Color Doppler imaging of fibroadenomas of the breast with histopathologic correlation

Fibroepithelial lesions of the breast: improving the accuracy of imaging diagnosis and reducing unnecessary biopsy

Fibroadenomas and phyllodes tumours are fibroepithelial lesions of the breast. Fibroadenomas are common benign breast masses encountered both symptomatically and incidentally. Phyllodes tumours are uncommon and usually present symptomatically. Management of fibroadenomas focuses on reducing biopsies without missing cancers while radiological management of phyllodes tumours should focus on predicting the need for surgical excision with or without margins.

Fibroadenomas: a multidisciplinary review of the variants

Fibroadenomas are the most common benign breast lesions in women. Hormonal activities, particularly an increase in oestrogenic activity, have an important role in the aetiology of fibroadenomas. They are commonly detected incidentally. Most fibroadenomas have similar imaging findings and these lesions can be defined as simple fibroadenomas (SFAs). However, due to different histopathologic characteristics and components, variants of fibroadenomas have been described. These variants include; juvenile, giant, complex, myxoid, cellular, and hyalinised fibroadenomas. The diagnoses of these variants are important. They have different clinical behaviours, potential for malignant transformation, and treatment strategies. We present imaging findings of SFAs and other variants of fibroadenomas. To our knowledge, there is no review in which imaging findings of all fibroadenoma variants are presented together.

Primary Rhabdomyosarcoma of the Breast: Imaging Findings and Literature Review

Background

Primary breast rhabdomyosarcoma (RMS) can occur in children. There is a lack of knowledge regarding radiologic findings and added diffusion-weighted magnetic resonance imaging (MRI) features of RMS in the literature.

Case Report

A 12-year-old girl was diagnosed with primary alveolar RMS of the breast. Gray scale ultrasound revealed posterior acoustic enhancement behind a well-circumscribed, multilobulated hypoechoic mass. Doppler ultrasound revealed increased peripheral and central vascularity. Hypointense septations on T2-weighted image exhibiting more enhancement than the stroma on late gadolinium-enhanced images were striking within a hyperintense mass. A hyperintense hemorrhagic focus on T1-weighted image was present in the absence of any necrosis. Avid enhancement on early postcontrast images proceeding from the periphery to the center was depicted.

Conclusion

A rapidly enlarging mass with an echogenic peripheral rim together with posterior acoustic enhancement on gray scale ultrasound, intense vascularity on Doppler ultrasound, axillary lymphadenopathy, and satellite nodules on MRI should raise suspicion. Enhancing central and peripheral septations are suggestive of RMS. Dynamic contrast-enhanced MRI in suspected cases can provide valuable data in the differential diagnosis.

Role of 3D power Doppler ultrasound in the further characterization of suspicious breast masses

PURPOSE

To investigate effectiveness of vascular indices obtained with 3D power Doppler ultrasound in the further characterization of breast masses and prevention of unnecessary biopsies.

MATERIALS AND METHODS

Between April 2013 and March 2014, 109 patients (age range, 17-85 years; mean age, 47 years) with 117 radiologically or clinically suspicious breast masses were prospectively evaluated with 3DPDUS before biopsy. Mass volume (MV), vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using Virtual Organ Computer-aided Analysis (VOCAL) software and they were correlated with the final diagnosis. Cutoff values of vascular indices were determinated and diagnostic efficacy was calculated with receiver operating curve (ROC) analysis.

RESULTS

All vascular indices, age of patients and tumor volume were significantly lower in benign masses compared with malignant ones (p<0.001). AUCs were 0.872, 0.867 and 0.789 for VI, VFI and FI, respectively. The diagnostic efficacy of VI (for cutoff 1.1; 83% sensitivity, 82% specificity and 82% accuracy) and VFI (for cutoff 0.4; 80% sensitivity, 83% specificity and 80% accuracy) were significantly higher than FI (for cutoff 33,9; 73% sensitivity, 69% specificity and 71% accuracy). It was found that with the use of vascular indices of 3DPDUS in the further characterization of suspicious breast masses between 24% to 37% of unnecessary biopsies could have been avoided.

CONCLUSION

The vascular indices obtained with 3DPDUS seem reliable in the further characterization of suspicious breast masses and might be used to decrease unnecessary biopsies.

Sonographic appearances of juvenile fibroadenoma of the breast

OBJECTIVES

The purpose of this study was to evaluate characteristic features of juvenile fibroadenoma of the breast on sonography.

METHODS

Our study included 34 juvenile fibroadenomas confirmed by surgical biopsy or sonographically guided 8-gauge vacuum-assisted biopsy in 23 patients (age range, 15-47 years; mean age, 25 years). Sonographic findings of the lesions were analyzed retrospectively by 2 radiologists in consensus according to the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) lexicon. The BI-RADS final assessment category was also established.

RESULTS

On sonography, all fibroadenomas presented as masses. The mean size was 30 mm. Regarding shape, there were 29 oval, 2 round, and 3 irregular masses. The margins were circumscribed in 24, indistinct in 5, microlobulated in 4, and angular in 1. Regarding echogenicity, 16 masses were hypoechoic, 16 isoechoic, and 2 complex echoic. Posterior acoustic characteristics included posterior acoustic enhancement in 22 masses (65%), posterior shadowing in 1, and no posterior acoustic features in 9; this information was not available in 2. The lesion boundary presented as an abrupt interface in 32 and an echogenic halo in 2. The orientation was parallel in 32 and nonparallel in 2. Calcifications were present in 3 cases and absent in 31. On color Doppler sonography, the masses were usually hypervascular with vessel counts of 5 or more (87%). The BI-RADS final assessment categories were 3 in 24 and 4a in 10.

CONCLUSIONS

The dominant sonographic presentation of juvenile fibroadenoma is a circumscribed oval hypoechoic or isoechoic mass, which resembles that of simple fibroadenoma. Juvenile fibroadenomas frequently show posterior acoustic enhancement and hypervascularity on color Doppler sonography.

Diagnosis of solid breast tumors using vessel analysis in three-dimensional power Doppler ultrasound images

This study aims to evaluate whether the distribution of vessels inside and adjacent to tumor region at three-dimensional (3-D) power Doppler ultrasonography (US) can be used for the differentiation of benign and malignant breast tumors. 3-D power Doppler US images of 113 solid breast masses (60 benign and 53 malignant) were used in this study. Blood vessels within and adjacent to tumor were estimated individually in 3-D power Doppler US images for differential diagnosis. Six features including volume of vessels, vascularity index, volume of tumor, vascularity index in tumor, vascularity index in normal tissue, and vascularity index in surrounding region of tumor within 2 cm were evaluated. Neural network was then used to classify tumors by using these vascular features. The receiver operating characteristic (ROC) curve analysis and Student's t test were used to estimate the performance. All the six proposed vascular features are statistically significant (p < 0.001) for classifying the breast tumors as benign or malignant. The A Z (area under ROC curve) values for the classification result were 0.9138. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis performance based on all six proposed features were 82.30 (93/113), 86.79 (46/53), 78.33 (47/60), 77.97 (46/59), and 87.04 % (47/54), respectively. The p value of A Z values between the proposed method and conventional vascularity index method using z test was 0.04.

Has color Doppler a role in the evaluation of mammary lesions?

Has color Doppler a role in the evaluation of mammary lesions? A schematic review of color Doppler diagnostic criteria, indicating a benign or malignant lesion, are described.Malignant tumors have a tendency to show increased vascularization, but avascular tumors may be found as well as hypervascular benign tumors.Number of vessels, blood-flow velocity, and intra-tumoral vessel resistance assessed by color Doppler ultrasonography don't permit clear differentiation between malignant and benign tumors, but intra-tumoral blood-flow analysis well correlates with aggressiveness and histological grade of the mass, so a preoperative assessment using Color Doppler may give preliminary prognostic informations useful for therapeutic planning.Color Doppler ultrasound may be valuable also in assessing the efficacy of neoadjuvant chemotherapy and in particular of antiangiogenesis treatments.Color Doppler ultrasound has many other useful applications in the evaluation of diseases of the female and male breast, that are reviewed in the paper.Color Doppler however is not conceived as a stand-alone examination, but associated with B-mode ultrasound that is quite effective as a diagnostic tool, often not requiring Doppler informations.

Vascular morphology and tortuosity analysis of breast tumor inside and outside contour by 3-D power Doppler ultrasound

This study aimed to evaluate morphologic and tortuous features of vessels inside and outside the tumor region on three-dimensional power Doppler ultrasonography (PDUS) in 113 breast mass lesions, including 60 benign and 53 malignant tumors. Compared with benign lesions, malignant breast lesions had significantly larger values of vascular morphologic and tortuous features and larger tumor sizes. The receiver operating characteristic curve analysis and Student's t-test were used to estimate the performance of a proposed classification system using 13 vascular features and tumor size selected by the neural network. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value and the A(Z) value of the diagnosis performance based on 14 features were 89.38% (101/113), 84.91% (45/53), 93.33% (56/60), 91.84% (45/49), 87.50% (56/64) and 0.9188, respectively. The three-dimensional PDUS morphologic and tortuous characteristics of blood vessels inside and outside breast mass lesions can be effectively used to classify benign and malignant tumors.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings

BACKGROUND

Sonography is usually requested to evaluate palpable pediatric breast lumps, and solid masses are almost always fibroadenomas. Lack of familiarity with the findings of fibroadenomas can lead to diagnostic uncertainty and sometimes unnecessary biopsy and excision. We sought to review the spectrum of sonographic findings in our cases of pathology proven pediatric fibroadenomas.

OBJECTIVE

The purpose of this retrospective study was to describe the sonographic appearances of pathologically proven pediatric breast fibroadenomas.

MATERIALS AND METHODS

A query of the Department of Radiology database at our institution was performed for all patients younger than 19 years who underwent breast US from January 2001 to June 2009. A total of 332 patients were identified: 282 girls (85%) and 50 boys (15%). Ninety-one girls and no boys had a solid breast mass based on US findings. Forty-three children had a total of 49 pathologically proven breast masses with the diagnoses of fibroadenoma (44), hamartoma (1), non-Hodgkin lymphoma (1), tubular adenoma (1), pseudoangiomatous stromal hyperplasia (1) and lactation changes (1). Reviews of medical records, histological results and sonographic examinations of all pathology-proven fibroadenomas were performed. US findings were characterized according to location, multiplicity, size, shape, echogenicity and homogeneity, definition of margins, posterior acoustic features and Doppler vascularity.

RESULTS

The vast majority of solid breast masses in girls are histologically benign. Fibroadenomas accounted for 91% of the pathologically proven solid breast masses. Common findings on US imaging are an oval shape, hypoechoic echo pattern, posterior acoustic enhancement and internal Doppler signal. Lobulations were found in 57% of the masses. Less common findings are absent internal vascular flow and complex echo pattern, while isoechoic echo pattern, posterior shadowing and angular margins are rare or unusual.

CONCLUSION

Fibroadenomas represent the most common solid mass in the breasts of girls. Sonographic appearances are usually characteristic and do not significantly differ from those found in adults. The radiologist must be aware of common and uncommon sonographic appearances of fibroadenomas in the pediatric age group and should be cautious when recommending histological confirmation based on imaging findings, as breast malignancy is extremely rare.