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MALIGNANT BREAST LESIONS

Malignancies develop over a long period of time. When a carcinoma is contained and has not invaded the basal membrane structure, it is considered insitu.

Most cancers originate in the terminal ductal lobular units.
The breast lobules are concentrated in the upper outer quadrant so about 50% of cancers can be found there followed by retroareolar area (17%), upper inner quadrant (15%), lower outer quadrant (10%) and lower inner quadrant (5%).

According to the American Cancer Society, any of the following unusual changes in the breast can be a first sign of breast cancer:
  • swelling of all or Breast_symtoms_pic2.jpgpart of the breast
  • skin irritation or dimpling
  • breast pain
  • nipple pain
  • redness, scaliness, or thickening of the nipple or breast skin
  • a nipple discharge other than breast milk
Link – Breast Cancer
http://www.youtube.com/watch?v=JcPzS4JQkNg&feature=related



Ductal Carcinoma In situ

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Ø Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means "in its original place.
Ø " DCIS is called "non-invasive" because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue.
Ø DCIS isn’t life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.
Ø When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a recurrence are under 30%.
INVASIVE DUCTAL CARCINOMA (IDC)
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Ø Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma, is the most common type of breast cancer.
Ø About 80% of all breast cancers are invasive ductal carcinomas.
Ø Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means that the cancer began in the milk ducts
Ø It refers to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body.

LOBULAR CARCINOMA IN SITU (LCIS)


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Ø LCIS usually does not cause any signs or symptoms, such as a lump or other visible changes to the breast. LCIS may not always show up on a screening mammogram.
Ø One reason is that LCIS often lacks microcalcifications, the tiny specks of calcium that form within other types of breast cancer cells. On a mammogram, microcalcifications show up as white specks. It’s believed that many cases of LCIS simply go undiagnosed, and they may never cause any problems.
Ø In more than half of cases, LCIS is “multifocal,” meaning that multiple lobules have areas of abnormal cell growth inside them. In about one-third of women with LCIS, the other breast is affected as well.
Ø Sonographically, its ill-defined, markedly hypoechoic and usually does not have microcalcifications. There could be visual breast distortion without a palpable mass.



INVASIVE LOBULAR CARCINOMA (ILC)

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Ø Invasive lobular carcinoma may not cause any symptoms. Sometimes, an abnormal area turns up on a screening mammogram (x-ray of the breast), which leads to further testing. Invasive lobular carcinomas tend to be more difficult to see on mammograms than invasive ductal carcinomas.
Ø The first sign of ILC is a thickening or hardening in the breast that can be felt, rather than a distinct lump. Other possible symptoms include an area of fullness or swelling, a change in the texture of the skin, or the nipple turning inward.

COMEDO CARCINOMA

Ø A type of non-invasive cancer that usually does not spread. Some of the cancer cells die off and form small groups, called "comedo necrosis". (Necrosis means dead cells.) It tends to grow fast and suggests a higher risk of invasive cancer in the future.
Ø Intraductal solid carcinoma in which the lactiferous ducts are filled with yellow paste like material that looks like small plugs.
Ø If there is nipple discharge, it will be frequently be clear than bloody.
Ø In the advanced stage, the clinical signs are nipple retraction, dominant mass and fixation

PAPILLARY CARCINOMA
Ø Invasive papillary carcinomas of the breast are rare, accounting for less than 1-2% of invasive breast cancers.
Ø It initially arises from the intraductal mass. It arises from a benigh ductal papilloma. The earliest sign is bloody nipple discharge
Ø In most cases, these types of tumors are diagnosed in older women who have already been through menopause.
Ø An invasive papillary carcinoma usually has a well-defined border and is made up of small, finger-like projections.
Ø It has more favorable prognosis than other kinds of carcinomas.

PAGET’S DISEASE

Ø Paget's disease of the nipple is a rare form of breast cancer in which cancer cells collect in or around the nipple. The cancer usually affects the ducts of the nipple first (small milk-carrying tubes), then spreads to the nipple surface and the areola (the dark circle of skin around the nipple). The nipple and areola often become scaly, red, itchy, and irritated.
Ø Paget's disease of the nipple accounts for less than 5% of all breast cancer cases in the United States. Being aware of the symptoms is important, given that more than 97% of people with Paget's disease also have cancer, either DCIS or invasive cancer, somewhere else in the breast. The unusual changes in the nipple and areola are often the first indication that breast cancer is present.
Ø It arises in retroareolar ducts and grows in the direction of the nipples spreading into the intraepidermal region of the nipple and areola.
Ø Sonographically, it presents as a retroareolar mass with irregular margins, heterogeneous internal echoes and attenuation with posterior shadowing.

SCIRRHOUS CARCINOMA
Ø It’s a type of intraductal tumor with extensive fibrous tissue proliferation.
Ø Clinical signs are very firm, nodular frequently, nonmovable mass often with fixation and flattening of overlying skin and nipple retraction.
Ø The deep lying scirrhous carcinoma may grow into and become fixed to the thoracic wall.

MEDULLARY CARCINOMA


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Ø Medullary carcinoma of the breast is a rare subtype of invasive ductal carcinoma (cancer that begins in the milk duct and spreads beyond it), accounting for about 3-5% of all cases of breast cancer. It is called “medullary” carcinoma because the tumor is a soft, fleshy mass that resembles a part of the brain called the medulla.
Ø It is a densely cellular tumor containing large, round oval tumor cells.
It is rare comprising of less that 5% of breast cancers. The age of occurrence is slightly lower than for the average breast cancer. It occurs in women younger than 50 yrs.
Ø Medullary carcinoma is more common in women who have a BRCA1 mutation. Studies have shown that medullary carcinoma is also more common in Japan than in the United States.
Ø Medullary carcinoma doesn’t grow quickly and usually doesn’t spread outside the breast to the lymph nodes. For this reason, it’s typically easier to treat than other types of breast cancer.

Colloid Carcinoma


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Ø It’s a rare type of ductal carcinoma accounting for approximately 3% of breast carcinomas. It is also called mucinous carcinoma of the breast. In this type of cancer, the tumor is formed from abnormal cells that “float” in pools of mucin. In mucinous carcinoma, however, the mucus becomes a main part of the tumor and surrounds the breast cancer cells.
Ø Mucinous carcinoma tends to affect women after they’ve gone through menopause. Some studies have found that the usual age at diagnosis is 60 or older.
Ø Mucinous carcinoma is less likely to spread to the lymph nodes than other types of breast cancer. It’s also easier to treat.
Ø Sonographically, it has smooth margins and posterior enhancement.

TUBULAR CARCINOMA



Ø Tubular carcinoma of the breast is a rare subtype of invasive ductal carcinoma (cancer that begins inside the milk duct and spreads beyond it). Tubular carcinoma accounts for about 1-2% of all breast cancer cases.
Ø In this type of cancer, the tumor is usually small and made up of tube-shaped cells that are low grade. “Low grade” means they look somewhat similar to normal, healthy cells and tend to grow slowly.
Ø It represents extremely well differenctiated form of infiltrating ductal carcinoma usually less than 2 cm in dimension.
Ø It has poorly circumscribed margins and a hard consistency.
Ø Tubular carcinoma of the breast is less likely to spread outside the breast than other types of breast cancer. It’s also easier to treat.


Sonographic characteristics
Benign
Potentially Malignant
Absence of malignant findings
x

Hyperechoic/ intense, fibrous tissue like
x

Two or three macrolobulations
x

Ellipsoid shape/ wider than tall, parallel to the skin
x

Pseudocapsule/ thin, echogenic, well-circumscribed
x

Spiculations/ alternating hyper and hypoechoic straight lines

x
Height/ width >1 or non parallel to the skin

x
Angular margins

x
Shadowing/ through transmission attenuated

x
Branch pattern extensions / multiple radial projections, peri or intra-ductal, nipple oriented

x
Markedly hypoechoic ..

x
Microcalcifications

x
Duct extension / single radial projection, peri or intra-ductal, nipple oriented

x
Microlobulations

x
Intracystic nodule*, parietal thickening*

x
Link -Ultrasound Elastography http://www.youtube.com/watch?v=uulyRhtkzmc&feature=related

Microlobulations, duct extensions, and posterior acoustic shadowing are also suspicious for breast cancer

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

ULTRASOUND IMAGES OF THE BREAST

===1) Ultrasound images of lactating breast:

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This ultrasound image shows prominent and dilated mammary ducts in the lactating breast. The ducts are seen as tubular hypoechoic structures, which widen as they approach the nipple. Sometimes, it may be possible to see fat drops within the milk secretions in the ducts. These appear as mildly echogenic debris within the ducts.



2) Malignant lesion of the breast:

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This ultrasound images reveal a hypoechoic, poorly defined, irregular mass in the breast. There is also evidence of acoustic shadowing posteriorly. These findings on sonography suggest malignant mass of the breast.



3)Carcinoma of breast:

The ultrasound images show a typical proven case of cancer of the left breast. The tumor is seen as a well defined hypoechoic mass with microlobulation or fine irregularities of the margins. In addition, the mass shows multiple echogenic areas along the rim a clear sign of malignancy in breast carcinoma.



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Galactocele of breast:



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This young female, lactating patient presented with slowly enlarging mass of the right breast. It was non tender and patient had no h/o pyrexia. Sonography of the breast shows a 3 cms. sized hypoechoic (almost cystic) lesion with through transmission. Color doppler images of the breast showed no signficant enhancement of vascularity. These ultrasound images of the breast suggest Galactocele. Galactoceles are formed by cystic dilatation of the lactiferous ducts and contain milk. They are seen in lactating women.

5)Giant fibroadenoma or Juvenile fibroadenoma:

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These ultrasound images of the left breast in a 15 yr. old female patient show a large (the mass measured 8.2 cms.), more or less homogenous, well defined mass with posterior acoustic enhancement. These findings suggest a diagnosis of giant fibroadenoma of the left breast. The main differential diagnosis in such a case would be phyllodes tumor. However, phyllodes tumor is seen in females over 30 yrs. of age. Despite the rapid increase in size of the mass, in this case, the potential for malignancy is very low.

7) Fibroadenosis of breast:

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Benign breast masses: fibroadenosis:

This young female patient presented with pain in the right breast and "lumpy feeling" on palpation. Sonography of the right breast showed a hypoechoic, lobulated, well defined mass in the breast. A few anechoic spaces (cystic areas) were also present. Such ultrasound images (appearances) are usually seen in fibroadenosis of the breast. Fibroadenosis is characterized by pain breast with or without palpable masses (lumps). On histopathology, there may be microcysts, fibrosis, adenosis of hyperplastic changes of the breast epithelial tissue. Repeat/ follow up ultrasound would usually show resolution of the mass (usually after 1 to 2 months). It is often difficult to distinguish fibroadenoma from fibroadenosis purely on the basis of sonography alone.