Download of the breast

Module Seven
Harry H. Holdorf
PhD, MPA, RDMS (Ab, Ob/Gyn, Br), RVT, LRT(AS), CCP
Module 7- Malignant Disease
Breast Cancer
 Although we know some of the risk factors that increase a
woman’s chances of developing breast cancer, we do not yet
know what causes most breast cancers.
 What we do know is:
 The most common sign of breast cancer is a new lump or
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mass
90% of breast cancers originate in the duct
Most cancers arise from the TDLU
A larger percentage of cancers are located in the UO quadrant
Breast cancers have a variety of sonographic and
mammographic features that often appear similar to benign
diseases.
Where the cancers originate
What are the types of Cancer?
 Sarcomas
 Leukemias
 Lymphomas
 Carcinomas
 Others
Sarcomas
 Are cancers that originate in fibrous tissue, muscle, or
fat.
 These are known as soft-tissue sarcomas
 Sarcomas can also arise from bone or cartridge
Leukemias
 Cancers of the blood cells
 Arising in the blood forming organs, such as the
spleen and bone marrow
Lymphomas
 Cancers arising in the lymphatic system
 A network of vessels and nodes that act as the body’s
filter system
 There are more than 30 different types of lymphomas
Carcinomas
 Is the most common type of cancer
 Arise in the body’s organs
 About 80% of all cancers are carcinomas
 Arising from the breast, prostate, stomach, and colon,
and some types of skin cancers
Other
 Melanomas
 Certain types of brain tumors
Breast cancer progression
 Even though there are may types of breast cancers, the
development of breast cancer is thought to be
progressive in nature.
 It is theorized that the normal epithelium of the TDLU
gives rise to cellular change, termed hyperplasia.
Atypical hyperplasia may give rise to cancer cell
growth within the duct, known as ductal carcinoma In
Situ (DCIS). DCIS may give rise to invasive cancer cells,
known as invasive carcinoma. Invasive carcinoma has
the ability to metastasize to other organs.
Epidemiology
 Breast cancer is the most common cancer among
women. It occurs more often than the total number of
female colon, uterine, ovarian, and cervical cancers
combined.
 Breast cancer is the second leading cause of cancer
death in women, exceeded only by lung cancer.
 In 2013, the American Cancer Society estimated that
over 230,000 new cases of breast cancer was diagnosed
in the United States. The incidence rate for female
breast cancer began to decline in 2000. Since 2003,
rates have been generally steady.
 Although women can get breast cancer at almost any
age, they rarely get it before age 30. Most cases occur in
middle-aged and older women.
 Male breast cancer makes up less than 1% of the total.
 Breast cancer is also less common in certain parts of
the world and among certain ethnic groups. For
example, women who live in the far East, particularly
in Japan, have relatively low rates. But, Japanese
women who live in the United States have breast
cancer rates similar to American women. White
women have a slightly higher risk of breast cancer than
African American women. Asian, Hispanic, and
American Indian women have a lower risk.
 One in every 8 will develop breast cancer
 A dramatic decrease of almost 7% of breast cancer
cases from 2002 to 2003 was attributed to the
reduction in use of HRT, reported by a national
Women’s Health Initiative study.
Risk Factors
 A risk factor is anything that increases a person’s
chance of getting a disease. Having a risk factor,
however, does not necessarily mean that a person will
develop the disease. Some women with one or more
risk factors never develop breast cancer. Also, a
woman’s risk may change over time.
 Several factors have been associated with breast
cancer. These include the following:
 1. Gender:
 Breast cancer is approximately 100 times more common
in women than in men.
 This is the most significant risk factor.
 2. Age:
 A woman’s risk of developing breast cancer increases
with age. This is the second strongest risk factor.
 3. Family history of breast cancer
 The risk of breast cancer is higher among women whose
blood relatives have the disease. Relatives can be from
either the mother’s or father’s side of the family.
 Having a first-degree relative (mother, sister, or
daughter) with breast cancer approximately doubles a
woman’s risk. Having two first-degree relatives
increases the risk 5 times. The risks associated with
second or greater degree relatives (grandparents,
aunts, cousins) with breast cancer are much less clear.
Women with a family history of breast cancer in a male
relative may also have an increased risk.
 Also, a woman with a mother diagnosed with breast
cancer at the age of 40 has a greater risk than a women
with a mother who developed the disease at age 70.
Family history continued…
 There is a rare inherited condition in which nearly all
female members of a single family develop breast
cancer. Fortunately, this familial form of breast cancer
makes up only 5% to 10% of all breast cancer patients.
 Genetic research
 The reason for this increased risk reflects that genes play
a significant role in the development of breast cancer.
Cancer of the breast likely results from inherited genetic
mutations.
What are BRCA1 and BRCA2?
BRCA1 and BRCA2 are human genes that produce tumor
suppressor proteins. These proteins help repair damaged
DNA and, therefore, play a role in ensuring the stability
of the cell’s genetic material.
When either of these genes is mutated, or altered, such
that its protein product either is not made or does not
function correctly, DNA damage may not be repaired
properly. As a result, cells are more likely to develop
additional genetic alterations that can lead to cancer.
Specific inherited mutations in BRCA1 and BRCA2
increase the risk of female breast and ovarian cancers.
Together, BRCA1 and BRCA2 mutations account for
about 20 to 25 percent of hereditary breast cancers and
about 5 to 10 percent of all breast cancers. In addition,
mutations in BRCA1 and BRCA2 account for around 15
percent of ovarian cancers overall . Breast and ovarian
cancers associated with BRCA1 and BRCA2 mutations
tend to develop at younger ages than their nonhereditary
counterparts.
A harmful BRCA1 or BRCA2 mutation can be inherited
from a person’s mother or father. Each child of a parent
who carries a mutation in one of these genes has a 50
percent chance of inheriting the mutation.
 Studies have shown that about 10% of breast cancer
cases result from mutations of the BRCA1 and BRCA2
genes.
 BRCA genes help prevent cancer by producing a
protein that controls normal cell growth. If a person
inherits mutations of the BRCA genes, chances of
developing breast cancer increase.
 Approximately 50% to 60% of women with inherited
BRCA mutations will develop breast cancer by age 70.
 BRCA mutations also increase the risk of ovarian
cancer.
 4. Personal history of Breast Cancer
 A woman with cancer in one breast has a 3 to 4 times
increased risk of developing a new cancer in either
breast. This is irrelevant of recurrent cancer.
 5. Menstrual Periods:
 Women who start menstruating at an early age (before
age 12) or who went through menopause at a late age
(after 50) have a slightly higher risk of breast cancer.
 6. Child bearing:
 Women who have not had children or who had their
first child after age 30 have a slightly higher risk of breast
cancer.
Risk factors recap
 75% of patients with breast cancer have no family
history
 Early menarche/late menopause = higher risk
 Nulliparity / late first pregnancy = higher risk
 7. Hormonal Influence:
 The body’s hormonal environment likely influences the
risk of developing breast cancer.
 Longer periods of estrogen and progesterone activity
within a woman’s lifetime seem to increase the risk.
 Therefore, prolonged use of Oral Contraceptives may
increase the risk of breast cancer, although studies are
unclear.
 Studies suggest the use of Hormone Replacement
Therapy (HRT) after menopause increase the risk of
breast cancer.
 HRT (the combination of estrogen and progesterone) is
used to lessen the severity of menopausal symptoms.
However, this prolongs a woman’s exposure to estrogen
influences.
 8. Personal history of cancer:
 Women with a personal history of cancer, especially
ovarian or endometrial cancer, have a slightly higher
risk.
 9. Biopsy finding of Atypical Hyperplasia:
 Women whose earlier biopsies were diagnosed as
“proliferative changes without atypia” or “usual
hyperplasia” have a slightly increased risk of breast
cancer. But a previous biopsy result of “atypical
hyperplasia” increases the risk 4 to 5 times.
What does BRCA stand for?
 BRCA stands for BReast CAncer susceptibility gene.
 There are two BRCA genes: BRCA1 and BRCA2.
 Normally, they help protect you from getting cancer.
 But when you have changes or mutations on one or
both of your BRCA genes, cells are more likely to
divide and change rapidly, which can lead to cancer.
 10. Radiation Therapy:
 Women who have had radiation therapy to the chest
area as treatment for another cancer (such as
lymphoma), are at increased risk for breast cancer.
 11. Obesity:
 Obesity is associated with the development of breast
cancer, especially after menopause.
 Having more fatty tissue can increase a woman’s
estrogen level.
A healthy diet and exercise may be the best defense
against breast cancer.
Non-Invasive Breast Cancer
 Breast Cancers that are considered non-invasive have
not spread beyond the membrane or structure
supporting the cancer (duct or lobule).
 There are two types of non-invasive breast cancer:
DCIS (Ductal Carcinoma In Situ) and LCIS (Lobular
Carcinoma In Situ). Both are considered an early form
of breast cancer with good prognosis for a cure.
According to the American Cancer Society, the
current 5-year survival rate for non-invasive
breast cancer is 98%.
Ductal Carcinoma In Situ (DCIS)
 Ductal Carcinoma In Situ represents malignant
changes of the ductal epithelium without extension
past the basement membrane. In Situ means the
cancer is confined within the space it occupies (the
duct) and has not spread.
 DCIS is the most common non-invasive cancer and the
2nd most common breast cancer overall.
Normal Duct and DCIS diagram
DCIS:
 Arises from the TDLU (Terminal Ductal Lobular Unit)
 Is usually confined to one lobe or segment
 Is considered to be a precursor to invasive ductal
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carcinoma
If not treated, will progress to invasive cancer in 30% to
50% of women.
May not form a distinct tumor
May have dilated ducts
Microcalcifications are common
Is best diagnosed by Mammography
Has 2 forms: non-comedo and comedo
 Comedo means Blackhead/and essentially means
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something you can squeeze, like an acne lesion.
Comedo is a subtype of DCIS indicating a high grade
of disease, which translates to higher risk for
development of invasive breast cancer.
Comedo looks and acts differently from other In Situ
subtypes.
The center of the duct is plugged with dead cellular
debris, known as Necrosis.
This is a sign of rapid and aggressive growth.
Non-Comedo DCIS:
 Also known as low-Grade DCIS, is slow growing and less
aggressive than Comedo DCIS.
 Non-Comedo DCIS:
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Makes up 40% of all DCIS
Carries a 10-fold risk for the development of invasive
carcinoma
Has 3 cellular classifications, each with different architectural
patterns within the duct that may only be distinguished on
biopsy:
1.
Cribiform-perforated form (sieve-like)
2.
Micropapillary-clumpy, along the wall
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Solid- occupies entire lumen of duct
Comedo DCIS
 Also known as high-grade DCIS, is an aggressive
intraductal carcinoma.
 The ducts completely fill and dilate with abnormal cells
that quickly spread.
 The characteristic features that distinguishes Comedo
from Non-Comedo is necrosis.
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Comedo DCIS:
 Makes up 60% of all DCIS
 Carries a high risk for development of invasive carcinoma
 Has central necrosis within the tumor (probable cause of
microcalcifications)
 Involves multiple ducts within a segment
 Usually much larger than non-Comedo
 May have micro-invasion
Micro-Invasion is when cancer cells are found outside the
duct with an intact basement membrane.
Clinical features of DCIS include:
 Asymptomatic patient
 Possible palpable mass of varying size, shape, and consistency
 Possible nipple discharge
Sonography may reveal:
 Mass or no mass
 Shadowing artifact
 Architectural distortion
 Possible duct dilatation
 Microcalcifications (although not reliable on sonography)
Mammography detects
 Mass or no mass
 Clustered microcalcifications
 Linear, branch pattern microcalcifications
 Mammography is the most effective imaging method for
detecting Microcalcifications.
 Sonography is not particularly useful in evaluating
DCIS, especially if no distinct mass is seen.
Irregular clustered microcalcifications of ductal
carcinoma In Situ.
Lobular Carcinoma In Situ
 Lobular
Carcinoma In Situ (LCIS) represents
malignant changes in the lobular epithelium without
invasion outside the lobule (non-invasive cancer). It is
also known as lobular neoplasia and often considered a
pre-cancerous lesion.
Lobular Carcinoma In Situ on Sonography
 Mammography and Sonography are not particularly
helpful in the diagnosis of LCIS.
 Microcalcifications are not common
LCIS with MRI
LCIS:
 Arises form the lobule
 Generally affects premenopausal women
 Involves tumor growth that completely fills the lobule
 Is usually extremely small
 Usually does not present as a palpable mass
 Is often bilateral and multicentric (found in more than one
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quadrant) on initial diagnosis
Carries a 10-fold risk for the development of invasive
carcinoma
Is associated with invasive carcinoma to the opposite breast
Is generally not associated with microcalcifications
Is difficult to detect on Mammography and Sonography
May be detected on an incidental finding on biopsy
Invasive Breast Cancer
 Invasive carcinoma (or infiltrating Carcinoma) represents a
spectrum of breast cancers that offer malignant extension
beyond the duct or lobule. The tumor arises from the
TDLU and invades the surrounding stroma and fatty
tissues having the potential to metastasize.
 Several common types include:
 Invasive Ductal Carcinoma, NOS (not otherwise specified)
 Invasive lobular carcinoma
 Medullary carcinoma
 Colloid (mucinous) carcinoma
 Tubular carcinoma
 Papillary Carcinoma
 There are several rare forms of breast cancer including:
 Adenoid Cystic Carcinoma
 Squamous Cell Carcinoma
 Granular Cell Tumors
 Angiosarcoma
 Each of the different types of Invasive Carcinomas have a
variety of clinical, Mammographic, and sonographic
presentations.
Invasive Ductal Carcinoma
 Invasive Ductal Carcinoma (IDC) represents malignant
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changes of the ductal epithelium with invasion through the
basement membrane outside the duct.
IDC has the ability to metastasize to other parts of the body
through the bloodstream and lymphatic system.
Most Invasive Ductal Carcinomas are scirrhous-type, which
present the classic hard, gritty texture with an irregular
shape.
Most present as a palpable mass.
This is likely caused by the invasion of surrounding tissue
creating a host response or fibrotic reaction –
DESMOPLASIA.
As the tumor continues to grow, the margins become more
angular and spiculated.
 Invasive Ductal Carcinoma is the most common
type of breast cancer accounting for 75% of cases.
Normal Duct/DCIS/IDC Diagram
Clinical Features of IDC include:
 Palpable mass (palpable size is often larger than imaging
appearance)
 Hard, gritty texture
 Tumor is fixed (immovable)
 Skin dimpling, skin retraction, or nipple retraction
On Mammography, IDC may appear as
 Radiopaque
 Spiculated, lobulated or irregular margins
 Microcalcifications
 Thickened and or retracted Cooper’s ligaments.
Invasive Ductal Carcinoma on mammography
Invasive Ductal Carcinoma on
Mammography
 Sonographically, Invasive Ductal Carcinoma may appear:
 Solid mass
 Irregular shape, Angular or spiculated margins
 Taller-than-wide
 Markedly hypoechoic
 Heterogeneous internal appearance
 Partial or complete posterior shadowing
 Duct Extension or Branch Pattern
 Thickened, straightened, or retracted Cooper’s ligaments
 Fascia plane disruption
 Early IDC may appear as a well-circumscribed, homogeneous,
hypoechoic mass, with no shadowing (benign appearance).
Scirrhous-type tumors offer shadowing from the center of the
lesion.
IDC on sonography
IDC on sonography
Invasive Lobular Carcinoma
 Invasive
Lobular Carcinoma (ILC) represents
malignant changes of the lobular epithelium with
invasion outside the lobule.
 ILC has the ability to metastasize to other parts of the
body through the lymphatic system and bloodstream.
 Invasive Lobular Carcinoma is the second most
common type of invasive breast cancer accounting for
8-15% of cases
Spiculated Invasive Lobular
Carcinoma on mammography
ILC on sonography
Invasive Lobular Carcinoma:
 Is the most frequently missed breast cancer
 Is usually non-palpable
 Usually does not have microcalcifications
 Tumors are highly infiltrative and aggressive
 May produce an area of architectural distortion without
a mass
 Is more likely to be multifocal, multicentric, and
bilateral than IDC
 Is difficult to detect on mammography and sonography
 If a mass is present:
 Sonography may be more effective at demonstrating ILC
than mammography
 It may not be differentiated from Invasive Ductal
carcinoma on Mammography and Sonography
 The mass may appear as a spiculated, ill-defined,
radiopaque density on mammography
 The mass may appear as an ill-defined, markedly
hypoechoic lesion on sonography.
Medullary Carcinoma
 Medullary Carcinoma accounts for approximately 5%
of all invasive cancers.
 Medullary carcinoma tends to occur in younger
women and represents 11% of breast cancers found in
women under age 35.
 These highly cellular tumors tend to grow rapidly and
can become quite large.
 Medullary Carcinoma is the most commonly mistaken
cancer for a benign fibroadenoma.
 Medullary Carcinoma:
 Is a well-circumscribed, soft tumor
 Is non-tender, compressible, and slightly movable
 Tends to be non-infiltrative
 Is not associated with microcalcifications
 Is commonly mistaken for a fibroadenoma
 Is more common among Asian and African-American
women
 Carries a good prognosis
Medullary Carcinoma on MRI
Medullary Carcinoma on
Sonography
Sonography may reveal:
 Large, solid mass
 Round, oval, or macro-lobulated shape
 Smooth borders, may have microlobulated margins on
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close inspection
May be taller-than-wide
Hypoechoic appearance
Homogeneous or mild heterogeneous internal
appearance
Possible enhancement (due to highly cellular nature)
Shadowing is uncommon
Possible central necrosis
Colloid Carcinoma
 Colloid (Mucinous) Carcinoma accounts for 2 to 3% of
all breast cancers.
 Mucinous tumors contain mucous-producing cancer
cells that create a gelatin or syrup-like interior.
 As the tumor grows, it forms a large, firm, smooth
mass
Colloid (Mucinous) Carcinoma on
Mammography
Colloid or Mucinous Carcinoma on
Sonography
Colloid Carcinoma:
 Is slow-growing, non-aggressive tumor
 Is a circumscribed, soft tumor
 Typically affects elderly women
 Carries a good prognosis and metastatic disease is
uncommon
Sonography demonstrates:
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Hypoechoic or isoechoic in comparison to fat
Well-circumscribed lesion
May have microlobulation
Homogeneous internal appearance
Shadowing is uncommon
May appear similar to a complicated or complex cyst
Tubular Carcinoma
 Tubular Carcinoma accounts for approximately 2 to 3%
of all breast cancers.
 Tubular Carcinoma:
 Usually appears as a relatively small lesion
 Carries a good prognosis
 Has been associated with a benign radial scar and may
not be differentiated by imaging means
Tubular carcinoma
Tubular Carcinoma on Sonography
 Mammography demonstrates:
 Long spicules radiating from a small, radiolucent mass
 Sonography may reveal:
 A small, hypoechoic mass
 Ill-defined margins
 Posterior shadowing
Papillary Carcinoma
 Papillary carcinoma may be non-invasive or invasive,
and represents the malignant version of an intraductal
papilloma.
 Non-invasive Papillary Carcinoma is often included in
the spectrum of Non-Comedo DCIS.
 Invasive Papillary Carcinoma accounts for 0.3 to 2% of
all breast cancers.
Non-Invasive Papillary Carcinoma
on Sonography
Invasive Papillary Carcinoma on
Sonography
 Papillary Carcinoma:
 Primarily affects postmenopausal women
 Presents as a subareolar mass
 May present with bloody nipple discharge (However, this
more likely indicates benign intraductal papilloma)
 Imaging features will likely not distinguish between benign
intraductal papilloma, non-invasive papillary carcinoma, and
invasive papillary carcinoma.
 Sonography may reveal:
 Well marginated, solid mass
 May also appear complex
 May have duct dilatation
 May have microcalcifications
 If the duct becomes obstructed, an intracystic Papillary
Carcinoma may develop. This must be differentiated from a
benign intracystic papilloma.
Miscellaneous Cancer Topics
Paget’s Disease
 Paget’s Disease is a rare condition associated with breast
cancer seen in less than 1% of cancer patients.
 Paget’s Disease begins as an underlying breast cancer
that spreads upward within the ducts to the surface
epithelium of the nipple.
 The disease is almost always associated with invasive
carcinoma, but may be seen with carcinoma in situ.
Paget’s Disease
Paget’s Disease:
 Causes the skin of the nipple and areola to appear crusted,
scaly, and red.
 May cause the skin to bleed or ooze
 May cause burning and itching of the affected area
 Is generally diagnosed clinically
 Mammography may reveal:
 A negative examination
 Possible underlying breast cancer
 Sonography may demonstrate:
 Skin thickening of the nipple or areola
 Possible duct dilatation
 Possible underlying breast cancer
Crusty, scaly appearance of the nipple and areola is a
common presentation
Inflammatory Carcinoma
 Inflammatory Carcinoma is a rare, but aggressive type of
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breast cancer.
It accounts for 1 to 3% of all breast cases.
Inflammatory carcinoma occurs due to a primary breast
cancer invading the lymphatic vessels of the breast.
Invasive Ductal Carcinoma is the most common primary.
Spread of the cancer throughout the lymphatics is rapid
and diffuse with possible metastasis to the opposite breast.
Prognosis for the patient is poor.
Inflammatory carcinoma”Peau d’orange” sign
Inflammatory Carcinoma mammography
Inflammatory Carcinoma:
 Causes the breast to become warm, red, swollen, hard
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and painful.
Skin demonstrates classic sign – “peau d’ orange” or
orange peel appearance due to edema and thickening
May cause flattening or retraction of the nipple
May present with a palpable mass (Primary Cancer)
May present with axillary lymph node enlargement
Must be differentiated from severe mastitis
Sonography may reveal:
 Skin thickening
 Dilated lymphatic vessels
 Diffuse appearance of the parenchymal layer
 Tissue plane disruption
 Increased Doppler signals in all tissues
Multifocal Carcinoma
 Multifocal Carcinoma refers to 2 or more malignant
lesions found within the same ductal system or same
quadrant of the breast
 Multifocal carcinoma likely represents one primary
cancer that spreads up and down the ducts.
 It may, however, represent two distinct cancers along
the same ductal system or same quadrant.
Multifocal carcinoma represents 2 or more cancers
found within 5cm distance.
Multifocal Breast cancer on
mammography
Multicentric Carcinoma
 Multicentric Carcinoma refers to 2 or more malignant
lesions found in separate quadrants of the same breast
or found in both breasts.
 Multicentric involvement may result in a worse
prognosis.
Multicentric carcinoma represents 2 or more cancers
found greater than 5sm distance
Whole breast sonography may be warranted in assessing
multifocal and or multicentric breast disease.
Multicentric Carcinoma on
mammography
Male Breast Cancer
 Although breast cancer is 100 times more common in
women, breast cancer may occur in men.
 Male Breast Cancer accounts for approximately 1% of
all breast cancers.
Male Breast cancer on
Mammography
Male breast cancer on ultrasound
Breast cancer in men:
 Has associated risk factors
 Advanced age
 Family history of breast cancer
 Radiation exposure
 Cryptorchidism (Undescended testes)
 Testicular injury or surgical removal of tests
 Klinefelter’s syndrome (xxy sex chromosomes)
 Usually arises in the subareolar region
 Is most commonly DCIS or Invasive Ductal Carcinoma
 Presents with symptoms similar to female breast cancer
including palpable nodule
 Presents with mammographic and sonographic features
similar to female breast cancer
Phyllodes Tumor
 Phyllodes tumor, previously known as Cystosarcoma
Phyllodes, is a rare type of lesion arising form the
stroma (connective tissue) of the breast.
 A Phyllodes tumor is usually benign, but on occasion,
may be malignant.
 Phyllo means leaf-like
Phyllodes tumor- clinical
assessment
Phyllodes tumor on sonography
Phyllodes tumor
 Can be benign or malignant and are considered a
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transitional type of tumor
Typically occur in women age 30 to 50
Contain stromal tissue with mucinous, hemorrhagic, or
cystic fluid
Is usually solitary
Tends to grow rapidly and become quite large
Has large lobulations presenting a leaf-like (cleft) shape.
Appears as a large, palpable, firm, mobile mass that may
bulge the skin
Has a tendency to reoccur
Malignant Phyllodes tumor:
 Is a form of sarcoma
 Tends to be polylobulated (large multiple lobulations)
 May grow faster than the benign form
 May spread to the lung through the bloodstream
 Is treated by lumectomy or mastectomy
 Does not respond well to hormonal, chemo, or radiation
therapies.
Sonography may reveal:
 Large, solid, well-circumscribed mass
 Smooth, lobulated borders
 Hypoechoic or isoechoic internal echogenicity
 Homogeneous
or heterogeneous appearance (with
necrosis)
 Possible acoustic enhancement
Lymphoma
 Lymphoma of the breast may be a primary or
secondary disease.
 Primary lymphoma originates within the lymph nodes
associated with the breast, especially the axillary or
intra-mammary lymph nodes.
 Secondary or metastatic lymphoma arises from the
lymphatic system elsewhere in the body and
metastasizes to the breast.
 Metastatic lymphoma is more common than primary
lymphoma of the breast.
Lymphoma on Mammography
Normal intra-mammary lymph
node
Abnormal lymph node
Both Primary and Metastatic Lymphoma:
 Make up less than 1% of breast cancers
 Affects women age 50 to 60
 Usually presents as a palpable breast mass with palpable
axillary lymph nodes
 Cannot be differentiated from other breast cancers on
Mammography or Sonography
 Biopsy is warranted for definitive diagnosis
Sonography Appearance:
 Singular or multiple, solid masses within the breast and
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or axilla
Hypoechoic
Oval shaped mass indicates a singular lymph node
Large, lobulated tumors likely represent multiple, fixed
lymph nodes
Smooth to irregular borders
Loss of definition of the fatty hilum of the lymph node
Possible acoustic enhancement
Metastasis
 Cancer may metastasize to and from the breast
through the lymphatic system, bloodstream, or by
direct invasion.
 Metastatic Disease from Primary Breast Cancer:
 Spreads to the …
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Lymph Nodes
Bone
Lung
Liver
Opposite Breast
 Axillary lymph nodes are the most common location
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of nodal metastasis.
The Sentinel Node Procedure will help to determine
the presence or absence of axillary node metastasis
MRI is the excellent tool in evaluating lymph node
metastasis
A nuclear medicine bone scan and Chest x-ray are
common procedures to evaluate the presence of bone
and lung metastasis from breast cancer
A Positron Emission Tomography (PET) scan is also
useful in diagnosing metastasis.
Sonography and CT may also be used in the
assessment and staging of primary breast cancer.
Bone mets from Breast cancer on
Nuclear Medicine Bone scan
Lung mets from breast cancer on a
chest x-ray
Metastasis continued
 Metastatic Disease to the breast from another primary
cancer:
 Is uncommon and accounts for less than 2% of cancers
found in the breast
 Metastasizes from:
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Melanoma (most common)
Lymphoma
Lung
Sarcoma
Ovary
Opposite breast (likely Lymphatic route)
 On sonography, breast metastasis may appear as:
 Multiple, well-circumscribed palpable masses
 Hypoechoic
 Usually located in the superficial fat layer
 Often bilateral
Breast Metastasis from Melanoma
on sonography
BIRADS
 Diagnostic Imaging procedures are used to classify a
breast lesion according to its likelihood of being
malignant.
 Radiologists now classify breast lesions according to
the
American
College
of
Radiology
(ACR)Classification System Known as BIRADS (Breast
Imaging Reporting and Data System).
 The ACR BIRADS includes the following 7 categories:
 Category 0 = needs additional imaging
 This category represents inconclusive findings requiring
additional evaluation including spot compression,
magnification, or special mammographic views,
ultrasound, MRI, etc.
 Category 1 = Normal
 This category includes generally fatty replaced breasts
that are without clinical problems. Routine follow-up
 Category 2 = Benign
 This category includes breasts with dense tissue,
implants, or with many benign lesions, such as cysts,
lymph nodes, or fibroadenomas. Routine follow-up
 Category 3 = Probably Benign
 This category includes findings that are very unlikely to
be cancer (i.e., round or oval solid masses). Short-term
follow-up or biopsy is considered.
 Category 4 = suspicious
 This category includes findings that are often cancer
(i.e., irregular solid masses, microcalcifications, growth
of a solid mass). Biopsy is considered
 Category 5 = Malignant
 Most breast lesions that fall into this category are cancer
(i.e., spiculated mass, solid mass with nipple retraction
or skin thickening). Appropriate action should be taken.
 Category 6 = known biopsy-Proven Malignancy
 This category is reserved for lesions with biopsy proof of
malignancy prior to treatment/therapy. Appropriate
action should be taken.
 Purpose of BIRADS
 Place breast disease in a category regarding its likelihood of
being breast cancer
 Create a reliable database for patient follow-up and research
 Properly evaluating and classifying breast lesions on
both mammography and sonography aids in making an
appropriate and timely diagnosis, and reduces the risk
for ambiguous reporting and miscommunication
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