Cystic masses of the breast by xiu

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Cystic masses of the breast by xiu

  1. 1. Present by Ekkasit MD. Cystic Masses of the Breast R e s i d e n t s ’ S e c t i o n • P a t t e r n o f t h e M o n t h : AJR : 194, February 2010 By Neely Hines - Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School.
  2. 2. Introduction Cystic lesions of the breast – Most present between 30 and 50 years of age. – Asymptomatic or symptomatic ( nipple discharge or a palpable mass)
  3. 3. Introduction • On mammography – Round, oval, or lobulated mass – Circumscribed margins.
  4. 4. Introduction • On mammography – Round, oval, or lobulated mass – Circumscribed margins. Obscured due to pericystic fibrosis.
  5. 5. Palpable left breast mass.
  6. 6. Palpable left breast mass. Grade I intracystic papillary carcinoma.
  7. 7. Further Evaluations. Compression views • Improved assessment of lesion morphology : shape, margins • Associated findings such as calcifications or distortion. Additional imaging at different angles • Permit localization three dimensionally in the breast leading to targeted ultrasound.
  8. 8. Further Evaluations. Ultrasound • Differentiate cystic from solid lesions. Assessment of a mass seen on US • shape, orientation, margin, boundary, inte rnal echotexture, posterior acoustic features, surrounding tissue, calcifications, and vascularity.
  9. 9. Cystic Masses of the Breast Simple cyst or not ? Not simple cyst imaging-guided intervention is necessary to exclude a solid mass.
  10. 10. Simple Cysts • Most common masses seen at mammography. • Result from dilatation and effacement of theTDLU. • Frequently multiple and fluctuate in size on serial examinations.
  11. 11. Simple Cysts • Mammographic findings: – Circumscribed round or oval mass. • Ultrasound: – Sonographic criteria set forth by Stavros: • Anechoic. • Well circumscribed with a thin echogenic capsule. • Increased through-transmission. • Thin edge shadows. – BI-RADS 2
  12. 12. Simple Cysts • MRI : – Round, oval shape. – Content : follow fluid signal on all sequences and do not enhance. – However, the periphery of the cyst may enhance if there is surrounding pericystic inflammation.
  13. 13. Simple cyst
  14. 14. (b) Multiple cysts. (a) Bilateral MLO mammograms show multiple circumscribed masses in both breasts. (b) US images show anechoic well-defined masses with (a) smooth walls and posterior acoustic enhancement.
  15. 15. Simple Cysts • Aspiration may be performed if : – Symptomatic. – The cyst prevents adequate compression for mammography. • Aspirated fluid is typically not sent for cytology except if it is bloody or the patient requests.
  16. 16. Simple Cysts • The differential diagnosis for a simple cyst includes – Galactocele – Hematoma – Oil cyst.
  17. 17. Complicated Cysts • A cyst that meets all criteria of simple cyst except contains intermal echoes or fluid-fluid levels.
  18. 18. Complicated Cysts • MRI: – T1WI : Intermediate or high signal because of proteinaceous contents or blood products. – T2WI : Variable depending on the cyst contents.
  19. 19. Complicated cyst
  20. 20. Complicated Cysts • Appropriate classification of complicated cyst = BI-RADS 3 – Because there is only a 0.2% chance of malignancy. – Aspiration or short-interval follow-up should be offered.
  21. 21. Complicated Cysts • The differential diagnosis of a complicated cyst: – Galactocele – Hematoma – Oil cyst. – Abscess.
  22. 22. Complex Cysts • Thick walls • Some discrete solid component – Septa greater than 0.5 mm thick – Mural nodules.
  23. 23. Complex Cysts Differential diagnosis Cyst with a mural Complex cyst: nodule: – Papillary tumor. – Hematoma. – Atypical ductal – Galactocele. hyperplasia. – Abscess. – DCIS – Fat necrosis. – Necrotic neoplasm.
  24. 24. Simple cyst Complicated cyst Complex cyst • Simple cyst • Galactocele • Galactocele • Galactocele • Hematoma • Hematoma • Hematoma • Oil cyst. • Fat necrosis. • Oil cyst. • Abscess. • Abscess. • Necrotic tumor. • Papillary tumor. • Atypical ductal hyperplasia. • DCIS
  25. 25. Galactocele • Accumulation of milk distal to an obstruction in the terminal ductal unit. • Most galactoceles resolve with conservative management.
  26. 26. Galactocele The age of the milk products determines its mam-mographic and sonographic appearances. • Mammographic images: – Typical - Circumscribed oval or round mass. – Late - Fat density layering on top. • US: – Acute setting - a complicated cyst or anechoic fluid with thin septa. – The galactocele ages - increases in complexity, fat–fluid levels. – Milk curdles - solid components within the cyst. – Finally - a solid echogenic mass.
  27. 27. Magnified lateral MLO Complicated cyst Mammographic and US images of left breast in lactating patient who presented with palpable lump shows galatocele.
  28. 28. Fat contenting mass Complicated cyst Galactocele Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation
  29. 29. Hamartoma like mass Complex cyst Galactocele Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation
  30. 30. Cystic mass with fat-fluid level galactocele Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation
  31. 31. Galactocele • Interventions: – When the diagnosis is uncertain. – Occasionally, develop superimposed infection.
  32. 32. Hematoma • History of surgery, trauma or anticoagulant therapy. • The age of the blood products determines the specific appearance.
  33. 33. Hematoma • US: – A hyperacute hematoma : a simple cyst with internal echoes, which rapidly becomes a complicated cyst. – Common appearance - a complex cyst with internal debris and a thick echogenic wall. – Avascular mural nodularity and septa. • MRI: – Variable depending on the age of the blood products. – Peripheral enhancement reflects the healing process and inflammation.
  34. 34. Hematoma in woman who sustained thoracic trauma in motor vehicle collision. -Mixed density and partially circumscribed macrolobulated mass in upper central right breast. -US show complex cyst.
  35. 35. • US shows a fluid-fluid level containing mass without color flow within the mass. • NECT confirm hematoma. BY Rathachai Kaewlai, M D
  36. 36. Hematoma If the clinical history is suggested : BI-RADS 3. If there is no history of recent trauma : BIRADS 4.
  37. 37. Fat Necrosis • May be seen after surgery, RT, and trauma. • Pathologically: Hemorrhage within fat, cystic degeneration, calcifications, fibrosis, scar formation. • S&S: – Most often – asymptomatic – Occasionally - a tender palpable lump.
  38. 38. Fat Necrosis Mammography: • Vague ill-defined asymmetries • Spiculated masses • Dystrophic calcifications.
  39. 39. Fat Necrosis US: variable depending on the stage of the process. • Solid mass. • Complex mass. • Isoechoic or anechoic mass • Variable shadowing. • Increased echogenicity of the subcutaneous fat and hyperechoic masses almost always indicates a benign finding. • Varying degrees of fibrosis may give an appearance suspicious for malignancy.
  40. 40. Fat Necrosis MRI: variable depending on the stage of the process. • Coarse calcifications may create signal voids. • Fibrosis can appear as distortion with or without spiculation. • Variable signal on T1WI - substantial fibrosis. • Signal intensity changes of fat. • Lack of internal enhancement. • Mimic malignancy: Progressive-to-rapid contrast enhancement and sometimes rim enhancement.
  41. 41. Fat Necrosis • Correlation of the MRI findings with mammography can be helpful when fat necrosis is a diagnostic consideration because most often there are characteristic findings that confirm the diagnosis. • The findings of lack of internal enhancement on MRI and signal intensity changes of fat on MR images often can avoid biopsy and permit classification of this finding as BI-RADS 2.
  42. 42. MAM: low-attenuation mass in operative bed US: complex avascular mass.
  43. 43. MAM : dystrophic and spherical calcifications in area of prior surgery. US: anechoic cyst.
  44. 44. T2WI Unenhanced T WI MR images of third patient show low to intermediate signal intensity on unenhanced T1-weighted image, intermediate signal on T2-weighted sequence, and suspicious enhancement with washout kinetics after administration of gadolinium. T WI with Gd
  45. 45. Breast Abscess • Breast abscess is a complication of mastitis. • Most commonly in lactating women. • Typically presentation: fever, chills, breast erythema, and tenderness. • Imaging is used to differentiate between cellulitis or mastitis and abscess.
  46. 46. Breast Abscess US: • Oval, lobulated, or irregular-shaped cyst with internal debris. • Thick hyperemic walls. • Motion of debris in the cavity. • Surrounding edema of the skin and subcutaneous tissues.
  47. 47. Breast Abscess MRI: • Round or irregular mass. • T1WI - Intermediate SI centrally and a low- signal peripheral rind that avidly enhances. • T2WI - High SI within the skin and breast parenchyma.
  48. 48. Gray-scale image in breast-feeding patient shows ill-defined complex cyst with solid and hypoechoic elements with low-level internal echoes, consistent with abscess Notice diffuse overlying skin thickening
  49. 49. Image in another patient shows macrolobulated complex cyst with internal echogenic material and peripheral vascularity, also consistent with abscess.
  50. 50. Breast Abscess Treatment options: • Percutaneous drainage in conjunction with antibiotic therapy. • Surgery is necessary for cases that are refractory to antibiotics and percutaneous drainage • for markedly multiloculated lesions.
  51. 51. Intracystic Papilloma • Common cause of a cyst with a mural nodule.
  52. 52. Intracystic Papilloma US: • Cyst with a mural-based nodule is often seen. • In some cases, the solid component may extend beyond the cyst toward the nipple. • The cyst may contain debris.
  53. 53. Intracystic Papilloma MRI: • Distended duct that may have high signal on T1WI if the duct contains proteinaceous debris or hemorrhage. • A round filling defect may be seen within the duct. • Papillomas enhance avidly with gadolinium.
  54. 54. Intracystic papilloma. Ultrasound in this -year-old woman with palpable lump in right breast showed small vascular mural-based nodule within fluid-filled cyst.
  55. 55. Intracystic Papilloma • The diagnosis of benign papilloma cannot be reliably made with imaging. • A biopsy must be performed, and the appropriate classification of this lesion is BI-RADS 4.
  56. 56. Necrotic Neoplasms • Must always be considered in DDx of a complex cyst. • Necrosis most frequently develops in a rapidly growing invasive ductal carcinoma.
  57. 57. Necrotic Neoplasms US: • An irregular mass with a central cystic component. • Peripheral and some internal vascularity. • BI-RADS 4 and the need for performing a core biopsy.
  58. 58. Necrotic Neoplasms MRI: • An irregular or, less commonly, a circumscribed mass. • Heterogeneous or rim enhancement.
  59. 59. Multiple irregular masses with associated pleomorphic calcifications.
  60. 60. Two of masses show complex cystic lesions with areas of internal avascularity, consistent with necrosis, and other areas of internal vascularity, consistent with viable tumor.
  61. 61. Summary • Cystic lesions are commonly encountered in breast imaging. • Careful attention to the detailed characteristics of the cystic mass and correlation with patient history.
  62. 62. Cystic Masses of the Breast Simple cyst or not ? Not simple cyst imaging-guided intervention is necessary to exclude a solid mass.
  63. 63. Simple Cysts – Sonographic criteria set forth by Stavros: • Anechoic. • Well circumscribed with a thin echogenic capsule. • Increased through-transmission. • Thin edge shadows. – BI-RADS 2
  64. 64. Simple cyst Complicated cyst Complex cyst • Simple cyst • Galactocele • Galactocele • Galactocele • Hematoma • Hematoma • Hematoma • Oil cyst. • Fat necrosis. • Oil cyst. • Abscess. • Abscess. • Necrotic tumor. • Papillary tumor. • Atypical ductal hyperplasia. • DCIS

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