STRUCTURE

Mimickers of breast malignancy: imaging

findings, pathologic concordance
and clinical management
Oleh : dr. Widya Pratiwi Radam
Narasumber:
dr. RR. Lydia Purna Widyastuti S. Kuntjoro Sp. Rad (K)
Introduction
the purpose of this review:
The clinical presentation of illustrate the wide range of suspicious
several benign breast can mimic mammographic, sonographic, and
breast cancer. magnetic resonance imaging (MRI)
features associated with benign breast
diseases

understanding the range of clinical and imaging

findings >>> important to ensure appropriate
radiologic-pathologic correlation and clinical
management
Inflammatory Breast Conditions
a heterogeneous group of breast conditions characterized by a marked inflammatory process.

Inflamatory breast condition in this review:

1. Mastitis and Breast abses
2. Granulomatous mastitis
3. Lympositic mastophaty
Infectious mastitis
and breast abscess
Breast abscess is a complication of infectious mastitis

• Abscesses can be associated with lactation

Puerperal abscesses • Puerperal abscesses tend to be peripheral in location

• Independent of pregnancy
• >> younger women.
•
Nonpuerperal abscesses Lesi: Periareolar and typically have worse outcomes
and a higher rate of recurrence
• Risk factors >>> smoking and diabetes
IMAGING FINDING
Mammograpy MRI
• skin thickening, asymmetry, a mass, • T2-hyperintense >> progressive
or architectural distortion enhancement kinetics
• thin rim of peripheral enhancement

Sonography
• Hypoechoic collections of variable shapes and sizes / continuous and
multiloculated
• a thick echogenic rim and increased vascularity >> suggesting malignancy
• increased parenchymal echogenicity >> inflamed glandular parenchyma.
• Skin thickening, distended lymphatic vessels, and inflammatory axillary
adenopathy
Patients with a clinical presentation typical of a breast
abscess require a short-term, 7- to 14-day follow-up
after treatment with antibiotics and drainage.

Inflammatory breast cancer

• breast erythema and swelling in the absence of an
abscess on ultrasound evaluation
• older non-lactating patients
• patients who are at increased risk of breast cancer

Mammography is initially delayed In lactating

patients until acute symptom resolve, and
indicated for patient who have prolonged simptom
Granulomatous mastitis
• an inflammatory breast >> unknown etiology.
• Parous women of childbearing age,
• Clinical:
firm palpable mass
skin erythema or pain
draining sinus tracts and nipple discharge

Mammograpy
>> a variety of presenting features such
as masses, asymmetries, or trabecular
and skin thickening
Sonographically
• Multiple irregular hypoechoic masses ,
Continuous and can appear tubular.
• In other cases >> parenchymal distortion
with increased shadowing,
• skin thickening and edema

MRI
masses with circumscribed margins and rim enhancement and heterogeneous non-mass
enhancement in a segmental or regional distribution
Lymphocytic mastopathy
• a perivascular and perilobular inflammatory process of the breast parenchyma
incited by the inflitration of lymphocytes
• Clinically
 Pain
 Mobile
 Discrete breast masses>>closely mimicking malignancy.
• Multicentric and bilateral.
• lymphocytic mastopathy is associated with diabetes; autoimmune disorders such
as Hashimoto’s thyroiditis, Sjögren’s syndrome, and systemic lupus
erythematosus and gynecomastia
• Mammographi>>
ill-defined mass or asymmetry.
• Sonography>>
hypoechoic irregular mass with
posterior acoustic shadowing or an
area of shadowing
• MRI >>> heterogeneously
enhancing masses and non mass
enhancement.
• self-limited.
• Recurrence has been reported in
patients who undergo surgical
excision.
PROLIFERATIF BREAST CONDITION
Fat Necrosis

• a proliferative condition commonly seen as a result of breast surgery,

infection, trauma, or radiation.
• Fat necrosis comprises 2.75% of breast lesions and is incited by the
destruction of adipocytes, which causes an inflammatory process.
• Clinical features:
 Palpable masses,
 Pain
 Skin changes such as skin tethering, skin thickening, and dimpling
 Ultrasound features of fat necrosis that
Mammograpy mimic malignancy :
• Dystrophic calcifications • irregular hypoechoic masses with
or oil cysts. posterior acoustic shadowing
Imaging findings that can
closely mimic malignancy:
• irregular and spiculated
masses, architectural
MRI
distortion, asymmetries,
Benign feature
coarse heterogeneous
• T1 hyperintensity on non-fat suppresed T1 sequences with
and even branching or
corresponding drop in signal on fat-suppressed T1 and T2
pleomorphic calcifications
sequences.
Malignancy feature
• irregular enhancing masses, with or without a thick, irregular
rim.
Stromal fibrosis
• proliferation of stroma with obliteration of the mammary acini and
ducts on pathologic analysis.
• a localized area of fibrous tissue associated with hypoplastic mammary
ducts and lobules
• Stromal fibrosis is not an uncommon pathologic diagnosis, representing
2%-9% of biopsied breast lesion
• Stromal fibrosis can be seen in the setting of malignancy and has a
reported upgrade rate to malignancy of 7%
 Ultrasound features Sonographic
• masses and non-mass lesions.
Mammograpy • In most cases, the masses are oval or round
• Stromal fibrosis can also present as
• calcifications, irregular masses in 13% of cases
followed by masses
and asymmetries.
• Tomosynthesis >>
architectural
distortion
MRI
masses, non-mass enhancement and foci of enhancement .
masses can demonstrate variable shapes and kinetics .
Stromal fibrosis (Mammografi)
Stromal fibrosis (Sonografi)
SCLEROSING ADENOSIS
• a proliferative breast condition of the terminal lobular unit characterized by
distortion of the lobules with an increased number of acini and desmoplasia
• >> perimenopausal women
• coexist with other benign proliferative lesions such as
 Sclerosing papilloma
 Complex sclerosing lesions
 Ultrasound features :
Mammograpy
• circumscribed mass, with
• amorphous, pleomorphic,
variable echogenicity.
and punctate
• mimic malignancy :
calcifications.
suspicious features such
• Irregular margins, more
as an irregular mass or
commonly has
focal areas of shadowing
circumscribed margins
without a mass
Sclerosing adenosis (Mammografi)
management of sclerosing adenosis
● a circumscribed mass or amorphous or punctate calcifications in a
grouped distribution with adequate sampling >>> Sclerosing adenosis

● If the imaging findings are more suspicious such as an irregular mass or

pleomorphic calcifications in a segmental or linear distribution
>> biopsy to exclude a coexisting malignancy
Benign Breast Tumors
Hamartoma
• Hamartomas are uncommon, slow-growing tumors that represent
4.8% of benign breast tumors. (“breast within a breast”)
• Breast hamartomas are circumscribed benign tumors that are
composed of variable amounts of fat, fibrous tissue, and glandular
tissue.
• Hamartomas can mimic circumscribed malignant tumors, such as
phyllodes tumor or breast sarcoma
 Sonographic
• a parallel mass with circumscribed
margins and heterogonous
Mammograpy echotexture due to variable amounts
• a hamartoma has a of fat and glandular tissue
characteristic benign
appearance of a fat-
containing
circumscribed mass. MRI
• heterogeneous circumscribed
mass with a thick capsule, usually
with heterogenous progressive
enhancement kinetics
Pseudoangiomatous stromal hyperplasia
(PASH)
• It is characterized by proliferation of the fibrous stroma lined by a
complex network of slit-like spaces and slender spindle cells.
• PASH is associated with hormone exposure
oral contraceptive use,
premenopausal and perimenopausal women onhormone replacement therapy
• the true etiology is still unclear
• Differential diagnosis includes a low-grade angiosarcoma and phyllodes
tumor
 Sonography
• Variable appearance,
• oval, circumscribed hypoechoic mass to the
irregular
• mixed echogenicity mass
Mammograpy
an oval or round
noncalcifed mass with
circumscribed margins
ranging from 0.3 to 11 cm
MRI
• a circumscribed mass resembling a
fibroadenoma
• but it can also present as non-mass
enhancement in a focal or segmental
distribution
• T2-hyperintense slit-like spaces with
cystic components favors the PASH
Tubular Adenoma
• a rare benign tumor of the breast representing 0.13%-2.9% of all benign
breast neoplasms .
• >> younger women of childbearing age.
• Tubular adenoma and fibroadenoma are both epithelial tumors
• Tubular adenoma is histologically distinguished from a fibroadenoma by
its tightly packed tubular or acinar epithelium and sparse connective
tissue
 Mammographically,
• tightly grouped
microcalcifications

Sonographically,
• oval parallel masses with
circumscribed margins,
• irregular hypoechoic masses 
DESMOID FIBROMASTOSIS
● A rare benign mesenchymal tumor characterized by the proliferation of
fibroblasts and myofibroblasts, accounting for 0.2% of all breast tumors.
● Associated with trauma, surgery, and Gardner syndrome.
● a tendency for local recurrence
● More common locations include the abdominal wall, retroperitoneum, and
the mesentery.
 Sonography
a hypoechoic irregular mass with
posterior acoustic shadowing
Mammograpy
an irregular, high-
density mass with
spiculated margins
MRI
• Heterogeneously enhancing mass, often with a
progressive enhancement pattern.
• MRI is the modality of choice to assess extent of
disease and to evaluate for chest wall involvement
● Standard treatment >> surgical excision with wide margins, particularly in
cases of tumor growth or progressive disease
● non-steroidal antiinfammatory drugs, chemotherapeutic agents,
hormonal therapy, and radiation treatment
Granular Cell Tumor
• Granular cell tumor is an extremely rare tumor of neural origin.
• It is more commonly found in the head and neck and chest wall regions,
with only 4%-6% of cases located in the breast
• Predilection for premenopausal and African American women
• Preferentially found in the upper inner quadrants of the breast.
• Physical examination:
Massa fixed
Pain
palpable mass with associated skin dimpling
 Sonography
Mammograpy a hypoechoic mass with irregular
present as a mass with or circumscribed margins is usually
indistinct or spiculated margins seen
Conclusion

Awareness of multiple malignancy mimickers, rare and

common, is vital to clinical practice and plays a key role in
radiologic-pathologic concordance, ensuring appropriate
clinical managemen
 THANK YOU
MOHON SARAN DAN ASUPAN