Age range - simple cysts
35-50
Simple cysts may ___ after menopause (except in those using ___).
regress, HRT
🎗 Simple cysts tend to result from the obstructed ducts at level of ___.
TDLU
What causes the obstructed ducts that lead to simple cysts?
fibrosis or proliferative changes in the duct epithelium, sometimes hormonal changes
- single or multiple
- unilateral or bilateral
- variable size
- palpable or non-palpable
- silent or painful
- moveable
- compressible
7 aspects of cysts:
On mammo, simple cysts appear… (4)
- rounded
- smooth margins
- radiopaque (water density)
- halo sign (lucent rim of fat)
On sonography, what three criteria are required for a cyst to be classified as simple?
- anechoic
- well-circumscribed
- acoustic enhancement
What % of breast cysts are simple?
11%
Next steps when sonography finds a simple cyst?
none, unless it’s so big/painful that it needs aspiration
- improper TGC
- overall gain too high
- focus wrong
- too superficial
- too deep
- small cyst size
- side lobe artifact
- slice thickness artifact
- volume averaging artifact
What technical issues can cause artifact in a simple cyst?
- complicated
- complex
- clustered micro
- septated
- calcified
5 kinds of non-simple cysts
This kind of cyst contains homogeneous low-level internal echoes with fluid-fluid or fluid-debris levels which react with gravity.
complicated
What % of complicated cysts are malignant?
0-1.4%
🎗 Two important types of complicated cysts
- galactocele (milk)
2. sebaceous (sebum)
- low to med level echoes
- heterogeneous internal appearance
- gravity-dependent fluid levels
- septations
- wall thickening
- total or partial wall calcification
- partial enhancements or shadowing
On sonography, complicated cysts may demonstrate… (7)
🎗 How to tell complicated cysts from complex, intraductal papilloma or papillary carcinoma?
No doppler flow will be detected within the debris of a complicated cyst.
🎗 What are the two dynamic ways to eval if a cyst is complicated?
- jiggle test - see if debris floats around
2. check for gravity dependence - move pt from supine to upright
This kind of cyst contains a solid component.
complex
What % of complex cysts are malignant?
23%
This kind of cyst is hard to distinguish from a hypoechoic mass.
clustered microcysts
This kind of cyst contains one or several internal septations.
septated cyst
This kind of cyst has partial or total wall calcification.
calcified cyst
🎗 This is a milk-filled cyst caused by obstruction of a lactiferous duct.
galactocele
T/F? Galactoceles only affect breastfeeding people.
FALSE, both lactating and non-lactating are affected
Where are galactoceles generally located?
subareolar
- rounded, well-defined mass
- hypo to isoechoic
- homogenous internal appearance
- acoustic enhancement
- no internal doppler signal
- may also see dilated ducts, mastitis, abscess
sonographic appearance: galactocele (6)
🎗 This cyst results from an obstructed sebaceous gland associated with the skin.
sebaceous cysts
🎗 Sebaceous cysts contain…
sebum, an oily substance
Where are sebaceous cysts generally located?
around the Montgomery glands of the areolar or the inframammary fold, very surface
- rounded well-defined mass
- hypo to isoechoic
- superficial location (stand-off pad)
- track or stem through dermal layers (‘claw’ sign)
- acoustic enhancement
- no internal doppler signal
Sonographic appearance: sebaceous cyst (6)
🎗 What’s the other name for a sebaceous cyst?
epidermal inclusion cyst
This is the term for a wide range of benign changes.
fibrocystic changes
This is the most common disorder of the breast accounting for nearly half of all surgical procedures.
fibrocystic changes
age range - fibrocystic changes
60-90% of females between the ages of 20-40
T/F? Fibrocystic changes are usually unilateral
FALSE, bilateral
Mammography identifies fibrocystic changes as an increased ___ of the breast tissue in comparison to a previous study.
density
- cysts of various size (simple & complicated)
- cyst clusters
- hyperechoic fibroglandular layer
- dilated ducts
Sonographic appearance: fibrocystic changes (4)
🎗 This is the classic sonographic appearance of fibrocystic changes.
cluster of cysts
Why are fibrocystic changes significant clinically?
They produce masses that must be biopsied to differentiate from carcinoma.
- bilaterality
- multiple nodules
- pain prior to menses
- greenish discharge
Tell-tale characteristics of Fibrocystic changes (4)
🎗 This is the most common benign solid tumor of the breast.
fibroadenoma
age range: fibroadenoma
20-40
- 🎗 rounded
- circumscribed
- radiopaque (water density)
- may have halo
- may have calcifications
- indistinguishable from a cyst
on mammography, a fibroadenoma appears (6)
- 🎗 arise from the TDLU
- <3 cm
- 🎗 more common in African American
- pregnancy causes rapid growth
- single or multiple
- painless, palpable mass
- firm or rubbery
- moveable, not fixed
- 🎗 pseudo-encapsulated (due to compression of adjacent tissues)
- necrosis and calcification
common characteristics: fibroadenoma (10)
- 🎗 rounded
- well-defined
- mildly hypo or isoechoic
- homogeneous
- 🎗 thin, echogenic pseudocapsule
- 🎗 wider than tall
- maybe compressible
- edge shadowing
- no significant enhancement or shadowing
- peripheral/internal doppler flow
sonographic appearance: fibroadenoma (10)
🎗 This is seen in adolescent girls and is a highly cellular type of benign fibroadenoma.
juvenile (giant) fibroadenoma
Juvenile fibroadenoma tumors grow [slowly/rapidly] and may measure ___.
rapidly, >5 cm
This is a benign tumor growing from the ductal epithelium projecting into the lumen of the duct.
intraductal papilloma
age range: intraductal papilloma
30-55
🎗 What is the most common cause of bloody nipple discharge?
intraductal papilloma
- typically subareolar
- single or multiple
- usually < 2 cm
- non-palpable
- 🎗 may have ‘raspberry’ appearance
- tumor may cause duct obstruction
- frequent symptom is nipple discharge (serous or bloody)
- ductography may be helpful
common characteristics: intraductal papilloma
The injection of contrast into the lactiferous duct to demonstrate (or not) filling defects
ductogram (galactogram)
- small solid lesion within the duct
- hypo- or isoechoic
- rounded or tubular
- associated with duct dilatation
- radial scanning is optimal
- 🎗 doppler signal within the solid component
sonographic appearance: intraductal papilloma
This is the focal dilatation of a duct caused by an obstructing papilloma. Clinical symptoms are the same as intraductal papilloma.
Instracystic papilloma
- round or oval cyst containing solid mural tumor
- tumor appears hypo- or isoechoic
- doppler signal within the solid component
sonographic appearance: intracystic papilloma
🎗 This rare condition is characterized by cysts, duct ectasia, intraductal hyperplasia, and sclerosing adenosis.
juvenile papillomatosis
This is also known as ‘Swiss Cheese Disease’.
juvenile papillomatosis
age range: juvenile papillomatosis
less than 30
This usually presents as a mass located in the periphery of the breast resembling a fibroadenoma, but 25% of patients have a positive family hx of breast cancer.
juvenile papillomatosis
- hypoechoic ill-defined mass
- heterogeneous
- may have visible cysts and/or duct ectasia
sonographic appearance: juvenile papillomatosis
🎗 This is an encapsulated tumor of mature adipose tissue
lipoma
Clinically these are soft compressible mobile masses
lipoma
- radiolucent (fat density)
- circumscribed
- thin capsule
mammography: lipoma
- oval and well-defined
- isoechoic (depending on the density)
- homogeneous
- 🎗 compressible
- usually superficial
- may be mistaken for a fat lobule
sonographic appearance: lipoma
🎗 These are the only breast lesion with a true capsule
lipoma
🎗 This is a rare type of fatty breast tumor - nonenscapsulated, composed of fat, fibrous and glandular tissues.
fibroadenolipoma
This is also known as a hamartoma.
fibroadenolipoma
age range: fibroadenolipoma
over 35
- well-defined, pseudocapsule
- oval or lobulated
- echogenicity depends on amounts of fat, fibrous, and glandular tissue
- possible shadowing
- may be quite large
fibroadenolipoma
This typically arises as a rapidly enlarging palpable mass during pregnancy - benign but usually removed due to size and aggresiveness
lactating adenoma
- large, well-defined mass
- lobulated margins
- multiple septations within the mass
lactating adenoma
🎗 This condition causes marked pain, swelling, and redness. The most common form is lactational (puerperal).
mastatis (breast inflammation)
Severe mastatis may be hard to distinguish from ___ so follow up is necessary.
inflammatory carcinoma
- infected cysts
- subareolar abscess
- post surgical inflammation
- plasma cell (periductal) inflammation
- tuberculosis
- inflammatory carcinoma
non-lactational mastatis
- firm, tender, swellen breast
- localized skin thickening and redness
- purulent nipple discharge
- tender axillary lymph nodes
- leukocytosis and fever
signs of mastatis
- increased echogenicity of subcutaneous fat and parenchymal layers (edema)
- possible shadowing due to cellulitis
- disrupted ill-defined tissue planes
- skin thickening
- possible dilated ducts
- increased doppler signal
sonographic appearance: mastatis
🎗 This is a complication of lactational or nonlactational mastatis.
abscess
An abscess is typically found in the __ region and may require surgical drainage.
subareolar
- complex predominatly cystic mass
- thick irregular borders
- acoustic enhancement
- localized skin thickening
- increased doppler signal at the periphery
sonographic appearance: abscess
🎗 This usually begins with dilated lactiferous ducts. WBC and plasma cells irritate the lining and an infection develops.
plasma cell mastitis
This is also known as periductal mastitis
plasma cell mastitis
- nipple discharge
- palpable hard mass
- subareolar location
- nipple retraction
- possible linear calcifications (rod-shaped on mammo)
- breast inflammation
common characteristics: plasma cell mastitis
- dilated ducts with internal debris or wall thickening
2. localized skin thickening
sonographic appearance: plasma cell mastitis
This is a rare benign lesion of the breast caused by an overgrowth of the stromal tissue.
pseudoangiomatous stromal hyperplasia (PASH)
age range: PASH
reproductive age
This may appear as a benign appearing solid mass or an area of architectural distortion.
PASH
The thickness of breast skin is usually…
0.5 to 2.0 mm
🎗 This is extremely useful in evaluating skin thickness
stand off pad
interruption of the dermis layer is suspicous for …
carcinoma
- trauma
- benign inflammation
- fat necrosis
- post surgical scarring
- malignancy
- radiation therapy treatment
- restriction of venous return
causes of skin thickening
This is bilateral mild discharge from a nonlactating or pregnant person.
galactorrhea
Galactorrhea may be __-induced or __-induced.
endocrine (pituitary adenoma), medication (BCP)
This discharge is unilateral, from multiple ducts, and appears pus-y
purulent discharge
Nipple discharge from breast tumors usually arises from …
a single duct and breast lobe
- intraductal papillary carcinoma (mal)
- DCSI (mal)
- Invasive ductal carcinoma (mal)
- intraductal papilloma (ben)
breast tumors that cause nipple discharge
- serous: clear yellow fluid
- serosanguineous: pinkish fluid
- sanguineous: red bloody fluid
- watery: clear, pale yellow fluid
types of discharge that may indicate breast cancer
discharge caused by fibrocystic (benign) changes is…
green
- fat necrosis
- hematoma
- seroma
- lymphocele
- post operative scarring
benign conditions that follow breast trauma
This is a thickening or scarring in the fatty tissue that is caused by an injury to the breast
fat necrosis
🎗 This may simply occur in obese women with fatty pendulous breasts
fat necrosis
This appears like either an oil cyst or a firm, fixed, spiculated mass
fat necrosis
This is a blood-filled tumor following direct trauma
hematoma
The echogenicity of a hematoma depends on…
the amount of coagulation. Can be anechoic, complex or hyperechoic
This is a localized collection of serous fluid within the breast, usually following a surgical or invasive procedure.
seroma
Variously as…
- simple cyst
- free fluid appearance with angular margins
- low level internal echoes
- thick walled with septations
sonographic appearance: seroma
This cystic tumor filled with lymph may occur following breast surgery
lymphocele (appears like simple or complex cyst)
This presents as a palpable mass following breast surgery
post operative scarring
- thin shadow from skin surface
- spiculated, fixed, hypoechoic mass with shadowing
- no increase flow on doppler
sonographic apperance: post operative scarring
This benign enlargement of a breast lobule is due to epithelial and stromal hyperplasia.
sclerosing adenosis
In this condition, the acini of the TDLU increase in number and produce a distorted, spiking, infiltrative appearance.
sclerosing adenosis
The primary significance of sclerosing adenosis is it’s …
ability to mimic cancer.
- architectural distortion
- spiculated appearance
- microcalcifications
mammographic appearance: sclerosing adenosis
- irregular spiculated or lobulated mass
- hypoechoic
- possible shadowing
- no increased doppler signal
sonographic appearance: sclerosing adenosis
This is the invasion of ductal epithelium into the surrounding stromal tissues, not associated with trauma. 🎗
radial scar
in __% of cases, radial scar is associated with tubular carcinoma.
20%
Radial scars are usually less than __ cm and non palpable.
1 cm
- spiculated
2. may have calcifications
mammo appearance: radial scar
- irregular spiculated lesion
- possible shadowing
- no increased doppler signal
sono appearance radial scar
🎗 This is a rare thrombophlebitis of a superficial bein of the breast.
Mondor’s disease
Mondor’s disease is usually associated with the ___, affects the ___, and tends to be caused by __.
lateral thoracic vein, lateral half, trauma
- palpable tender cord-like superficial mass
2. fever
Mondor’s disease
- superficial tortuous tubular lesion
- anechoic or hypoechoic
- stand off pad may be useful
sono appearance: Mondor’s disease
🎗 Causes of ___
- ovarian (enlargement, cyst)
- adrenal (tumor, hyperplasia)
- thyroid (hypo-)
- pituitary (early gonadotropin)
precocious puberty
🎗 This is the most common cause of precocious puberty.
ovarian enlargement and/or hyperstimulation
🎗 This is the non neoplastic enlargement of the male breast, may be unilateral or bilat
gynecomastia
My present as:
- breast enlargement
- palpable subareolar nodule
- breast tenderness/soreness
- skin thickening
- possible nipple discharge
gynecomastia
Causes of __:
- hormonal changes
- estrogen tx of prostate ca
- testicular failure
- neoplasms (test., adrenal, lung)
- chronic disease (liver, renal, pulmonary)
- meds (digitalis, antidepressant, antiHTN)
- marijuana
- Klinefelter’s (XXY)
gynecomastia
sono appearance:
- presence of glandular tissue
- poss dilated ducts
- increased fat
gynecomastia
