Solid breast masses containing small cystic portion in US: Correlation with pathology

1. Solid breast masses containing small cystic portion in US: Correlation with pathology Hyo Soon Lim MD., Hyun Jun Oh MD., Suk Hee Heo MD., Jae Kyu Kim MD., Jin Gyoon Park MD., Heoung Keun Kang MD. Department of Diagnostic Radiology Chonnam National University Medical School

2. Complex cystic mass • i) Predominantly cystic lesion with solid components ii) Predominantly solid with cystic components Both benign and malignant breasts lesions can be seen as complex cystic masses

3. Complex cystic mass Cystic with solid element Solid with cystic features Post op fluid collection Complex fibroadenomas Hematoma Pseudoangiomatous Abscess stromal hyperplasia Papilloma Phyllodes Oil cyst (fat necrosis) Invasive ductal carcinoma Galactocele Mucinous carcinoma Papillary carcinoma Metastatic disease

4. Purpose • To illustrate various solid breast masses containing small cystic portion in sonography with pathologic correlation

5. Complex fibroadenoma Fibroadenoma that contain • Cyst formation (greater than 3mm) • Apocrine metaplasia frequently causes small cysts to form within the nodule • Epithelical hyperplasia with epithelial type microcalcifications • Sclerosing adenosis

6. A B Fig. 1. Complex fibroadenoma with apocrine metaplasia. A 30-year-old woman with a screen-detected mass at US. • Oval, hypoechoic mass (black arrow) with small cystic spaces (white arrows) was detected. • Photomicrograph of histopathologic specimen shows cyst with columnar cells and papillary projection (H&E, X200).

7. A B Fig. 2. Complex fibroadenoma. A 19-year-old woman presents with a mass. • Oval, slightly hypoechoic mass with small cystic spaces (white arrows) and tiny echogenic dots. • Photomicrograph of histopathologic specimen shows cysts (arrows) and microcalcifications (H&E, X20).

8. Fig. 3. Complex fibroadenoma with cyst. A 74-year-old woman presents with a mass. Oval, isoechoic mass (black arrow) with posterior acoustic enhancement. A small cyst greater than 3mm is noted (white arrow) in the mass.

9. Phyllodes tumor • Fibroepithelial tumors • Less than 1 % of all breast neoplasm • Cystic change – may be seen more common in malignant tumors • Increased cellularity of the stroma and projection of stromal elements into cystic spaces to create a leaflike (phyllodes) pattern characterized phyllodes tumors

10. A B Fig. 4. Benign phyllodes tumor in a 45-year-old woman presented with a palpable mass. • Lobulated hypoechoic nodule with slitlike cystic clefts (arrow). • Photomicrograph of histopathologic specimen shows leaflike processes lined by bland epithelium and hypercelluar stroma with projection into cystic spaces (H&E, X100).

11. Lactating adenoma • Typically present during pregnancy • May be arise from preexisting fibroadenomas, tubular adenomas, and lobular hyperplasia  undergo lactational changes because of the altered physiologic state • Some have multiple cystic spaces and show more compressibility in comparison than any solid breast tumor

12. ` ` A B Fig. 5. Lactating adenoma. A 35-year-old woman with nipple discharge and increased prolactin level. A. Sonogram show solid mass with anechoic cystic spaces (thin arrows) representing lactational lobules. B. Photomicrograph shows a secretory lobules (thin arrows) separated by connective tissue and lined by secreting cells. The lumen of the acini is filled with secretions (thick arrows) (H&E stain, X100).

13. A B Fig. 6. Fibrocystic change. A 30-year-old woman with a screen-detected mass at US. • Oval, slightly hypoechoic mass (black arrow) with small cystic spaces (white arrow) was detected. • Photomicrograph of histopathologic specimen shows mammary ductal structure, acini, and multiple cystic spaces (arrows) filled with precipitated fluid and stromal fibrosis (H&E).

14. Hemangioma • Usually clinically inapparent and incidental findings at histology • Larger hemangiomas - as nonpalpable mammographic nodule • Cavernous, capillary, and mixed form - depending on the size of vessels contained within

15. Hemangioma Varible echogenicity : mild hypoechoic, isoechoic, hyperechoic - Depend on contained vessels size and the presence or absence of fibrosis, thrombosis, or phlebolith within hemangioma - the larger the vessel channels, the more hypoechoic the lesion will appear

16. A B Fig. 7. Hemangioma. A 57-year-old woman with a palpable mass. • Mediolateral oblique veiw of mammogram shows lobulated, circumscribed mass with phleboliths. B. Sonogram demostrates well-circumscribed hypoechoic mass with punctate bright echogenic foci (black arrow) which represents phleboliths and cystic spaces (white arrow).

17. C Fig. 7. Hemangioma. A 57-year-old woman with a palpable mass. C. Photomicrographs of histopathologic specimen reveals that the tumor is composed of blood-filled vascular spaces lined by endothelial cells (H&E, X100).

18. Seroma • Localized collection of serous fluid • Result from surgical procedure lymphatic disruption due to axillary dissection • The larger the seroma, the longer the it will take to resolve and be complicated by secondary infection

19. Seroma • US - simple cysts or complex cysts with diffuse low-level internal echoes • Fibrinous adhesion -> multiple, avascular thin, echogenic or thick, isoechoic septation that bridge the fluid collection

20. Fig. 8. Post operative fluid collection (Seroma). A 51-year-old woman after conserving surgery and axillary lymph node dissection. Sonogram demostrates complex cystic mass with multiple thick, isoechoic septation that bridge the fluid collection.

21. A B Fig. 9. Old abscess. A 38-year-old woman presents with a mass. • Oval, complex cystic mass in subareolar area. • Photomicrograph of histopathologic specimen shows inflammatory infiltrate, fibrosis, foam cells (macrophage), inflammatory giant cells and epithelial degeneration (H&E, X40).

22. Intraductal papillary neoplasm • Intraductal papilloma - A branching epithelial tumor originating from the wall of the mammary duct - Consists of fibrovascular stroma and epithelium with inner myoepithelial and outer columnar epithelial cell layer - The epithelium may show hyperplasia, but mitotic figures are uncommon and no epithelial atypia or dysplasia

23. Intraductal papillary neoplasm • Intraductal and Intracystic papillary carcinoma - malignant variants of intraductal papilloma - Intracystic carcinoma is located within large cystic ducts - Neoplastic cells has the appearance of low grade DCIS

24. A B Fig. 10. Intraductal papilloma. A 48-year-old woman presents with a mass. • A predominantly solid mass with small cystic space and posterior sonic enhancement. • Photomicrograph of histopathologic specimen. On one half of the specimen, the papilloma almost completely fills the cyst (arrows), only a small portion of it is actually attached to the wall of the cyst (H&E, X100).

25. Invasive ductal carcinoma • Invasive ductal carcinoma, NOS - most common type of breast cancer, representing 65% to 75% of mammary carcinoma - Grading is based on assessing: the degree of tubule and glandular structure formation, nuclear pleomorphism, and mitotic count - Invasive ductal carcinoma associated with necrosis presenting with complex cystic mass

26. A B Fig. 11. Invasive ductal carcinoma, NOS. A 45-year-old woman presents with a mass. • Predominantly solid mass with cystic areas, heterogeneous echotexture, irregular margins, and posterior acoustic enhancement. • Photomicrograph of histopathologic specimen shows invasive ductal carcinoma with central necrosis (H&E, X100).

27. Fig. 12. Malignant adenomyoepithelioma. A 34-year-old woman presents with a mass. Predominantly solid mass with cystic area (arrow), heterogeneous echotexture, and irregular margins. Macroscopically, well capsulated multilocular mass with focal hemorrhage.

28. Conclusion Complex cystic masses can be seen in a variety of circumstances Both benign and malignant breasts lesions can be seen as complex cystic masses, although there can be significant overlap in the diagnostic consideration