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. 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. INTRODUCTION
• The breasts are a pair of glandular organs
• Function: lactation.
• Dynamic structure ; undergoes changes
throughout a woman’s reproductive life.
5. INTRODUCTION
• Breast diseases : variety of conditions .
• Benign or Malignant.
• Most common presentation: a palpable lump.
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. ROLE OF IMAGING IN DIAG.
• Accurate imaging is vital:
-Identify cancers
-Avoid false positives
-Avoid False negatives
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. ROLE OF IMAGING IN DIAG.
• The Royal College of Radiologists and the
American College of Radiology guidelines:
• <35years, USS
• >35years, Mammo.
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. ROLE OF IMAGING IN DIAG.
• USS method of choice in differentiating
between cystic and solid lesions and in
providing guidance for interventional
procedures.
16. FIBROADENOMA
• Fibroadenoma is an oestrogen-induced benign
breast tumour .
• Arises from the terminal duct lobular unit
(TDLU) .
17. FIBROADENOMA
• Most common benign solid tumour among
women of child-bearing age.
• Peak incidence: 3rd decade, second peak 5th
decade.
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. FIBROADENOMA
• Due to hormonal influence on this tumour;
-Slight enlargement at the end of the menstrual
cycle.
-During pregnancy.
-Regression after menopause.
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. FIBROADENOMA
Show a smooth or gently lobullated contour.
An echogenic pseudocapsule is usually
demonstrated.
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.
24. FIBROADENOMA
Isodense lesions, smooth, discrete margins.
Margins may be lobular in larger tumours.
Degenerated fibroadenomas usually contain
calcifications:
coarse or popcorn-like pathognomonic.
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. 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. 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. 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. FIBROCYSTIC CHANGE
• Breast cysts appear as rounded or oval shaped
well defined sonolucent lesions with
imperceptible walls and posterior acoustic
enhancement.
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. FIBROCYSTIC CHANGE
• Teacup-like calcifications on horizontal beam
• Rounded smudged calcifications on
craniocaudal projections depicting the
• Classic milk of calcium pathognomonic.
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.
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.
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.
49. LIPOMA OF THE BREAST
• Benign mesenchymal tumours composed of
mature adipose tissue.
• Mostly asymptomatic and coincidentally
discovered on routine mammography.
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. 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. 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.
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.
60. GYNAECOMASTIA
• Is seen in patients with gynaecomastia for
longer than 1 year.
• Fibrosis becomes the dominant process and is
irreversible.
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.
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.
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.
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. BREAST ABSCESS
• The predominant infectious organism:
Staphylococcus aureus, often the penicillinase-
producing type.
• Other common types include Staphylococcus
epidermidis and Proteus mirabilis.
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. 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. 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. BREAST ABSCESS
• For the purpose of follow up 3-D
measurement of the abscess and the volume
should be given.
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. 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. 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. 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. 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.
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. 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. 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. 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. 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. 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. 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. FAT NECROSIS
• On ultrasound, the lesion may occasionally
represent an intracystic carcinoma and
mammographic correlation and biopsy are
recommended in these circumstances.
101. GALACTOCELE
• Most common benign breast lesion typically
occurring in young lactating women.
• They mostly occur on cessation of lactation.
102. GALACTOCELE
• Essentially a retention cyst resulting from
lactiferous duct occlusion.
• There is a predilection towards the
retroareolar region.
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. 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. GALACTOCELE
When contents are old milk and water, due to
highly viscous old milk, gives a hamartoma-like
appearance on mammogram.
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%.
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. 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. 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. INVASIVE DUCTAL CARCINOMA
• Masses usually show spiculated or indistinct
margins.
• Rarely however, a mass with circumscribed
margins may be seen.
116. INVASIVE DUCTAL CARCINOMA
• Extensive intraductal component is not
uncommon and may manifest
mammographically as linearly arranged
calcifications .
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. 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.
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. INVASIVE LOBULAR CARCINOMA
• Mammographically,
Non-specific.
Commonest abnormality an ill-defined
isodense mass with obscured, spiculated
margins.
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. 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. 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. INVASIVE LOBULAR CARCINOMA
In some cases, no abnormality may be
detected.
The only abnormality might be suspicious
shadowing with no obvious mass.
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. INFLAMMATORY BREAST Ca.
• Account for 1-4% of all breast cancers,
typically occurring in women between 4th to
5th decades.
139. INFLAMMATORY BREAST Ca.
• Mammographic findings include:
Tumour mass
Microcalcifications
Features of inflammation: skin thickening
coarsened trabeculae, increased density
Axillary lymphadenopathy
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.
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. 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.
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.
