Classic Papers in Breast Disease

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Core-needle biopsy was performed. Grey-scale ultrasound image shows well circumscribed hypoechoic nodule, with significant vascularity on power Doppler. The patient had a remote history of breast cancer treated with mastectomy. Gray-scale ultrasound showed an enlarged axillary node with abnormally thickened cortex. Core biopsy revealed metastatic breast cancer. Granulomatous mastitis: a year-old woman, postpartum, presenting with erythema, skin thickening and draining sinus.

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Grey-scale ultrasound image a , b showed irregular hypoechoic mass with peripheral vascularity. Special stains for fungus and mycobacterium were negative. Follow-up after conservative treatment and steroids were done. The follow-up ultrasound image d revealed significant improvement. Findings were consistent with granulomatous mastitis. Mammogram a , b reveals a dense partially circumscribed mass in the upper outer quadrant with associated microcalcifications.

With a reported incidence of 1. Though, any tumour can metastasise to the breast, non-mammary metastatic lesions are rare. Imaging entails targeted ultrasound and diagnostic mammography. Most metastases appear as well-circumscribed masses which lack calcifications, although psammomatous calcifications may be seen if the primary is of ovarian or thyroid origin.

Metastatic lesions are more likely multiple and bilateral and are often found in the subcutaneous fat, whereas primary breast cancers develop in glandular tissue. Percutaneous core biopsy permits diagnosis when clinically needed to guide management. Substantial physiological changes during pregnancy and lactation make it challenging to evaluate patients presenting with a breast problem.

Most findings in pregnant and lactating patients are benign. An awareness of the imaging features of the various benign and malignant diseases during these physiological states, permits optimal management. Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author s and the source are credited.

Skip to main content Skip to sections. Advertisement Hide. Download PDF. Breast disease in the pregnant and lactating patient: radiological-pathological correlation. Open Access. First Online: 25 July Objective Substantial physiological changes occur during pregnancy and lactation, making breast evaluation challenging in these patients.

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Conclusions Evaluation of the pregnant and lactating patients who present with a breast problem is challenging. An overall diffuse increase in breast density accompanied by breast enlargement is commonly seen on mammography Fig. Murphy et al. The imaging features of breast cancer on the mammogram are identical to those seen in non-pregnant women These are spiculated or irregular masses, pleomorphic linear branching or grouped microcalcifications, focal asymmetries and architectural distortion.

Detection is sometimes difficult as the overlying dense tissue may obscure the findings. Open image in new window. There is a limited role for breast MRI during pregnancy as intravenous gadolinium crosses the placenta. The routine use of contrast-enhanced MRI in the evaluation of pregnant patients is not appropriate and is recommended only in situations where the risk—benefit ratio is clear [ 10 ]. Contrast enhanced MRI can be safely performed in lactating women.

Background enhancement on MRI refers to normal enhancement in glandular tissue. The degree of background enhancement can influence sensitivity of MRI [ 11 , 12 , 13 ]. Lactating breast tissue has a uniformly long T2, resulting in diffuse high signal intensity on T2-weighted MR images. Normal lactating tissue shows rapid enhancement followed by an early plateau of enhancement, unlike normal non-lactating breast tissue, which shows mild and progressive enhancement [ 14 ] Fig.

Breast cancers are visible during lactation owing to their lower signal intensity on T2-weighted images and more intense initial contrast enhancement with early washout compared with normal breast tissue [ 14 ] Fig. When the lactational change presents as a palpable or radiographically visible mass, the benign finding is referred to as a lactational adenoma.

It is the most common breast mass during pregnancy [ 17 ]. Usually during the third trimester it reduces in size or regresses spontaneously after delivery. It occasionally recurs with subsequent pregnancies. Lactational adenomas can mimic other benign breast tumours such as fibroadenomas, phyllodes tumour and circumscribed malignancies. Although these neoplasms are known to grow due to rising oestrogen levels associated with pregnancy, their aetiology is somewhat ambiguous as some suggest they represent a variant of fibroadenoma, tubular adenoma, lobular hyperplasia or arise de novo.

The consensus is they are tubular adenomas with lactational changes [ 18 ].

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These tumours commonly lack a capsule, which may explain the absence of a discernible margin. On histopathology, both lactational change and lactational adenoma show lobular expansion with numerous enlarged and dilated acini separated by connective tissue. On ultrasound, lactational change occasionally is visible as a homogeneous to heterogeneous mass Fig. In general the features are benign; however, the mass can mimic malignancy, showing irregular margins and posterior shadowing, warranting biopsy [ 19 , 20 , 21 ]. Mammography most often shows a circumscribed mass with no associated calcifications.

Benign calcifications are sometimes seen in lactating patients undergoing imaging for a breast problem or for screening.

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In general, calcifications are not a common mammographic feature of lactational or post-lactational breast. On mammography, these are usually diffuse or regional, predominantly punctate calcifications, and could be bilateral or unilateral Fig. Rarely, the calcifications may be grouped, and in those cases, stereotactic biopsy may be indicated to exclude malignancy Fig.

In a series of case reports, all cases had bilateral and diffuse distribution with focal groups, of which some had a linear branching pattern, some had a casting pattern [ 22 ] and some diffuse with regional distribution [ 23 ]. On histology, the calcifications are seen in both ducts and lobules. The small rounded microcalcifications in the lobular acini likely reflect the granular pattern as seen as focal groups, whereas larger calcifications in dilated ducts correspond to the casting pattern on mammography[ 22 ].

These are possibly related to milk stasis or apoptosis associated with lactation [ 24 , 25 ]. Patients typically present with a tender pea-size to wedge-shaped lump [ 28 ], which is related to mechanical obstruction secondary to a change in infant feeding pattern, or scarring from previous surgery, or infection [ 29 ]. This may be in the retroareolar region but can occur in any location in the breast. On ultrasound, the imaging appearance is variable, ranging from a discrete non-compressible mass or duct Fig.

For recurrent blocked ducts, an obstructive lesion should be excluded. Ultrasound-guided aspiration is rarely performed as this is typically managed with warm compresses, massage and frequent milk expression. Direct aspiration could be performed for symptom relief and diagnosis. If symptoms do not resolve this may progress to mastitis [ 30 ]. WHO defines mastitis as an inflammatory condition of the breast which may or may not be accompanied by infection.

It is most commonly seen during lactation with a reported incidence of 6. Although various aetiologies likely exist milk stasis, blocked ducts, engorgement or physical injury to the breast , one more common theory is that poor attachment of the infant to the breast leads to cracking of the nipple epithelium, creating a retrograde path for bacteria to enter the breast tissue [ 32 ].

Milk stasis provides a medium for bacterial growth. The most common causative organism of lactation-related mastitis and abscess is Staphylococcus aureus. Patients can present with breast pain, redness, and swelling and may have flu-like symptoms. Imaging on ultrasound may reveal skin thickening, areas of decreased parenchymal echogenecity or increased fat echogenecity, increased vascularity on colour Doppler and reactive or enlarged axillary nodes [ 33 ] Fig.

Treatment typically entails antibiotics and frequent breast feeding or breast emptying to limit milk stasis. Treating mastitis promptly prevents abscess formation. It is the most common benign breast lesion in lactating women and can present in the third trimester, after delivery, or even after cessation of breast feeding. Galactoceles typically occur as a result of an obstructed duct leading to distension of proximal lobular segments. Patients most often present with a tender mass.

The imaging appearance of galactocele is variable, depending on the amount of fat, protein and water content [ 38 ]. On mammography, a mass with a fat-fluid level on the lateral projection is a diagnostic sign in the appropriate clinical setting. On ultrasound, most lesions appear benign with thin, well-circumscribed margins; the internal appearance may be homogeneous with low level echoes or heterogeneous, depending on its contents.

It may appear multicystic or have a complex echotexture Fig.

The margins vary from well-defined to ill-defined, depending upon the amount of surrounding inflammation. If asymptomatic, or if typical with a fat-fluid level, galactoceles can be managed conservatively. It is the most common benign breast tumour in young women. Women typically present with a firm mobile mass.

Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease
Classic Papers in Breast Disease Classic Papers in Breast Disease

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