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International Breast Ultrasound School Course June 2010, Athens Greece

Athina Vourtsis MD, Phd e-mail

• Pre-malignant lesions. • Lesions show cytological or histological atypia. • Lesions that may be associated with local malignant change. • Lesions that may be markers for increased risk anywhere in either breast. • Lesions that maybe locally aggressive.

Topics that will be discussed are: -

Columnar Cell Lesions


Atypical ductal hyperplasia (ADH)


Atypical lobular hyperplasia (ALH)


Lobular carcinoma in situ (LCIS)


Papillary lesions


Phyllodes tumor


Radial Scar

What are the Mammographic and Sonographic appearance of “high risk� breast lesions? Only three of these entities have fairly unique imaging appearances that can be described. Papillary lesions Phyllodes tumors Radial scars

The other entities have no distinctive imaging appearances of there own, but instead, present as either: The underlying entity in which they arose, or the associated proliferative changes with which they present.

Columnar Cell Lesions • Columnar cell lesions – Epithelium changes of the TDLU from low cuboidal to tall columnar epithelium. – CCLs differs with respect to the degree of changes formed:

1. CCC – Columnar cell change Single layer of columnar cells –– no further evaluation 2. CCH - Columnar cell hyperplasia - Multiple layers of columnar cells with stratification and apical tufting. 3. FEA - The flat epithelial atypia – Monomorphic cells with cytological atypia - when FEA is found in FNA or core biopsy an excision is indicated!

Columnar cell lesions • Mammographic Findings – Non specific mammographic features. – Clustered or round punctuate microcalcifications. – Frequently coexists with other proliferative lesions. – Best imaging diagnostic tool is mammography. – Protocol advised: spot compression magnification views in CC and 90 lateral projections.

Columnar cell lesions- flat epithelial atypia

Case 1. A 49-year-old-woman. 1st screening mammo. Multiple clusters of amorphous microcalcifications. Core biopsy showed Columnar cell changes – flat epithelial atypia.

Columnar cell lesions- flat epithelial atypia associated with ADH.

Case 1 continues. Open excision – Histology showed flat epithelial atypia coexisting with atypical ductal hperplasia. No evidence of malignancy.

What are “high risk” breast lesions?

Premalignant Lesions

Most frequent: •

Atypical ductal hyperplasia (ADH)

Atypical lobular hyperplasia (ALH)

Lobular carcinoma in situ (LCIS)

Increase the risk of breast carcinoma by 4 to 5x. (8 to 10x)

No specific mammographic or ultrasonographic features. Incidental findings identified histologically in breast tissue biopsied for other lesion.

Atypical Ductal Hyperplasia (ADH)

Atypical Ductal Hyperplasia (ADH) 2x increased lifetime risk of subsequently developing invasive disease. Family history of cancer in first degree relative the risk is doubled!!

• Intraductal epithelial proliferation of monomorphic cells. • Architectural and or cytological features nearly meet criteria for low grade DCIS. • ADH is regarded as nonobligatory precursor to DCIS and invasive carcinoma. • Distinction between ADH and DCIS is quantitative based on extent of involvement. • Atypia based on uniformity of individual cells and their arrangement.

Atypical Ductal Hyperplasia (ADH) Mammographic Appearance - Calcifications. - Amorphous - Punctuate - Pleomorphic

- May be incidental finding with other lesions. - Often incidentally seen with in excisional specimens of IDC and ILC.

Atypical Ductal Hyperplasia (ADH) Sonographic appearance - ADH has no specific appearance of its own. - ADH sonographic appearance is that of the underlying process in which it arose. - Usually florid duct hyperplasia - Less often sclerosing adenosis - Least often within the surface epithelium of a large duct papilloma

- The appearance of these is simply: - Enlargement of the lobules - Less often enlargement of the ducts

Atypical Ductal Hyperplasia (ADH)

Case 2. A 44-year-old-woman. 1st screening mammo. A cluster of amorphous micro-calcifications. Histology: ADH

Atypical Ductal Hyperplasia (ADH) Presenting as an enlargement

of TDLU - non-specific finding!

Case 2. A 44-year-old-woman. US was performed after the 1 st screening mammo. Enlargement of the TDLU corresponding to the amorphous micro-calcifications.

Atypical Lobular Hyperplasia (ALH) Lobular Carcinoma in Situ (LCIS)

Atypical Lobular Hyperplasia (ALH) Lobular Carcinoma in Situ (LCIS) Are high risk lesions associated with an increased risk of malignancy in either breast. These lesions represent a continuum and collectively are referred as “lobular neoplasia”. They include a spectrum of proliferative changes that range from ALH to LCIS. • •

Both entities arise in the TDLU. Proliferation of monomorphic lobular type cells, which eventually fill, distend and obliterate the acini.

In ALH the cells do not fill or distend more than 50% of the lobular acini whereas in LCIS the neoplastic cells fill and expand the lobules and terminal ducts.

Atypical Lobular Hyperplasia (ALH) – Moderate risk for breast cancer (4-5x)

Mammographic Appearance • Usually does not produce any characteristic mammographic findings. • Usually incidental in biopsy of amorphous calcifications – are often multifocal and bilateral. • May be incidental with other benign lesions. • Often incidentally seen with in excisional specimens of IDC and ILC.

Atypical Lobular Hyperplasia (ALH)

Case 3. A 54-year-old-woman. A cluster of amorphous micro-calcifications, being stable > five year. Histology: Atypical lobular hyperplasia.

Lobular Carcinoma in Situ (LCIS) – 8-10x Increased-risk marker for the development of infiltrating Ca in either breast; Regardless of the mechanism involved a women with LCIS has a 15% risk of developing an invasive ductal or lobular carcinoma in the breast which the LCIS has been discovered and a similar risk (15%) for controlateral development of cancer over the next 30 years. Some investigators have speculated that individual foci of LCIS may progress to invasive disease.

Lobular Carcinoma in Situ (LCIS) – 8-10x Mammographic Features •Microcalcifications of various types – led to biopsy. •Calcifications have not distinctive morphologic features. Usually are not seen in the LCIS itself. •May be incidental with other lesions – adjacent or in a fibroadenoma, sclerosing adenosis, or apocrine metaplasia or with in excisional specimens of IDC and ILC. •Rarely appears as a mass with lobular shape. •Preoperative localization of LCIS is not possible. •Approximately 50% of proven microscopically foci of LCIS have normal mammograms. •An observation regarding the tendency of LCIS to develop more often in persistence for the patients age dense parenchymal pattern type ACR 4.

Lobular Carcinoma in Situ coexisting with DCIS

Case 4. A 47-year-old-woman with (-) family history. 4th screening mammo. Stable bilateral scattered calcifications.

Lobular Carcinoma in Situ coexisting with DCIS

Case 4 continues. A new cluster of pleomorphic calcifications developed. Histology: Multifocal LCIS and the coexistence of ductal carcinoma in situ with micro invasion.

Intraductal Papilloma

Intraductal Papilloma Benign ductal neoplasm. Proliferation of epithelial and myoepithelial cells supported by a fibrovascular stalk. •

Central (80%) – Usually solitary, larger ducts, intracystic, more frequently presents with nipple discharge. Peripheral (20%) – often multiple, arise in TDLU.

Foci of DCIS or ADH can be seen in benign papillary lesions and are more common in patients with multiple peripheral papillomas than in those with solitary central papillomas.

Intraductal Papilloma - Papillomatosis Solitary intraductal - arise from the terminal portions of the duct. According to a Consensus committee of the College of American Pathologists women with solitary intraductal papilloma have a 1,5 – 2 times relative risk of developing invasive breast carcinoma in their lifetime. Intraductal papilloma demonstrates area of atypical ductal hyperplasia than is associated with a moderately increased risk (4-5 times) for breast cancer.

Multiple papillomas - arise in TDLU.

Is considered a premalignant condition – similar to LCIS. Women with multiple papillomas have a 7.4-times life risk of developing breast carcinoma.

Rarely papilloma may lie entirely in the nipple – called superficial papillary adenomatosis.

Intraductal Papilloma Mammographic appearance: •

Round or oval density

Well circumscribed or indistinct margins

Often very dense (when contain blood)

Cluster of calcifications fine or coarse rarely

Solitary or multiple dilated ducts

Often mammograms are normal.

The overall

sensitivity for detection of papillary lesions on mammography is low (35%).

Intraductal Papilloma Ultrasonographic appearance: •

Isoechoic or hypoechoic well defined mass.

Smooth wall cystic lesion with some solid component – intracystic lesion –.

Duct ectasia with a focal intraluminal soft tissue

mass •

US shows better the extend of the lesion, is used for pre-operative localization and for biopsy guidance.

Color Doppler – demonstrate a fibrovascular stalk.

Intraductal Papilloma

Case 5. Mammography of a 70-year-old woman with a bloody nipple discharge. Mammography shows prominent tubular densities in the subareolar area associated with rounded, eggshell like calcifications. Histology: Benign papilloma.

Intraductal Papilloma

Case 6. Mammogram (-) with ACR parenchyma type 4. Palpable nodule in the 5 o clock position of the right breast-. Histology papilloma.

Intraductal Papilloma

Case 6 continues. Vascularity identified in the fibro vascular core of the papilloma might suggest the diagnosis.

Intraductal Papillary Lesions Imaging Findings: There are no specific imaging findings to distinguish 

benign papilloma

papilloma with atypia or

malignant papillary lesions

Intraductal Papillomas with higher risk of atypia or malignancy may appear : Ultrasonographic appearance: •

Presence of microcalcifications

Indistinct margins – angles

Expands the duct more than the fluid

Isoechoic lesions longer than 2.0cm

Involves branches – TDLU’s

Intraductal Papilloma

Case 7. Ultrasound in a 70-year-old woman with a bloody nipple discharge. Hypoechoic solid soft tissue mass and a duct extension. This indicates a large duct papilloma in about 90%.

Intraductal Papilloma

Case 7 continues However in about 10% they may contain ADH or might present DCIS, biopsy should always be considered!

Large Intraductal Papilloma

Case 8. Mammogram of a 45-year old woman with two prior operations for papillomas. Presented with a new palpable mass.

Large Intraductal Papilloma

Case 8 continues. 3D Ultrasound shows a large isoechoic soft tissue mass.

Large Intraductal Papilloma

Case 8 continues. 3 D US with Tomographic Ultrasound Imaging (TUI)

Literature: Tavassoli FA, et al. World Health Organization Classification of Tumours. Lyon, France: IARC, 2003, 9-112.

Literature: Mangi AA, Smith BL, Gadd MA, et al. Surgical management of phyllodes tumors. Arch Surg 1999;134:487–492. Buchanan EB. Cystosarcoma phyllodes and its surgical management. Am Surg 1995;61:350–355.

Ultrasonographic appearance 

Hypoechoic round or oval shape mass.

 Circumscribed margins and < frequently indistinct.

 Posterior acoustic enhancement.  Mild hypoechoic internal echoes.  Heterogeneous echo pattern.  Intramural cystic structures.  Color Doppler – vascularization non-specific.

Case 9

Case 10 US scan in 35- year-old woman with palpable masses show two oval masses, hypo echoic with horizontal orientation.

Features compared to identify potential differences between Phyllodes tumors vs. Fibroadenomas

Features compared to identify potential differences between Phyllodes tumors vs. Fibroadenomas

Case 11. US in a 27- year-old woman with a palpable mass. Histology benign phylloid tumor

Phyllodes Tumor

The appearance of these breast tumors on sonography and mammography are usually similar. Therefore it is not possible to allow distinction of a giant fibroadenoma from a phyllodes tumor that needs wider excision.

Tumors Size: Tumors >3 cm or larger being significantly more likely to be malignant.

Borders of the wall of the cysts: Smooth or irregular. tumors.





Literature: Liberman L et al. Radiology 1996; 198: 543. Yabuuchi H et al. Radiology 2006;241:241(3):702-709.

Radial Scar

Radial Scar significance as a high risk lesion remains controversial ! • Some data suggests that radial scar is a generalized risk marker.  2x risk of subsequent breast cancer in either breast. 

4-5x risk of breast cancer if associated with ADH.

• The clinical importance is its association with atypical ductal hyperplasia or malignancy in the periphery of the lesion that has led to recommendation for surgical excision rather than core biopsy. • In 22% of lesions suspected of being radial scar lesions at imaging are actually carcinomas at biopsy. • Therefore, core biopsy prior to excision allows attempt at clear margins and sentinel node biopsy at initial surgery.

Mammography â&#x20AC;&#x201C; is usually an incidental finding 1. Spiculated density with radiolucent center / absence of a central opacity. 2. Elongated thin radiating spicules. 3. Fat captured between the spicules. 4. Architectural distortion. 5. Variable appearance on different projections. 6. Associated calcifications have been reported. 7. Absence of palpable lesion and skin thickening.

Radial scar - Sonographic Findings usually suspicious but not specific for RS Some radial scars seen on mammography are not seen on US Sonographic visualization is relative to the degree of peripheral proliferative changes or when associated with malignancy. Central fibroelastotic scar varies in echogenicity – depending upon the echogenicity of the surrounding tissues.

• appears hypoechoic when surrounded by hyperechoic fibrous tissue. • can appear hyperechoic when surrounded by isoechoic proliferative changes. • may not be visible in cases where the proliferative changes are so dominant that the lesion appears to be a solid nodule. • architectural distortion - tethering of Cooper ligaments. These lesions may cause shadowing and be “taller than wide” – indistinguishable from small low grade IDC or tubular carcinomas.

Radial scar

Case 12. Screening mammogram in a 46-year-old mammogram. Craniocaudal view show an architectural distortion without a central mass.

Radial Scar Parenchymal distortion without a central mass

Case 13. Screening mammogram in a 43-year-old woman with breast implants.

Radial scar Hypoechoic mass

Case 13 continues.

Radial scar Hyperehoic central scar is seen when there is cystic dilatation in periphery

Radial scar hypoechoic when surrounded by hyperechoic fibrous tissue

Case 14. Screening ultrasound in a 29-year-old woman.

Radial scar

Case 14 continues. Hypoechoic, angular, similar to small low grade IDC or lobular carcinoma

Diagnostic Pitfalls The mammographic appearance of a non-palpable circumscribed






Therefore fibroadenoma, papillomas, phyllodes tumor





distinguished (Infiltrating

from ductal

carcinoma, medullary, mucinous and pappilary carcinoma)






mammogram. Variability in mammographic interpretation among experienced radiologistâ&#x20AC;&#x2122;s.

Diagnostic Pitfalls

Parenchymal distortion without a central mass

Radial scar

Invasive Lobular Carcinoma


International Breast Ultrasound School Course June 2010, Athens Greece Athina Vourtsis MD, Phd e-mail •Pre-malignant...