Hyperechoic lesions of the breast: radiologic-histopathologic correlation

Unusual US Findings of Diffuse Large B-Cell Lymphoma of the Breast: A Case Report

Lymphoma is an uncommon type of breast malignancy, with low prevalence. The ultrasonographic findings of breast lymphoma have been described as nonspecific. Breast lymphoma most commonly appears as a solitary hypoechoic mass on US, and usually shows hypervascularity on color Doppler US. Herein, we report an unusual case of breast lymphoma that presented as multiple bilateral hyperechoic nodules on US.

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.

Multimodal Ultrasonography Features of Breast Lymphomas: 3 Cases Report

To investigate the multimodal ultrasonography (US) features of breast lymphomas (BLs). Multimodal ultrasonography was performed on three patients who had been diagnosed BLs by pathology in our hospital. Two cases of primary BLs appeared hyper hyperechoic and hypoechoic, and one case of second BL appeared isoechoic and hypoechoic. Elastography of two lesions was soft elasticity and the elasticity score was 2 points. Contrast-enhanced ultrasound (CEUS) revealed rapid uniform high enhancement with clearly defined after injection. There are some common features in ultrasound. Combined with those features can help to improve the sonographer's understanding and diagnosis of the BLs.

Comparing Breast Hemangiomas to Breast Angiosarcomas: An Imaging Based Review

Vascular tumors of the breast are rare, and most can be classified as either hemangiomas or angiosarcomas. Breast hemangiomas are benign vascular tumors that are often found incidentally at pathologic examination. Breast hemangiomas may mimic low grade angiosarcomas, which are malignant vascular tumors. This article illustrates the imaging characteristics of breast hemangiomas and breast angiosarcomas across multiple imaging modalities.

Fat necrosis in the breast: a multimodality imaging review of its natural course with different aetiologies

Fat necrosis of the breast is a commonly encountered condition in daily practice. It is a benign pathology, but it can have variable manifestations and patterns that may sometimes mimic malignancy, depending on its stage of evolution and its underlying cause. This review demonstrates the wide spectrum of appearances of fat necrosis on mammography, digital breast tomosynthesis (DBT), ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and positron-emission tomography (PET). Sequential follow-up images are included in some cases to illustrate the temporal change of the findings. The typical location and distribution of fat necrosis from a comprehensive list of aetiologies are discussed. Improved knowledge of the multimodality imaging features of fat necrosis could enhance diagnostic accuracy and clinical management, thus avoiding unnecessary invasive investigations.

Mixed and Purely Hyperechoic Breast Masses: A Radiologic-Pathologic Review

Breast US is a mainstay of modern-day breast imaging, especially in the diagnostic and interventional realm. The BI-RADS atlas described six echo patterns relative to the subcutaneous mammary fat: anechoic, hypoechoic, complex cystic and solid, isoechoic, heterogeneous, and hyperechoic. Hyperechoic breast masses demonstrate increased echogenicity relative to subcutaneous mammary fat or equal to fibroglandular tissue. Pathologically, the hyperechoic pattern at breast US results from the intermingling of different components: adipose tissue, fibrous tissue or stroma, secretions, blood or vascularity, and calcifications. Most hyperechoic masses are benign, especially homogeneously hyperechoic masses. However, hyperechogenicity does not exclude malignancy. Two echo patterns have been identified in hyperechoic malignant lesions, including those with a hypoechoic center and hyperechoic rim known as the rim pattern and a mass with hyperechoic areas distributed through the mass known as a dispersed pattern. This article aims to illustrate the echogenic patterns of breast lesions and various benign and malignant hyperechoic breast lesions with radiologic-pathologic correlation and to increase awareness of heterogeneously hyperechoic breast lesions as a manifestation of malignancy.

Fat necrosis: A consultant's conundrum

Fat necrosis of the breast is a benign non-suppurative inflammation of the adipose tissue and often mimics breast cancers, posing a diagnostic challenge for the clinician and radiologist. It has a myriad of appearances on different imaging techniques, ranging from the pathognomic oil cyst and benign dystrophic calcifications to indeterminate focal asymmetries, architectural distortions, and masses. A combination of different modalities can assist a radiologist in reaching a logical conclusion to avoid unnecessary interventions. The aim of this review article was to provide a comprehensive literature on the various imaging appearances of fat necrosis in the breast. Although a purely benign entity, the imaging appearances on mammography, contrast-enhanced mammography, ultrasound, and magnetic resonance imaging can be quite misleading, especially in post-therapy breasts. The purpose is to provide a comprehensive and all-inclusive review on fat necrosis with a proposed algorithm allowing a systematic approach to diagnosis.

Ultrasound Imaging Morphology is Associated with Biological Behavior in Invasive Ductal Carcinoma of the Breast

Objectives:

Ultrasound (US) is commonly used for diagnostic evaluation of breast lesions. The objective of this study was to investigate the association between US imaging morphology from routine radiologists’ interpretation and biological behavior such as receptor status and tumor grade determined from histopathology in invasive ductal carcinoma (IDC).

Material and Methods:

This retrospective study included 453 patients with pathology-verified diagnosis of IDC who had undergone US imaging and had surgery over a 5-year period. US and surgical pathology reports were reviewed and compiled. Correlation analyses and age-adjusted multivariable models were used to determine the association between US imaging morphology and receptor status, tumor grade, and germ line mutation of the breast cancer genes (BRCA1 and BRCA2). The odds ratio (OR), area under receiver operating characteristic curve (AUC), and 95% confidence intervals (CI) were obtained.

Results:

The likelihood for high-grade cancer increased with size (OR: 1.066; CI: 1.042–1.091) and hypo-echogenicity (OR: 2.044; CI: 1.337–3.126), and decreased with angular or spiculated margins (OR: 0.605; CI: 0.393–0.931) and posterior acoustic shadowing (OR: 0.352; CI: 0.238–0.523). These features achieved an AUC of 0.799 (CI: 0.752–0.845) for predicting high-grade tumors. The likelihood for Estrogen Receptor-positive tumors increased with posterior acoustic shadowing (OR: 3.818; CI: 2.206–6.607), angulated or spiculated margins (OR: 2.596; CI: 1.159–5.815) and decreased with US measured tumor size (OR: 0.959; CI: 0.933–0.986) and hypoechoic features (OR: 0.399; CI: 0.198– 0.801), and achieved an AUC of 0.787 (CI: 0.733–0.841). The likelihood for Progesterone Receptor-positive tumors increased with posterior acoustic shadowing (OR: 2.732; CI: 1.744–4.28) and angulated or spiculated margins (OR: 2.618; CI: 1.412–4.852), and decreased with US measured tumor size (OR: 0.961; CI: 0.937–0.985) and hypoechoic features (OR: 0.571; CI: 0.335–0.975), and achieved an AUC of 0.739 (CI: 0.689–0.790). The likelihood for Human epidermal growth factor receptor 2-positive tumors increased with heterogeneous echo texture (OR: 2.141; CI: 1.17– 3.919) and decreased with angulated or spiculated margins (OR: 0.408; CI: 0.177–0.944), and was marginally associated with hypoechoic features (OR: 2.101; CI: 0.98–4.505) and circumscribed margins (OR: 4.225; CI: 0.919–19.4). The model with the aforementioned four US morphological features and achieved an AUC of 0.686 (CI: 0.614–0.758). The likelihood for triple-negative breast cancers increased with hypo-echogenicity (OR: 2.671; CI: 1.249–5.712) and decreased with posterior acoustic shadowing (OR: 0.287; CI: 0.161–0.513), and achieved an AUC of 0.739 (CI: 0.671– 0.806). No statistical association was observed between US imaging morphology and BRCA mutation.

Conclusion:

In this study of over 450 IDCs, significant statistical associations between tumor grade and receptor status with US imaging morphology were observed and could serve as a surrogate imaging marker for the biological behavior of the tumor.

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.

Unusual Male Breast Lesions

Most of male breast masses are benign with gynecomastia being the most common entity encountered. Primary male breast cancer accounts for less than 1% of the total number of breast cancer. Male breast can be affected by a variety of conditions affecting the female breast with less frequency due to the lack of hormonal influence and consequent glandular sub-development. Imaging features of male breast masses are quite similar to the female breast. Therefore, using the knowledge of the female breast and applying it may help in the diagnosis and management of male breast abnormalities. In this article, we aim to review a variety of unusual male breast masses. We discuss the demographics of male breast tumors, describe the diagnostic algorithm for evaluating male breast masses, and review the imaging features of rare breast masses and mimickers of male breast cancer.

Breast hamartoma: Unusual radiological presentation

Breast hamartomas are uncommon slowly growing lesions. Imaging findings are specific and usually relay on common mammographic picture of breast within breast appearance. I present a case of 48 years female patient, with recent history of palpable right breast mass, the imaging findings are atypical for breast hamartoma. The unusual presentation of breast hamartomas necessitates biopsy to exclude tumor. Incidence of malignancy is low, however has been reported before. Characteristic radiological imaging can help to minimize unnecessary surgery and morbidity.

Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease

Due to postoperative changes, imaging evaluation of patients with palpable masses after mastectomy can be challenging. There is considerable overlap between the imaging characteristics of recurrent disease and benign postoperative findings in patients with or without breast reconstruction. US is the initial modality of choice for evaluating palpable masses in most patients after mastectomy. In cases where US findings are not classic, however, other modalities are useful in problem solving, including both mammography and MRI. It is imperative that radiologists are educated about benign and malignant imaging characteristics, further workup considerations, and appropriate management. In cases where findings are not characteristic across multiple imaging modalities, biopsy may be warranted.

Ultrasound Diagnosis of Breast Lymphoma and the Identification of Breast Infiltrating Ductal Carcinoma

OBJECTIVES

By analyzing the B-mode ultrasound and color Doppler flow imaging characteristics of breast lymphoma (BL) and breast infiltrating ductal carcinoma (BIDC), we expected to discriminate these diseases.

METHODS

Thirty-two patients with BL and 30 with BIDC confirmed pathologically were selected. The BL group was divided into nodular and diffuse groups. We analyzed and compared the general and imaging characteristics of the BL subgroups and the BIDC group.

RESULTS

The mean maximum diameter of BL was 54.93 ± 43.74 cm, and that of BIDC was 23.90 ± 6.79 cm (P < .05). The differences between the nodular BL and BIDC groups in a circumscribed margin (60.00% versus 20.00%), calcification (20.00% versus 53.33%), aggregation characteristics (0.00% versus 53.33%), and density (73.33% versus 10.00%) were statistically significant (P < .05). The differences between the diffuse BL and BIDC groups in calcification (6.67% versus 53.33%), aggregation characteristics (6.67% versus 53.33%) and density (40.00% versus 10.00%) were statistically significant (P < .05). The difference in a circumscribed margin (60% versus 13.33%) between the BL subgroups was statistically significant (P < .05). The blood flow signal in BL lesions was richer than that in BIDC lesions (P < .05).

CONCLUSIONS

Extrasuperior-quadrant single lesions in the BL group were larger than those in the BIDC group. The edges of the lesions in the nodular BL group were circumscribed and dense. Lesions in the diffuse BL group did not have a circumscribed margin, calcification, aggregation characteristics, or density. The blood flow signal in BL lesions was richer than that in BIDC lesions.

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.

Fat necrosis in the Breast: A systematic review of clinical

Breast fat necrosis (FN) originates from aseptic fat saponification, which is a typical lipid cyst or a spiculated lesion called mammographic presentation which mimics malignancy. In order to avoid biopsy, it would be necessary to identify the spectrum of fat necrosis appearances. A systematic research was conducted in October 2018 by using PubMed, MEDLINE, Embase, Google Scholar databases and Google to search for science literature published after 2004. Therefore, the aim of this systematic review, it is that the FN can provide radiologists, surgeons, and oncologists with better insight and help them manage the condition efficiently.

A pictorial review: multimodality imaging of benign and suspicious features of fat necrosis in the breast

Fat necrosis of the breast is a well-described benign entity that can result in unnecessary biopsy of breast lesions. The pathogenesis of fat necrosis is a non-suppurative inflammatory process of adipose tissue, which may be seen after trauma, surgery, biopsy, post-breast reconstruction, post-fat grafting, post-radiotherapy, infection, and duct ectasia, among other conditions. Clinically, these patients may be asymptomatic or may present with a palpable lump, skin tethering, induration, and occasionally axillary lymphadenopathy. Depending on the time at which diagnostic imaging is performed, fat necrosis can have highly variable appearances on different modalities as it evolves. This is directly related to whether inflammation or fibrosis is predominating within the lesion, and correlation with clinical history is paramount in evaluating these patients. This review aims to analyze benign and suspicious imaging features of fat necrosis confirmed by tissue sampling. Knowledge of both benign and malignant-appearing features of fat necrosis on conventional modalities such as mammography and ultrasound, as well as newer applications including digital breast tomosynthesis, PET/CT, and MRI, should help the radiologist minimize the number of unnecessary biopsies.

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.

Sonoelastography of Breast Lymphoma

Breast lymphomas only account for approximately 0.15% of malignant breast carcinomas. Half of these are primary lymphomas, and the other half are metastatic to the breast. Ultrasound elastography has been proven to aid in the diagnosis of breast lesions as malignant or benign, with malignancy appearing stiffer compared with normal breast tissue. However, in this study, we review the findings of breast lymphoma on strain and shear wave ultrasonography. Lymphoma appears drastically different on sonoelastography than primary breast cancers, and it could easily be interpreted as benign. Therefore, the unique imaging findings in addition to the patient's clinical history are important in differentiating lymphoma of the breast from other possible diagnoses.

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.

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.

Fat Necrosis of the Breast: A Pictorial Review of the Mammographic, Ultrasound, CT, and MRI Findings with Histopathologic Correlation

Fat necrosis of the breast is a challenging diagnosis due to the various appearances on mammography, ultrasound, CT, PET-CT, and MRI. Although mammography is more specific, ultrasound is a very important tool in making the diagnosis of fat necrosis. MRI has a wide spectrum of findings for fat necrosis and the appearance is the result of the amount of the inflammatory reaction, the amount of liquefied fat, and the degree of fibrosis. While CT and PET-CT are not first line imaging examinations for the diagnosis of breast cancer or fat necrosis, they are frequently performed in the surveillance and staging of disease. Knowledge of how fat necrosis presents on these additional imaging techniques is important to prevent misinterpretation of the imaging findings. Gross and microscopic appearances of fat necrosis depend on the age of the lesion; the histologic examination of fat necrosis is usually straightforward. Knowledge of the variable appearances of fat necrosis on a vast array of imaging modalities will enhance a radiologist's accuracy in the analysis and interpretation of fat necrosis versus other diagnoses.

Lymphoma affecting the breast: a pictorial review of multimodal imaging findings

Hematological malignancies rarely affect the breast, and the majority of those that do are lymphomas. In this review, we describe the clinical aspects and multimodal imaging findings of breast lymphoma. We also illustrate the key clinical and radiological findings that allow it to be distinguished from various other malignant and benign diseases of the breast. Breast lymphoma manifests as a breast mass, a change in the subcutaneous tissue or the skin, or enlargement of the associated lymph node on radiological examination. Radiological findings associated with other breast malignancies, such as calcifications, spiculations, or architectural distortions are extremely rare. Skin and subcutaneous changes frequently accompany T-cell lymphoma. Multimodal breast imaging characteristics may aid in the diagnosis of breast lymphoma.