Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
142
Fig. 7.1 Breast fi broadenoma. ( a ) 1–7 .
Grayscale US, CDI, PDI, 3DPD, and
compression sonoelastography. ( b )
Pappenheim-stained image of a section;
original magni fi cation, ×1,000
7 Differential Diagnosis of Breast Diseases
a1
a2
a3
1437.1 Benign Lesions
a4
a5
Fig. 7.1 (continued)
144
7 Differential Diagnosis of Breast Diseases
a6
a7
Fig. 7.1 (continued)
Fig. 7.1 (continued)
1457.1 Benign Lesions
b
Fibroadenoma exhibits different US features
depending on the size. Nodules smaller than
1 cm often are characterized with roundish
shape, homogeneous structure, decreased
echodensity, and smooth or irregular contours.
Fibroadenoma of more than 2 cm in size more
often has regular spherical or oval shape with
accurate and smooth or irregular contours.
Surrounding tissues, normally, do not change.
Well-outlined isolated adipose lobules can
imitate fi broadenoma. The most important is to
differentiate between fi broadenoma and nodular
breast carcinoma expansive growth.
According to Haylenko et al. ( 2005 ) and
Sinyukova et al. ( 2007 ) , US usually fails to detect
the vessels in fi broadenoma, especially in subcentimeter nodules. Rarely, 1–2 normal vessels
with low velocities can be imaged: PSV, 0.19–
0.2 m/s; EDV, 0.06–0.1 m/s; RI, 0.63–0.79; and
PI, 1.21–1.65. Zabolotskaya and Zabolotsky
( 2000 ) reported hypervascularization with CDI
and PDI in 36 % of fi broadenomas.
The sensitivity of US in the diagnosis of breast
fi broadenoma accounts for 89–91.2 % with
speci fi city of 78–92.5 % and diagnostic accuracy
of 91–92.7 % (Rahimzhanova et al. 2011 ) .
Patients with fi rst-detected fi broadenoma are
subject to lesion biopsy with cytology (or histology) to de fi ne the type of the tumor and the degree
of proliferation of glandular epithelium. The
growth of fi broadenoma, the size larger than
2 cm, expressed proliferation of glandular epithelium, especially with dysplasia or atypia, are
indications for lumpectomy or excisional biopsy.
Phyllodes tumor is a mixed tumor of the
breast, which consists of connective and epithelial tissues. It demonstrates the incidence not
exceeding 0.5–2 % of all breast lesions (Trufanov
et al. 2009 ) . Phyllodes tumor affects women of
any age and exhibits two peaks in 16–20 years
and 40–50 years. The tumor is, as a rule, represented with a solitary lesion. It may lie dormant
for a long period and suddenly start fast growth.
Pregnancy can induce its growth. Due to the fast
size increase of phyllodes tumor, it is often diagnosed being quite large. It is clinically represented with a well-circumscribed lesion of
lobulated structure. Giant tumor can occupy the
major part of the breast, induces skin thinning,
and activates subcutaneous venous pattern.
Characteristic US features of phyllodes tumor
are listed below (Fig. 7.2 ):
146
7 Differential Diagnosis of Breast Diseases
Fig. 7.2 Phyllodes tumor. Grayscale US and PDI
1477.1 Benign Lesions
Hypo- or isoechoic breast lesion •
Irregular echostructure with multiple anechoic •
fl uid collections and incorporations (especially
in large lesions)
Roundish shape •
Distinct contours, regular borders •
Often with symmetric lateral shadows and •
posterior acoustic enhancement
Expressed intranodular hypervascularity with •
CDI, PDI, and 3DPD
Irregular mosaic staining with US elastography •
Phyllodes tumors may exhibit benign (60–
70 %), malignant (25–30 %), or intermediate features (Trufanov et al. 2009 ) . In cases of malignant
transformation of connective tissue component,
they may develop different sarcomas, such as
fi bro-, lipo-, hondro-, osteo-, or rhabdomyosarcomas. Malignant transformation of connective tissue and epithelial components results in
carcinosarcomas. Early detection of phyllodes
tumor assumes its accurate differentiation from
fi broadenoma. As compared with fi broadenoma,
phyllodes tumor has more cellular stroma with
complex architectonics and often with larger
degree of nuclear polymorphism. The type of
growth is de fi ned with histological examination
of core biopsy samples.
Lipoma is a benign tumor originating from
adipose tissue. It accounts for 9 % of all breast
lesions (Rozhkova 1993 ) . True lipoma consists of
mature adipose tissue surrounded with a capsule.
It is represented with a mobile soft lesion of
roundish or oval shape with palpation, which is
often (not always) accurately delimited from the
surrounding tissues. US diagnosis of breast
lipoma, as a rule, is not dif fi cult.
Characteristic US features of breast lipoma
are listed below (Fig. 7.3 ):
Lesion with decreased or normal echodensity, •
comparable to normal adipose breast tissue
Sometimes irregular structure at the expense •
of fi brous incorporations
Easily deformed with compression •
Without posterior enhancement or shadow •
Always avascular with CDI, PDI, and 3DPD •
Regular mosaic staining with US elastography •
Differential diagnosis with liposarcoma is
always necessary. The latter exhibits fast growth,
relatively decreased echodensity, tuberous margins, increased density with elastography and
palpation, and pathological vascularization.
Tumor biopsy veri fi es the diagnosis.
Intraductal papilloma is represented with a
lesion that grows within the lumen of lactiferous
ducts of the breast (Fig.
7.4 ). Solitary or multiple
lesions may arise. Intraductal papilloma is associated with abnormal discharge from the nipples.
Similar discharge less often occurs at duct ectasia
or fi brous mastopathy. However, 13 % of cases of
bloody nipple discharge and 7 % of cases of
serous discharge are consequences of ductal
breast carcinoma. One basic method of revealing
intraductal masses is ductography – the method
of arti fi cial contrasting of lactiferous ducts with
iodine-containing water-soluble agents while
performing X-ray mammography ( Fig. 1.3 ).
Intraductal lesions are the absolute indication for
breast surgery. Ductography usually follows routine mammography and cytology of nipple discharge smears. Triad of cytologic features
including macrophages, erythrocytes, and papillary structures or separate glandular epithelial
cells is typical for intraductal papilloma.
Nevertheless, ductography is contraindicated in
patients with in fl ammatory process in breast
ducts or breast carcinoma. That aims to avoid
spreading of the infection in the fi rst cases and
cancer cells in the second. The value of US in
diagnosis of intraductal pathology is limited with
such factors as resolution of the equipment (conventional scanner detects lesions greater than
2–3 mm) and the size of an intraductal lesion
(tumors are often smaller than 2 mm).
Intraductal papilloma can cause isolated dilation of a duct (ducts) in retroareolar area or breast
periphery. The tumor itself looks like a solid
papillary lesion of ordinary or increased echodensity with lobulated bordering located within a
cystic cavity.
Ductal papillomatosis of peripheral or terminal
ducts (further than 3 cm from the nipple) accompanied with atypical epithelial hyperplasia with
cytology is highly suspicious for ductal cancer.
US usually succeeds to differentiate intraductal papilloma only in cases of large lesions or
signi fi cant dilation of lactiferous ducts.
148
Fig. 7.3 Breast lipoma. ( a )
Grayscale US. ( b )
Pappenheim-stained image of
a section; original
magni fi cation, ×100
7 Differential Diagnosis of Breast Diseases
a
b
7.2 Non-tumoral Diseases
Non-tumoral breast pathology confers pathological processes of different etiology and pathogenesis. About 30 % of them associate with
hyperplasia of ductal and/or lobular epithelium
(Trufanov et al. 2009 ) .
Mastitis is an in fl ammatory nonspeci fi c process
in the breast. It is divided into lactational (up to
90 %) and non-lactational types. The in fl ammatory
process can be acute or chronic. Acute mastitis
exhibits the following phases of development:
serous in fl ammation, in fi ltration, and abscess.
Mastitis has the following US features
(Fig. 7.5 ):
Thickening of the skin over the area of •
in fl ammation (it exceeds the same of healthy
areas and the other breast)
Increase in echodensity of subcutaneous fat •
Indistinct margin between the deep layer of derma •
and adjacent structures (fat or glandular tissue)
Poor differentiation of the structure of breast •
parenchyma
One or several hypoechoic areas with distinct •
or vague margins within breast parenchyma
Underlined connective tissue component •
Fig. 7.4 Intraductal breast
papilloma. ( a ) Grayscale US.
( b ) Pappenheim-stained
image of a section; original
magni fi cation, ×100
1497.2 Non-tumoral Diseases
a
b
Cystic cavities and/or dilatations of lactifer-•
ous ducts
Regular vascular pattern of breast paren-•
chyma, uniform reduction of the vessel’s cali-
ber with CDI or PDI
Enlargement of axillary lymph nodes •
The expression of US features directly depends
on clinical symptoms. In some cases, such as late
or inadequate treatment, the in fl ammation develops from serous in fi ltration to diffusive purulent
stage with fi ne foci of purulent fusion of the
parenchyma, which aggregate and form abscesses.
Breast abscesses can be classi fi ed in accordance
to their location into subcutaneous, subareolar,
intramammary, and retromammary. In the majority of cases, the infection enters the breast tissue
through the damaged skin of the nipple, areola, or
epithelium of lactiferous ducts. However, the
infection may develop due to weak immune
response with hematogenic or lymphogenous
contamination. The knowledge of clinical signs
of acute mastitis is important for differential
diagnosis with in fi ltrative type of breast carcinoma. Acute mastitis exhibits acute beginning
with severe pain, local edema and hyperemia,
dense in fi ltration, local hyperthermia, and fever.
150
Fig. 7.5 Mastitis.
Sonograms. Grayscale US
7 Differential Diagnosis of Breast Diseases
Formation of an abscess is usually characterized
with the decrease of pain and development of
fl uctuation in the area of in fl ammation.
Breast abscess is sonographically characterized with a mass of heterogeneous structure due
to anechoic necrotic foci and echogenic detritus,
which is accurately boarded by echogenic pseudocapsule (Fig.
7.6 ). Abscess can show mainly
hypoechoic or anechoic structure. It is avascular
with CDI and PDI and often surrounded with the
zone of increased vascularity.
Follow-up of the patients with acute mastitis
with appropriate conservative treatment generally reveals the normalization of skin thickness
and breast tissue structure (decrease in the number and size of hypo- and anechoic areas, disappearance of reactive lymph nodes).
In cases of dif fi culties in the differentiation of
acute mastitis and diffuse type of breast carcinoma, special care should be paid to case history,
clinical data, mammographic features, and US
features. The biopsy of the breast and abnormal
Fig. 7.6 Breast abscess.
Grayscale US
1517.2 Non-tumoral Diseases
lymph nodes with cytology or histology is of
great bene fi t. Core biopsy in cases of expressed
in fl ammatory process is often impossible and in
diffuse type of breast carcinoma appears not
informative.
Breast trauma may be accompanied with
hemorrhage and breast hematoma (Fig. 7.7 ).
Posttraumatic changes include the following
periods: acute, the fi rst 4–7 days; intermediate,
up to 2 weeks; and late, the term within a year
and longer after the trauma. Division into the
periods is necessary for correct interpretation of
sonographic and clinical signs. During the fi rst
few days and weeks, hematoma is detected with
US as anechoic incorporations of roundish or
irregular shapes of various sizes, as a rule, located
super fi cially. Breast hematoma demands special
attention as it can be the fi rst sign of a malignant
tumor, considering neoangiogenesis (vessels
within a malignant neoplasm have no muscular
layer, are fragile, and easily damaged). Hematoma
undergoes slow resorption and/or organization.