content. Echogenic, vascular rim. Axillary lymphadenopathy
  82. 82. BREAST ABSCESS • On ultrasound, breast abscess can easily mimic other entities such as a breast malignancy or a breast haematoma on imaging grounds alone. • In practice, the most difficult differentiation is from a galactocoele.
  83. 83. BREAST ABSCESS • Mammography is very rarely indicated or useful. • Mammography is recommended to exclude the possibility of malignancy in non-puerperal abscesses, in ladies over 30 years and in puerperal abscesses with a prolonged clinical course.
  84. 84. BREAST ABSCESS • Mammographic appearances are often non specific and in the age group where breast abscesses are most often found, mammography is rarely done. • Findings which may be demonstrated are skin thickening and an asymmetric density, mass or distortion.
  85. 85. BREAST ABSCESS • These findings are not specific for abscess or malignancy; however presence of suspicious microcalcifications is more specific for malignancy and a biopsy to rule out carcinoma should be carried out.
  86. 86. BREAST ABSCESS
  87. 87. BREAST ABSCESS
  88. 88. BREAST ABSCESS
  89. 89. FAT NECROSIS • A pathological process that occurs when there is saponification of local fat. • A benign inflammatory process and is becoming increasingly common with greater use of breast conserving surgery and mammoplasty procedures.
  90. 90. FAT NECROSIS • Most at risk are middle-aged women with pendulous breasts. • Aetiologically, in everyday practice, trauma and surgery are the most common cause.
  91. 91. FAT NECROSIS • Trauma includes seat belt injury, contact sports. • Surgical procedures include implant removal breast biopsy, prior reconstruction. • There is no relationship between fat necrosis and subsequent breast carcinoma.
  92. 92. FAT NECROSIS • Mammographically, An ill-defined and irregular, spiculated mass- like area. Associated calcification can be seen, which can mimic that of more malignant entities such as DCIS.
  93. 93. FAT NECROSIS • The changes are often seen and correlated with the position of surgical scarring on the breast itself. • The calcification of fat necrosis is typically peripheral with a stippled curvilinear appearance creating the appearance of lucent "bubbles" in the breast parenchyma.
  94. 94. FAT NECROSIS • With time, it becomes more defined and well- circumscribed giving rise to an oil cyst. • Oil cysts can have very fine curvilinear calcification of the walls. • The centre of the lesion becomes increasingly homogenous with fat-density. The cyst wall calcify in about 5%.
  95. 95. FAT NECROSIS • Sonographically, Fat necrosis may be seen as a hypoechoic mass with well defined margins with/without mural nodule(s). Aspiration of an oil cyst shows typically a milky, emulsified fat appearance.
  96. 96. FAT NECROSIS • On ultrasound, the lesion may occasionally represent an intracystic carcinoma and mammographic correlation and biopsy are recommended in these circumstances.
  97. 97. FAT NECROSIS
  98. 98. FAT NECROSIS
  99. 99. FAT NECROSIS
  100. 100. FAT NECROSIS
  101. 101. GALACTOCELE • Most common benign breast lesion typically occurring in young lactating women. • They mostly occur on cessation of lactation.
  102. 102. GALACTOCELE • Essentially a retention cyst resulting from lactiferous duct occlusion. • There is a predilection towards the retroareolar region.
  103. 103. GALACTOCELE • Mammographic appearance of galactocoele can be varied depending on the fat and protein content and the consistency of the fluid. Due to significant fat content the mass may appear radiolucent; i.e. PSEUDOLIPOMA.
  104. 104. GALACTOCELE When the milk is in fresh liquid state, a characteristic fat fluid level is seen due to viscosity difference. • This can be demonstrated on mediolateral view with the beam horizontal to the upright patient; i.e. Fat-fluid level within a cyst.
  105. 105. GALACTOCELE When contents are old milk and water, due to highly viscous old milk, gives a hamartoma-like appearance on mammogram.
  106. 106. GALACTOCELE • On ultrasound appearances can be widely variable. Thin-walled cystic mass with low level internal echoes 50%. Complex cystic-solid mass 37%. Solid mass 13%.
  107. 107. GALACTOCELE
  108. 108. GALACTOCELE
  109. 109. GALACTOCELE
  110. 110. GALACTOCELE
  111. 111. COMMON MALIGNANT LESIONS
  112. 112. INVASIVE DUCTAL CARCINOMA • Commonest histologically diagnosed breast malignancy accounting for 50-70% of invasive breast cancers. • Most tumours are believed to arise from the ducts within the terminal ductal lobular unit (TDLU).
  113. 113. INVASIVE DUCTAL CARCINOMA • In a study conducted in this department, peak presentation of IDC was in the age groups 31- 45 years. • Patients are much older in the West. Generally in 5th – 6th decade.
  114. 114. INVASIVE DUCTAL CARCINOMA • Mammographically, Findings vary greatly and reflect gross tumour morphology and histological heterogeneity. Include irregular masses with or without microcalcifications and architectural distortion.
  115. 115. INVASIVE DUCTAL CARCINOMA • Masses usually show spiculated or indistinct margins. • Rarely however, a mass with circumscribed margins may be seen.
  116. 116. INVASIVE DUCTAL CARCINOMA • Extensive intraductal component is not uncommon and may manifest mammographically as linearly arranged calcifications .
  117. 117. INVASIVE DUCTAL CARCINOMA • Sonographically, Appear as irregular, microlobullated, hypoechoic masses. Widest diameter of the tumour perpendicular to the skin surface. Hyperechoic margins and Posterior shadowing = Desmoplasia.
  118. 118. INVASIVE DUCTAL CARCINOMA • However, in high grade variants that are highly cellular with little desmoplasia, posterior enhancement may be observed. • Axillary lymphadenopathy is a prominent feature.
  119. 119. INVASIVE DUCTAL CARCINOMA
  120. 120. INVASIVE DUCTAL CARCINOMA
  121. 121. INVASIVE DUCTAL CARCINOMA
  122. 122. INVASIVE DUCTAL CARCINOMA
  123. 123. INVASIVE DUCTAL CARCINOMA
  124. 124. INVASIVE DUCTAL CARCINOMA
  125. 125. INVASIVE DUCTAL CARCINOMA
  126. 126. INVASIVE LOBULAR CARCINOMA • 2ND most common invasive breast malignancy accounting for about 5-15% of all invasive breast tumours. • Arise from the terminal ductules of the breast lobules and are more common in elderly women; 2% <35years.
  127. 127. INVASIVE LOBULAR CARCINOMA • Mammographically, Non-specific. Commonest abnormality an ill-defined isodense mass with obscured, spiculated margins.
  128. 128. INVASIVE LOBULAR CARCINOMA ILC may only be a one view finding; usually the CC view which is typically better compressed than the MLO view. Subtle mammographic findings such as asymmetric densities and architectural distortion commoner in ILC >> IDC.
  129. 129. INVASIVE LOBULAR CARCINOMA “Shrinking breast phenomenon” may be seen where in a large tumour, the affected breast appears mammographically smaller compared to the normal breast due to decreased compliance and compressibility.
  130. 130. INVASIVE LOBULAR CARCINOMA • Sonographically, An irregular, angular hypoechoic mass. Heterogenous internal echoes with ill-defined or spiculated margins and posterior acoustic shadowing. Axillary lymphadenopathy
  131. 131. INVASIVE LOBULAR CARCINOMA In some cases, no abnormality may be detected. The only abnormality might be suspicious shadowing with no obvious mass.
  132. 132. INVASIVE LOBULAR CARCINOMA
  133. 133. INVASIVE LOBULAR CARCINOMA
  134. 134. INVASIVE LOBULAR CARCINOMA
  135. 135. INVASIVE LOBULAR CARCINOMA
  136. 136. INVASIVE LOBULAR CARCINOMA
  137. 137. INFLAMMATORY BREAST Ca. • A relatively uncommon but aggressive form of invasive breast carcinoma. • Any pathological sub-type of breast cancer may be involved.
  138. 138. INFLAMMATORY BREAST Ca. • Account for 1-4% of all breast cancers, typically occurring in women between 4th to 5th decades.
  139. 139. INFLAMMATORY BREAST Ca. • Mammographic findings include:  Tumour mass  Microcalcifications Features of inflammation: skin thickening coarsened trabeculae, increased density Axillary lymphadenopathy
  140. 140. INFLAMMATORY BREAST Ca. • Ultrasound may be helpful to locate a hypoechoic shadowing mass, which can be obscured on mammography by diffusely increased breast density.
  141. 141. INFLAMMATORY BREAST Ca.
  142. 142. INFLAMMATORY BREAST Ca.
  143. 143. INFLAMMATORY BREAST Ca.
  144. 144. INFLAMMATORY BREAST Ca.
  145. 145. ASSOCIATED LYMPHADENOPATHY • Normal lymph nodes: short axis diameter < 10mm. • Oval shaped • Smooth regular contour • Central hilum: echogenic on USS; lucent on mammogram.
  146. 146. NORMAL AXILLARY LN: MAMMO
  147. 147. NORMAL AXILLARY LN: USS
  148. 148. ASSOCIATED LYMPHADENOPATHY • Abnormal lymph nodes: inflammatory / malignant, short axis diameter > than 10mm.
  149. 149. ASSOCIATED LYMPHADENOPATHY • Inflammatory enlargement: proportionate in all directions elliptical-shaped enlargement. • Neoplastic enlargement: disproportionate in its shortest plane abnormal “rounding” of the node.
  150. 150. ASS LYMOCIATEDPHADENOPATHY • Sonographic features suggestive of malignant infiltration include: -Eccentric cortical thickening. -Eccentric mediastinal compression. -Focal inward convex compression of the mediastinum (rat bites). -Mediastinal obliteration. -Loss of the thin echogenic outer capsule. -Presence of angular margins.
  151. 151. ASSOCIATED LYMPHADENOPATHY • Mammographically; -Loss of the normal fatty hilum, -Loss of the normal oval or reniform shape, -Poorly circumscribed margins, -Increased size and opacity
  152. 152. ASSOCIATED LYMPHADENOPATHY
  153. 153. ASSOCIATED LYMPHADENOPATHY
  154. 154. ASSOCIATED LYMPHADENOPATHY
  155. 155. ASSOCIATED LYMPHADENOPATHY
  156. 156. ASSOCIATED LYMPHADENOPATHY
  157. 157. SUMMARY/CONCLUSION • Many of the commonly encountered breast lesions have classic imaging features. • There are a few exceptions. • Knowledge of imaging features enables the radiologist to make proper diagnosis and contribute towards effective management.
  158. 158. THANK YOU FOR LISTENING
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