THE BREAST DURINGTHE BREAST DURING

PUBERTY, PREGNANCY AND PUBERTY, PREGNANCY AND LACTATIONLACTATION

Dr. Varda Stahl-KentDr. Varda Stahl-KentDEPARTMENT OF RADIOLOGY AND THE DEPARTMENT OF RADIOLOGY AND THE

M. FANNY BREAST CARE INSTITUTEM. FANNY BREAST CARE INSTITUTE

ASSAF HAROFE MEDICAL CENTERASSAF HAROFE MEDICAL CENTER

EMBRIOLOGY OF THE BREASTEMBRIOLOGY OF THE BREAST

At about the sixth week of embrionic life, breast At about the sixth week of embrionic life, breast precursor develops from ectodermal origin.precursor develops from ectodermal origin.The “milk line” extends from the axillary area to The “milk line” extends from the axillary area to the groin region.the groin region.Portions of the milk line atrophy except in the Portions of the milk line atrophy except in the region of the fourth intercostal space, from which region of the fourth intercostal space, from which mammary tissue develops.mammary tissue develops.When portions of the milk line do not regress, When portions of the milk line do not regress, there is accessory breast tissue or accessory there is accessory breast tissue or accessory nipple.nipple.

CHANGES IN THE BREAST DURING CHANGES IN THE BREAST DURING CHILDHOODCHILDHOOD

Branching of main ducts –terminal buds – Branching of main ducts –terminal buds – TDLU’sTDLU’s

Proliferation and enlargement of adipose Proliferation and enlargement of adipose cellscells

Increasing of stroma and blood vesselsIncreasing of stroma and blood vessels

ULTRASOUND APPEARANCE OF THE ULTRASOUND APPEARANCE OF THE BREAST DURING CHILDHOODBREAST DURING CHILDHOOD

BREAST DEVELOPMENT DURING BREAST DEVELOPMENT DURING PUBERTYPUBERTY

Estrogen responsible for ductal development.Estrogen responsible for ductal development.

Progesterone responsible for lobulo-alveolar Progesterone responsible for lobulo-alveolar development.development.

Breast bud appearance – telarche – mean age Breast bud appearance – telarche – mean age 9.8 years.9.8 years.

Premature breast development – before age 8.Premature breast development – before age 8.

Delayed breast development – after 13.Delayed breast development – after 13.

Asymmetric breast development not uncommon, Asymmetric breast development not uncommon, not to be mistaken for a mass.not to be mistaken for a mass.

TANNERTANNER PHASES OF PUBERTAL PHASES OF PUBERTAL BREAST DEVELOPEMENTBREAST DEVELOPEMENT

1 – nipple elevation1 – nipple elevation

2 – nipple and breast projection from chest 2 – nipple and breast projection from chest wall, palpable tissue in subareolar regionwall, palpable tissue in subareolar region

3 - increased glandular tissue and areolar 3 - increased glandular tissue and areolar sizesize

44 - development of nipple-areolar complex - development of nipple-areolar complex

5 - final adolescent development with 5 - final adolescent development with smooth breast contoursmooth breast contour

THE BREAST IN ADOLESCENCETHE BREAST IN ADOLESCENCE

ASYMMETRICAL DEVELOPMENT IN A 13-ASYMMETRICAL DEVELOPMENT IN A 13-YEAR-OLD GIRLYEAR-OLD GIRL

DEVELOPMENTAL ANOMALIESDEVELOPMENTAL ANOMALIES

Polymastia Polymastia – aberrant breast – ectopic breast tissue with aberrant breast – ectopic breast tissue with

no nipple or areola, usually close to the no nipple or areola, usually close to the normal breast (axilla, infraclavicular region normal breast (axilla, infraclavicular region etc). Cancer and fibroadenoma may occur.etc). Cancer and fibroadenoma may occur.

– Supernumerary breasts – have nipple, areola Supernumerary breasts – have nipple, areola or both, with or without breast tissue. or both, with or without breast tissue. Anywhere from the axilla to the groin, but may Anywhere from the axilla to the groin, but may occur in many other areas.occur in many other areas.

ACCESSORY BREAST TISSUE ACCESSORY BREAST TISSUE SEPARATED FROM THE MAIN BUDSEPARATED FROM THE MAIN BUD

ASYMMETRICAL DEVELOPMENTASYMMETRICAL DEVELOPMENT

Poland’s syndrome – Poland’s syndrome – – Agenesis of pectoralis muscle and breast Agenesis of pectoralis muscle and breast

tissue on one side.tissue on one side.

Asymmetrical development of breast Asymmetrical development of breast tissue only.tissue only.

POLAND’S SYNDROMEPOLAND’S SYNDROME

MASSES IN THE PEDIATRIC AND MASSES IN THE PEDIATRIC AND ADOLESCENT PATIENTADOLESCENT PATIENT

Mostly benign etiology:Mostly benign etiology:– GynecomastiaGynecomastia– CystCyst– FibroadenomaFibroadenoma– Phyllodes tumor (rare – only up to 10% under 20y)Phyllodes tumor (rare – only up to 10% under 20y)– Lymph nodeLymph node– GalactoceleGalactocele– Duct ectasiaDuct ectasia– Juvenile PapillomatosisJuvenile Papillomatosis– InfectionInfection

Only 0.2% of primary breast cancers occur in Only 0.2% of primary breast cancers occur in this age group.this age group.

GYNECOMASTIAGYNECOMASTIA

Neonatal period.Neonatal period.Adolescence (peak at 13-14 years). Common, Adolescence (peak at 13-14 years). Common, frequently resolves within 2 years.frequently resolves within 2 years.Elderly men.Elderly men.Pathologic processes: renal or liver diseases, testicular Pathologic processes: renal or liver diseases, testicular or adrenal tumors, hyperthyroidismor adrenal tumors, hyperthyroidismMedications: estrogen, psychoactive drugs, Medications: estrogen, psychoactive drugs, cardiovascular drugs, diuretics, chemotherapy, drugs of cardiovascular drugs, diuretics, chemotherapy, drugs of abuse abuse

Ultrasound demonstrates hypoechogenic breast tissue in Ultrasound demonstrates hypoechogenic breast tissue in subareolar region.subareolar region.

GYNECOMASTIA OF PUBERTYGYNECOMASTIA OF PUBERTY

Common etiology: transient imbalance between Common etiology: transient imbalance between estrogen and androgen.estrogen and androgen.– By the end of puberty, estrogen increases X3 and By the end of puberty, estrogen increases X3 and

testosterone X30testosterone X30– the ratio estrogen : testosterone may be greater than the ratio estrogen : testosterone may be greater than

normal for a certain period normal for a certain period

Breast tissue of affected individuals may be Breast tissue of affected individuals may be more sensitive to estrogen.more sensitive to estrogen.Kleinfelter synd. (47 xxy)Kleinfelter synd. (47 xxy)Significant association with varicocele in the Significant association with varicocele in the ages 12-14ages 12-14

BILATERAL, ASYMMETRICAL BILATERAL, ASYMMETRICAL GYNECOMASTIAGYNECOMASTIA

ASSYMETRICAL GYNECOMASTIAASSYMETRICAL GYNECOMASTIA

CYSTCYST

Most common in the ages 30-50, but may occur Most common in the ages 30-50, but may occur in any age group.in any age group.

Cysts are common - about 20% of the masses Cysts are common - about 20% of the masses in the young age groupin the young age group

Caused by dilation of the lobular acini – either Caused by dilation of the lobular acini – either from obstruction of ducts or from imbalance of from obstruction of ducts or from imbalance of production and absorption.production and absorption.

On ultrasound: anechoic, smooth wall, through On ultrasound: anechoic, smooth wall, through transmission (backwall enhancement).transmission (backwall enhancement).

FIBROADENOMAFIBROADENOMA

The most common mass excised in the pediatric and The most common mass excised in the pediatric and adolescent age groupadolescent age group (50-75%)(50-75%)Sometimes very large ( “giant fibroadenoma” if larger Sometimes very large ( “giant fibroadenoma” if larger than 8 cm).than 8 cm).Contains normal epithelial (mostly ductal ) and stromal Contains normal epithelial (mostly ductal ) and stromal elements elements Stimulated by hormonal changesStimulated by hormonal changesCommonly regresses around the age of 40Commonly regresses around the age of 40Does notDoes not have a malignant potential have a malignant potentialOn ultrasound: homogeneous, surrounded by a thin On ultrasound: homogeneous, surrounded by a thin pseudocapsule, few large lobulations or none, may have pseudocapsule, few large lobulations or none, may have backwall enhancement, usually a single vessel.backwall enhancement, usually a single vessel.

18 Y-O, FIBROADENOMA18 Y-O, FIBROADENOMA

TUBULAR ADENOMATUBULAR ADENOMA

An uncommon benign mass with a An uncommon benign mass with a dominant uniform tubular element and dominant uniform tubular element and sparse stroma, hence “true” adenomasparse stroma, hence “true” adenomaOccurs mostly in young, non-pregnant Occurs mostly in young, non-pregnant women. Unrelated to contraceptives.women. Unrelated to contraceptives.On ultrasound – resembles fibroadenomaOn ultrasound – resembles fibroadenomaIn older patients – may contain In older patients – may contain microcalcifications seen on mammography microcalcifications seen on mammography and ultrasound.and ultrasound.

14 Y-O,TUBULAR ADENOMA14 Y-O,TUBULAR ADENOMA

JUVENILE PAPILLOMATOSISJUVENILE PAPILLOMATOSIS

Approximately 50% by age 20Approximately 50% by age 20

Solitary mass clinically resembling FASolitary mass clinically resembling FA

Pathology: multiple cysts separated by Pathology: multiple cysts separated by firm fibrous septae, may be filled with firm fibrous septae, may be filled with secretionssecretions

Complete excision recommended – 10-Complete excision recommended – 10-15% risk of Ca.15% risk of Ca.

JUVENILE PAPILLOMATOSISJUVENILE PAPILLOMATOSIS

INFECTIONINFECTION

Most common organisms – Most common organisms – staphylococcus and streptococcus.staphylococcus and streptococcus.

Diabetic patients or patients under steroids Diabetic patients or patients under steroids – more prone.– more prone.

MALIGNANCY IN THE BREAST DURING MALIGNANCY IN THE BREAST DURING PUBERTYPUBERTY

Primary breast cancer exceedingly rare Primary breast cancer exceedingly rare – previous irradiation a predisposing previous irradiation a predisposing

factorfactor

Metastases – from Rhabdomyosarcoma, Metastases – from Rhabdomyosarcoma, Non-Hodjkin lymphoma, leukemia, Non-Hodjkin lymphoma, leukemia, malignant melanomamalignant melanoma

Metastases may present as round, regular Metastases may present as round, regular masses.masses.

NON-HODJKIN LYMPHOMA NODULES IN NON-HODJKIN LYMPHOMA NODULES IN THE BREASTTHE BREAST

CHANGES OF THE BREAST DURING CHANGES OF THE BREAST DURING PREGNANCYPREGNANCY

Early in the first trimester:Early in the first trimester:– Proliferating glandular epithelium causes branching of Proliferating glandular epithelium causes branching of

the ducts.the ducts.– Amount of fat and connective tissue decreases.Amount of fat and connective tissue decreases.

Second trimester:Second trimester:– Alveolar epithelium differentiates into a secretory Alveolar epithelium differentiates into a secretory

epithelium.epithelium.– Arborization of the alveoli causes enlargement of the Arborization of the alveoli causes enlargement of the

breast.breast.– Colloid accumulates in the alveoliColloid accumulates in the alveoli

CHANGES OF THE BREAST DURING CHANGES OF THE BREAST DURING PREGNANCYPREGNANCY

Third trimester:Third trimester:– Differentiation of the of the milk-producing Differentiation of the of the milk-producing

cells and synthesis of milk.cells and synthesis of milk.– In the last days before delivery - increase of In the last days before delivery - increase of

blood flow in the breast and filling of the blood flow in the breast and filling of the alveoli and ducts with colostrumalveoli and ducts with colostrum

THE BREAST IN THE LAST TRIMESTERTHE BREAST IN THE LAST TRIMESTER

CHANGES OF THE BREAST DURING AND CHANGES OF THE BREAST DURING AND AFTER LACTATIONAFTER LACTATION

Immediate post partum enlargement due to Immediate post partum enlargement due to colostrum accumulationcolostrum accumulation

Milk secreted into alveoli 3 – 7 days post partumMilk secreted into alveoli 3 – 7 days post partum

Breastfeeding stimulates further release of Breastfeeding stimulates further release of prolactinprolactin

Post lactational changesPost lactational changes– Periductal and perivascular stromal tissue increasesPeriductal and perivascular stromal tissue increases– Alveolar cells and ductal branches regressAlveolar cells and ductal branches regress

THE BREAST DURING LACTATION - THE BREAST DURING LACTATION - IMAGINGIMAGING

Diffuse increase in density on Diffuse increase in density on mammography - typicalmammography - typical

May have little or no change in densityMay have little or no change in density

Mild increase in parenchymal echogenicity Mild increase in parenchymal echogenicity on ultrasound.on ultrasound.

Post lactational benign calcifications Post lactational benign calcifications reported.reported.

LACTATING BREASTLACTATING BREAST

NORMAL LACTATING BREASTNORMAL LACTATING BREAST

DUCT CONTAINING MILKDUCT CONTAINING MILK

INDICATIONS FOR IMAGING OF THE INDICATIONS FOR IMAGING OF THE PREGNANT OR LACTATING PATIENTPREGNANT OR LACTATING PATIENT

Palpable lumpPalpable lump

Persistence of inflammatory processPersistence of inflammatory process

Suspected breast abscessSuspected breast abscess

Persistent bloody nipple dischargePersistent bloody nipple discharge

Pagetoid changes of the nipplePagetoid changes of the nipple

Axillary adenopathyAxillary adenopathySCREENING OF THE ASYMPTOMATIC SCREENING OF THE ASYMPTOMATIC PREGNANT PATIENT IS NOT INDICATEDPREGNANT PATIENT IS NOT INDICATED

INFLUENCE OF PREGNANCY AND INFLUENCE OF PREGNANCY AND LACTATION ON BREAST EVALUATIONLACTATION ON BREAST EVALUATION

Clinical examination extremely difficult.Clinical examination extremely difficult.

Breast masses may be masked or Breast masses may be masked or believed to resolve as the breast enlarges.believed to resolve as the breast enlarges.

Malignant masses may incorrectly be Malignant masses may incorrectly be attributed to benign processes. attributed to benign processes.

PATHOLOGICAL CONDITIONS IN THE PATHOLOGICAL CONDITIONS IN THE BREAST DURING PREGNANCY AND BREAST DURING PREGNANCY AND

LACTATIONLACTATION

InfectionInfection– MastitisMastitis– AbscessAbscess

Benign tumors – related to P & LBenign tumors – related to P & L– Lactating adenomaLactating adenoma– GalactoceleGalactocele

Other benign tumors, not necessarily related to P&LOther benign tumors, not necessarily related to P&L– Fibroadenoma -Phyllodes tumor Fibroadenoma -Phyllodes tumor – Hamartoma -Lipoma - PapillomaHamartoma -Lipoma - Papilloma

Malignant tumorsMalignant tumors– Primary - SecondaryPrimary - Secondary

BREAST IMAGING METHODS DURING BREAST IMAGING METHODS DURING PREGNANCY AND LACTATIONPREGNANCY AND LACTATION

Ultrasound examination directed at the region of Ultrasound examination directed at the region of interestinterest

If lesion still suspicious or malignancy is proven If lesion still suspicious or malignancy is proven – mammography , with limiting the number of – mammography , with limiting the number of exposures. Dose to fetus 0.4 mrad (10 rad or exposures. Dose to fetus 0.4 mrad (10 rad or greater shown to cause malformations)greater shown to cause malformations)

DENSITY OF THE BREAST INCREASES DURING DENSITY OF THE BREAST INCREASES DURING PREGNANCY AND EVEN MORE DURING LACTATION.PREGNANCY AND EVEN MORE DURING LACTATION.

RETURN OF THE DENSITY TO THE PRE-PREGNANT RETURN OF THE DENSITY TO THE PRE-PREGNANT STATE OCCURS 1 – 5 MONTHS POST LACTATION.STATE OCCURS 1 – 5 MONTHS POST LACTATION.

INFECTIONS DURING PREGNANCY AND INFECTIONS DURING PREGNANCY AND LACTATIONLACTATION

More common during lactation.More common during lactation.

Causative organisms are staphylococcus Causative organisms are staphylococcus aureus or streptococcus, from the infant’s aureus or streptococcus, from the infant’s nose or throat.nose or throat.

Usually resolve with antibiotics – penicillinUsually resolve with antibiotics – penicillin

An abscess should be drained, preferably An abscess should be drained, preferably under US guidance.under US guidance.

MASTITISMASTITIS

Erythema, pain and indurationErythema, pain and induration

Usually no need for imagingUsually no need for imaging– Imaging performed if there is no response to Imaging performed if there is no response to

antibiotics, or if an abscess is suspected antibiotics, or if an abscess is suspected clinically.clinically.

Fluid and edema seen among tissue Fluid and edema seen among tissue planes, thickened skin.planes, thickened skin.

NORMAL RT. BREASTNORMAL RT. BREAST MASTITIS LT.BREASTMASTITIS LT.BREAST

BREAST ABSCESSBREAST ABSCESS

Round or oval mass , may be irregularRound or oval mass , may be irregular

Through sound transmissionThrough sound transmission

Thick wallsThick walls

Fluid/debris levelFluid/debris level

Occasional air in cavity with bright reflectionsOccasional air in cavity with bright reflections

Increased vascularity in the periphery of the Increased vascularity in the periphery of the lesionlesion

Management is by aspiration and antibiotics.Management is by aspiration and antibiotics.

ABSCESS AFTER DELIVERYABSCESS AFTER DELIVERY

AIR IN AN ABSCESSAIR IN AN ABSCESS

GALACTOCELE - DEFINITIONSGALACTOCELE - DEFINITIONS

A milk-containing cyst that results from occlusion A milk-containing cyst that results from occlusion of a lactiferous duct and is lined by flattened of a lactiferous duct and is lined by flattened cuboidal epitheliumcuboidal epithelium

Retention of milk-like fluid (fatty material) in Retention of milk-like fluid (fatty material) in areas of cystic duct dilatation appearing usually areas of cystic duct dilatation appearing usually during or shortly after lactationduring or shortly after lactation– SOME GALACTOCELES HAVE BEEN REPORTED SOME GALACTOCELES HAVE BEEN REPORTED

WITH NO HISTORY OF LACTATION AND EVEN WITH NO HISTORY OF LACTATION AND EVEN PREGNANCY, PROBABLY DUE TO DUCTAL PREGNANCY, PROBABLY DUE TO DUCTAL OBSTRUCTION OF ANOTHER ETIOLOGY.OBSTRUCTION OF ANOTHER ETIOLOGY.

GALACTOCELE – CLINICAL GALACTOCELE – CLINICAL CONSIDERATIONSCONSIDERATIONS

Palpable, firm, mobile mass in pregnant, Palpable, firm, mobile mass in pregnant, lactating or early post lactational patient.lactating or early post lactational patient.

May be seen up to several years post lactationMay be seen up to several years post lactation

May be seen in chronic galactorrhea, in patients May be seen in chronic galactorrhea, in patients receiving prolactin stimulating agents or in receiving prolactin stimulating agents or in pituitary adenomapituitary adenoma

May occur after breast augmentationMay occur after breast augmentation

Rarely reported in postmenopausal women, in Rarely reported in postmenopausal women, in males and in infantsmales and in infants

GALACTOCELE – IMAGING FINDINGSGALACTOCELE – IMAGING FINDINGS

Well-circumscribed massWell-circumscribed mass

Echogenicity depends on the amount of fat Echogenicity depends on the amount of fat and protein within the milkand protein within the milk

Frequently subareolar but may be Frequently subareolar but may be anywhere in the breastanywhere in the breast

Solitary, multiple, unilateral or bilateralSolitary, multiple, unilateral or bilateral

Average size 2 cm, may exceed 5 cm.Average size 2 cm, may exceed 5 cm.

GALACTOCELE -MAMMOGRAPHIC GALACTOCELE -MAMMOGRAPHIC FINDINGSFINDINGS

-Mammograhy performed only if -Mammograhy performed only if appearance on ultrasound is suspicious.appearance on ultrasound is suspicious.

-Circumscribed mass of variable density.-Circumscribed mass of variable density.

-Fat-fluid level on lateral film, fluid-calcium -Fat-fluid level on lateral film, fluid-calcium level, peripheral curvilinear calcifications.level, peripheral curvilinear calcifications.

-Often obscured by surrounding dense -Often obscured by surrounding dense tissue.tissue.

GALACTOCELE – CYSTIC, WITH SEPTATIONS GALACTOCELE – CYSTIC, WITH SEPTATIONS

AND THICK FLUID CONTENTSAND THICK FLUID CONTENTS

COMPLEX-CYST APPEARANCECOMPLEX-CYST APPEARANCE25 CC OF MILK WERE DRAINED25 CC OF MILK WERE DRAINED

FAT FLUID LEVELFAT FLUID LEVEL

FAT - FLUID LEVEL WITH SHADOWINGFAT - FLUID LEVEL WITH SHADOWING

FAT-FLUID LEVEL WITH A CLOT OF MILKFAT-FLUID LEVEL WITH A CLOT OF MILK

MOVING OF THE FAT-FLUID LEVELMOVING OF THE FAT-FLUID LEVEL

GALACTOCELE CONTAINING FAT ONLY GALACTOCELE CONTAINING FAT ONLY (LIPOMA TYPE)(LIPOMA TYPE)

PSEUDOHAMARTOMA LIKE PSEUDOHAMARTOMA LIKE GALACTOCELEGALACTOCELE

GALACTOCELE WITH PERIPHERAL GALACTOCELE WITH PERIPHERAL CALCIFICATIONSCALCIFICATIONS

INFECTED GALACTOCELE- INFECTED GALACTOCELE- A COMPLEX CYSTIC MASSA COMPLEX CYSTIC MASS

RESOLUTION OF A GALACTOCELERESOLUTION OF A GALACTOCELE

INCOMPLETE RESOLUTION OF A INCOMPLETE RESOLUTION OF A GALACTOCELEGALACTOCELE

GALACTOCELE MIMICKING A TUMORGALACTOCELE MIMICKING A TUMOR

GALACTOCELE – MANAGEMENTGALACTOCELE – MANAGEMENT

Usually spontaneous resolutionUsually spontaneous resolution

No need for treatment unless suspicious No need for treatment unless suspicious or unless symptomatic relief needed.or unless symptomatic relief needed.

Aspiration under ultrasound guidanceAspiration under ultrasound guidance

After core biopsy fistulae may occur.After core biopsy fistulae may occur.

ASPIRATED GALACTOCELE CONTENTSASPIRATED GALACTOCELE CONTENTS

LACTATING ADENOMA – KEY FACTSLACTATING ADENOMA – KEY FACTS

The most common breast mass in a young The most common breast mass in a young pregnant patient.pregnant patient.Well-differentiated benign tumor .Well-differentiated benign tumor .Clinically soft , mobile, palpable mass.Clinically soft , mobile, palpable mass.Spontaneous regression after completion of Spontaneous regression after completion of breastfeeding.breastfeeding.Presentation may be delayed – up to 10 months Presentation may be delayed – up to 10 months after cessation of nursing.after cessation of nursing.5% undergo infarction and become painful5% undergo infarction and become painfulNo malignant potential.No malignant potential.

LACTATING ADENOMA – PROPOSED LACTATING ADENOMA – PROPOSED ORIGINSORIGINS

De novo in hormonally stimulated breastDe novo in hormonally stimulated breast

Arises from pre-existing fibroadenoma, Arises from pre-existing fibroadenoma, tubular adenoma or lobular hyperplasiatubular adenoma or lobular hyperplasia

Premature lactational changes, out of Premature lactational changes, out of phase with surrounding breast tissue.phase with surrounding breast tissue.

LACTATING ADENOMA – IMAGING - 1LACTATING ADENOMA – IMAGING - 1

Oval or macrolobulated hypoechoic mass.Oval or macrolobulated hypoechoic mass.

Parallel to skin.Parallel to skin.

Hyperechoic bands and pseudocapsule.Hyperechoic bands and pseudocapsule.

Posterior enhancement.Posterior enhancement.

Most often in anterior portion of breastMost often in anterior portion of breast

Hypervascular on doppler exam.Hypervascular on doppler exam.

20-30% compressibility20-30% compressibility

LACTATING ADENOMA – IMAGING - 2LACTATING ADENOMA – IMAGING - 2

Size – usually 2 – 4 cms, the largest Size – usually 2 – 4 cms, the largest reported - 21 cms.reported - 21 cms.

May be multiple.May be multiple.

Less common findings – Less common findings –

Posterior shadowing (occurs with Posterior shadowing (occurs with infarction)infarction)

Angulated or ill-defined margins.Angulated or ill-defined margins.

Hyperechoic or isoechoic.Hyperechoic or isoechoic.

VASCULAR LACTATING ADENOMAVASCULAR LACTATING ADENOMA

INFARCTED LACTATING ADENOMAINFARCTED LACTATING ADENOMA

LACTATING ADENOMA – D.D.LACTATING ADENOMA – D.D.(US)(US)

– FibroadenomaFibroadenoma– GalactoceleGalactocele– Complicated cystComplicated cyst– Tubular adenomaTubular adenoma– Well-circumscribed carcinoma.Well-circumscribed carcinoma.

LACTATING ADENOMA - MANAGEMENTLACTATING ADENOMA - MANAGEMENT

Spontaneous regression after completion of Spontaneous regression after completion of lactation.lactation.

If suspicious – core biopsy needed (FNA not If suspicious – core biopsy needed (FNA not diagnostic)diagnostic)

If very large and/or painful – Bromocriptine If very large and/or painful – Bromocriptine has been reported to reduce size, through has been reported to reduce size, through suppression of Prolactin.suppression of Prolactin.

FIBROADENOMAFIBROADENOMA

Most common benign tumor in all women Most common benign tumor in all women under 35under 35

Benign fibroepithelial tumorBenign fibroepithelial tumor

May develop or markedly enlarge during May develop or markedly enlarge during pregnancypregnancy

Variable appearance on ultrasound, Variable appearance on ultrasound, usually oval or macrolobulated, usually oval or macrolobulated, homogeneously hypoechoic . homogeneously hypoechoic .

FIBROADENOMA WITH INCREASED FIBROADENOMA WITH INCREASED VASCULARITYVASCULARITY

PHYLLODES TUMORPHYLLODES TUMOR

Rare tumor, histologically similar to Rare tumor, histologically similar to fibroadenoma, but 16 – 28% recur locally fibroadenoma, but 16 – 28% recur locally after excision.after excision.

Low incidence of metastases.Low incidence of metastases.

Solid, macrolobulated hypoechoic mass Solid, macrolobulated hypoechoic mass sometimes not homogeneous, or with sometimes not homogeneous, or with cystic spaces.cystic spaces.

May have posterior enhancement.May have posterior enhancement.

PHYLLODES TUMOR - MANAGEMENTPHYLLODES TUMOR - MANAGEMENT

F.N.A and core biopsy not reliable in F.N.A and core biopsy not reliable in differentiating Phyllodes tumor from differentiating Phyllodes tumor from fibroadenoma.fibroadenoma.

Excisional biopsy recommended.Excisional biopsy recommended.

If proven Phyllodes tumor – excision with If proven Phyllodes tumor – excision with clean margins indicated.clean margins indicated.

BLOODY NIPPLE DISCHARGE DURING BLOODY NIPPLE DISCHARGE DURING PREGNANCYPREGNANCY

Usually appears during the third trimester.Usually appears during the third trimester.The cause is increased vascularity, and a minor The cause is increased vascularity, and a minor trauma.trauma.Usually ceases with the onset of nursing, but Usually ceases with the onset of nursing, but may persist during lactation.may persist during lactation.Cytological analysis may be false positive.Cytological analysis may be false positive.US should be performed. US should be performed. If normal exams – follow-up every month.If normal exams – follow-up every month.If pathological cause suspected (mass, positive If pathological cause suspected (mass, positive cytology )- galactography and biopsy.cytology )- galactography and biopsy.

PREGNANCY-ASSOCIATED BREAST PREGNANCY-ASSOCIATED BREAST CANCERCANCER

Definition: breast cancer that occurs during Definition: breast cancer that occurs during pregnancy or within 12 months thereafterpregnancy or within 12 months thereafter

Incidence – 1:3,000 – 1:10,000 pregnancies Incidence – 1:3,000 – 1:10,000 pregnancies (most common cancer and cause of cancer (most common cancer and cause of cancer death in pregnancy)death in pregnancy)

0.2 – 3.8% of all breast cancers0.2 – 3.8% of all breast cancers

Approximately 7 – 14% of newly diagnosed Approximately 7 – 14% of newly diagnosed breast cancers in women under 40 are breast cancers in women under 40 are associated with pregnancy.associated with pregnancy.

PREGNANCY-ASSOCIATED BREAST PREGNANCY-ASSOCIATED BREAST CANCERCANCER

Distribution of histologic types – same as in non-Distribution of histologic types – same as in non-pregnant patients.pregnant patients.

2 – 4% - inflammatory carcinomas.2 – 4% - inflammatory carcinomas.

No evidence that pregnancy itself is a risk factor No evidence that pregnancy itself is a risk factor for the development of breast cancer.for the development of breast cancer.

Cancer is found frequently in an advanced Cancer is found frequently in an advanced stage.stage.

Prognosis similar to the non-pregnant patients Prognosis similar to the non-pregnant patients when matched for age and stage. when matched for age and stage.

INFLAMMATORY CARCINOMAINFLAMMATORY CARCINOMA

Erythema, warmth and induration with or Erythema, warmth and induration with or without “peau d’orange”without “peau d’orange”Typically evolves over 3 months or lessTypically evolves over 3 months or lessThe cause is embolization of dermal The cause is embolization of dermal lymphatics by tumor.lymphatics by tumor.Frequently misdiagnosed as mastitis or Frequently misdiagnosed as mastitis or abscessabscessBiopsy should be performed when an Biopsy should be performed when an abscess is drained during pregnancyabscess is drained during pregnancy

CAUSES FOR DELAY IN DIAGNOSIS CAUSES FOR DELAY IN DIAGNOSIS DURING PREGNANCY AND LACTATIONDURING PREGNANCY AND LACTATION

Difficulty in physical examination.Difficulty in physical examination.

Attribution of a mass to a benign process.Attribution of a mass to a benign process.

Hormones causing growth enhancement.Hormones causing growth enhancement.

Higher percentage of ER negative tumors Higher percentage of ER negative tumors which are more aggressive.which are more aggressive.

Rich blood supply probably enhances Rich blood supply probably enhances growth of metastases.growth of metastases.

EVALUATION OF A PALPABLE MASS IN EVALUATION OF A PALPABLE MASS IN THE PREGNANT OR LACTATING THE PREGNANT OR LACTATING

PATIENTPATIENTUltrasoundUltrasound– Cystic or galactocele – follow up.Cystic or galactocele – follow up.– Solid – biopsy.Solid – biopsy.

If lesion is clinically suspicious – F.N.A or core If lesion is clinically suspicious – F.N.A or core biopsy.biopsy.

If malignancy proven– tailored mammography If malignancy proven– tailored mammography to the lesion and contralateral MLO.to the lesion and contralateral MLO.– Dose to fetus 0.5mGy (natural background radiation Dose to fetus 0.5mGy (natural background radiation

during pregnancy 1.0 mGy)during pregnancy 1.0 mGy)

MRI IN THE PREGNANT PATIENTMRI IN THE PREGNANT PATIENT

Safety not clear.Safety not clear.

Gadolinium crosses Gadolinium crosses the placenta , causes the placenta , causes fetal malformations in fetal malformations in rats, and is to be used rats, and is to be used only if benefits only if benefits outweigh the risk, and outweigh the risk, and only after the first only after the first trimester.trimester.

BREAST BIOPSY DURING PREGNANCYBREAST BIOPSY DURING PREGNANCY

F.N.A may give false positive result.F.N.A may give false positive result.

Core or open biopsy preferred - but may Core or open biopsy preferred - but may cause milk fistula or infection.cause milk fistula or infection.

Excisional biopsy or incisional biopsy may Excisional biopsy or incisional biopsy may be performed under local anesthesia.be performed under local anesthesia.

Bleeding more common than in non-Bleeding more common than in non-pregnant patients.pregnant patients.

STAGEING BREAST CANCER IN THE STAGEING BREAST CANCER IN THE PREGNANT PATIENTPREGNANT PATIENT

Chest x-ray performed with abdominal shielding.Chest x-ray performed with abdominal shielding.

CT avoided because of inability to shield the CT avoided because of inability to shield the abdomen and because of the use of iodine abdomen and because of the use of iodine contrast material which may cause contrast material which may cause hypothyroidism in the newborn.hypothyroidism in the newborn.

Radionuclide bone scan is contraindicated (dose Radionuclide bone scan is contraindicated (dose is 20mCi)is 20mCi)

Sentinel lymph node mapping – not Sentinel lymph node mapping – not recommended.recommended.

TAKE-HOME MESSAGE - 1 TAKE-HOME MESSAGE - 1

Breast pathological conditions may be Breast pathological conditions may be found at all ages, but are uncommon in the found at all ages, but are uncommon in the younger age group , under 30.younger age group , under 30.

Ultrasound is the method of choice for Ultrasound is the method of choice for evaluating children, adolescents, pregnant evaluating children, adolescents, pregnant and lactating patients.and lactating patients.

Need for biopsy determined by imaging Need for biopsy determined by imaging findings and/or clinical impression.findings and/or clinical impression.

TAKE-HOME MESSAGE - 2TAKE-HOME MESSAGE - 2

A DOMINANT MASS IN THE PREGNANT OR A DOMINANT MASS IN THE PREGNANT OR LACTATING PATIENT SHOULD BE LACTATING PATIENT SHOULD BE PROMPTLY EVALUATED.PROMPTLY EVALUATED.

SCREENING MAMMOGRAPHY SCREENING MAMMOGRAPHY IN HIGH RISKIN HIGH RISK PATIENTS OVER 40PATIENTS OVER 40 SHOULD NOT BE SHOULD NOT BE POSTPONED. SHOULD BE PERFORMED POSTPONED. SHOULD BE PERFORMED AFTER NURSING. AFTER NURSING.