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152
7 Differential Diagnosis of Breast Diseases
Breast trauma can also induce breast fat necrosis,
which is de fi ned as hypoechoic or echogenic
breast fi elds of irregular shape with indistinct or
accurate margins, often with posterior acoustic
shadow. Architectonics of surrounding tissues is
quite often affected. Further, there appear coarse
calci fi cations, which exhibit irregular shape or
correspond to roundish margins of the lesion. The
a
location of such masses corresponds to the place
of former trauma or hematoma. Surgical interventions, in fl ammatory processes, local ischemia,
and other conditions also can lead to such lesions.
They need to be differentiated with breast
malignancies.
Breast trauma or surgery in patient’s history
and absence of malignant signs with US and
b1
Fig. 7.7 Posttraumatic breast hematoma, acute period. ( a ) Breast view. ( b ) Sonograms. Gray scale and PDI
b2
1537.2 Non-tumoral Diseases
b3
Fig. 7.7 (continued)
mammography suggest lipogranuloma. It is necessary to remember about the possibility of recurrent breast carcinoma in the scar. FNAB and
cytology assist in correct diagnosis. Breast MRI
and excision biopsy may be indicated in most
ambiguous cases.
154
7 Differential Diagnosis of Breast Diseases
Breast condition is associated with female sex
hormones. Nevertheless, one important mechanism of pathological in fl uence considered is the
depression of progesterone against super fl uous
(relative or absolute) level of estrogens. The
changes in breast structure and function are
named fi brocystic breast disease (FBD).
Fibrocystic breast disease is characterized with
abnormal ratio of epithelial and connective tissue
components and a wide range of proliferative and
regressive breast changes. There are many synonyms of this condition, such as diffuse cystic
mastopathy, chronic cystic mastitis, fi brocystic
mastopathy, mammary dysplasia, and ReclusSchimmelbusch disease. FBD is the most widespread benign breast disease that affects 30–63 %
of women. Diffuse mastopathy is observed in
29.4–42.6 % of women more often at the age of
30–50 years. It accounts for 29–95 % in fertile
women with gynecologic disorders (Portnoy et al.
1995 ) . Breast carcinoma arises 3–5 times more
often against benign diseases, especially in the
cases of nodular type of FBD with epithelial proliferation (30–40 times more often than in normal
breast tissue) (Sinyukova et al. 2007 ) . The diagnosis of different types of mastopathy is important
because these processes can hide clinical signs
and complicate breast imaging of carcinoma.
Clinical features are nonspeci fi c and confer
general symptoms, such as pain, palpable breast
lesions, and discharge from nipples. The disease
exhibits hyperplasia of ductal epithelium and
sclerosis of connective tissue with histology that
results in the development of cysts.
US features of diffuse FBD (Fig.
7.8 ) are the
following:
Irregular dilation of lactiferous ducts •
Dense Cooper’s ligaments •
Fine-grained highly echoic glandular tissue •
Multiple anechoic incorporations (cysts) •
Poor asymmetric vascular pattern of breast •
parenchyma
The opinions about the changes in blood fl ow
in the vessels within and outside of the abnormal
area are ambiguous. Smirnova ( 1995 ) and Vetshev
et al. ( 1997 ) report that PSV in the fi elds of mastopathy does not exceed 0.09 m/s (as compared to
the norm of 0.13–0.16 m/s).
The risk of malignancy in non-proliferative
types of FBD is 0.9 %, and in cases of expressed
proliferation, it is 2–3 % (Korzhenkova 2004 ) .
The sensitivity of US in diagnosis of FBD
accounts for 77.8 % with speci fi city of 99.5 %
and diagnostic accuracy of 93.2 %.
Nodular mastopathy is a pathological condi-
tion with one or several dense foci within the
breast. It is, fi rst of all, a clinical concept. There
is a wide range of diseases that hide behind the
mask of nodular mastopathy, such as local fi brosis
(45 %), cyst (22 %), fi broadenoma (17 %), lipoma
(10 %), breast carcinoma, oleogranuloma, and
cystadenopapilloma (Korzhenkova 2004 ) .
Histological examination of the fi elds of
nodular mastopathy detects hyperplasia of glandular lobules, cysts, fi brosis, proliferation of
cellular elements of cysts and ducts lumen, and
other changes. Atypia of epithelium is regarded
a precancer.
US features of nodular mastopathy are listed
below (Fig.
7.9 ):
Solitary or multiple fi elds of decreased •
echodensity
Various dimensions •
Irregular shape •
Indistinct borders •
A- or hypovascularity with CDI, PDI, and •
3DPD
According to Sinyukova et al. ( 2007 ) , CDI
more often reveals linear vessels in nodular mastopathy without any change in its intensity. The
average PSV is 0.16–0.50 m/s, EDV, 0.07 ± 0.04;
PI, 1.2 ± 0.38; and RI, 0.65 ± 0.1.
US picture of nodular mastopathy often does
not differ from the early stage of a breast carcinoma; therefore, all kinds of nodular hyperplasia
should have morphological veri fi cation. Microscopic substrate, which represents the clinical
syndrome of FBD, confers all structural elements
of the mammary gland – lobules, cystically transformed ducts, and fi brous and adipose tissues.
Lobules, ducts, or cystic lesions may prevail, but
fi brous tissue is always presented in signi fi cant
amount. Dilation of lactiferous ducts and ductal
cysts in diffuse and nodular mastopathy often
results from excessive fi brosis of parenchyma
with local compression of lactiferous ducts.
1557.2 Non-tumoral Diseases
Cystic lesions are the most frequent feature of
FBD. The mechanism of appearance of cysts
implicates on one hand excessive fl uid secretion
by epithelial cells, which undergo apocrine metaplasia, and disturbance of fl uid absorption in
ducts on the other. Cysts are palpated as individual
Fig. 7.8 Diffuse FBD. Sonograms. Gray scale, panoramic scan, 3D, 3DPD, and US elastography
156
Fig. 7.8 (continued)
7 Differential Diagnosis of Breast Diseases
1577.2 Non-tumoral Diseases
Fig. 7.8 (continued)
158
7 Differential Diagnosis of Breast Diseases
Fig. 7.8 (continued)
1597.2 Non-tumoral Diseases
or multiple elastic movable lesions, often painful
with compression. They can be individual, multiple (more often), unilateral, bilateral, simple, or
complex. US permits precise differentiation of
cysts in 100 % of cases, while they are clinically
de fi ned as palpable lesions and mammographically detected as foci of average intensity within
the glandular triangle, which are accurately bor-
Fig. 7.9 FBD. Nodular type.
Sonograms. Gray scale, PDI,
and panoramic scan
dered or merging with surrounding breast
structures.
The majority of breast cysts exhibit typical US
features (Fig.
7.10 ) as follows:
Anechoic structure •
Homogeneous structure •
Roundish or oval shape •
Distinct accurate margins •
160
Fig. 7.9 (continued)
7 Differential Diagnosis of Breast Diseases
Fig. 7.9 (continued)
1617.2 Non-tumoral Diseases