1. BENIGN MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers

2. Benign Masses • Fibroadenoma • Fibroadenoma variants : complex FAtubular adenoma, lactating adenoma • Phylloides Tumor • Hamartoma • Lipoma • Focal Fibrosis • Diabetic mastopathy • Fibrocystic change

3. I. Fibroadenoma • Arise from a single TDLU and contain both stromal (fibroma) & epithelial (adenoma) elements • Edge is “pushing” not infiltrating & becomes “encapsulated” by compressed breast tissue • FAs with cysts, apocrine metaplasia, or sclerosing adenosis are called COMPLEX

4. FA – cont. • Peak incidence – 20-30 yr & again 40-50 yr • Usually 2-3 cm but giant FA & juvenile FA can grow to 10 cm • Estrogen stimulation is important so most common when unopposed (anovulatory) i.e.. in adolescence and perimenopause • Multiple in 25% also bilateral

5. FA – sonographic appearance • Oval, lobulated • Circumscribed with echogenic capsule • Parallel • Iso or hypoechoic • Normal or enhanced transmission with edge shadows • Tiny ones (<1cm) may be round & can’t DD from a complex cyst • May mimic duct extension

6. oval lobulated irregular

7. hypoechogenic isoechogenic

8. Calcifications in FA

9. Ca++ FA in pathology

10. FA – cont. • Wide variability in histologic composition • Wide variability in sonographic appearance • Bilateral multiple FAsup to 10 nodules in each breastno need to Bx all of themnew ones will almost always developneed 6 mo. F/U

11. II. FA variants – Complex FA • The epithelial components undergo proliferative change and we may see:sclerosing adenosis, cysts, apocrine metaplasia, amorphous calcifications • About 20% of all FAs are complex !(-) FHx increases risk for CA 3x(+) FHx increases risk for CA 4x • Risk is generalized for the whole of both breasts.

12. II. FA variants – Complex FA • The diagnosis is histological • U/S: may see internal cysts or heterogeneous echo pattern • Seen at older age – median age 47 yrs • Only 1.5% contained a CA AJR:2008;190:214-218

13. cysts & sclerosis ComplexFAs

14. II. FA variants – Tubular Adenoma & Lactating Adenoma • Almost pure epithelial growth with very little or NO stromal component • Tubular adenoma is very rare • Lactating adenoma is common during pregnancy (mainly 3rd trimester) and lactation

15. II. FA variants – Tubular Adenoma & Lactating Adenoma • Lactating adenoma may arise de novo, from a FA or from a tubular adenoma • U/S: oval, spindle shaped, parallel, hypo-hyperechoic, enhancement, Doppler (+), microlobulated

16. spindle shaped microlobulated Tubular adenomas

17. hypo IDC-Grade 3 hyper Lactating adenomas

18. III. Phylloides Tumor • Rare – peak at 40-50 yr but can occur in teenagers • Very rapid growth – up to 15 cm • 2/3 benign 1/3 malignant • Mix of very cellular stromal and epithelial elements • U/S: oval, well circumscribed, capsule, hypo, enhancement, “cystic slits”

19. Phylloides with cystic clefts

20. The faces of phylloides

21. IV. Hamartoma • Localized overgrowth of fibrous, epithelial and fatty elements = normal breast tissue • Other names: adenolipofibroma, lipoadenofibroma, fibroadenolipoma • U/S: oval, very heterogeneous, capsule, parallel

22. Classic hamartoma

23. Hamartoma on mammo & CT

24. V. Lipoma • Overgrowth of fatty tissue • They are actually in the skin NOT in the breast • May grow up to 20 cm !!!! • U/S: completely isoechoic with the other fat lobules or mildly hyperechoic, soft and compressible

25. fat necrosis hyper iso

27. VI. Focal Fibrosis • FIBROUS MASTOPATHY • Can cause tender/non-tender palpable lump • May see focal asymmetry on mammo – UOQ

28. VI. Focal Fibrosis • Pathology: dense stromal fibrous tissue without cells • U/S: purely hyperechoic & homogeneous, no capsule tapers into Cooper’s ligaments so can be teardrop or spindle shapedBEWARE: DD with echogenic rim !!!

29. MUST have mammographic correlation

30. VII. Diabetic Mastopathy • Occurs in premenopausal women • Most have Type I diabetes before the age of 20 yr • Usually a very hard palpable lump • May be multifocal, multicentric and bilateral

31. VII. Diabetic Mastopathy • Mammo: non specific asymmetry • U/S: VERY SCARY !!!!!! Ill-defined, angular, microlobulated, hypoechoic, not parallel, intense shadowing • ALL go to Bx.

34. VIII. Fibrocystic Change • Huge spectrum from all the types of cystic change to benign proliferation forming a solid nodule • Adenosis & Sclerosing Adenosis:TDLUs enlarge and increase in numbernormal lobules – 2 mmadenosis – 5 mm • Mammo: focal asymmetry, masses, “starry night” calcifications • U/S: extremely varied

37. adenosis with amorphous ca++ adenosis with cysts hypoechoic adenosis in hyper glandular tissue

38. Adenosis and blunt duct adenosis

39. adenosis blunt duct adenosis

40. “starry night” of sclerosing adenosis

41. The faces of sclerosing adenois central fibrosis branching distended terminal lobule

42. Sclerosing adenosis with spiculation & halo

43. Sclerosing adenosis with ca++

44. Remember algorithm and technique • Know your anatomy • Must correlate with mammo & clinical presentation • Huge overlap of findings • Better than doing mammograms all day!

45. Thank You !