Ultrasound of Benign Pathology. Reni Butler, M.D. Department of Radiology and Biomedical Imaging Yale School of Medicine

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1 Ultrasound of Benign Pathology Reni Butler, M.D. Department of Radiology and Biomedical Imaging Yale School of Medicine

2 Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

3 Simple Cyst

4 Cystic Lesions: Definitions and BI-RADS Assessment Simple Cyst Complicated Cyst Clustered Microcysts Complex Solid and Cystic mass BI-RADS 2 BI-RADS 2 or 3 BI-RADS 3 BI-RADS 4

5 Complicated Cyst

6 Complicated Cyst vs. Solid Mass Mobile echoes No internal blood flow Assess margins and orientation Optimize scanning technique Consider context

7 36 y/o with palpable left breast mass

8 36 y/o palpable left breast mass At Presentation 4 Months Later

9 Invasive Ductal Carcinoma

10 Invasive Ductal Carcinoma

11 Complicated Cyst Acorn cyst - fluid-fluid level BI-RADS 2

12 Complicated Cyst Single thin septation BI-RADS 2

13 Clustered Microcysts Cysts < 2-3 mm with <0.5 mm septations BI-RADS 3

14 Complex Solid and Cystic Mass Papilloma with ADH

15 Complex Solid and Cystic Mass Invasive Ductal Carcinoma

16 Complex Solid and Cystic Mass BI-RADS 4 Differential Diagnosis Papillary lesion Intracystic papilloma/intracystic papillary carcinoma Fibroadenoma/Phyllodes Tumor Necrotic IDC/ILC Abscess Hematoma

17 Cystic Lesions: Definitions and BI-RADS Assessment Simple Cyst Complicated Cyst Clustered Microcysts Complex Solid and Cystic mass BI-RADS 2 BI-RADS 2 or 3 BI-RADS 3 BI-RADS 4

18 Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Fibroadenolipoma (Hamartoma) Lipoma Fibroadenoma Hematoma Abscess Fat Necrosis Papilloma

19 Normal Intramammary Lymph Node Long axis 1 cm Cortical thickness 2 mm Vascularity central

20 Abnormal Intramammary Lymph Node Metastatic Intramammary Lymph Node Invasive Ductal Carcinoma

21 54 y/o woman for screening mammogram

22 Current Prior

23 Right ML Magnification View

24

25 Invasive Ductal Carcinoma

26 Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Correlate with Mammography Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

27 Lipoma Homogeneously hyperechoic Circumscribed oval mass with parallel orientation Echogenic capsule CORRELATE WITH MAMMOGRAPHY

28 Lipoma

29 Invasive Ductal Carcinoma

30 Lipoma Invasive Ductal Carcinoma

31 Fibroadenolipoma Circumscribed mass containing both fat and fibroglandular components Oval mass with parallel orientation Echogenic pseudocapsule CORRELATE WITH MAMMOGRAPHY

32 Fibroadenolipoma Circumscribed mass containing both fat and fibroglandular components Oval mass with parallel orientation Echogenic pseudocapsule CORRELATE WITH MAMMOGRAPHY

33 Fibroadenolipoma

34 Fat Necrosis The Great Mimicker Develops 6 months or more after surgery or trauma to the breast May be indistinguishable from malignancy on all modalities, including PE, mammography, US, and MRI Critical to: 1. Obtain history 2. Compare to prior studies 3. Correlate with all available modalities

35 Fat Necrosis

36 61 y/o woman with left breast palpable mass & h/o falls

37 Left MLO Left CC

38 42 y/o with h/o right mastectomy and DIEP flap reconstruction - palpable mass in medial breast

39 2D Tomo

40 76 y/o woman with h/o left lumpectomy new palpable left breast mass

41

42 Fat Necrosis Concordant or Discordant?

43 Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

44 Fibroadenoma Which of these lesions would you biopsy?

45 32 y/o woman with palpable left breast mass Meets BI-RADS 3 criteria presumed FA, stable on F/U

46 28 y/o woman 4 weeks post-partum with palpable left breast mass Does this lesion meet BI-RADS 3 criteria? No!

47 At Presentation 6 month F/U Palpable Mass Left Breast Left Axilla Invasive Ductal Carcinoma, Grade 3, ER/PR-, Her2Metastatic to 5 Axillary LNs

48 57 y/o with mass seen on routine screening mammogram

49 Fibroadenoma

50 74 y/o with new palpable right breast mass and recent benign screening mammogram Calcifying Degenerative Fibroadenoma

51 Fibroadenoma Fibroadenoma TN IDC Fibroadenoma Fibroadenoma

52 22 y/o woman with palpable left breast mass After Full-Term Pregnancy

53 Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Correlate with Clinical History Abscess Papilloma

54 56 y/o with palpable left breast mass in region of bruising 2 months after fall Diagnosis of hematoma requires: 1. Supporting clinical history 2. Absence of internal vascular flow 3. Follow-up to resolution

55 65 y/o woman with palpable right breast mass after right breast trauma

56

57 At presentation 1 Year Later

58 33 y/o lactating woman with painful right breast mass

59

60 Puerpueral Abscess Successfully Treated with US-guided Aspiration and Oral Antibiotics

61 Breast Abscess Puerpueral (14-59%) Lactational Primiparous Skin laceration S.aureus Oral antibiotics and aspiration Intralesional antibiotics if large Indwelling catheter if >5 attempts Radiographics 2011;31:

62 Breast Abscess Non-Puerpueral (41-86%) Central (most common) Young women smokers Squamous metaplasia Mixed flora 25% bilateral, 1/3 cutaneous fistulas Oral and intralesional antibiotics Surgery if >7 attempts Lannin 50% of recurring abcesses require surgery 28% recur without surgery, 79% recur in spite of surgery Radiographics 2011;31:

63 Breast Abscess Non-Puerpueral (41-86%) Peripheral Older women with underlying conditions Usually S. aureus Oral antibiotics and aspiration Radiographics 2011;31:

64 Breast Abscess Presentation Clinical context Lactational Young women smokers Older women with underlying conditions Symptoms Pain, warmth, erythema Fever in minority Radiographics 2011;31:

65 Breast Abscess Imaging Ultrasound first-line modality Hypoechoic mass of variable shape & size Thick echogenic periphery with increased vascular flow Mammography R/O inflammatory CA Non-lactational, especially in older women Protracted course Radiographics 2011;31:

66 Breast Abscess Management Oral antibiotics US-guided aspiration 18 g aspiration needle C+S on aspirated fluid Follow-up Repeat US in 1-2 weeks Re-aspirate/ adjust antibiotic coverage if needed Surgical excision if unsuccessful after multiple attempts Radiographics 2011;31:

67 54 y/o woman with h/o abscess treated with antibiotics and US-guided aspiration x 3

68 Non-Puerpueral Abscess Requiring Multiple USguided Aspirations and Chnages in Oral Antibiotics

69 59 y/o woman with h/o palpable tender mass treated with antibiotics x 10 days

70

71 Invasive Ductal Carcinoma

72 72 y/o woman with new onset bloody left nipple discharge Differential Diagnosis Intraductal papillary lesion DCIS Inspissated debris

73 Vacuum Assisted Core Needle Biopsy May Be Helpful Intraductal Papilloma

74 Benign Lesions Distinction between benign and malignant NOT always clear Identify pathognomonic benign features Be alert for potentially malignant features Remember that no modality exists in a vacuum Correlate with other modalities, i.e., mammography for fat-containing lesions Correlate with clinical history, i.e., hematoma and abscess Further data needed on large/growing fibroadenomas and papilloma management

75 Thank You!

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