Benign Lesions Flashcards
Most common cause of bloody nipple discharge
Papillomas
What’s a trigger point?
The compression over a papilloma which elicits the discharge
What is necessary in patient’s with papilloma’s, as a mammogram usually appears normal?
Ductogram
Sono appearance of a papilloma?
Homogenous, hypoechoic and connected to a vascular stalk
Usually not palpable
Solitary papillomas arise from the _____ whereas multiple peripheral papillomas originate from within the _____.
duct, TDLU
Swiss cheese appearance
Juvenile Papillomatosis
Sono appearance of juvenille papillomatosis ?
Well circumscribed, heterogenous w one or several small cystic areas seen near the borders of the lesion.
Juvenille papilloma’s are large tumors, typically around 4cm in size.
True
Most common benign soft tissue mass of the breast?
Lipoma
FA’s and lipomas can look very similar. How can we tell the difference?
Lipoma’s are far more compressible than fibroadenoma’s. (30%)
Sono appearance of Phyllodes tumors
Rapidly enlarging. Well circumscribed, hypoechoic oval mass. Decreased through transmission. Can see cystic spaces.
Difference between Phyllodes tumor and lactating adenoma?
Lactating adenoma will be seen in patients who are pregnant or nursing.
Sono appearance of lactating adenoma:
A large, oval, well-defined, mobile, macrolobulated mass w echogenic bands within. Also demonstrate posterior acoustic enhancement
How do we differentiate fibroadenoma’s from tubular adenoma’s?
They appear similar, however TA’s will have tightly packed punctate calcifications within.
Sono appearance of tubular adenomas:
Mobile. Homogenous, hypoechoic, well circumscribed margins and little through enhancement.
What is described as a “breast within a breast” on mammo?
Hamartoma (fibroadenolipoma or adenofibrolipoma)
Sono appearance of a hamartoma:
Appearance varies based on composition ( fibrous vs fatty tissue). May exhibit a mixed echotexture w hyperechoic tissue surround hypoechoic areas.
Breast inflammation and/or infection occurs most frequently during:
Lactation
Acute mastitis is usually widespread across the entire breast for a short period of time.
False – it is confined to one area of the breast. Only if the infection is carried by the lymphatics or blood vessels can it spread throughout the breast.
What typically causes acute postpartum mastitis ?
Bacterial invasion through an irritated nipple and is precipated by milk stasis. Occurs around 2wks PP.
Most common bacterial cause of acute postpartum mastitis?
Staphyoloccocus aureus, originating from the nursing child.
Chronic mastitis is the inflammation of glandular tissue and is usually seen in?
Elderly women
Chronic mastitis clinical symptoms?
Nipple discharge and retraction
Ultrasound examination of those with mastitis appears as:
Normal, or
skin thickening/edema, altered tissue echogenicity, increased volume of tissue, ductal ectasia or dilation of lymph vessels parallel to the skin
Most common form of mastitis?
Occurs in the puerpheral period (<6wks after birth) during lactation. Caused by an obstruction of a lactiferous duct
Mastitis can lead to a(n):
abscess
Ballottement:
A technique for palpating an organ or floating structure by bouncing it gently and feeling it rebound. A “color swoosh” is shown as the necrotic tissue moves back and forth with compression and compression release.
Difference between periductal mastitis and duct ectasia:
Periductal mastitis: NON dilated subareolar ducts that become infected. Affect younger women.
Duct Ectasia: dilated subareolar ducts that are less likely to become infected. Affect older women.
What condition can we see a spontaneous drainage from the mass or nipple?
Abscess
A patient w a history of smoking, has spontaneous drainage, nipple inversion, fever, red skin and warm skin. What is likely happening?
Abscess
Chronic vs acute abscess:
Chronic: More defined, central fluid collection w posterior enhancement
Acute: irregular borders, thick walls and a central fluid collection w free air within the mass
The most common type of closed or blunt trauma is?
contusion – hematoma or bruise. Ex. seatbelt injury
Fat necrosis is most common in
Obese women with large breasts
What is most common in the end stage of fat necrosis?
Oil cysts
What does fat necrosis appear as?
A firm, shadowing, irregular mass that may mimic carcinoma. Can be associated with skin retraction and architectural distortion.
What diagnoses oil cysts (fat necrosis)?
FNA
Fat necrosis changes to what appearance over a period of time?
Partially or totally calcified
What’s the most common post surgical complication?
Seroma (50-60%)
A patient underwent a lumpectomy for breast cancer. Upon US eval, an oval, well circumscribed, thick walled, complex, cystic mass w fat locules and septations was found near the scar. What is this?
Seroma
What’s a common complication following radiation?
skin thickening (up to 2 yrs after)
Skin thickening is defined by which measurement?
2mm
Radial scars are not related to previous trauma or surgery.
True– they are actually benign.
Radial scars have what appearance on mammo? They are hard to identify on which view?
They appear as a spiculated lesion w or w/o calcification. They appear stellate with a central lucent core. Hard to identify in an orthogonal view
Are radial scars palpable?
No
Are radial scars malignant?
No, but may be a precursor to carcinoma, especially if they’re >2cm.
Mondor’s Disease:
Thrombophlebitis of the subcutaneous veins of the breast.
Which veins are most common affected with Mondor’s disease?
Lateral thoracic and thoraco-epigastric veins
What is the sonographic and mammographic appearance of Mondor’s disease?
Sono - tubular, hypoechoic structure (thrombosed vein)
Mammo- beaded, subcutaneous vein w skin retraction and rarely vein calcification.
A patient presents with tenderness, and pain on the right breast. Upon physical examination, skin retraction is noted over a cord-like structure extending on the chest wall. What is this?
Mondor’s disease
What is commonly seen in women w long term type 1 diabetes?
Diabetic fibrous mastopathy
Sono appearance of diabetic fibrous mastopathy
Single or multiple, firm-to-hard breast lumps, ill-defined, non-tender, shadowing, hypoechoic, attenuating, easily moveable and without fixation to the skin
Biopsy is performed to differentiate from cancer
What’s adenosis?
proliferation of the ducts and lobules
What’s epitheliosis?
hyperplasia of the epithelial cells within the ducts or lobules
What’s fibrosis?
proliferation of stromal tissue
What’s the etiology of a radial scar?
Unknown
What does BIRADS stand for
Breast imaging reporting and data system
What’s the most common palpable pseudomass?
Fibrous ridge
Fibrous ridges usually demonstrate ______________ when compared to surrounding fat?
pure echogenicity
Large lesions are more likely to be malignant.
false - size is not a good indicator of malignancy
The prescence of what malignant characteristic has the greatest individual sensitivity and overall accuracy of any of the features?
Angular margins
Spiculated margins area more common for ________ grade cancers where as angular margins are more common for ____ grade
low ; high
In order to evaluate the borders of a lesion, what’s a technique we could use ?
Heel toe
What’s the reason that a malignant mass is hard and has no mobility?
Fibroelastic host response or reactive fibrosis
Desmoplastic reaction:
The body’s attempt to “wall off” a cancer, with the formation of fibrois connective tissue in order to limit invasion. Thought to be responsible for the shadow seen on high resolution imaging
What may a echogenic rim of variable thickness represent?
tumor extension, desmoplasia or slightly compressed breast tissue
Shadowing is more common with _____ grade cancers
low
Enhancement is more common with _____ grade cancers
high
If calcifications are diffusely scattered, they are favoured to be
benign
Calcifications that are segmentally distributed or linearly distributed are
suspicious for DCIS
Clustered calcifications may either be benign or malignant and are considered to be of
immediate concern
Vascular and skin calcifications are
benign
Popcorn calcifications, moc, plasma cell mastitis, eggshell, suture and dystrophic are
benign
Fine linear, fine linear branching and fine pleomorphic calcifications are
suspicious for malignancy
Amorphous and coarse heterogenous are
of immediate concern
If calcifications remain stable, the risk of malignancy
is low
Malignant vascular characteristics
multiple vessels 25% vessels related to tumor volume 5 or more intratumoral vessels numerous peripheral vessels multiple tortuous vessels multiple shunts
Benign masses tend to remain in a
single tissue plane
Duct extension
tumor extension into a single duct, towards the nipple
Branch pattern
tumor extension into the smaller ducts leading away from the nipple
Peau d’Orange
Orange skin. Describes the appearance of the breast when there is an underlying cancer, typically IBC
The presence of multiple, identical lesions _________ the risk of malignancy
reduces
What is the most common lesion of the breast?
Fibrocystic breast changes (50%)
What age range do we typically see FBC?
20-50
Simple cysts are relatively uncommon before the age of
30
What is the age range for cysts?
34-55
Cysts must be at least ________ before they can be reliably detected with US?
3mm
What characteristics do simple cysts show:
anechoic
smooth borders
enhancement
A complex cyst does not demonstrate: (4)
echo free
round/oval shape
smooth contour w well defined borders
enhancement
What may be the reason that a cyst is complex?
infection
hemorrhage
wall calcification
or intramural tumor
Acorn cyst
fluid-fluid level
Galactocele appears:
ranges from anechoic to solid
What is a defining characteristic of a galactocele:
PAE
also lactating woman
What confirms the diagnosis of a galactocele:
aspiration of a thick, milky fluid
Where do sebaceous cysts most often occur?
axilla, intramammary fold or medial portion of the breast
Complex cyst that derives its name from the mobility of the highly reflective echoes contained within:
Gurgling cyst
Is apocrine metaplasia benign or malignant
benign
What age range do we most often see aprocrine metaplasia?
40-50 yrs old
Aprocine metaplasia appearance:
lobulated mass composed of clusters of small, 2-5mm dilated acini w septations and partial acoustic enhancement
Aprocrine metaplasia does not increase the risk of breast cancer, however:
it occurs most commonly in breasts w cancer
What makes up approximately 50% of all benign breast pathologies?
FA’s
What is the most common solid breast mass found in females under the age of 35?
FA’s
Most common age range for FA’s?
15-35yrs, but are also found in older women undergoing HRT
How big are giant fibroadenomas?
can reach up to 10-15 cm in size
although most are about 2-4cm
What masses can calcify and exhibit a popcorn-like pattern?
FA’s
The long axis of a FA is usually
parallel to the skin surface
Approximately _____% of FA’s have a complex appearance
33
If a FA is larger than ______ it should be biopsied
4cm
We also follow them looking for changes
A 15yr old girl presents with a very large mass, which stretches the overlying skin and displaces the nipple. She also has dilated veins. What is this likely to be?
Juvenile FA
What’s the most common breast sarcoma?
Phyllodes tumor
Age range of Phyllodes tumors
mean age 45yrs
Where are papillomas most often located?
SA
Up to 50% of patients w _______________ have a 1st degree relative w a history of breast cancer
Juvenile papillomatosis
How to juvenile papillomatosis tumors present?
painless, solitary, unilateral masses that arise from the milk duct
Large tumors
Nipple discharge
Well circumscribed heterogenous w cystic areas
Are lipomas typically unilateral or bilateral
Unilateral
Are hamartoma’s slow or fast growing
Slow
How does a hamartoma feel on clinical examination?
mobile and compressible
What is a hamartoma composed of?
fatty and fibrous tissue, as well as normal and dysplastic mammary tissue
What are typical findings of mastitis?
decreased echogenicity, increased volume of tissue and mild ductal ectasia
Where are breast abscesses most commonly found?
areolar or periareolar region
can be associated w lymphadenopathy or nipple inversion
What is a common type of edema
premenstrual
Cancer recurrence is suspected if the size of the breast scar:
increases after 2 stable clinical examinations
People who have underwent radiation therapy can have skin thickening up to _______ following treatment
2 years
Causes of skin thickening?
carcinoma trauma inflammation venous obstruction lymphatic obstruction CHF nephrotic syndrome
Radial scars aka
complex sclerosing lesions
