Journ al of the Korean Radiologica l Society 1995 : 33(3) : 443- 447

Ultrasonographic Findings of Breast Diseases

During Pregnancy and Lactating Period 1

Yeon Hee Lee, M.D2. , Yong Hyun Park , M.D. , Tae Hee Kwon , M.D .

Purpose: To evaluate ultrasonographic findingsand usefulness in the diagnosis of breast diseases during pregnancy and lactating period.

Methods and Materials: The authors evaluated the ultrasonographic findings of 18 breast diseases during pregnancy and lactation retrospectively. The ultr­asonographic examinations were performed with linear-array 5 MHz transducer (AT니. Final diagnoses were obtained by the excisional biopsy, fine needle aspir­ation and clinical follow-up.

Results: Total 18 cases of breast diseases were consisted of 8 cases of gala­ctocele, 4 cases of fibroadenoma , 3 cases ofaxillary accessory breast, 2 cases of lactating adenoma , and 1 case of phylloidestumor. The ultrasonographic findings of the above breast diseases were valuable in the diagnosis and therapeutic plan­nlng .

Conclusion: Ultrasonography is the initial and useful method of diagnosing breast diseases during pregnancy and lactating period.

Index Words: Breast. US Breast neoplasms, US

INTROCUCTION

During pregnancy, patients complain of breast dis­comfort , pain or mass but mammography cannot be taken due to possible radiation hazard to the fetus After delivery , mammography of lactating breast is lim­ited in detecting a mass lesion due to hypertrophied , dense breast parencymal tissue which can mask the mass density.

Ultrasonogram has no radiation hazard(1) and is ef­fective in the detection of the mass especially in dense breasts , so it is of great use in the exam ination of breast diseases during pregnancy and lactating period.

The authors have experienced various breast dis­eases during pregnancy and lactation and these tried to find the usefulness of ultrasonography in these pa­patients

' Departm ent이D i agn ostic Radiology, Cha Women’s Hospi tal olSeoul 2Department ofDiagnostic Radiology, Dankook Uni versity College 01 Medicine Received October 14, 1994; Accepted August28, 1995 Address reprint requests to :Yeon Hee Lee, M.D. , Department 01 Radiology Dankook Un iversity Hospital ~ 29 Anseodong Chonan Choongnam 330-714 Korea

Tel. 82-417- 550-6921 Fax. 82-417- 552-9674

MATERIALS and METHODS

The authors reviewed the ultrasonographic findings of 18 breast lesions of 17 female patients retrospe­ctively. Mean age ofthe patients was 29.5 years and the age range was 24 - 35 years. Five patients were preg­nant and 13 patients were postpartum with in one year at the time of examination. The most common symptom was palpable breast mass(72.2 % ) (Table 1).

The exam inations were performed with a hand - held , linear -array 5 MHz transducer(ATL Ultramark 9, 80-thell , Washington , U.S.A) and a sonopad was used wh­enever a lesion is located superfic ially.

Final diagnoses wer e obtained by means of surgical excision in 11 cases , fine needle aspiration in 4 cases of galactoceles , and combination of clinical and sono­graphic findings in 3 cases ofaxillary accessory bre­asts. In five pregnancies , the excision was performed after del ivery.

RESULTS

Total of 18 breast lesions were examined by ultra­sonography due to subjective symptoms. The final di ­agnoses were 8 cases of galactoceles , 4 cases of fib roadenomas, 3 cases ofaxillary accessory breà.sts ,

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Journal of the Korean Radiological Society 1995 ; 33(3) : 443- 447

2 cases of lactating adenomas, 1 case of benign phy­Iloides tumor.

Patients with accessory breast of axilla (3 cases) complained swelling of the axillary area with or without pain. Ultrasonographic findings showed brease paren­chymal echoes in axillary area without a definite mass or Iymphadenopathy. After delivery, swelling of both axillary area disappeared and so did the symptoms. Three patients with fibroadenomas showed a well de­fined , low echogenic, oval shaped mass lesions, but the lateral shadowing was not seen(Fig. 1). One case showed a well defined mass which had a lobulated bor­der and dense central calcification . The diameter ofthe fibroadenomas were less than 2 cm in all cases. Micro­scopic findings showed variable parenchymatous du­ctal hyperplasia corresponding to those of the sur­rounding breast.

Ultrasonographic findings of galactoceles(8 cases) were cystic masses with variable internal echoes In 5 cases , well defined , single chambered , purely cystic mass lesions were noted. One case showed 3.1 X 1.2 cm sized purely cystic mass with multilocular cham­bers and the pathology showed multiple ductectasias without inflammatory changes (Fig. 2a). Two , relatively large (3.5 X 2.1 cm and 2.8 X 2.0 cm in size in each) cystic masses contained highly echogeni c. nodular densities with posterior shadowing suggesting curds

(25%) but which was not confirmed by pathology (Fig. 2b). In 4 cases , after aspiration of mildly greenish fluid , the masses disappeared in palpation. In the other 4 cases, the excision of the masses was performed

In 2 cases of lactating adenoma, roughly 3 cm sized isoechoic mass was noted with ill defined border, mim­icking breast parencymal echogenicity adjacent to it. There was no characterirstic findings such as posterior enhancement, posterior shadowing, and calcification (Fig. 3)

One patient with phylloides tumor(1 case) showed hypoech이c oval shaped mass (13.5 X 10 X 6.5cm) with well defined border but definite clefts or cysts were not seen (Fig. 4).

DISCUSSION

In the evaluation of breast diseases, combined mo­dalities are used such as mammography, ultrasono­graphy, xeromammography , galactography and re­cently MRI(2 -4).

The usefulness of mammography in women less then 35 years of age is controversial. Mammography is apparently less effective in the evaluation of the radio­dense breasts of younger women than of the less ra­diodense breasts of older women. According to Ba­ssett et al(5) , in women less than 35 years of age, at

Table 1. Summary of 18 Breast Diseases During Pregnancy and Lactation Period

Diagnosis Age Symptom onset Symptom Physical Exam

Axillary 30 IUP24wk pai nl ess 1 eft axi 11 ary left axiliary sweliing accessory breast mass

27 IUP 19 wk painless bilateral bilateral axillary axillary mass swelling

24 IUP 8wk painfulleft axillary left axillary swelling

mass Fibroadenoma 30 IUP 6wk breast discomfort nodular breast

*35 P.P. 12m breast mass tender mass 29 P.P. 3m breastmass firm movable mass

27 P.P. 3m breastmass firm movable mass Gal actocel e 30 P.P. 3m left breast mass semifirm mass

25 P.P. 3m 1 eft breast mass cysticmass 34 P.P. 1 m leftbreastpain firm πlOvable πlass 32 P.P.12 m left breast mass firm movable mass 26 P.P. 1 m ri ght breast mass soft movable mass 30 P.P. 4m right breast mass firm movable mass

*35 P.P. 12 m breastmass tender mass 30 P.P.12m ri ght breast mass nodular mass

Lactating adenoma 28 P.P. 1 m right breast mass solidmass 33 P.P. 1 m 1 eft breast mass firm movable mass

Pylioides tumor 31 IUP28wk rapidly growing solidmass painf비 mass

IUP : Intrauterine pregnancy, P.P. : Postpartum, wk: weeks, m : months *The same patient showed both a fibroadenoma and a galactocele

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Yeon Hee Lee, et al: Ultrasonographic Findin gs of Breast Di seases During Pregnancy and Lactating Period

2a 2b Fig . 1. fibroadenomas A homogenous hypoechoic mass is well identified just beneath the skin. Fig. 2. galactoceles a. Multiseptated cystic mass is demonstrated and confirmed as multipl e ductectasias b. 111 defined hypoechoic mass with posterior enhancement is defined on ultrasonography that represents cystic mass. Multiple echogenic nodules with posterior shadowing are demonstrated at posterior wall ofthe mass suggesting curds

3 4

leasttwothirds ofthe breastwas radiodense. Therefore , the ultrasonography is recommended as

a primary imaging technique for the young women with breast pro비 ems. The rationale for this approach in younger women includes the lower prevalence of br­east cancer , the great likelihood that the breasts will be dense and poorly suited for mammography(6). Ultra­sonography may be also the initial mode of examin­ation in lactation or pregnant women , because the increased breast parenchymal density may obscure

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the mass.

Fig. 3. Lactating adenoma Ultrasonography reveal s an ill- defined and oval shaped isoechogenic mass that inter­mingled with normal parenchymal echoge­nicities Fig. 4. phylloides tumors Ultrasonogram shows large, relatively well defined hypoechoic mass without charac­teristic internal cl efts or cysts

During pregnancy and lactating period , striking ch­anges take place in the mammary gland. The ductal ­lobular -alveolar system undergoes considerable hy­pertrophy and prominent lobules are formed. Estrogen and progesterone secretion from the placenta is elev­ated and these are considered to be the major hor­mones responsible for full breast development(7 , 8).

T,herefore on ultrasonography, the glandular compo­nent dominates, giving a finely granular pattern and

Journ al of the Korean Radiological Society 1995; 33(3) : 443-447

highly reflective appearance with extreme compre­ssion of the subcutaneous and retromammary fat. The lactiferous ducts are also dilated and may reach a di­ameter of 7 -8 mm during lactation and are seen as cystic spaces(9). These changes are also noted within the tumor mass corresponding to those of breast pa­renchyme. Moran (8) reported that fibroadenomas are histologically modified at pregnancy and lactation.

Var i"able amounts of parenchymal hyerplasia deve­lops and rarely the early pregnancy changes might be mistaken for cancer. And for this reason the tumor have probably grown rapidly during this period. As we expected , postpartum diseases were lactation related pathologies such as galactoceles, lactating adenomas, rapidly growing fibroadenomas , and phylloides tumor

A galactocele is a milk containing cystthat develops during lactation and shows variable ultrasonographic findings wh ich include a pure cyst , a multiseptated cyst and echogenic debris floating within the cysts. Accord­ing to Salvador(1 0) , the echolucency of the upper fluid and the high echogenicity of lower component was the characteristic finding , but in this study such finding was not seen. The presence of the line separating both components suggests two fluids with the upper having a lower specific gravity (fat) than the lower (milk) . The presence of solid , mobile echogenic contents with dis­tal acoustic shadowing in fluid cavity was the charac­teristic findings of galactocele in this study and the nodules may be cholesterol crystal or curded milk(1 1). Ultrasonography was useful and easy modality for fol­low-up after the aspiration whether the cyst remained ornot.

Fibroadenomas are readily detectable during this period due to development of pain or growing mass (8) caused by the hormonal changes and high prevalence rate(12 , 13, 14, 8) in young ages. Ultrasonographic fin­dings of fibroadenomas during pregnancy and lac­tating period showed no different findings as compared with those of conventional fibroadenomas , but lateral shadowing was not noted at al l.

Lactating adenomas are circumscribed benign tu­mors composed predominantly of glandular structures with scanty stroma with promineht secretary changes in the ducts. Therefore the histologic findings raise the question of whether these are unique tumors or focally hyperplastic lobules(15). In our study the masses sh­owed isoechogenicity with hy

eves et al. (18) suggest phylloides tumors are related with pregnancy and lactation. In our case, the mass was rapidly growing during pregnancy.

The axillary accessary breasts were the cause of swelling and pain ofaxillary area in the pregnant wo­men and were easily recognized by ultrasonogrphy without any further work -up. After delivery, the symp­toms were subsided

In conclusion , ultrasonography should be the initial and probably sole imaging modality in patients with breast diseases during pregnancy and lactating pe­riod. However, the limitations of sonography include inability to depict microcalcifications, difficulty in imaging fatty breasts , inability to differentiate benign from malignant solid masses, and unreliable depiction 。f solid mass smaller than 1 cm(19). So if solid mass lesions are detected during pregnancy and lactating period by ultrasonography that persist after delivery, excision ofthe masses is definitely needed

REFERENCES

1. Whang IS, Kim YS , Suh HS. Ultrasonographic lindings 01 breast lesions. Journal of Korean Radiologic Society 1990 ; 26 ‘ 581-588

2. Teixidor HS, Kaszam E. Combined mammographic, sonographic evaluation ofbreast masses. AJR 1977; 128 : 409-417

3. Fleicher AC. Palpable breast masses: Evaluation by high fre­quency, hand-held real time sonography and xeromammo­graphy. Radiology 1983 ; 148 : 81 3-817

4. Oh KK , Lee KS , Sohn SK. Variable complementary combined radiologic imaging methods for breast disease Journal of

Korean Radiologic Society 1985 ; 21 (5) : 223-236 5. Bassett LW, Ysrael M, Gold RH , Ysrael C. Usefulness of ma­

mmography and sonography in women less than 35 years of age Radiology 1991 ; 180 : 831-835

6. Harper AP , Kelly-Fry E, Noe S. Ultrasound breast imaging-the method of choice for examining the young patient. Ultrasound

Med Bio/1981 ; 7 : 231-237 7. Smith MS. Lactation. Patton HD , Fuchs AF , Hille B, Scher AM ,

Steiner R‘ Textbook of Physiology. 21st edition Philadelphia Saunders 1989 ; 1408-1421

8. Moran CS. Fibroadenoma of the breast during pregnancy and lactation. Arch Surg 1935 ; 31 : 688-708

9. Guyer PB, Dewbury KC. Clinical ultrasound-a comprehensive text, vol 11 , Abdominal and general ultrasound : Breast Ultra­

sound 1989 ; 709-735 10. Salvador R, Salvdor M, Jinenez JA, Martinez M, Casas L. Ga­

lactocele of the breast: radiologic and ultrasonographic findings The British Journal of Radiology 1990 ; 63 : 140-142

11 . Jokich PM , Monticciolo DL, Adler YT. Breast ultrasonography. In Silver B ed. Ultrasonography of small parts. Radiol Clin North Am

1992; 30(5) : 993-1 009 12. Yoon CS, Kim MH , Ahn CS, Oh KK. Ultrasonographic evaluation

。1 libroadenoma in the breast : primary signs of mass. Journal of

Korean Radiological Society 1994 ; 30(1) : 193-196 13. Fornage BD‘ Lorigan JG, Andry E. Fibroadenoma of the breast

sonographic appearance. Radiology 1989 ; 172: 671-675 14. Oavid Lp , Thomas JA. Diagnostic histopathology of the breast

3rd series. Washigton: AFIP(Armed Forces Institute of Pathol

。gyJ, 1987 ; 80-83

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Yeon Hee Lee, et al : Ultrasonographic Findings of Breast Diseases During Pregnancy and Lactating Period

15. Buchberger W, Strasser K, Heim K, Muller E, Schrocksnadel H. 17. Treves N, Sutherland DA. Cystosarcoma phylloides olthe Breast

Phylloides tumor: Findings on mammography, sonography, and : a malignant and a benign tumor, a clinicopathologic study 01

aspiration cytology in 10 cases. AJR 1991 ; 157 : 715-719 seventy seven cases. Cancer 1951 ; 4: 1286-1332

16. Oh KK, Ji H, Lee KS, Jeong HJ. Evaluation 01 Cystosarcoma 18. Bassett LW, Kimme-Smith C. Breast Sonography. AJR 1991 ; 156 :

phylloides in Korean women. Journal of Korean Radiologic So- 449-455

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대 한 방사선 의 학회 지 1995 ; 33(3) : 443- 447

임신 및 수유기 유방 질환의 초음파 소견1

1 차병원진단방사선과

2 단국대 학교 의 과대학 진 단방사선과학교실

이연희2 .박용현·권태희

목 적 :임신 및 수유기의 유방 검사는 태아에 미칠 방사선의 영향에 대한 우려와 유방실질의 비후로 인해 증가된 실질 음

영때문에 필름 유방촬영보다는 초음파 검사가 유용하게 이용된다.

임신 및 수유기에 호발하는 유방질환과 초음파 소견에 대해 알아보고자 하였다.

대상 및 방법 :임신 및 수유기에 유방의 통증 혹은 종괴로 내원하여 초음파검사를 시행하고 수술， 서|침흘입 및 추적검사로

확진된 18예의 유방질환을 대상으로 후향적으로 분석하였다.

결 과:총 18예의 유방질환 중 유선 낭종 (Oalactocele )OI 8예로 가장 많았고 섬유선종(tibroadenoma) 4예， 액와부유방

(axi llary accessory breast) 3예， 수유성 선종 (Iactating adenoma)2예， 양성 엽상 낭상 육종 (benign‘ phylloides tumor) 1 예

였다.

상기 유방질환의 초음파 소견은 비임신 비수유기의 유방 초음파 소견과 유사하였으며， 특히 수유기에 많은 유선 낭종의

진 단 및 추적 검사에 초음파검사가 유용하였다.

결 론:유방초음파검사는임신과수유기의 유방질환진단에 유용한검사법이라생각된다.

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국제 학술대회 일정표 [III]

1996/04/14-19 9th World Congress of the Int. Radiation Protection Association (l RPA) venue: Hofburg Congress Center Vienna, Austria contact: IRPA9 Congress Org. Ct. , Austropa-Interconvention,

P.O. Box 30, A-1043 Vienna, Austria. (te! : 43 - 1 - 58800 - 299 ; fax: 43 -1 - 5867127)

1996/04/18 - 25 Annual Meeting Society of Magnetic Resonance venue: Vancouver, Canada. contact: SMRI.,

213 West Institute Place, Suite 501 Chicago, I1Iinois 60610, USA. (tel: 1-312-7512590 ; fax: 1-312-9516474)

1996/04/ 23-26 The 6th Int. Symposium of Interventional Radiology & Newvascular Imaging venue: Amori, Japan contact: Prof. S.D. Takekawa, M .D., Hirosaki Univ. Sch. of Med,

Dept. of Radio1ogy, Hirosaki 036, Japan. (teI: 81 -1 72 - 335 111 ; fax: 81 -1 72 - 335627)

1996/04/ 23-26 Pragomedica ’ 96 : Int. Exhibition of Medical Engineering , Diagnosis & Therapy venue: Exhibition Grounds Prague, Czech RequbIic contact: Mr. Jaros1av Cepek, INCHERA Company Ltd. ,

28. rijna 13, P.O. Box 555, 111 21 Praha 1, Czech Republic. (tel : 42 -2 - 24195358 ; fax: 42 -2 - 24195286)

1996/04/ 24-26 Esdir Seminar-Non Invasive Vascular Imaging venue : Bordeaux, France. contact: Prof. N. Grenier, Service de Radio1ogie,

P1ace AmeIie Raba Leon, F-33076 Bordeaux, France. (teI : 33 - 56795599 ; fax: 33 - 56795639)

1996/04/25-28 MR11996: Neuro Weekend Review venue: The Westin Hotel Cincinnati, Ohio, USA contact: Stephen J. Pomeranz, M.D. , MRI Education Foundation,

2600 Euc1id Avenue, Cincinnati, OH 45219-2199, USA (teI: 1-513 -2813400 ; fax: 1 -513 -2813420)

1996/04/27-03 Annual Meeting of the Society of Magnetic Resonance venue : New York Hi1ton & Towews New York, NY, USA contact : SMR Centra1 Offoce, 2118 Mivia Street,

Suite 201, Berki1ey, CA 94704, USA (te1: 1 - 510 - 841 1899; fax: 1 - 510 -8412340)

1996/05/00-00 33RD Annual Congress European Society of Paediatric Radiology venue: Boston, MA, USA. contact: Prof. F. Brunel1e, Hop. des Enfants Ma1ades,

149 Rue de Sevres, F-75730 Paris cedex 15, France. (tel : 33 -1 -44495173 ; fax: 33 -1 -444951 70)

제공:대한방사선의학회 국제협력위원회

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