Hypoechoic nodules in breast

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Imaging echogenic breast masses

The ACR BI-RADS lexicon describes an echogenic breast mass on ultrasonography (US) as having an echogenicity greater than subcutaneous fat or equal to fibroglandular tissue.1 An echogenic sonographic appearance is attributed histologically to fat, fibrous contents, vascular origin or high cellularity of lesions.2,3

Echogenic breast lesions are uncommon, comprising only 0.6-6% of breast masses and 0.6% of all biopsied lesions.3,4 The majority of these lesions are benign. There are rare malignancies that can present as echogenic masses however, and thorough sonographic assessment according to the ACR BI-RADS criteria must be performed to correctly categorize these lesions and avoid misdiagnosis.

In this article, we will review the imaging features of common benign and malignant echogenic breast lesions on ultrasound (Table 1), emphasizing their correlation with clinical history, mammographic appearance, lesion location and ultrasound features to establish a correct differential diagnosis, determine the need for biopsy and assess the imaging-pathology concordance after biopsy.

Benign hyperechoic lesions

Fat necrosis

Fat necrosis is a common benign entity; it can result from direct trauma, surgery, radiation therapy or infection. On imaging it can mimic malignancy depending on the extent of histiocytic infiltration, hemorrhage, fibrosis, and calcification.2,5

The ultrasound appearance of fat necrosis is variable, ranging from cysts to complex cystic masses to hyperechoic masses.6 On mammography (MG), fat necrosis can present as lipid cysts, calcifications, focal asymmetries, spiculated masses or architectural distortion.4 Careful correlation with the patient’s history and the mammogram findings is prudent to suggest the diagnosis and avoid biopsy (Figure 1).

Fibroadenoma

Fibroadenomas are common benign breast lesions that are composed of stromal and epithelial components, are hormonally sensitive, and more frequent in younger women.3 On US, they typically present as an oval circumscribed mass, and >90% are uniformly hypoechoic. Rarely, they present as hyperechoic (4%) masses (Figure 2).7

Fat necrosis and fibroadenoma were the most frequent observed benign pathologies on ultrasound guided core biopsies of hyperechoic lesions.8

Lipoma

Lipomas are common benign fatty tumors in the breast that are composed of mature lipocytes, usually subcutaneous in location and often unilateral and solitary.2,4 On ultrasound, lipomas can appear as hypoechoic, isoechoic, or hyperechoic masses.4 On mammography, it presents as a radiolucent fat density mass surrounded by a thin fibrous radiopaque capsule confirming benignity (Figure 3).2,4

Angiolipoma

Angiolipomas are composed of mature lipocytes with variable vascular proliferation.9 The pathologic hallmark is scattered microthrombi in small blood vessels.4 On US, angiolipomas are commonly round or oval sub-cutaneous isoechoic to hyperechoic masses with internal vascularity.4,9 Mammography usually shows a dense mass or mixed density asymmetry.4,9 There are no specific imaging features of angiolipomas however, and biopsy is needed for confirmation.4,9

Hematoma

Breast hematoma is a localized collection of blood that can result from direct trauma, surgery, biopsy or rarely occur spontaneously in those with coagulopathy.4,9 The US appearance depends on the age of blood products; it can be hyperechoic from the acute to chronic stages.9 Lipomas, fat necrosis, primary breast cancer and hematologic metastases are in the differential diagnosis of a hyperechoic hematoma.9 Correlation with the patient’s clinical history is essential for the correct diagnosis. A history of trauma favors hematoma. When there is no clear history of trauma or a known extramammary malignancy, a short term follow-up or biopsy may be indicated to exclude malignancy (Figure 4).4,9

Hamartoma (Fibroadenolipoma)

Hamartomas have an incidence of 0.1-0.7% in the breast.3,9 They are composed of variable proportions of fat, glandular and fibrous tissue which determines their imaging appearance.3,9 Frequently they are asymptomatic, but they can present as painless masses. On mammography, hamartomas appear as mixed density (reflecting the fat to stroma ratio), circumscribed masses surrounded by a pseudocapsule.9 At US, these masses are compressible by the transducer and the echo pattern is usually hypoechoic, isoechoic, or mixed echogenicity; but 12-43% of hamartomas appear hyperechoic.3 If it increases in size or density on mammogram or the appearance is atypical, further workup with US and core biopsy are indicated (Figure 5).9

Silicone granuloma (siliconoma)

Siliconoma is an inflammatory mass arising from the presence of free silicone, related to extracapsular rupture or free silicone injection.4,10 On mammography, a silicone granuloma appears as a hyperdense mass of similar density to the silicone implant.4 Ultrasound shows a hyperechoic mass with well-defined anterior margin and posterior dirty shadowing “snowstorm sign” (Figure 6) or an anechoic cystic mass.4,10 Appropriate clinical or surgical history in the setting of aforementioned imaging findings is diagnostic for siliconoma.4

Pseudoangiomatous stromal hyperplasia (PASH)

PASH is a benign proliferative mesenchymal lesion of the breast stroma, seen in perimenopausal women or those receiving hormones.2,3 PASH may present as a rare nodular, and sometimes palpable, form or a diffuse form.2,3 At mammography, PASH can appear as a circumscribed, non-calcified mass or asymmetry. 2,3 At US, PASH often appears as an ovoid or ill-defined, heterogeneous mass and rarely can be hyperechoic.2,3 The imaging features of PASH are not specific, and biopsy is necessary to exclude malignancy (Figure 7).4

Abscess

Abscess is a collection of pus within the breast, usually from mastitis, and presents with pain, erythema and fever.4,11 Abscesses can be classified as “puerperal” (related to childbirth or lactation) or “nonpuerperal”.11 Puerperal abscess are caused by penetration of staphylococcus aureus through a cracked nipple.4,11 Nonpuerperal abscesses are often associated with diabetes, smoking, obesity, and black race and can be subareolar or peripheral.4,11 At US, an abscess may be echogenic, but more often is a complex cystic mass with peripheral vascularity (Figure 8).4,11 Failure to respond to antibiotics and persistence on imaging , should prompt biopsy to exclude inflammatory breast cancer.4,11

Duct ectasia

Duct ectasia is dilation of the retroareolar ducts from chronic inflammation.4,12 Clinically, it can be asymptomatic or present with nipple discharge. US shows anechoic dilated ducts with or without an avascular intraductal mass.4,12 Intraductal masses can have both benign and malignant pathologies: duct ectasia, fibrocystic change,papillary lesion, DCIS, and IDC.4 Central duct location, multiple similar appearing ducts without internal vascularity, smooth wall and lack of adjacent mass supports a benign pathology.4,12

Epidermal and sebaceous cysts

Epidermal and sebaceous cysts are common dermal lesions and clinically indistinguishable.4,13 Both are retention cysts arising from hair follicles plugged with keratin.13 They are usually palpable and may become inflamed with discharge seen from a small skin orifice.13 US appearance can be cystic, hypoechoic, or echogenic depending on the internal contents (Figure 9).13 Ultrasound demonstration of internal vascularity should prompt biopsy. In contrast, a dermal tract confirms a benign skin lesion.4,13 Needle biopsy of a suspected skin cyst should be avoided as rupture of the cyst can incite an intense inflammatory reaction.13

Galactocele

Galactoceles are milk filled retention cysts caused by blockage of the breast lactiferous duct.4 They are common in pregnant or breast-feeding woman, typically presenting as a painless lump. The mammographic and ultrasound appearance depends on the percentage of fat and protein.14 A galactocele that is predominately milk content has fat density on mammogram and is hyperechoic on US (Figure 10).4,14 Aspiration of a galactocele is both diagnostic and therapeutic, yielding milky fluid.14

Hemangioma

Hemangiomas are common vascular tumors seen in the breast.3,9,15 Pathologically, there are two types: capillary and cavernous (more common subtype) related to the size of their vascular channels on histology.9,15 On US, they are usually superficial, oval, circumscribed masses. Their echotexture may be hypoechoic, isoechoic, or less commonly hyperechoic (33% of cases).3,9,15 The imaging appearance is not specific and biopsy is performed for diagnosis. Excessive bleeding can occur during biopsy, a clue to the diagnosis. Rarely, excision after biopsy is recommended to exclude angiosarcoma.15

Malignant hyperechoic lesions

Although typically hypoechoic, a small subgroup of breast malignancies (0.5%) can present as hyperechoic lesions.4,9,16

Invasive ductal carcinoma (IDC)

IDC is the most common (75%) breast cancer, presenting as an asymptomatic screen detected or palpable mass +/-nipple discharge.3,4 At US, it is classically a hypoechoic mass with non-circumscribed margins; however, in 2% of cases it may be hyperechoic.3,4,17 Echogenic breast masses on sonography with mammographic features such as interval development, spiculated margin, suspicious microcalcifications, or architectural distortion warrant biopsy.4

Some invasive breast cancers have a small hypoechoic central focus enclosed by a larger hyperechoic halo. Scanning only through the hyperechoic halo, and not recognizing the central nidus can cause such lesions to be mistaken for a purely echogenic, likely benign finding (Figure 11).18 Additionally, during core biopsy of an echogenic mass with posterior shadowing, care should be taken to biopsy the solid anterior echogenic component.

Invasive lobular carcinoma (ILC)

ILC is the second most common (10%) breast cancer.19 Histologically, it infiltrates along the ducts in single rows without a desmoplastic reaction.9,19 The common mammographic appearance is a spiculated mass or architectural distortion (Figure 12A), however ILC can be occult on MG. Features such as absence of a definable mass and hyperechogenicity are relatively frequent on ultrasound (Figure 12B).9,18,19

Hyperechoic lesions are 10X more frequent in ILC, and metastases to the axillary nodes can also appear hyperechoic.9,16 The infiltrative spread of ILC results in more reflective surfaces for the ultrasound beam, the postulated cause of hyperechogenicity.19

Mucinous (colloid) carcinoma

Mucinous carcinoma is a rare breast malignancy, more common in older women.20,21,22 Histologically, it is subdivided into pure or mixed subtypes, depending on the mucin content. The pure subtype has a favorable prognosis with lower incidence of axillary metastasis.18 On mammography, mucinous carcinoma is usually a round or oval, dense circumscribed mass. Ultrasound typically shows an isoechoic or hypoechoic mass, but rarely can be hyperechoic.20,21,22 Ultrasound homogeneity favors a pure subtype, whereas heterogeneity is predictive of mixed subtype with less favorable histological grade (Figure 13).18

Lymphoma

Primary breast lymphoma, where the breast is the only organ affected, is rare.2 The more common secondary lymphoma is associated with extramammary involvement at diagnosis, and the most common subtype is diffuse B cell non-Hodgkin’s lymphoma.9 Lymphoma usually affects older patients, presenting as a palpable mass, sometimes with skin changes, edema and palpable lymph nodes.9,18 Mammogram findings include a circumscribed noncalcified mass, multiple masses or diffuse increased density with skin thickening.9,18,23 On ultrasound, breast lymphomas are typically hypoechoic and frequently hypervascular, less often a mixed echogenic (Figure 14) or echogenic mass.9,18,23

Metastasis

Metastases to the breast are rare, most commonly from melanoma, lung cancer, lymphoma and ovarian cancer.4 A typical presentation is fast growing, painless, palpable masses which can be bilateral.2 Mammography usually shows single or multiple circumscribed masses.2,18 Ultrasound shows hypoechoic or rarely hyperechoic lesions.2,18

An echogenic mass with internal vascularity requires biopsy, as more than half of breast lymphomas and the majority of melanoma metastases are hypervascular (Figure 15).4

Angiosarcoma

Angiosarcoma is an uncommon breast malignancy of endovascular origin with poor prognosis.24,25 There are two subtypes: primary, occurring sporadically in young women, and secondary, seen following breast cancer treatment in older women with prior history of radiation therapy or post-surgical lymphedema.2,24 Angiosarcomas present as palpable masses or skin discoloration which may be mistaken for bruising, delaying the diagnosis.24 Ultrasound often shows single or multiple, hypervascular, circumscribed or ill-defined hypoechoic masses. However 44% of angiosarcomas can present as mixed echogenic or echogenic lesions (Figure 16).9

Conclusion

Hyperechoic breast lesions, although rare, are not all benign. Occasionally a breast malignancy can present as a hyperechoic mass. The worrisome features in a sonographically echogenic lesion are: irregular shape, non-circumscribed margin, and nonparallel orientation.16 The decision to biopsy should be based on the most suspicious US features, correlation with the mammographic appearance, and the clinical history. When used in conjunction, this knowledge can help the radiologist formulate an accurate differential diagnosis and management plan.

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The hypoechoic Mass – Solid breast nodule or Lump

If a solid breast nodule appears on ultrasound to be ‘taller-than-wide‘, this is suspicious of malignancy.

The textbook may say: when a patient is scanned by ultrasound, they are usually in a supine position, and as a result the normal ’tissue planes’ on the breast will have a horizontal orientation. If a mass or part of the mass seems longer in the anteroposterior dimension (tallness) compared to either the sagittal or transverse dimensions (depth and width) then one can conceive that this may be a malignancy ‘aggressive enough’ to overcome normal breast tissue barriers and planes and grow vertically.

Umm.. sorry, I just can’t get my brain to think of breasts as horizontal and vertical 2D. Taller-than-wide irks me. Students, learn to love the curves and flow of things – it will help you notice more abnormalities.

Light and Dark on Breast Ultrasound

Hypoechoic breast lesions are suspicious for malignancy and on ultrasound imaging they will tend to look darker than the surrounding isoechoic fat. But malignancies can also show as isoechoic or hyperechoic lesions on breast ultrasound, so it is not a rigid rule by any means.

“Hypoechoic” with “smooth margins” is probably benign.

Microlobulations and duct extensions on Ultrasound

‘Microlobulations‘ on breast ultrasound indicate the presence of lots of very small (1mm to 2 mm) lobulations on the surface of a solid breast nodule. So, these lobulations will be quite similar to mammogram findings. As the number of these microlobulations increase, the probability that the breast mass is malignant also increases.

A ‘duct extension‘ appears on ultrasound as a ‘radially oriented’ projection that seems to arise from the lesions an axis oriented towards the nipple.

These projections often occur both within or around breast duct. Sometimes, you will see a duct extensions/projection has developed as a ‘bridge’ between multi-focal malignancies. This is different from a ‘branch pattern’ in which multiple extensions arise from the mass but extend away-from the nipple. A branching pattern tends to indicate a tumor growth advancing away from the nipple. Any apparent growth that is long enough to visibly fill a duct and branch, no matter what direction is goes, will be suspicious for malignancy. So, in this case, a biopsy will be necessary.

Posterior acoustic shadowing is suspicious for breast cancer

If a breast lesion shows posterior acoustic shadowing on ultrasound this means that there is something about the mass or around the mass which attenuates (reduces) the sonic beam strength in comparison to normal adjacent tissues.

Posterior acoustic shadowing is suspicious for malignancy, but tends to be associated with low to intermediate grade breast tumors.

What may be happening is that a slow growing breast tumor causes a secondary ‘desmoplastic response’ in the surrounding tissue. That means that dense fibrous and connective tissues are growing around the tumor as a kind of defense mechanism by the body; to ‘contain’ the neoplastic growth.

High grade malignancies in the breast grow too fast for this desmoplastic reaction to occur. However, posterior acoustic shadowing caused by a desmoplastic reaction can be found in benign breast neoplasms as well.

For example, fibrosis inside a tumor can block ultrasound from passing deeper, causing acoustic shadowing. But most benign tumors do not usually shadow unless they are calcified. So, again a biopsy may be necessary.

Calcifications on breast ultrasound are also suspicious for malignancy

Mammography is more sensitive than ultrasound when it comes to the detection of microcalcifications. Calcifications on a solid mass which appear ‘punctate’ are highly suspicious of malignancy and will usually appear on ultrasound as bright, punctate foci.

Since malignant breast lesions are typically either intensely or mildly homogeneous hypoechoic solid masses, on ultrasound this provides a ‘background’ which makes it easier to view calcifications sonographically. So, while calcifications are usually not seen on ultrasound, when they do appear vividly, it is highly suspicious for malignancy.

Spiculations and irregular borders have the highest positive predictive value for breast cancer

In terms of the suggested ‘BI-RADS‘ descriptors for malignant breast nodules, spiculated margins have a positive predictive value for malignant breast cancer of about 85%.

Masses showing an irregular shape or non-parallel orientation are also quite suggestive of malignancy, with a positive predictive value in the 62% to 69% range.

Other studies place a higher predictive value on the presence of an irregular border (about 88% predictive of malignancy). In addition increase in vascularity in the hypoechoic mass predicts malignancy about 82% of the time.

The ultrasound image below shows an irregular vascularized retroareolar mass, with calcifications. This is very likely to be infiltrating ductal carcinoma and your doctor will recommend a biopsy straight away.

A Benign hypoechoic mass on ultrasound

On ultrasound, a benign breast mass will typically be well defined and with smooth margins. The lesion might also be macrolobulated or with just 2 to 4 mild lobulations.

Benign breast lesions also tend to be ovoid or round in shape, and are often ‘wider-than-tall’ (which indicates a parallel orientation to the chest wall).

The echo texture of a benign mass will usually be homogeneous with an isoechoic, hyperechoic, to mildly hypoechoic echogenicity.

Some benign lesions will also exhibit mild acoustic enhancement on ultrasound, and might be slightly compressible. Vascularity in an ultrasound of a benign mass is variable and will depend on the specific histology of the suspicious mass.

In terms of sonographic features suggestive of benign breast lesions, a well circumscribed margin has a positive predictive value for being benign about 90% of the time. Also, an ‘oval shape’ indicates a benign lesion about 84% of the time. Breast lesions with a ‘parallel’ orientation are predictive of benignity almost 80% of the time.

Medics sometimes refer to the quality of the margins of a breast lesions on ultrasound as the ‘capsule‘. If the margin of the suspected mass seems well-circumscribed in both it’s inner and outer edges and is thin and even, this tends to be a sign of a benign mass. The lesion is ‘encapsulated’ by the compressed adjacent breast tissue and the mass itself is ‘pushing against’ this tissue, rather than infiltrating and invading it.

An Ultrasound Image of a Benign Mass

Sometimes you do see a mild undulation in contour on ultrasound with a benign fibroadenoma. But there should not be many of these mild ‘lobulations’. So, doctors consider any more than three lobulations as a potentially malignant sign. Of greater concern, are more numerous, smaller and sharper microlobulations than one tends to find in benign breast cancer tumors.

Breast lesions which appear as having a marked and uniform hyperechogenicity are highly predictive of a benign lesion. This feature typically represents normal fibrous changes within the breast.

But when there are some regions that show either hyperechogenicity or iso-echogenicity that are larger than normal (larger than either normal ducts or terminal ductal-lobular units) that would indicate a ‘medium’ level of concern. Indeed, this situation will probably result in a biopsy, particularly if these areas are not contained within fat lobules.

The ‘compressibility’ of a breast lesions on ultrasound refers to changes in the shape of a lesion as a result of the pressure applied by the probe. A solid, likely malignant, breast lesion will not ‘compress’ at all from the pressure of the probe.

However, a tumor of benign fibrous or glandular tissue, such as a fibroadenoma, will show some soft tissue compressibility. A benign breast fibroadenoma is usually oriented horizontally, more wide than tall. Often the compression of the scanner will cause a ‘flattened’ oval shape of a fibroadenoma, which would not occur with solid, malignant breast lesions.

Breast ultrasound sometimes detects abnormal axillary lymph nodes

Sometimes a breast ultrasound will pick up an enlarged node in the axilla. Many breast cancer oncologists would take an enlarged axillary node on ultrasound as proof positive for lymph node metastasis, even without a lymph node dissection. (Sometimes patients will not agree to a lymph node dissection to check for breast cancer metastasis). There is also a very small chance that enlarged lymph node could be a breast lymphoma.

The ‘odds ratio’ of potentially malignant sonographic features is highest for lack of a well-circumscribed margin

If the findings of ultrasound imaging of suspicious breast nodules where expressed as an odds ratio ( the odds of a person with these features as having breast cancer, as compared to an breast ultrasound where these features are not present) it may be suggested that breast lesions without a well-circumscribed margins are almost 17 times more likley to indicate malignant breast cancer.

Breast sonograms showing a heterogeneous echo texture are about 8 times more likely to be breast cancer. The ‘incompressibility’ of a breast lesion on ultrasound would tend to be almost 9 times more likely to be malignant.

Ultrasound interpretations are not always straight forward

Not all suspicious breast lesions will be straightforward in their ultrasound appearance and diagnosis. In some cases the findings are still inconclusive.

In this case, doctors will recommend short interval follow-up, or biopsy. But, one of the reasons to use ultrasound in the first place, is because medics suspect the hypoechoic mass is benign. So, the use of ultrasound is often to confirm the cystic nature of the lesion. For example, ultrasound can not always reliably confirm the diagnosis of a breast abscess.

Further Reading

  • Mammogram shows mass: What to do next
  • Common Mammogram findings
  • Breast Self-Examination
  • Breast Cancer Screening List of Posts
  • The Very Best Type of Breast Lump
  • Incidence and Survival Rates Post
  • Breast Cancer Symptoms

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More references for this section are on this page.

What Is a Hypoechoic Mass?

A hypoechoic mass can form anywhere in the body. It has a number of causes, including harmless ones.

A hypoechoic mass may be a tumor or abnormal growth. It may be benign or malignant. A benign tumor may grow but it will not spread (metastasize) to other organs. A malignant (cancerous) tumor can spread and invade other parts of the body.

In some cases, an ultrasound scan may be the first exam to check organs and tissues. It acts like a flashlight beam that shows shapes and shadows inside the body. An ultrasound cannot tell whether a hypoechoic mass is benign or malignant, or what has caused it.

If you have a hypoechoic mass, your doctor may recommend other tests to learn more about it, including:

  • CT scan
  • MRI scan
  • mammogram
  • biopsy
  • blood tests
  • follow-up ultrasound scans

Scans show features which may indicate a cancerous mass, such as:

  • a shadow or halo appearance
  • a fuzzy or irregular outline rather than smooth
  • a branching or starburst pattern
  • an angular shape rather than rounded or oval
  • fading rather than a uniform shade
  • fast growth
  • calcifications
  • tentacle-like growths
  • blood vessels in or around it

Breast

Breast cancer is the second leading cause of cancer-related death in women. Regular breast exams and screening are important. However, most growths found in the breast are benign. Most benign and malignant masses in the breast are hypoechoic.

Some benign masses in the breast can look like cancer because they have similar features.

Causes of benign hypoechoic masses in the breast include:

  • apocrine metaplasia
  • fat necrosis
  • fibroadenoma
  • fibrocystic change
  • fibromatosis or desmoid tumor
  • granular cell tumor
  • myofibroblastoma
  • pseudoangiomatous stromal hyperplasia
  • radial scar
  • sclerosing adenosis
  • spindle cell lesions
  • tubular adenoma

Other causes of benign masses include infections, trauma, and inflammatory conditions due to:

  • abscess
  • Cooper’s ligament
  • mastitis
  • granulomatous mastitis
  • breast infarction or calcification
  • diabetic mastopathy
  • fibrotic scars
  • sarcoidosis
  • injected silicone

Some malignant breast tumors are:

  • invasive ductal carcinoma
  • invasive lobular carcinoma
  • inflammatory breast cancer

Cancerous hypoechoic masses of the breast will typically have distinct characteristics, such as:

  • being deeper or taller than they are wide
  • having a duct extension
  • having both hypoechoic and hyperechoic lines radiating from its surface

Liver

Hypoechoic masses in the liver are commonly discovered during scans of the abdomen. They typically form as a single spot in the liver, but some people may have more than one. More than 20 percent of adults have a benign liver hypoechoic mass. They can occur in a healthy liver and may not cause symptoms. Some benign types are:

  • liver abscess
  • hepatic angiomas
  • focal nodular hyperplasia
  • hepatic adenomas

A cluster of hypoechoic masses in the liver may be caused by cancer that has spread from another part of the body. This is called liver metastasis. Other malignant causes include:

  • non-Hodgkin’s lymphoma
  • primary hepatic lymphoma
  • hepatocellular carcinoma
  • fibrolamellar carcinoma
  • bile duct cancer (cholangiocarcinoma)
  • angiosarcoma
  • sarcoma

Kidney

Ultrasound scans are particularly important in examining the kidneys, and changes in the tissues can be easily seen.

Almost 25 percent of hypoechoic masses in the kidneys are benign (noncancerous) or indolent (grows slowly) cancer, such as:

  • oncocytoma
  • angiomyofibroma

The most common malignant tumor in the kidney is renal cell carcinoma. It makes up almost 86 percent of all cancers of the kidney. This growth can be a hypoechoic mass.

Other cancerous hypoechoic masses in the kidneys include:

  • adenocarcinoma
  • clear cell carcinoma
  • kidney metastasis
  • papillary renal cell carcinoma
  • squamous cell carcinoma
  • transitional cell carcinoma
  • Wilms tumor

Uterus

Fibroids, also called leiomyomas or myomas, are common growths in the uterus. They show up as hypoechoic masses on an ultrasound. These benign tumors may occur in almost 70 percent of women by the age of 50. Fibroids are solid masses that are normally made up of fibrous connective tissue and smooth muscle. Most women with fibroids will have more than one.

Other types

In the pancreas, cancerous tumors and a benign condition called pancreatic and peripancreatic tuberculosis (PPT) are hypoechoic on an ultrasound.

Hypoechoic masses can also form in the:

  • stomach
  • testicles
  • ovaries
  • intestines
  • thyroid gland
  • skin

Ultrasound waves cannot see through the skull and other bony areas as well as they can in softer, tissue areas. The lungs are also difficult to view with an ultrasound because they’re air-filled. Other scans are commonly used to check for tumors in these areas.

Innovations in Breast Imaging: How Ultrasound Can Enhance the Early Detection of Breast Cancer

Solid Masses

If the solid nature of a breast mass has been determined, further categorization is usually of academic interest only. While certain characteristics on ultrasound may help differentiate between a benign lesion and a carcinoma, most of these lesions, except those that are quite small and benign-appearing, will need biopsy. The decision to follow rather than promptly biopsy these lesions must be made on the basis of a combination of clinical findings, mammographic appearance, and stability or change over time. On average, a lesion may be monitored about 6 months, but this time period is extremely variable.

Fibroadenomas and benign fibrous nodules can have a variable appearance ultrasonographically. A well-defined round or oval appearance is most common, although the lesions can be lobulated or even have irregular contours. Most are hypoechoic with homogeneous internal echoes. They have variable degrees of sound penetration. Although no posterior acoustic phenomenon is the most common finding, posterior acoustic enhancement may be seen. Other qualities that suggest a benign solid lesion over a carcinoma include the location and lateral dimension. Fibroadenomas tend to be located more superficially than are carcinomas. When fibroadenomas are oval, their long axis is usually parallel to the skin surface in keeping with their growth along breast tissue planes. A ratio of the lateral to the anterior-posterior diameter of greater than 1.0 suggests that the lesion is benign.

Unfortunately, carcinomas also have a variable ultrasonographic appearance. The classic description is that of an ill-defined hypoechoic mass with a heterogeneous interior and posterior acoustic shadowing (Fig. 6). However, on occasion carcinomas can be quite well-defined and may even show posterior enhancement.

Figure 6. Ill-defined hypoechoic mass is classic with carcinoma. In this infiltrating carcinoma, heterogeneous internal pattern demonstrates both hypoechoic and hyperechoic regions and jagged margins.

When a solid nodule demonstrates all of the characteristic findings of a benign lesion including homogeneous echotexture, a well-circumscribed ovoid shape, a thin echogenic rim, good sound transmission, and thin edge shadows, it can be classified as probably benign. These lesions have less than a 5% chance of malignancy. A single atypical or malignant characteristic prevents such a classification. Most often it is the small fibroadenoma (<1cm) that can be diagnosed as probably benign and, if so desired, be observed clinically. Larger fibroadenomas tend to have either a heterogeneous interior or lobulated margins and must therefore be classified as indeterminate. These will require biopsy to confirm the diagnosis (Fig. 7).

Figure 7. This classic suspicious ultrasound lesion demonstrated heterogeneous internal pattern with both hypoechoic and anechoic areas; indistinct, even jagged, margins; irregular posterior shadowing; and lateral over anterior/posterior ratio of less than 1. On core biopsy, this indeterminate lesion was found to be infiltrating carcinoma.

Benign and malignant characteristics of breast lesions at ultrasound

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    • breast screening programmes
  • mammography
    • breast imaging and the technologist
    • forbidden (check) areas in mammography
    • mammography views
      • craniocaudal view
      • mediolateral oblique view
      • additional (supplementary) views
        • true lateral view
          • mediolateral view
          • lateromedial view
        • lateromedial oblique view
        • late mediolateral view
        • step oblique views
        • spot view
        • double spot compression view
        • magnification view
        • exaggerated craniocaudal (axillary) view
          • XCCL view
          • XCCM view
        • cleavage view
        • tangential views
        • caudocranial view
        • bullseye CC view
        • rolled CC view
        • elevated craniocaudal projection
        • caudal cranial projection
        • 20° oblique projection
        • inferomedial superolateral oblique projection
        • Eklund technique
    • normal breast imaging examples
  • digital breast tomosynthesis
  • breast ultrasound
    • breast echotexture/tissue composition
    • breast ultrasound features: benign vs malignant
    • ultrasound evaluation of breast cysts
    • volumetric breast ultrasound
  • breast ductography
  • breast MRI
    • breast MRI classification flowchart
    • breast MRI enhancement curves
  • breast morphology
    • architectural distortion
    • asymmetry in breast size
    • breast density
      • asymmetrical breast density
    • breast implants
      • capsular contracture
      • gel bleed in breast implants
      • rupture of breast implants
        • keyhole sign
        • linguine sign
        • salad oil sign
        • snowstorm sign
        • stepladder sign
        • subcapsular line sign
        • teardrop sign
    • fibrocystic change
    • free silicone breast injections
    • parenchymal patterns in breast imaging
    • tubular breasts
  • breast pathology
    • malignant lesions
      • breast cancer
        • breast adenocarcinoma
          • ductal breast carcinoma
            • ductal carcinoma in situ (DCIS)
              • comedo-type ductal carcinoma in situ
              • non-comedo type ductal carcinoma in situ
            • invasive ductal carcinoma
              • extensive intraductal component
              • invasive ductal carcinoma not otherwise specified
                • scirrhous carcinoma of the breast
              • medullary carcinoma of the breast
              • mucinous carcinoma of the breast
              • Paget disease of the breast
              • tubular carcinoma of the breast
                • tubulolobular carcinoma of the breast
              • malignant papillary lesions of the breast
                • papillary carcinoma of the breast
                  • intracystic papillary carcinoma of the breast
          • lobular breast carcinoma
            • lobular carcinoma in situ (LCIS)
            • invasive lobular carcinoma of the breast
        • adenoid cystic carcinoma of the breast
        • apocrine carcinoma of the breast
        • breast cancer metastases
          • metastatic intramammary lymph node
        • breast lymphoma
          • breast implant-associated anaplastic large cell lymphoma
        • breast sarcoma
          • angiosarcoma of the breast
          • pleomorphic sarcoma of the breast
          • fibrosarcoma of the breast
          • myxofibrosarcoma of the breast
          • leiomyosarcoma of the breast
          • primary osteosarcoma of the breast
        • inflammatory carcinoma of breast
        • intracystic breast cancer
        • male breast cancer
        • malignant phyllodes tumor
        • metastases to the breast
        • metaplastic carcinoma the breast
        • gamuts
          • multifocal breast cancer
          • pregnancy-associated breast cancer
          • radiation-induced breast cancer
          • recurrent breast cancer
          • residual breast cancer
          • metachronous breast cancer
          • multicentric breast cancer
          • synchronous breast cancer
          • triple receptor negative breast cancer
          • well-defined breast cancer
    • borderline breast disease / high risk breast lesion
      • atypical ductal hyperplasia
      • atypical lobular hyperplasia
      • columnar alteration with prominent apical snouts and secretions (CAPSS)
      • flat epithelial atypia
      • lobular intraepithelial neoplasia (LIN III)
      • papillary lesions of the breast
      • radial scar / complex sclerosing lesion
      • sclerosing adenosis
    • benign lesions
      • adenosis of the breast
        • blunt duct adenosis of the breast
        • microglandular adenosis of the breast
      • benign papillary lesions of the breast
        • papilloma
          • solitary papilloma of breast
            • central solitary papilloma of breast
            • peripheral solitary papilloma of breast
            • intraductal papilloma
              • sclerosing papilloma
          • multiple papillomata of breast
            • juvenile papillomatosis of breast
      • breast cyst
        • breast sebaceous cyst
        • complex breast cyst
      • breast hematoma
      • breast hamartoma
        • breast within a breast
      • breast lipoma
      • ductal adenoma of the breast
      • epidermal inclusion cysts of the breast
      • fat necrosis of the breast
      • fibroadenoma
        • complex fibroadenoma
        • giant fibroadenoma
        • juvenile fibroadenoma
      • granular cell tumor of the breast
      • gynecomastia
      • lymphocytic mastitis
        • diabetic mastopathy
      • ​mammary fibromatosis
      • oil cyst
      • phyllodes tumor
      • post-surgical breast scar
      • post-radiation breast changes
      • post-traumatic fibrosis
      • pseudoangiomatous stromal hyperplasia (PASH)
      • pseudogynecomastia
      • tubular adenoma
    • breast calcifications (approach)
      • morphology
        • microcalcifications within breast
          • pleomorphic microcalcifications within breast
          • rounded microcalcification within breast
          • punctate microcalcification within breast
          • amorphous calcification within breast
        • macrocalcifications within breast
          • coarse macrocalcifications within breast
          • popcorn calcification within breast
          • egg shell/rim calcification within breast
      • distribution
        • cutaneous calcification
        • diffuse/scattered calcification
        • regional calcification
        • clustered calcification / grouped calcification
        • linear calcification
        • segmental calcification
      • location
        • lobular calcification within breast tissue
        • intraductal calcification within breast tissue
        • milk of calcium within a breast cyst
        • vascular calcification in breast tissue
        • skin (dermal) calcification in / around breast tissue
        • suture calcification within breast tissue
        • stromal calcification within breast tissue
        • artifactual calcification from outside the breast
      • suspicious breast calcifications
    • infection/inflammation
      • breast abscess
        • subareolar abscess
      • breast cellulitis
      • mammary duct ectasia
      • mastitis
        • puerperal mastitis
        • plasma cell mastitis
        • granulomatous mastitis
    • vascular lesions
      • breast aneurysm
      • breast varix
    • systemic disease
      • breast amyloidosis
      • granulomatosis with polyangiitis: breast manifestations
    • gamuts
      • breast lumps
        • stellate breast lesions: causes (mnemonic)
      • giant breast masses
      • differential diagnosis of dilated ducts on breast imaging
      • fat-containing breast lesions
      • hereditary breast and ovarian cancer syndrome
      • non-palpable breast lesions
      • male breast disease
    • classification systems
      • ACR 5-tier system
      • BI-RADS
        • BI-RADS 0
        • BI-RADS 1
        • BI-RADS 2
        • BI-RADS 3
        • BI-RADS 4
        • BI-RADS 5
        • BI-RADS 6
      • Nottingham classification
      • RCR 5-point system
      • Tabar 5-tier grading system
      • WHO classification of breast tumors
  • breast cancer staging

Ultrasound of left breast showing a hypoechoic nodule with a maximum diameter of 9 mm with ill defined margins. 

… is estimated that less than 0.5% of breast cancer is represented by malignant lymphomas, 17% of secondary breast localizations are lymphomas, and 0.7% of all NHL have a breast localization 1-5 . Primary breast lymphoma is a rare disease (accounts for 0.04% to 0.5% of all breast malignancies) and even more rare is a metastatic local- ization of lymphoma to the breast (accounts for 0.07% of all breast malignancies), which is usually associated to other extranodal lymphomas 1-5 . A 65 year old lady presented to our department with a cutaneous nodule in the left scapulohumeral region, as- sociated with localised itching, without systemic signs or symptoms. The cutaneous nodule was clinically evident in the form of a hard, poorly mobile lump with respect to surrounding tissues. Histological diagnosis after sur- gical excision was of follicular B cell NHL. According to histological result, since the surgical excision was non radical, with the tumor extending to the resection margins (R1), an adjuvant radiotherapy in the left scapulohumeral region was delivered (40 Gy total in 20 fractions). The patient did not undergo any chemotherapy in view of the early stage of the lymphoproliferative disorder, which was limited to the cutaneous layer only, the lack of B symptoms, normal haematological and blood chemistry values, and the absence of lymphomatous colonies at the bone marrow biopsy. Staging of the NHL was complet- ed with a total body multi-slice computed tomography (MSCT) and ultrasound examination targeted to most common lymph node sites of metastasis (axilla, groin, and neck), thereby confirming the solitary local manifes – tation of the lymphoproliferative disorder. Clinical and radiological follow-up examinations were always negative for the next three years during which the patient remained in complete remission. Ap- proximately three years after the diagnosis of follicular NHL, a screening mammography revealed the presence of a nodular opacity 10 mm in size with ill-defined mar – gins in the retroareolar region of the left breast (Figure 1 craniocaudal and oblique projections). A complementary ultrasound examination in this site showed a hypoechoic nodule with a maximum diameter of 9 mm, characterized by a non homogeneous echo- graphic structure, with ill defined margins (Figure 2). The above findings were suspicious for malignancy. Ultrasound examination also revealed a 16 mm lymph node in the homolateral axilla with a conserved hilar structure, however with a slightly thickened cortex, and hence of doubtful pathological significance. During the same ultrasound sitting, a fine needle aspira – tion cytology was performed which confirmed the presence of malignant cancer cells, with C5 grading, according to the European Guidelines for quality assurance in breast cancer screening and diagnosis 6 . Histopathology following central quadrantectomy of the left breast and sentinel node biop- sy in the homolateral axilla showed an infiltrating ductal carcinoma with intermediate grade of differentiation (G2) with an extensive solid-type intraductal component. Senti- nel node examination was free of metastasis. Following a multidisciplinary team meeting, in view of the local exten- sion of the disease, the endocrine responsiveness, and the clinical history, the patient was advised to undergo a 5-year adjuvant endocrine therapy with an aromatase inhibitor. One year after the diagnosis of breast carcinoma, this being 4 years after diagnosis of cutaneous NHL, dur- ing which the patient was in complete remission for this lymphoproliferative disorder, the NHL re-presented itself with both a scapulohumeral local relapse and a right su- perior external quadrant breast metastasis. The breast lo- calization was identified during clinical examination, and subsequently investigated with mammography (Figure 3 craniocaudal and oblique projections), ultrasound (Figure 4), and a fine needle aspiration cytology: the latter con – firming the presence of a metastasis of the lymphoprolif – erative disorder. After a few days the patient underwent a day-sur- gery procedure under local anaesthetic to remove the left scapulohumeral cutaneous nodule and the right breast nodule under ultrasound guidance. The histopathology indicated that both lesions were referable to cutaneous and breast localizations of follicular B cell non-Hodgkin lymphoma (Immunophenotype of the neoplastic popula- tion was positive for CD10, bcl-2, CD20, and negative for CD3. The proliferation fraction (Ki-67) was equal to 30%. Molecular analysis revealed a translocation t(14,18) involving bcl-2 gene in a small percentage of neoplastic cells (5%)). The re-staging of the lymphoproliferative disease by diagnostic imaging (MSCT, ultrasound ex- amination) and bone marrow aspiration did not show any evidence of metastasis elsewhere, thereby confirming the local cutaneous relapse and the right breast localization as the only sites of disease. It was decided that chemo- therapy and immunotherapy (Clorambucil and Ritux- imab) were needed to treat the cutaneous lymphoma in addition to the aromatase inhibitor which the patient was already taking for the treatment of the breast carcinoma diagnosed 1 year previous to this. As part of the clinical follow up 1 year later, bilateral mammography showed opacity of 10 mm in size with ill defined margins in the right superior external quadrant; with a complementary ultrasound examination showing a hyperechoic area of 12 mm in size referable to post biopsy changes, at the site of the previous lymphatic disease . The patient is cur- rently performing all routine examinations as standard follow-up for breast carcinoma and lymphoproliferative disorder. The role of radiotherapy in the treatment of both Hodgkin and non-Hodgkin lymphoma is well estab- lished. Some studies reported a possible aetiological role of radiotherapy in the development of breast carcinoma following treatment of NHL 7-9 , and in the development of breast cancer following treatment Hodgkin lympho- mas 10-15 . The risk seems to be related to the radiation dose received by the patient 10 . Such an aetiological role could also be used to explain our clinical case. A causal relationship between the radiotherapy (40 Gy total dose) for adjuvant treatment of the left scapu- lohumeral cutaneous nodule, and the onset of infiltrating ductal carcinoma in homolateral breast could be hypoth- esized. On the other hand, the two neoplasms could have no causal relationship but be unrelated events, in view of the long latency period described in literature between the radiation dose and onset of the neoplasm, although in the case being assessed, only 3 years passed between the radiotherapy for NHL and the diagnosis of homolat- eral ductal carcinoma. Another interesting aspect is the progression of NHL: the local cutaneous relapse and the secondary localization in the right breast occurred with- out systemic involvement, both from a clinical (absence of B symptoms) and haematological-biochemical point of view (normal blood chemistry and heamtaological val- ues, absence of lymphomatous colonies from the bone marrow aspiration). The right breast localization is also unusual since it cannot be connected by simple lymphatic diffusion, the site of the primary lymphoma being the left scapulohumeral region. From a diagnostic point of view, imaging techniques are of limited use in the differential diagnosis of the two neoplastic disorders however both mammography and ultrasound examination can suggest the presence of a suspicious lesion in an oncological sense. We have presented our case report regarding this clinical scenario in which a patient developed a ductal carcinoma of the breast 3 years post treatment of an ex- tranodal NHL, followed by NHL relapse 1 year later at the original cutaneous site of disease and metastasis to the contralateral …

PICTORIAL ESSAY

Year : 2014 | Volume : 1 | Issue : 1 | Page : 45-51

The study of different presentations of breast lumps in radiographic imaging
Shalini Saraswat1, Amit Kumar2
1 Assistant Professor, Department of Radiodiagnosis, Teerthanker Mahaveer Medical College & Research Centre, Moradabad – 24400, U.P, India
2 Assistant Professor, Department of ENT, Teerthanker Mahaveer Medical College & Research Centre, Moradabad – 24400, U.P, India

Date of Web Publication 3-Jul-2017

Correspondence Address:
Shalini Saraswat
Assistant Professor, Department of Radiodiagnosis, Teerthanker Mahaveer Medical College & Research Centre, Moradabad, U.P
India

Source of Support: None, Conflict of Interest: None

Abstract

Introduction: Breast USG is an established and accurate tool for the primary evaluation of breast lumps and pathology. It also compliments X-ray mammography in further evaluation and characterization of breast masses and thus avoids surgeries in benign breast diseases and pathology. Method: For USG examination of the breast lumps, a linear-array transducer of 5-7 MHz frequency is required with a good resolution machine. Results: We present a pictorial essay on the role of USG in evaluation and characterization of various breast lumps and pathology. Conclusion: Breast sonography considerably improves the visualization and evaluation of lumps in mammographically radiodense breasts and helpful in the characterization of it, either as solid or cystic lesion. It also improves the specificity of X-ray mammography when used as an adjunct to it. It is also helpful in guiding FNAC/biopsy from the breast masses.

Keywords: Breast, Sono-mammography,ultrasound, X- ray mammography

How to cite this article:
Saraswat S, Kumar A. The study of different presentations of breast lumps in radiographic imaging. Acta Med Int 2014;1:45-51

Introduction

Because of increased incidence of breast cancer in females, a breast lump may worry both the patient and clinician. Breast ultrasonography is appropriate investigation for the initial evaluation of a female younger than 30 years with a palpable breast lump and also helpful in the evaluation of X-ray mammographic abnormalities i.e. masses, focal asymmetric densities, areas of architectural distortion and palpable abnormalities not seen mammographically. Additional imaging with MRI and FNAC/biopsy might be needed in the cases, for the confirmation of the sonographic diagnosis.
USG guided core-needle biopsy (CNB) is a frequently performed and accurate alternative to stereotactic/excisional biopsy., USG may be guided aspiration of symptomatic cysts, complicated cysts, and possible abscesses are also readily performed.
USG feature analysis of breast masses continues to improve, though interobserver variability continues to be a problem, in avoiding biopsy., An illustrated Breast Imaging Reporting and Data System (BI-RADS) ultrasonographic lexicon helpful in improving observer performance.

Method

For USG examination of the breast lumps, a linear-array transducer of 5-7 MHz frequency is required with a good resolution machine. The patient is scanned in the supine position for the inner part of thebreast and then in the contralateral posterior oblique position with the ipsilateral raised arm, for the axilla and upper outer quadrants.

Result & Discussion

Normal anatomy

Figure 1: Normal breast anatomy on USG. a) hyperechoic-skin, b) hypoechoic-subcutaneous fat, c) hyperechoic-fibroglandular breast parenchyma, d) hypoechoic-retromammary fat, e) hyperechoic-muscle. c) Cooper’s ligaments
Click here to view

On sonography, normal breast parenchyma has alternate hyperechoic and hypo echoic layers:
Skin – hyperechoic
Subcutaneous fat – hypoechoic
Fibroglandular breast parenchyma – hyper echoic
Retromammary fat – hypo echoic
Muscle (Pectoralis major)– hyperechoic
Cooper’s ligaments are echogenic bands that suspend the breast from the superficial layer of the fascia.
Ductal ectasia

Figure 2: Breast USG shows dilated ducts in Retroareolar region
Click here to view

Duct ectasia most commonly affects the ducts in Retroareolar region but may also involve the smaller peripheral ducts. USG shows tubular anechoic dilated structures or ducts filled with echoes, and there may be associated nipple discharge. Duct ectasia usually present as a painful breast and/or palpable lump, or the condition may be asymptomatic and apparent only at imaging as an incidental finding.
Breast cystsa,b

Figure 3a, 3b: Breast USG shows a simple anechoic cystic lesion with posterior acoustic enhancement (Fig.3a). Another complex cystic lesion with dense internal echoes, layered in dependent region (Fig.3b)
Click here to view

Simple cysts in the breast are anechoic lesions on USG, with a thin echogenic capsule, posterior acoustic enhancement, and thin clear edge shadow. Complex cysts are heterogeneous, have internal echoes, septations, thick irregular walls or internal solid components. Complex cysts, especially those with internal solid components, may turn out to be malignant on histopathology.
Intraductal and intracystic papillomas/papillary carcinoma a, b

Figure 4a, 4b: Intracystic (Fig.4a) and intraductal papillomas (Fig.4b). Breast USG in a 46-year-old female with a palpable lump and bloody right nipple discharge shows a complex cystic lesion with an intracystic, solid echogenic polypoidal mass (Fig.4a). Another patient with similar complaints shows a dilated duct in retroareolar region along with intraductal polypoidal solid echogenic component (Fig.4b)

Breast Papillomas may be intracystic a or intraductal b. They could not be differentiated from papillary carcinomas only by sonographic features. FNAC/biopsy of the lesions is required to rule out malignancy. Intraductal papillomas/carcinomas usually present with a complaint of bloody nipple discharge.
Fibroadenoma

Figure 5: Fibroadenoma. Breast USG in a 29-year-old female shows a homogenous, hypoechoic, gently macrolobulated lesion with edge shadow, suggestive of a fibroadenoma

Fibroadenoma is the most common benign breast tumor in young females. It may increase in size during adolescence, pregnancy and lactation. It may also present with atrophic changes after menopause. On USG, it is usually homogenous, well-defined, hypoechoic, oval, wider than tall, with/without posterior acoustic enhancement. The calcifications within a fibroadenoma are usually of the coarse variety and may show posterior acoustic shadowing on USG. Fibroadenomas with complex features on USG have a higher incidence of transformation into breast cancer.
Juvenile breast fibroadenoma

Figure 6: 13-year-old girl with unilateral breast hypertrophy. On USG, a large, well-defined hypoechoic mass lesion is noted in left breast

Juvenile fibroadenoma is the most frequent benign tumor of the breast in adolescents and young females, tends to be between 11 and 18 years, which coincides with the puberty onset.,
Giant breast fibroadenoma

Figure 7: Giant fibroadenoma: A large, well circumscribed, lobulated, hypoechoic mass lesion in right breast at 7 – 12 o’clock position measuring approximately. 10.2 x 8.4cm

Giant fibroadenoma is defined to be more than 5 cm in diameter, and/or weighing more than 500gm. Giant fibroadenomas are rare breast lesions, representing less than 4% of all fibroadenomas. They present as a rapidly growing, well circumscribed, unilateral breast mass lesion. Its close differential is Cystosarcoma Phyllodes Tumors on USG.
Intramammary/axillary lymph nodes a, b

Figure 8a, 8b: Breast USG in a 40 years female shows an enlarged intramammary hypoechoic lymph node in left axillary tail region with loss of fatty hilum a. Another patient with left axillary lymphadenopathy shows multiple enlarged hypoechoic lymph nodes on USG with increased vascularity on color Doppler b

Lymph nodes are most commonly located in the upper outer quadrant, primarily in the Axillary tail region. Hilar notch and fatty hilum should be visible to make the diagnosis. Normal intramammary lymph nodes are usually less than 1 cm in short axis diameter along with loss of fatty hilum and increased vascularity on color Doppler.
Galactoceles

Figure 9: Breast USG in a young woman with a palpable left breast mass who had recently given birth, shows a well defined lesion filled with uniform echoes in left breast at 3 o’clock position. On aspiration, this yielded a milky substance

It usually occurs during lactation or shortly after stoppage of breast-feeding, caused by an obstruction in milk duct. At X-ray mammography, galactoceles may present as an indeterminate mass, unless fat-fluid level is seen within. Even if the fat-fluid level is not present, a benign pathology can be considered, by the identification of fat within the lesion. US may show a complex mass. The diagnosis should make on the basis of the clinical history and aspiration.
Cystosarcoma phyllodes tumors

Figure 10: Breast USG in a 38 years old female with complaint of rapidly growing lump in the left breast, shows a well-defined, lobulated, hypoechoic, encapsulated, moderately vascular mass with multiple internal linear, anechoic “clefts” and cystic spaces

They are fibroepithelial stromal tumors of the breast. These can be either benign or malignant. They are rapidly growing tumors, with high recurrence rate and may even metastasize in rare cases. On USG, these are usually benign-looking lesions with internal clefts, cystic spaces and are moderately vascular on Doppler.
Breast abscess a, b, c

Breast abscess is usually present clinically with high-grade fever, painful breast lump, skin erythema and edema. Acute abscesses may occur during lactation, due to blockage in the duct with secondary milk collection and infection.
Breast edema

Figure 12: Breast edema: USG shows skin thickening and subcutaneous edema with a generalized increased echogenicity of the breast parenchyma

Edema of the breast can occur in inflammatory/infective conditions, following surgery or radiation. It may also occur due to venous or lymphatic obstruction as present in neoplastic etiology.
Lipomas

Figure 13: Lipomas: Breast USG shows a well-defined, ellipsoid, predominantly echogenic mass lesion seen superficially in the left breast parenchyma, suggestive of a lipoma

These are fatty tumors in the breast parenchyma and vary in appearance on USG, ranging from uniformly echogenic to heterogeneous or completely anechoic lesions e.g.: Oil cysts.
Hamartomas or fibroadenolipomas

Figure 14: Hamartoma/fibroadenolipoma: Breast USG in a 37 years old patient shows a soft, well-circumscribed tumor with mixed internal echogenic and hypoechoic areas and focal calcifications

These are fat-containing, benign tumors in the breast parenchyma along with varying amount of fibrous tissue. They are heterogeneous in nature with mixed internal hypoechoic and echogenic areas.
Fat necrosis in breast

Figure 15: Fat necrosis in breast: An ill defined echogenic mass lesion with internal hypoechoic areas, in a patient presented with a history of right breast trauma

Fat necrosis is a common entity. However, may pose a difficulty to clinicians and sonologist, because of its different manifestations and USG appearances. Fat necrosis may result from accidental trauma, after surgery or radiation therapy. When symptomatic, fat necrosis typically presents as a small, painless, ill-defined breast mass. The sonographic features are varied and depend on the degree of fibrosis in lesion. It may present as a solid echogenic mass, a complex mass with mural nodules or internal echogenic bands, an anechoic mass with posterior enhancement or shadowing, as an isoechoic mass. The margins range from well circumscribed to indistinct to spiculated. A mass with echogenic internal bands that shift in orientation with changes in patient position has been described as a specific sonographic indicator of fat necrosis. It is thought that these echogenic bands represent the interface between the fat and the serous–hemorrhagic components of fat necrosis.
Invasive ductal carcinoma

Figure 16: Invasive ductal carcinoma. Breast USG shows an ill-defined, irregular, microlobulated heterogeneously hypoechoic lesion with infiltrative and spiculated margins

These are usually irregular, ill-defined, microlobulated heterogeneous lesions with infiltrative, spiculated margins. They may be taller than wide in dimensions. Microcalcifications may be usually seen as echogenic foci within the lesion.
Invasive lobular carcinoma

Figure 17: Invasive lobular carcinoma. 71 years old female presented with a complaint of a palpable lump in the right breast. USG shows a large, ill-defined, heterogeneous, hypoechoic lesion with area of architectural distortion

Invasive lobular carcinoma is the second most common breast malignancy and may be seen in elderly females. Lesions have variable appearances on X-ray mammography and sonomammography so can be missed on X-ray mammography. On USG, tumor appearances are ranging from findings similar to ductal carcinomas to areas of architectural distortion. Some of these tumors may even not visualized on USG.
Medullary carcinoma

Figure 18: Medullary carcinoma. Breast USG shows a hypoechoic, well-circumscribed mass with posterior enhancement in left breast at 12 o’clock position

These are uncommon breast malignancy. On sonography, it shows benign feature like homogenous, hypoechoic lesion with well-circumscribed margins with/without posterior acoustic enhancement.
Mucinous carcinoma

Figure 19: Mucinous carcinoma. Breast USG shows an ill defined lesion with echogenic internal contents

It is also uncommon breast malignancy. The mucin contents of the tumor may be echogenic on USG.
Recurrent breast cancer

Figure 20: Recurrent breast carcinoma. 48 years old patient with a history of left mastectomy for a malignant mass, present with a palpable lump on the left chest wall after 3 years of surgery, USG reveals an irregular, microlobulated, taller-than-wide mass lesion on chest wall suggestive of tumor recurrence

Recurrence of tumor may occur even years after treatment of the primary breast malignancy. So follow up is required in all the cases. It may occur in the residual breast tissue or even in the chest wall in cases of complete mastectomy. It may metastasize even after primary surgical resection of the tumor.
Gynecomastia

Figure 21: Gynecomastia. In this male patient, breast USG shows an ill-defined, hypoechoic area of fibroglandular parenchyma with fatty tissues

Gynecomastia is more common in the male breast than malignancy. Usually it presents as palpable lump or asymmetry in the breast region. It is seen as a hypoechoic lesion in retroareolar region, similar to fibroglandular breast tissue of the female breast.
Male breast cancer

Figure 22: Male breast cancer. In a 60-year-old male patient with a palpable hard lump in the left breast USG reveals an irregular, hypoechoic mass lesion with multiple spiculations in retroareolar region

About 1% of all breast cancers occur in the male patient. If there is the presence of any lesion within male breast tissue on USG, histopathology is must as incidence of malignancy is high in male breast lesions. Sonography findings are similar as of female breast cancer.

Conclusion

Breast sonography considerably improves the visualization and evaluation of lumps in mammographically radiodense breasts and helpful in the characterization of it, either as solid or cystic lesion. It also improves the specificity of X-ray mammography when used as an adjunct to it.

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