Echogenic breast masses at US: to biopsy or not to biopsy?

Mammary myofibroblastoma of the male breast: a case report and literature review

Mammary myofibroblastoma (MFB) is a rare benign spindle cell tumour predominantly affecting males, but also observed in postmenopausal females. Its diagnosis remains challenging owing to overlapping histological features with malignant lesions and limited tissue sampling in core biopsies. We present a case of incidentally discovered mammary MFB in a 63-year-old man and review its clinical, radiological and histopathological characteristics. The patient, who had a history of distal pancreatectomy and splenectomy, presented with an incidental left anterior chest wall nodule discovered on computed tomography scan. Clinical examination revealed a benign left retroareolar lump, confirmed by breast ultrasound and mammography. Ultrasound-guided core biopsy demonstrated characteristic spindle cells, prompting immunohistochemical staining confirming the diagnosis of MFB. The lesion was surgically excised with clear margins. Mammary MFB is commonly seen in postmenopausal women and older men, presenting as painless, mobile breast lumps. Imaging findings are nonspecific, resembling fibroadenomas or fat necrosis. Histologically, MFB lacks mammary ducts or lobules and displays characteristic spindle cells with collagenous stroma. Immunohistochemistry aids in differentiating it from other spindle cell tumours. Surgical excision is curative, with no reported cases with recurrence. Mammary MFB should be considered in the differential diagnosis of breast masses in males and postmenopausal women. Despite the challenges in diagnosis, its benign nature and favourable prognosis warrant timely recognition and appropriate management through surgical excision. Further research is needed to establish clear management guidelines and explore its underlying pathogenesis.

Approach to Nonmass Lesions on Breast Ultrasound

Nonmass lesions in breast ultrasound (US) are areas of altered echogenicity without definite margins or mass effect. However, these lesions may show calcifications, associated architectural distortion, or shadowing just like masses. They vary in their echogenicity, distribution, ductal or nonductal appearance and the associated features that can be seen in variety of benign and malignant pathologies. With no uniform definition or classification system, there is no standardized approach in further risk categorization and management strategies of these lesions. Malignant nonmass lesions are not uncommon and few sonographic features can help in differentiating benign and malignant pathologies. US-guided tissue sampling or lesion localization can be preferred in the nonmass lesions identified on second look US after magnetic resonance imaging or mammography. This article aims to describe various imaging patterns and attempts to provide an algorithmic approach to nonmass findings on breast US.

Fibrocystic Change

Fibrocystic changes are commonly seen in clinically symptomatic patients and during imaging workup of screening-detected findings. The term "fibrocystic changes" encompasses a broad spectrum of specific benign pathologic entities. Recognition of classically benign findings of fibrocystic changes, including cysts and layering calcifications, can prevent unnecessary follow-ups and biopsies. Imaging findings such as solid masses, nonlayering calcifications, and architectural distortion may require core needle biopsy for diagnosis. In these cases, understanding the varied appearances of fibrocystic change aids determination of radiologic-pathologic concordance. Management of fibrocystic change is typically conservative.

Angiolipoma an Uncommon Breast Mass in Men: A Case Series

Angiolipomas are uncommon benign masses of the breast which are rarely described in the male breast. They do not have a typical mammographic appearance and can present with concerning features such as microcalcifications or irregular borders. Ultrasound is helpful in evaluating these masses most commonly appearing as oval, circumscribed, and hyperechoic. Clinical, radiological, and pathological information needs to be carefully evaluated as angiolipomas can be confused with malignant pathology. Three cases of angiolipomas of the male breast are reported in this study with mammographic, sonographic, and pathologic correlation.

Bright Is Not Always Better: A Pictorial Review of Hyperechoic Malignant Breast Masses

Hyperechogenic breast lesions are a relatively rare finding at breast ultrasonography and are traditionally thought to be benign. However, hyperechogenicity on the ultrasound alone does not provide enough evidence to rule out malignancy completely. We herein reported a short series of nine cases of echogenic malignant breast lesions, which include invasive ductal carcinoma, ductal carcinoma in situ, invasive lobular carcinoma, angiosarcoma, lymphoma, and metastasis to the breast. Echogenic breast lesions should be carefully evaluated and properly categorized based on any other suspicious sonographic characteristics and must be correlated with mammographic findings and clinical history to lower the threshold for biopsy and avoid delay in diagnosis. Hyperechogenicity should not be considered as a characteristically benign feature and should not supersede the less specifically benign features of the same lesion on the other examination.

Angiosarcoma of the Breast: Overview of Current Data and Multimodal Imaging Findings

Angiosarcoma of the breast is a rare breast cancer, which can arise de novo (primary breast angiosarcoma, PBA) or as a secondary malignancy (secondary breast angiosarcoma, SBA) as a result of a biological insult. In the latter case, it is usually diagnosed in patients with a previous history of radiation therapy following a conserving treatment for breast cancer. Over the years, the advances in early diagnosis and treatment of breast cancer, with increasing use of breast-conserving surgery and radiation therapy (instead of radical mastectomy), brought about an increased incidence of the secondary type. PBA and SBA have different clinical presentations and often represent a diagnostic challenge due to the nonspecific imaging findings. The purpose of this paper is to review and describe the radiological features of breast angiosarcoma, both in conventional and advanced imaging to guide radiologists in the diagnosis and management of this rare tumor.

Radiologic and Pathologic Correlation for Angiolipomas of the Breast

Angiolipomas of the breast are rare; however, they are an important entity for the radiologist who determines radiologic-pathologic concordance and recommends appropriate management. They can present as a palpable concern, prompting diagnostic workup, or can be detected on screening breast examinations. They often present as a circumscribed low-density mass on mammography, which is hyperechoic on sonography; associated fibrin thrombi can produce soft tissue density and/or hypoechoic foci that appear hypointense on T1-weighted MRI. Due to the nonspecific radiographic appearance, tissue sampling is often required for definitive diagnosis. Pathologically, angiolipomas can be difficult to distinguish from angiosarcomas; however, scattered microthrombi in small blood vessels are a typical feature of angiolipomas. Generally, in the setting of radiologic-pathologic concordance, angiolipomas do not need to be excised and can be followed clinically when palpable. Surgical excision can be pursued when certain high-risk features, such as nuclear enlargement, an infiltrative pattern, endothelial mitoses, and a high proliferation rate, are present in the core-needle biopsy specimen.

Prevalence of different breast lesions in women of southern Punjab, Pakistan, characterized on high-resolution ultrasound and mammography

Background

The aim of the study is to characterize the breast lesions on high-resolution Ultrasound and digital mammography to find the patterns and prevalence of different breast lesions in different age groups of our population.

Results

This prospective study was conducted at a breast care clinic of a tertiary care hospital from Jan 2018 to Dec 2019. Patients with breast-related complaints were enrolled. Patients under the 35 years of age were evaluated on High-Resolution Ultrasound (HR-USG) and those over 35 years of age on digital Mammography. Any lesion on digital mammography was characterized on HR-USG. Fine Needle Aspiration (FNAC) and Trucut biopsy was done where pathological correlation required. Data of all enrolled patients were recorded and analyzed. Patients with known cases of carcinoma breast on follow-up were excluded from the study. Total 6850 patients enrolled in our breast care clinic during study period. 5111 were above the age of 35 years while 1739 were under the age of 35 years. No lesion could be found in 3915 patients and were reported normal. 2935 patients were found to have different breast lesions. The frequency of different lesions was different in both age groups. The overall frequency of lesions was as malignancy 16.2%, benign lesions including Fibroadenoma, simple cysts, Lipoma and Galactocele 16%, inflammatory lesions including abscess 7.86% and Duct Ectasia 2.75%.

Conclusions

In developing countries where mass screening programs are deficient, Breast Care clinics in tertiary care hospitals have a noteworthy role in early detection of breast cancer and other breast lesions.

A Case Series of Malign Hyperechoic Breast Lesions

BACKGROUND

Hyperechoic breast lesions are a rare group of breast masses in routine practice. Most of these lesions are benign. However, they rarely may be malignant. Hyperechoic lesions can be evaluated using the same criteria for malignant lesions. Clinical history, mammographic appearance, and certain sonographic features (non-circumscribed margins, irregular shape, presence of hypoechoic areas, nonparallel orientation, and association with microcalcifications can be suggestive of malignancy). In this article, hyperechoic breast lesions with malignant pathology have been presented.

METHODS

Seven cases during breast ultrasound examination were detected.

RESULTS

Four patients had invasive ductal carcinoma, 1 patient had invasive lobular carcinoma, 1 patient had high-grade ductal carcinoma in situ (DCIS), and 1 patient had lymphoma. Ultrasonography of the breast showed a heterogeneous appearance in all the patients, microcalcification in two patients, and an ambiguous contour in one patient.

CONCLUSION

Hyperechoic breast lesions should be evaluated using specific sonographic criteria to prevent misdiagnosis and identify patients who require biopsy and further examination.

Hyperechoic Lesions on Breast Ultrasound: All Things Bright and Beautiful?

Ultrasound (US) lexicon of the Breast Imaging Reporting and Data System (BI-RADS) defines an echogenic breast mass as a lesion that is hyperechoic in comparison with subcutaneous adipose tissue. However, at sonography, only 0.6 to 5.6% of breast masses are echogenic and the majority of these lesions are benign. approximately, 0.5% of malignant breast lesions appear hyperechoic. The various benign pathologic entities that appear echogenic on US are lipoma, hematoma, seroma, fat necrosis, abscess, pseudoangiomatous stromal hyperplasia, galactocele, etc. The malignant diagnoses that may present as hyperechoic lesions on breast US are invasive ductal carcinoma, invasive lobular carcinoma, metastasis, lymphoma, and angiosarcoma. Echogenic breast masses need to be correlated with mammographic findings and clinical history. Lesions with worrisome features such as a spiculated margin, interval enlargement, interval vascularity, or association with suspicious microcalcifications on mammography require biopsy. In this article, we would like to present a pictorial review of patients who presented to our department with echogenic breast masses and were subsequently found to have various malignant as well as benign etiologies on histopathology.

Digital Mammographic Features of Breast Cancer Recurrences and Benign Lesions Mimicking Malignancy Following Breast-Conserving Surgery and Radiation Therapy

Mammography after breast-conserving surgery and radiation therapy is an important tool for followup. Early diagnosis of local recurrence enables prompt treatment decisions, which may affect patient prognosis. For complicated post-treatment changes, radiologists sometimes have difficulties in interpreting follow-up mammography. Fat necrosis, dystrophic calcifications, suture calcification features, breast edema, seroma and distorted breast are benign changes related to treatment. These findings may mimic or hide tumor recurrence making it difficult to diagnose recurrences or prevent inappropriate biopsies. Recurrent tumors in follow-up mammography show several typical findings such as increasing asymmetric density, enlarging mass, reappearance of breast edema, and micro-calcifications. The purpose of this pictorial review is to demonstrate and discuss mammographic findings of recurrent tumors and important post-treatment changes that may mimic benign or malignant lesions, also using breast ultrasound images or breast magnetic resonance images. Recognizing post-treatment changes may help radiologists to more effectively identify candidates for suspected local recurrences.

A case report of a mammary myofibroblastoma in a male and literature review of radiologic and pathologic features of breast myofibroblastoma

We reported a 65-year-old male with a benign mammary myofibroblastoma. This report shows that not all masses of male breast are malignant. To differentiate benign masses from malignant neoplasms, careful preoperative diagnosis should be performed. Preoperative diagnosis of the tumor prevents placing a huge financial and mental burdens on patients.

Hyperechoic malignancies of the breast: Underlying pathologic features correlating with this unusual appearance on ultrasound

Hyperechogenicity in the breast on ultrasound (US) is usually regarded as a benign feature with only rare hyperechoic malignancies reported to date. In this study, we evaluated the pathologic findings on core needle biopsy of hyperechoic lesions and investigated the histologic features in malignancies that give rise to an echogenic pattern. A total of 163 core needle biopsies (CNB) were performed for "hyperechoic" or "echogenic" lesions between 1/1/05 and 7/31/17. Lesions were classified based on the proportion of hyperechoic areas identified. We found that all lesions with a homogenous hyperechoic pattern (>90% hyperechoic) were benign (n = 17), regardless of the type of margins. Malignancies were found in 21% (7/34, six invasive carcinomas and one lymphoma) of heterogenous lesions with ≥50% hyperechoic areas (all with noncircumscribed margins) and in 31% of lesions with <50% hyperechoic areas (19/61, 14 invasive carcinomas, two lymphomas, and three metastases), including five with circumscribed margins (one invasive carcinoma, one lymphoma, and three metastases). Two major US patterns were identified in malignant lesions, those with a hypoechoic center and hyperechoic rim, corresponding to a central tumor area with dense stroma and tumor cells infiltrating adipose tissue at the periphery ("rim pattern"), and a second "dispersed pattern" with hyperechoic areas distributed throughout the lesion. Hyperechoic malignancies were found to be comprised of a complex intermixture of elements of differing echogenicity including tumor cells, adipose tissue, and fluid (in tubules, stromal clefts, or blood vessels). Our findings support the importance of radiologists specifying the echogenic pattern of hyperechoic lesions, as heterogenous lesions are associated with a higher risk of malignancy and pathologists should be alert to the associated pathologic findings.

Malignant phyllodes tumor of the breast with liposarcomatous differentiation: A case report with imaging findings

Phyllodes tumors are rare neoplasms that account for 2.5% of all fibroepithelial lesions, and 10%-20% exhibit malignant transformation. Malignant transformation often occurs in the form of stroma, and usually shows fibrosarcomatous differentiation. Liposarcomatous differentiation is a rare, developed stromal component of phyllodes tumors, and little is known about their imaging findings. We present the case of a 47-year-old woman who was diagnosed with a malignant phyllodes tumor of the breast that contained liposarcomatous elements. The patient underwent wide surgical excision of the mass and has been treated with adjuvant radiation therapy.

Mesenchymal Lesions of the Breast: What Radiologists Need to Know

OBJECTIVE

Mesenchymal breast tumors originate from the various components of mammary stroma. The aim of this review is to discuss the clinical presentation, imaging appearance, and management of mesenchymal breast lesions.

CONCLUSION

Although many mesenchymal tumors exhibit characteristic findings on imaging, others show nonspecific characteristics and require tissue biopsy for diagnosis. An awareness of the clinical and imaging presentation is essential in guiding the differential diagnosis and patient management.

Hyperechoic breast images: all that glitters is not gold!

Abstract

Hyperechogenicity is a sign classically reported to be in favour of a benign lesion and can be observed in many types of benign breast lesions such as hamartoma, lipoma, angiolipoma, haemangioma, haematoma, fat necrosis, fibrosis and galactocele, among others. However, some rare malignant breast lesions can also present a hyperechoic appearance. Most of these hyperechoic malignant lesions present other characteristics that are more typically suggestive of malignancy such as posterior shadowing, a more vertical axis or irregular margins that help to guide the diagnosis. Post magnetic resonance imaging, second-look ultrasound may visualise hyperechoic malignant lesions that would not have been identified at first sight and radiologists must know how to recognise these lesions.

Teaching Points

• Some rare malignant breast lesions can present a hyperechoic appearance.

• Malignant lesions present other characteristics that are suggestive of malignancy.

• An echogenic mass with fat density on mammography does not require biopsy.

Imaging Features of Inflammatory Breast Disorders: A Pictorial Essay

Inflammatory breast disorders include a wide array of underlying causes, ranging from common benign infection, non-infectious inflammation and inflammation resulting from underlying breast malignancy. Because it is at times difficult to distinguish mastitis and breast cancer based on clinical features, awareness of detailed imaging features may be helpful for better management of inflammatory breast disorders. Therefore, this pictorial essay intends to demonstrate radiologic findings of a variety of inflammatory breast disorders, using selected cases with mammography, ultrasound and magnetic resonance images.

Sonographically Unusual Breast Carcinomas, 2 Case Reports

Background

For infiltrative breast lesions; sonography might not always be as helpful as mammography and MRI (magnetic resonance imaging). For higher sensitivity and specificity, these 3 imaging methods should be carried out together. Radiologists should be aware of the patient’s history and complaints. Patients who have a specific history like a long-term drug treatment or a palpable tumour should be approached differently.

Case Report

We would like to present 2 cases with atypical sonographic findings. The first case is an infiltrative breast cancer with occult sonography findings in a patient with a history of a long-term immunosuppressive drug treatment due to kidney transplantation and the second case is a malignant breast tumour which is hyperechogenic on sonography.

Conclusions

Overall breast sonography should always be correlated with mammography in patients over 40 years old and the images should be interpreted along with the patient’s history and clinical status.

Malignant hyperechoic breast lesions at ultrasound: A pictorial essay

Malignant breast lesions are typically hypoechoic at sonography. However, a small subgroup of hyperechoic malignant breast lesions is encountered in clinical practice. We present a pictorial essay of a number of different hyperechoic breast malignancies with mammographic, sonographic and histopathologic correlation. Suspicious sonographic features in a hyperechoic lesion include inhomogeneity in echogenic pattern, an irregular margin, posterior acoustic shadowing and internal vascularity. A hyperechoic lesion at ultrasound does not discount the need to undertake histological assessment of a mammographically suspicious lesion.

Predictors of Malignancy in Hyperechoic Breast Lesions

OBJECTIVES

Hyperechogenicity has been strongly associated with benign breast lesions. Although it is correct in most cases, hyperechogenicity must not always be considered synonymous with benignancy, as hyperechoic breast cancers do occur. The purpose of this study was to review clinical and imaging characteristics of hyperechoic breast lesions, looking for features associated with malignancy.

METHODS

Institutional Review Board approval was granted for this research. A total of 19,417 sonographic examinations were performed between January 2009 and June 2013. Among these, hyperechoic lesions with histologic diagnoses, stability on long-term followup, or characteristic imaging appearances were included in the study. The patients' clinical charts, mammograms, and sonograms were reviewed. The clinical and imaging features were recorded, and the data was analyzed by the χ(2) test, Fisher exact test, and independent-samples t test, looking for statistically significant predictors of malignancy.

RESULTS

Among the 19,417 scans, 42 patients (0.2%) with 44 hyperechoic lesions were identified. Twenty-six lesions fulfilling the inclusion criteria were included in the study: 5 malignancies (3 invasive ductal carcinomas, 1 invasive lobular carcinoma, and 1 invasive mucinous cancer) and 21 benign lesions. An irregular shape, a nonparallel orientation, and noncircumscribed margins were significantly associated with the risk of malignancy (P = .002, .02, and .01, respectively).

CONCLUSIONS

A hyperechoic breast lesion must not always be assumed to be benign. Instead, a full sonographic assessment according to the American College of Radiology Breast Imaging Reporting and Data System descriptors is needed for correct characterization and avoidance of misdiagnosis.

Hyperechoic breast lesions: anatomopathological correlation and differential sonographic diagnosis

Hyperechoic lesions are not a frequent finding at breasts ultrasonography, and most of times are associated with benign pathologies that do not require further evaluation. However, some neoplasms such as invasive breast carcinomas and metastases may present with hyperechogenicity. Thus, the knowledge about differential diagnoses and identification of signs of lesion aggressiveness are of great relevance to avoid unnecessary procedures or underdiagnosis, and to support the correct clinical/surgical approach. On the basis of such concepts, the present essay describes and illustrates the main features of hyperechoic lesions at breast ultrasonography in different cases, with anatomopathological correlation.

Four cases of echogenic breast lesions: a case series and review

Echogenic breast lesions are generally thought to be benign. We herein report four cases of echogenic breast lesions that were seen at our centre over 38 months. One patient had a prior history of wide excision and radiotherapy for breast cancer and was imaged as part of routine cancer surveillance, while the other three were recalled for further assessment following an abnormal screening mammogram. All four patients were assessed on ultrasonography, which demonstrated an echogenic lesion in each patient. All four lesions underwent ultrasonography-guided core biopsy, followed by excision biopsy. The indications for biopsy were interval increase in the size of lesion or indeterminate features demonstrated in the lesion. Three lesions were benign, while the lesion from the patient who had received previous radiotherapy was angiosarcoma. Not all echogenic lesions are benign and lesions with suspicious features on ultrasonography should undergo biopsy.

Metastatic Disease to the Breast From Extramammary Malignancies: A Multimodality Pictorial Review

This pictorial review demonstrates imaging features of extramammary malignancies metastatic to the breast seen with multiple modalities, including mammography, ultrasound, computed tomography (CT), positron emission tomography, and magnetic resonance imaging. Although rare, metastases to the breast may have a distinct imaging appearance from the appearance of primary breast cancers. They are important to identify because they can mimic benign breast disease and their treatment differs from that of primary breast cancer. Metastatic disease to the breast most commonly appears as a single round or oval mass with circumscribed margins. Sonographically it is usually hypoechoic, and with CT or magnetic resonance imaging it usually enhances. In contrast with primary breast cancer, breast metastases do not demonstrate spiculated margins and rarely have associated calcifications. A variety of clinical presentations of breast metastases are reviewed, including presentation with a palpable mass, detection at screening mammography, and detection with CT or positron emission tomography.