BENIGN MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers
Benign Masses • Fibroadenoma • Fibroadenoma variants : complex FAtubular adenoma, lactating adenoma • Phylloides Tumor • Hamartoma • Lipoma • Focal Fibrosis • Diabetic mastopathy • Fibrocystic change
I. Fibroadenoma • Arise from a single TDLU and contain both stromal (fibroma) & epithelial (adenoma) elements • Edge is “pushing” not infiltrating & becomes “encapsulated” by compressed breast tissue • FAs with cysts, apocrine metaplasia, or sclerosing adenosis are called COMPLEX
FA – cont. • Peak incidence – 20-30 yr & again 40-50 yr • Usually 2-3 cm but giant FA & juvenile FA can grow to 10 cm • Estrogen stimulation is important so most common when unopposed (anovulatory) i.e.. in adolescence and perimenopause • Multiple in 25% also bilateral
FA – sonographic appearance • Oval, lobulated • Circumscribed with echogenic capsule • Parallel • Iso or hypoechoic • Normal or enhanced transmission with edge shadows • Tiny ones (<1cm) may be round & can’t DD from a complex cyst • May mimic duct extension
oval lobulated irregular
Ca++ FA in pathology
FA – cont. • Wide variability in histologic composition • Wide variability in sonographic appearance • Bilateral multiple FAsup to 10 nodules in each breastno need to Bx all of themnew ones will almost always developneed 6 mo. F/U
II. FA variants – Complex FA • The epithelial components undergo proliferative change and we may see:sclerosing adenosis, cysts, apocrine metaplasia, amorphous calcifications • About 20% of all FAs are complex !(-) FHx increases risk for CA 3x(+) FHx increases risk for CA 4x • Risk is generalized for the whole of both breasts.
II. FA variants – Complex FA • The diagnosis is histological • U/S: may see internal cysts or heterogeneous echo pattern • Seen at older age – median age 47 yrs • Only 1.5% contained a CA AJR:2008;190:214-218
cysts & sclerosis ComplexFAs
II. FA variants – Tubular Adenoma & Lactating Adenoma • Almost pure epithelial growth with very little or NO stromal component • Tubular adenoma is very rare • Lactating adenoma is common during pregnancy (mainly 3rd trimester) and lactation
II. FA variants – Tubular Adenoma & Lactating Adenoma • Lactating adenoma may arise de novo, from a FA or from a tubular adenoma • U/S: oval, spindle shaped, parallel, hypo-hyperechoic, enhancement, Doppler (+), microlobulated
spindle shaped microlobulated Tubular adenomas
hypo IDC-Grade 3 hyper Lactating adenomas
III. Phylloides Tumor • Rare – peak at 40-50 yr but can occur in teenagers • Very rapid growth – up to 15 cm • 2/3 benign 1/3 malignant • Mix of very cellular stromal and epithelial elements • U/S: oval, well circumscribed, capsule, hypo, enhancement, “cystic slits”
IV. Hamartoma • Localized overgrowth of fibrous, epithelial and fatty elements = normal breast tissue • Other names: adenolipofibroma, lipoadenofibroma, fibroadenolipoma • U/S: oval, very heterogeneous, capsule, parallel
V. Lipoma • Overgrowth of fatty tissue • They are actually in the skin NOT in the breast • May grow up to 20 cm !!!! • U/S: completely isoechoic with the other fat lobules or mildly hyperechoic, soft and compressible
fat necrosis hyper iso
VI. Focal Fibrosis • FIBROUS MASTOPATHY • Can cause tender/non-tender palpable lump • May see focal asymmetry on mammo – UOQ
VI. Focal Fibrosis • Pathology: dense stromal fibrous tissue without cells • U/S: purely hyperechoic & homogeneous, no capsule tapers into Cooper’s ligaments so can be teardrop or spindle shapedBEWARE: DD with echogenic rim !!!
VII. Diabetic Mastopathy • Occurs in premenopausal women • Most have Type I diabetes before the age of 20 yr • Usually a very hard palpable lump • May be multifocal, multicentric and bilateral
VII. Diabetic Mastopathy • Mammo: non specific asymmetry • U/S: VERY SCARY !!!!!! Ill-defined, angular, microlobulated, hypoechoic, not parallel, intense shadowing • ALL go to Bx.
VIII. Fibrocystic Change • Huge spectrum from all the types of cystic change to benign proliferation forming a solid nodule • Adenosis & Sclerosing Adenosis:TDLUs enlarge and increase in numbernormal lobules – 2 mmadenosis – 5 mm • Mammo: focal asymmetry, masses, “starry night” calcifications • U/S: extremely varied
adenosis with amorphous ca++ adenosis with cysts hypoechoic adenosis in hyper glandular tissue
adenosis blunt duct adenosis
The faces of sclerosing adenois central fibrosis branching distended terminal lobule
Remember algorithm and technique • Know your anatomy • Must correlate with mammo & clinical presentation • Huge overlap of findings • Better than doing mammograms all day!