Imaging of

benign breast
lesions
R1 Kannika Subprasert
Radiology Department
Thammasat University
 scope
• ANATOMY OF NORMAL BREAST TISSUE
• IMAGING OF THE BENIGN BREAST DISEASE

• Benign Cystic Lesions of the Breast • Solid Benign Lesions of the Breast • High-risk breast diseases
• CYST • FIBROADENOMA • PHYLLODES TUMOR
• FIBROCYSTIC CHANGE • INTRAMAMMARY LYMPH NODE
• GALACTOCELE • LIPOMA
• DUCT ECTASIA • FIBROMATOSIS
• EPIDERMAL INCLUSION CYST AND SEBACEOUS CYST • FAT NECROSIS
• HAMARTOMA
• Infectious and Inflammatory Diseases of the
Breast
• MASITIS AND ABCESS
 ANATOMY OF NORMAL BREAST TISSUE

• The breast lies on the anterior chest wall over the pectoralis major muscle and extends from the 2nd -6th rib in the MCL
• breast tissue spreads from the lateral edge of the sternum-anterior axillary line & often extends into the axilla as the tail of Spence
• The suspensory ligaments of Cooper: support to the breast and attach the breast to the underlying fascia and pectoral muscles.
 ANATOMY OF NORMAL BREAST TISSUE
Acini (terminal ductules)
lobule
terminal ducts (ductules)

interlobular ducts

excretory ducts
lactiferous sinus (ampulla)
lactiferous ducts

• The breast consists of 15 to 20 lobes, each emptying into a separate major duct terminating in the nipple. nipple
• Each lobe (comprises all of the lobules and excretory ducts ) is surrounded by connective tissue and is divided into many lobules.
• The branching system ends at the terminal duct lobular unit (TDLU), which consists of an interlobular duct and an associated lobule.
mammogram
• A, Normal mammogram, mediolateral oblique projection.
• Fibroglandular prominent ducts arising at the nipple (N).
• Fat is radiolucent.
• P, pectoral muscle.

• B, Normal mammogram, craniocaudal projection.

• FG, fibroglandular tissue;
• N, nipple.
 BREAST TISSUE composition
• The fatty breast tissue serves as a lucent background against which radiodense abnormalities can be identified, whereas normal FG tissue
can obscure a mass. The 4 categories of tissue composition:

• (A) almost entirely fat; tissue density sensitivity of mammography

• (B) scattered fibroglandular densities;
• (C) heterogeneously dense tissue
• (D) extremely dense tissue (which could obscure a lesion on a mammogram).
 Normal anatomic variations

• Accessory breast tissue can be seen anywhere

along the milk line but is most often observed
in the axilla. It can be either in continuity with
or separate from the breast

• A variant, visualization of the sternalis m. on

the MLO projection, is present in <10% of
people.
NORMAL ULTRASONOGRAPHIC ANATOMY
Normal skin ≤ 3 mm & consists of parallel white lines beneath the lines produced by
the transducer.

A layer of subcutaneous fat

The FG tissue is hyperechoic (white) compared with the fatty tissue (gray to black).

retromammary fat

The chest wall: pectoralis muscle, the ribs, & the parietal pleura that encases the thoracic
cavity.
 PATHOLOGY OF THE BREAST
• A wide variety of benign lesions in ducts and lobules are observed in the breast.
• Most of these lesions are identified mammographically, or less commonly they present as a palpable mass.
• These changes have been divided into the following 3 groups, according to the subsequent risk of developing breast cancer:
• 1) nonproliferative breast changes
• (2) proliferative breast disease
• (3) atypical hyperplasia.
 scope
• ANATOMY, AND ULTRASONOGRAPHY OF NORMAL BREAST TISSUE
• IMAGING OF THE BENIGN BREAST DISEASE

• Benign Cystic Lesions of the Breast • Solid Benign Lesions of the Breast • High-risk breast diseases
• BREAST CYST • FIBROADENOMA • PHYLLODES TUMOR
• FIBROCYSTIC CHANGE • INTRAMAMMARY LYMPH NODE
• GALACTOCELE • LIPOMA
• DUCT ECTASIA • FIBROMATOSIS
• EPIDERMAL INCLUSION CYST AND SEBACEOUS CYST • FAT NECROSIS
• HAMARTOMA
• Infectious and Inflammatory Diseases of the
Breast
• MASITIS AND ABCESS
Benign Cystic Lesions
Breast cyst
• Definition • Prevalence and Epidemiology
• Cysts are caused by over-distension of TDLU → filling with • Usually found in 40-50 years old women
liquid, fibrosclerosis of the loose connective intralobular tissue & • Presented with palpable breast mass or cyclic pain associated
coalescence of single dilated ductules in a polylobated mass up to
with menstrual cycle
a single tensive cyst.
• In ACR BI-RADS cystic lesions are divided into 3 types:
• Simple cysts: benign lesions;
• Complicated cysts :very low potential for malignancy involving the wall.
• Complex cyst may be benign or malignant and have both a cystic and
solid component (CNB or excisional biopsy is recommended) (4 types by
adapted from Berg et al criteria)
Benign Cystic Lesions
• Imaging Findings by Modality Breast cyst
• Mammography MLO

• Radiopaque, circumscribed mass

• A round, oval, or lobular shape
• Most cysts are no calcification

A well-defined, intermediate-density lesion is seen in the inner upper quadrant of the left breast.
https://radiopaedia.org/cases/birads-ii-lesion-simple-breast-cyst-2?lang=us
Benign Cystic Lesions
• Imaging Findings by Modality
Breast cyst
• Ultrasonography
• Simple cyst; A well circumscribed appearance, anechoic contents, a thin
echogenic external capsule, with posterior acoustic enhancement
• Complicated cyst; Cyst with thin septation or internal echo
• Complex cyst; Cyst with thick wall or thick septation or intracystic nodule or
solid component
Benign Cystic Lesions
• Imaging Findings by Modality
Breast cyst
Simple cyst; Complicated cyst;
• Ultrasonography
• Simple cyst; A well circumscribed appearance, anechoic contents, a thin
echogenic external capsule, with posterior acoustic enhancement
• Complicated cyst; Cyst with thin septation or internal echo
• Complex cyst; Cyst with thick wall or thick septation or intracystic
nodule or solid component
Benign Cystic Lesions
Breast cyst

Type 1 : thick wall complicated cyst. Type 2

Benign Cystic Lesions
Breast cyst

Type 3 Type 4
Benign Cystic Lesions
Breast cyst
• Differential Diagnosis
• from Imaging Findings
• Can be mistaken for fibroadenoma
• or carcinoma
Benign Cystic Lesions
FIBROCYSTIC CHANGE
• Definition
• is not a disease but refers to a constellation of benign histologic findings.
• It was previously referred to as fibrocystic disease,
• women with nonproliferative fibrocystic breast changes.

• Prevalence and Epidemiology

• a common finding in younger and premenopausal women (cyst 40-50 yr).
• There is no increased risk for the subsequent development of breast cancer
• Etiology and Pathophysiology
• associated with hormonal shifts in E and P which affect the breast tissue.
Benign Cystic Lesions
FIBROCYSTIC CHANGE
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• M/C symptoms are palpable irregular nodules, cyclic pain & • presents with a palpable abnormality, it should be evaluated
tenderness, swelling, & fullness. with diagnostic mammography & ultrasonography.
• At dense with areas of thicker tissue having an irregular or • In the case of focal and unrelenting pain, mammography w/ or
ridge-like surface. w/o ultrasonography may be performed.
• sensitivity to touch with a burning sensation, pain is so severe
• usually occur in both breasts, most often in the UOQ (most of
the milk-producing glands )
Benign Cystic Lesions
FIBROCYSTIC CHANGE
• Imaging Technique and Findings

• No specific mammographic, ultrasound, or MRI appearance has been

documented, because these are normal breast tissue responses to
hormonal changes.

• micro and macrocystic formation, fibrosis, sclerosing adenosis,

adenosis, duct ectasia, apocrine metaplasia and hyperplasia
Benign Cystic Lesions
FIBROCYSTIC CHANGE
• Differential Diagnosis
• from Clinical Presentation • From Pathology Findings
• rare cases of breast carcinoma have been reported with pain, • a variety of benign mammary alterations
• cyclic tenderness and fullness of the breast bilaterally, most • microscopic cysts, apocrine metaplasia, nonproliferative ducts
likely a benign process. and/or ductal hyperplasia without atypia, stromal fibrosis,
and, occasionally, a mild degree of adenosis.

• from Imaging Findings

• no specific imaging findings associated with fibrocystic changes.
Benign Cystic Lesions
galactocele
• Definition • Prevalence and Epidemiology
• a benign milk-filled cyst. • almost always occur in women during or just after cessation of
lactation and rarely occur in men.

• Etiology and Pathophysiology

• presumably caused by ductal obstruction.
• It is not a common lesion but can be seen in pregnancy or in
the setting of chronic galactorrhea caused by a pituitary
adenoma, antipsychotic drugs
Benign Cystic Lesions
galactocele
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• a nontender, firm, freely mobile palpable mass. • Diagnostic mammography and ultrasonography may be
• They may be solitary or multiple circumscribed masses, performed in women age 30 years or older.
unilateral or bilateral,
• and often lack evidence of an acute inflammatory process.
Benign Cystic Lesions
galactocele
• Imaging Findings by Modality
• Mammography
• circumscribed mass with a fat-fluid level on upright horizontal
(mediolateral or lateromedial) beam film is diagnostic (classic sign)
• This finding will not be as apparent on MLO view.

• Pseudolipoma: due to significant fat content, the mass seems

radiolucent
• Pseudohamartoma: seen when contents are old milk and water.
Due to highly viscous old milk, significant separation of fat and
water is not possible
Benign Cystic Lesions
galactocele
• Imaging Findings by Modality
• Mammography
• circumscribed mass with a fat-fluid level on upright horizontal
(mediolateral or lateromedial) beam film is diagnostic (classic sign)
• This finding will not be as apparent on MLO view.

• Pseudolipoma: due to significant fat content, the mass seems

radiolucent
• Pseudohamartoma: seen when contents are old milk and water.
Due to highly viscous old milk, significant separation of fat and
water is not possible
Benign Cystic Lesions
galactocele
• Imaging Findings by Modality
• Ultrasonography
• have a variable appearance
• cystic/multicystic: ~50%
• mixed (cystic + solid): ~37%
• solid: ~13%
• circumscribed with low-level internal echoes and posterior acoustic
enhancement, similar to circumscribed solid breast tumors.
• contain a fluid debris level, with the proteinaceous debris appearing
highly echogenic
• contain the liquid fat appearing anechoic.
Benign Cystic Lesions
galactocele
• Differential Diagnosis
• from Clinical Presentation
• often present as palpable masses, the differential diagnosis would include
• malignancy or solid benign masses.

• from Imaging Findings

• hamartoma or lipoma.
Benign Cystic Lesions
DUCT ECTASIA
• Definition • Etiology and Pathophysiology
• a nonspecific dilation of the major subareolar ducts, with • Unknown cause
occasional involvement of smaller ducts. • inflammatory process, which leads to destruction of the elastic
• abnormal widening of one or more breast ducts to greater than network of the duct →duct ectasia &periductal fibrosis.
2 mm , or 3 mm at the ampulla. It can be due to benign or • the dilation is 1st perhaps caused by obstruction of the duct, &
malignant processes. that the inflammation is a 2nd phenomenon related to leakage
of duct contents.
• Some publications use this term synonymously with periductal
mastitis or plasma cell mastitis, while others suggest that they • Prevalence and Epidemiology
are distinct entities with a different pathogenesis • has been found in women of all ages
• is rarely seen in men.
Benign Cystic Lesions
DUCT ECTASIA
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• majority of patients are asymptomatic but the distended ducts • Asymptomatic
may be palpable on examination. • Annual screening mammography
• the earliest sign is spontaneous &intermittent nipple discharge. • Mammography, ultrasonography and possibly ductography if
• Spontaneous clear or bloody nipple discharge, papilloma or presented with palpable mass or spontaneous nipple discharge.
malignancy must be excluded.
• Nipple inversion or retraction can occur in the later stage
(malignancy should be excluded)
Benign Cystic Lesions
DUCT ECTASIA
• Imaging Findings by Modality
• Mammography
• filled with thick secretions &cellular debris, the material often calcifies.
• The typical secretory calcifications: dense, solid, and rod-like; they are
usually bilateral and diffuse.(classic sign)
• : contain internal lucencies when the duct secretions surround the
duct itself.

- early focal secretory calcifications may mimic malignant

microcalcifications
- asymmetrically dilated ducts represent an interval change or Biopsy should be considered.
contain pleomorphic calcifications
Benign Cystic Lesions
DUCT ECTASIA
• Imaging Findings by Modality
• Ultrasonography
• dilated ducts that may be filled with anechoic fluid, echogenic
debris, or both
Benign Cystic Lesions
DUCT ECTASIA
• Differential Diagnosis
• from Clinical Presentation
• malignancy or intraductal papilloma, if the patient presents with nipple discharge

• from Imaging Findings

• based on the imaging findings is limited.
• Occasionally, early focal secretory calcifications can mimic malignancy and would lead to
biopsy for accurate diagnosis.
Benign Cystic Lesions
epidermal inclusion cyst AND sebaceous cyst
• Definition
• Epidermal inclusion cysts or epidermal cysts are common
cutaneous lesions that represent proliferation of squamous
epithelium within a confined space in the dermis or subdermis.
• Prevalence and Epidemiology
• Epidermal inclusion cysts are not common , after reduction
mammoplasty or after other iatrogenic procedures.
• Sebaceous cysts are rare within the breast parenchyma.
• Etiology and Pathophysiology
• Epidermal inclusion cysts: obstruction of the infundibular
portion of the hair follicle, hence the term infundibular cyst,
traumatic implantation.
• Sebaceous cysts: retention cysts the acral surface of the skin by
implantation of the epidermis into the dermis.
Benign Cystic Lesions
epidermal inclusion cyst AND sebaceous cyst
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• an asymptomatic, palpable mass on the superficial or • often present with palpable masses
subcutaneous skin. • mammography and ultrasonography should be performed.
• When the cyst is ruptured, pain may be associated with lesion. • marked with a metallic BB before imaging.
Benign Cystic Lesions
epidermal inclusion cyst AND sebaceous cyst
• Imaging Findings by Modality
• Mammography • Ultrasonography
• circumscribed, round masses that may be projected over the • arise from the skin or immediate subcutaneous tissue of the
breast parenchyma on any view. Often, a portion of the border breast. skin surrounding the mass is described as the claw sign.
is ill defined • Most lesion are circumscribed and contain low-level internal
echoes, produced by the thick material within these lesions
Benign Cystic Lesions
epidermal inclusion cyst AND sebaceous cyst
• Differential Diagnosis
• from Clinical Presentation
• They can also be fixed to the skin and clinically resemble carcinoma.
• If ruptured, there may be pain associated with the lesion.

• from Imaging Findings

• Usually present as circumscribed masses with mammography and with ultrasonography
• can be mistaken for carcinoma or fibroadenoma.
 scope
• ANATOMY, AND ULTRASONOGRAPHY OF NORMAL BREAST TISSUE
• IMAGING OF THE BENIGN BREAST DISEASE

• Benign Cystic Lesions of the Breast • Solid Benign Lesions of the Breast • High-risk breast diseases
• CYST • FIBROADENOMA • PHYLLODES TUMOR
• FIBROCYSTIC CHANGE • INTRAMAMMARY LYMPH NODE
• GALACTOCELE • LIPOMA
• DUCT ECTASIA • FIBROMATOSIS
• EPIDERMAL INCLUSION CYST AND SEBACEOUS CYST • FAT NECROSIS
• HAMARTOMA
• Infectious and Inflammatory Diseases of the
Breast
• MASITIS AND ABCESS
Solid Benign Lesions
FIBROADENOMA
• Definition • Prevalence and Epidemiology
• a benign fibroepithelial proliferative tumor with the hallmark of • M/C breast masses encountered in women younger than 35 yr
a concurrent proliferation of glandular and stromal elements. • The M/C solid masses found in women of all ages.

• Etiology and Pathophysiology

• The exact etiology of fibroadenomas is unknown.
• They seem to be influenced by E levels.
• They are most often seen in premenopausal or pregnant
women, or in women who are postmenopausal and taking
hormone replacement therapy.
Solid Benign Lesions
FIBROADENOMA
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• are round, oval, freely mobile masses that may change with the • often present as palpable findings
menstrual cycle or pregnancy. • In patients younger than 30 yr, US is the initial study of choice.
• can be multiple. • In patients older than 30, mammography and US
• Most are less than 3 cm, but giant are large & can exceed 6 cm
• are mobile within the breast on palpation.
• Many fibroadenomas undergo hyalinization, degeneration, and
calcification after menopause and may become smaller
(Involuting fibroadenomas )
Solid Benign Lesions
FIBROADENOMA
• Imaging Findings by Modality
• Mammography
• circumscribed, round to oval masses or lobular, low to
equal density radiopaque masses.
Solid Benign Lesions
FIBROADENOMA
• Imaging Findings by Modality
• Mammography
• Many fibroadenomas begin to involute in the
postpartum period and after menopause, with hyaline
degeneration and subsequent calcification
• Involuting fibroadenomas have typical coarse
calcifications,
• which usually begin at the periphery of the mass and
coalesce and increase, often completely replacing the soft
tissue mass itself.
Solid Benign Lesions
FIBROADENOMA Classic Signs

• Imaging Findings by Modality

• Ultrasonography
• an oval, circumscribed, homogeneous solid mass with internal
echoes, often isoechoic or slightly hypoechoic to fat.
• Posterior acoustic enhancement is sometimes seen.
• Atypical findings seen in some fibroadenomas include
microlobulated or indistinct margins.
• An involuting fibroadenoma, acoustic shadowing is seen
because of calcification.
• In some cases: difficult to differentiate from a fat lobule.
Solid Benign Lesions
INTRAMAMMARY LYMPH NODE
• Definition • Prevalence and Epidemiology
• An intramammary lymph node is a lymph node found within • are commonly encountered on mammograms.
the breast parenchyma at any quadrant, excluding axillary • The vast majority seen on mammography are in the UOQ of
lymph nodes. the breast, the axillary tail, and the axilla.
• Etiology and Pathophysiology
• are usually a normal, incidental finding.
• may be involved with inflammation, granulomatous processes,
or metastatic carcinoma.
• Coarse calcifications are sometimes seen in LNs involved with
granulomatous disease such as histoplasmosis, tuberculosis, or
sarcoidosis.
Solid Benign Lesions
INTRAMAMMARY LYMPH NODE
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• are usually not apparent clinically and are seen incidentally on • An involved lymph node might appear abnormal on
imaging studies. mammography and require additional evaluation with
• Involved lymph nodes can present as a palpable finding. ultrasonography and possibly biopsy.
Solid Benign Lesions
INTRAMAMMARY LYMPH NODE
• Imaging Findings by Modality
• Mammography
• as oval or reniform, circumscribed noncalcified masses.
• The fat within the hilum of the ln is often seen as a lucency
• at the periphery when viewed in tangent or
• in the central portion of the mass when viewed en face.

Classic Signs
The fatty hilum of a normal intramammary lymph node is classically
described as notched on mammography with a kidney-shaped
architecture and is often located in association with a vessel.
Solid Benign Lesions
INTRAMAMMARY LYMPH NODE
• Imaging Findings by Modality
• Ultrasonography
• the periphery of a normal intramammary LN is hypoechoic relative
to fat and fibroglandular tissue.
• The fatty hilum is highly echogenic.

• In reactive processes, the normal architecture tends to be preserved

within the enlarged node and the echogenic hilum often remains
visible.
Solid Benign Lesions
INTRAMAMMARY LYMPH NODE
• Differential Diagnosis
• from Clinical Presentation
• is palpable, the clinical differential diagnosis includes both breast carcinoma and solid benign tumors.

• from Imaging Findings

• When atypical or frankly abnormal, other solid lesions of the breast with circumscribed margins ddx :
fibroadenoma, lipoma, and breast carcinoma as well as pathologic intramammary lymph nodes.
Solid Benign Lesions
LIPOMA
• Definition • Prevalence and Epidemiology
• are benign fatty tumors (mature adipose tissue) that may occur • occur in 1% of the population and may develop in virtually all
anywhere within the breast. organs throughout the body.
• Lipomas occur frequently in the breast but not as frequently as
• Etiology and Pathophysiology expected, considering the extent of fat that is present.
• unknown.
Solid Benign Lesions
LIPOMA
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• can be solitary or multiple. • a palpable finding, the workup should begin with
• Most lipomas are located in the subcutaneous fat. mammography in patients older than age 30.

• When palpable, they are usually soft and freely movable. • With the classic mammographic appearance, no further workup
is indicated.
• is one of the M/C causes of a palpable finding in a male patient.
Solid Benign Lesions
LIPOMA
• Imaging Findings by Modality
• Mammography
• a fat-containing, completely radiolucent lesion surrounded by a
thin radiopaque capsule.
• This appearance is diagnostic for a benign lesion, and further
workup or intervention is not necessary

Classic signs
The radiolucent mammographic appearance with a thin
radiopaque capsule is classic.
Solid Benign Lesions
LIPOMA
• Imaging Findings by Modality
• Ultrasonography
• When typical mammographic appearance is present is
• no indication of ultrasonography.

• For atypical lesion; appearance varies and can be

• completely isoechoic (to adjacent fat lobules),
• mildly hyperechoic, or
• isoechoic with numerous thin, internal echogenic septa
that course parallel to the skin.
Solid Benign Lesions
FIBROMATOSIS
• Definition • Etiology and Pathophysiology
• Fibromatosis of the breast (extra-abdominal desmoid tumor) is • is unknown.
a benign localized proliferation of fibroblasts that is
nonmalignant but does have a tendency to recur after excision.

• Prevalence and Epidemiology

• has been found in women of all ages
• is rarely seen in men.
Solid Benign Lesions
FIBROMATOSIS
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• a firm, freely mobile, nontender, palpable mass with occasional • presents as a palpable mass, the workup is that of
skin retraction or fixation to the pectoralis muscle. mammography, followed by ultrasonography, and core biopsy.
• The M/C presenting complaint is skin tethering.
Solid Benign Lesions
FIBROMATOSIS
• Imaging Findings by Modality
• Mammography • Ultrasonography
• a circumscribed or a spiculated mass without microcalcifications • usually presents as an irregular hypoechoic mass with indistinct
that can be indistinguishable in appearance from carcinoma. margins similar to that seen with malignancy.
Solid Benign Lesions
FAT NECROSIS
• Definition • Prevalence and Epidemiology
• Fat necrosis involves necrosis of adipose tissue • is a common benign condition.
• is characterized by the formation of small quantities of calcium
soaps when fat is hydrolyzed into glycerol and fatty acids.

• Etiology and Pathophysiology

• occurs after trauma (including surgery) to the breast.
Solid Benign Lesions
FAT NECROSIS
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• as a palpable mass, pain, skin thickening, or nipple retraction that • presents with a palpable finding, diagnostic mammography is
may mimic carcinoma. performed and infrequently ultrasonography and biopsy,
• commonly seen after lumpectomy and RT for breast carcinoma depending on the imaging characteristics.
and after extensive surgery such as reduction mammoplasty.

• .asymptomatic, with fat necrosis detected incidentally during

screening mammography.
Solid Benign Lesions
FAT NECROSIS
• Imaging Findings by Modality Classic Signs
The most classic appearance of fat necrosis is that of an oil cyst.
• Mammography
• have a variety of appearances., most cases:
a benign lesion.
• an oval mass containing fat density.
• a radiolucent or mixed fat and soft tissue
density circumscribed mass with a calcified
or noncalcified rim, known as a lipid or oil
cyst.
Solid Benign Lesions
FAT NECROSIS
• Imaging Findings by Modality
• Mammography
• the findings mimic carcinoma including
spiculated masses, sometimes with
microcalcifications and architectural distortion.
• Early peripheral calcifications may mimic
microcalcifications of malignancy
Solid Benign Lesions
FAT NECROSIS
• Imaging Findings by Modality
• Ultrasonography
• Early fat necrosis: usually manifested as an indistinct uniform
hyperechoic area, usually in the superficial tissue of the breast.
• fat necrosis progresses,: a heterogeneous appearance.
• Late: Calcified fat necrosis demonstrates ultrasonographic shadowing
Solid Benign Lesions
Hamartoma
• Definition • Prevalence and Epidemiology
• Variable normal constituents of breast tissue, including fat, • Women older than 35 yr
glandular tissue, and fibrous connective tissue.

• Etiology and Pathophysiology

• Unclear
• May be a result of dysgenesis rather than a true tumor.
Solid Benign Lesions
Hamartoma
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• Often asymptomatic • Mammography would be initial step for palpable mass patient.
• Some are palpable and usually painless.
Solid Benign Lesions
Hamartoma
• Imaging Findings by Modality
• Mammography
• The classic mammographic appearance
• The lesion is circumscribed and contains both fat and soft tissue
density surrounded by a thin radiopaque capsule, which is visible
when fat is identified on both sides.
• The appearance is similar to a “cut sausage” on radiography or a
“breast within a breast.”
Solid Benign Lesions
Hamartoma
• Imaging Findings by Modality
• Ultrasonography
• When typical mammographic appearance is present is no
indication of ultrasonography.
• For atypical lesion; usually distinguish between a cyst and
a solid mass.
• US appearance is variable.
• contain areas of low-level internal echogenicity
interspersed with irregular areas of hyperechogenicity
• the fatty tissue within the lesion may be highly
echogenic. → Mimic a fibroadenoma.
 scope
• ANATOMY, AND ULTRASONOGRAPHY OF NORMAL BREAST TISSUE
• IMAGING OF THE BENIGN BREAST DISEASE

• Benign Cystic Lesions of the Breast • Solid Benign Lesions of the Breast • High-risk breast diseases
• CYST • FIBROADENOMA • PHYLLODES TUMOR
• FIBROCYSTIC CHANGE • INTRAMAMMARY LYMPH NODE • Papillary lesions
• GALACTOCELE • LIPOMA • Flat epithelial atypia (FEA)
• DUCT ECTASIA • FIBROMATOSIS • Atypical ductal
• EPIDERMAL INCLUSION CYST AND SEBACEOUS CYST • FAT NECROSIS hyperplasia(ADH)
• HAMARTOMA • Lobular neoplasia(ALH and
• Infectious and Inflammatory Diseases of the LCIS)
Breast
• MASITIS AND ABCESS
High-risk breast diseases
PHYLLODES TUMOR
• Definition • Prevalence and Epidemiology
• is an uncommon neoplasm, benign • are uncommon and usually present in older patients (age 40-
• This tumor occasionally has been equated with a giant 52 years) when compared with fibroadenoma.
fibroadenoma because both contain epithelial and mesenchymal • The incidence has been reported as low as 0.3%-0.5% of all
elements, female breast tumors.
• but the stroma of the phyllodes tumor is much more cellular
than in a fibroadenoma. • Etiology and Pathophysiology
• unknown.
High-risk breast diseases
PHYLLODES TUMOR
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• M/C clinical presentation is a large and rapidly growing mass. • presents with a palpable abnormality, the imaging workup
• The clinical behavior of phyllodes tumor is unpredictable. should include diagnostic mammography and US.

• The majority of phyllodes tumors are benign, but approximately • CNB should also be performed.
5-25% contain areas of malignancy.
• Less than 20% of malignant lesions metastasize via Classic Signs
hematogenous spread, but when this occurs it is most commonly - a rapidly enlarging mass in a woman older than the typical age
to the lung, pleura, and bone. for fibroadenoma.
High-risk breast diseases
PHYLLODES TUMOR
• Imaging Findings by Modality
• Mammography
• most phyllodes tumors are large, circumscribed, noncalcified
masses that are round, oval, or lobulated.
• When small, the appearance is identical to a fibroadenoma.
• When large, the size may suggest the diagnosis.
• Calcifications are rare.
High-risk breast diseases
PHYLLODES TUMOR
• Imaging Findings by Modality
• Ultrasonography
• solid mass, often with inhomogeneous internal echoes and
posterior acoustic enhancement, and sometimes containing
small peripheral cystic spaces, and multilobulation.

• It is not possible to reliably differentiate between phyllodes

tumor, fibroadenoma, and a circumscribed carcinoma based
on the imaging features..
High-risk breast diseases
PHYLLODES TUMOR
• Differential Diagnosis
• from Clinical Presentation
• DDX from the clinical presentation of a palpable abnormality: fibroadenoma,
invasive carcinoma, and, possibly, papilloma.

• from Imaging Findings

• imaging appearance cannot be differentiated from fibroadenoma. Invasive tissue diagnosis is needed to differentiation
carcinomas and papillomas are also considerations.
• The presence of calcifications would discourage the diagnosis of phyllodes tumor.
 scope
• ANATOMY, AND ULTRASONOGRAPHY OF NORMAL BREAST TISSUE
• IMAGING OF THE BENIGN BREAST DISEASE

• Benign Cystic Lesions of the Breast • Solid Benign Lesions of the Breast • High-risk breast diseases
• CYST • FIBROADENOMA • PHYLLODES TUMOR
• FIBROCYSTIC CHANGE • INTRAMAMMARY LYMPH NODE
• GALACTOCELE • LIPOMA
• DUCT ECTASIA • FIBROMATOSIS
• EPIDERMAL INCLUSION CYST AND SEBACEOUS CYST • FAT NECROSIS
• HAMARTOMA
• Infectious and Inflammatory Diseases of the
Breast
• MASITIS AND ABCESS
 Infectious and Inflammatory Diseases of the Breast
• Definition • Prevalence and Epidemiology
• Mastitis ; inflammation of the parenchyma of the breast • Uncommon
• Infections: bacteria, fungi, or parasites. • Most cases occur during lactation, diabetic patients, and in
• Rarely, the breast may become infected with echinococcosis, heavy smokers (w/o known etiology.)
blastomycosis, schistosomiasis, loiasis, tuberculosis, or other
granulomatous and parasitic diseases • Etiology and Pathophysiology
• Noninfectious inflammatory processes: breast include plasma • Most cases of mastitis occur during lactation, are pyogenic, and
cell mastitis, granulomatous mastitis, and lymphocytic are caused by Staphylococcus aureus and Streptococcus species.
mastitis.
• Developed abscess formation
 Infectious and Inflammatory Diseases of the Breast
• Manifestations of Disease
• Clinical Presentation • Imaging Indications and Algorithm
• Early stage of acute mastitis; localized tenderness and swelling • Mammography and ultrasonography
with erythematous skin +/- fever • If the classic finding of abscess are identified by US,
• Suppurative stage; fluctuant abscess forms, very tender, fever, and percutaneous drainage can be performed with the aspirate sent
chills for culture and sensitivity
• Nonpyogenic/noninfectious mastitis; more subtle
• Pain or lump
• Incidental finding on screening mammography
 Infectious and Inflammatory Diseases of the Breast
• Imaging Findings by Modality
• Mammography
• Mastitis; skin and trabecular thickening
• Abscess; indistinct or spiculated masses

• M/C findings in pyogenic mastitis are skin and trabecular

thickening from breast edema, may be diffuse or focal.
 Infectious and Inflammatory Diseases of the Breast
• Imaging Findings by Modality
• Mammography
• Mastitis; skin and trabecular thickening
• Abscess; indistinct or spiculated masses

• visible within the edema, abscesses usually appear as

noncalcified oval masses with indistinct margins.
• Air is very rarely seen within an abscess.
• DDX: inflammatory carcinoma and other invasive breast
carcinomas.
 Infectious and Inflammatory Diseases of the Breast
• Imaging Findings by Modality
• Mammography
• unusual granulomatous and parasitic infections are usually
nonspecific and may include diffuse breast edema, masses,
and calcifications.

• Trichinosis infection may be seen mammographically as

diffuse punctate microcalcifications limited to the pectoralis
muscles bilaterally (Fig. 20-5)
 Infectious and Inflammatory Diseases of the Breast
• Imaging Findings by Modality
• Mammography
• unusual granulomatous and parasitic infections are usually
nonspecific (Fig. 20-4) and may include diffuse breast
edema, masses, and calcifications.

• Trichinosis infection may be seen mammographically as

diffuse punctate microcalcifications limited to the pectoralis
muscles bilaterally
 Infectious and Inflammatory Diseases of the Breast
• Imaging Findings by Modality
• Ultrasonography
• depicts abscess cavities within the area of infection and
inflammation. The skin thickening and breast edema

• Abscesses: irregular hypoechoic or anechoic masses with

indistinct margins, sometimes with fluid or debris levels and
usually with posterior acoustic enhancement.

• Rarely, air within an abscess may produce bright specular

reflections.
 Infectious and Inflammatory Diseases of the Breast
• Differential Diagnosis
• from Imaging Findings
• from an imaging standpoint includes a complicated cyst, complex mass (including necrotic
malignant neoplasm), and phyllodes tumor.
• Exclusion is inflammatory breast carcinoma
 Infectious and Inflammatory Diseases of the Breast
• Differential Diagnosis
• from Imaging Findings
• from an imaging standpoint includes a complicated cyst, complex mass (including necrotic
malignant neoplasm), and phyllodes tumor.
• Exclusion is inflammatory breast carcinoma
Thank you for your attenion
reference