What is Your Diagnosis

Fibroadenoma: This is a benign tumor of the breast that develops in younger women and then remains in place for a while and often involutes later in life, especially after menopause. In older women, new fibroadenomas are a rarity and are always very suspect. On physical examination, the fibroadenoma is usually a very mobile lesion. As it may grow rapidly and occasionally reaches a spectacular size, patients are often frightened. The mammogram displays the fibroadenoma as an oval and smoothly marginated mass, frequently speckled with coarse calcifications that may remind you of popcorn (Fig. 12.3a). Sonographi-cally the appearance of a fibroadenoma is compatible with a solid mass that shows a rather homogeneous internal echo without any dorsal echo shadowing and also a smooth contour (Fig. 12.3b). If the appearance of the lesion is not that clear-cut or if there is suspicion otherwise, an ultrasound-guided core needle biopsy is rapidly performed, which usually ends the diagnostic uncertainty.

I Cysts of the Breast

I Cysts of the Breast

Calcium Breast Mass

Fig. 12.4a This cyst projecting over the contour of the pectoral muscle has the typical appearance of a benign lesion: a well-defined and smooth margin along the entire circumference. Could this also be a fibroadenoma? Sure. Can breast cancer be excluded? Not based on the mammogram alone. b This lateral magnified view of a breast shows a lamination in some cysts, which are partially filled with milk of calcium—the so-called "teacup" phenomenon. This appearance is pathognomonic for cysts. c The ultrasound appearance of cysts is straightforward: there is no internal echo and an increased through-transmission of sound, which causes a segmental hyperecho-genicity of the tissue distal to the cyst (arrows). d If the cyst

Fig. 12.4a This cyst projecting over the contour of the pectoral muscle has the typical appearance of a benign lesion: a well-defined and smooth margin along the entire circumference. Could this also be a fibroadenoma? Sure. Can breast cancer be excluded? Not based on the mammogram alone. b This lateral magnified view of a breast shows a lamination in some cysts, which are partially filled with milk of calcium—the so-called "teacup" phenomenon. This appearance is pathognomonic for cysts. c The ultrasound appearance of cysts is straightforward: there is no internal echo and an increased through-transmission of sound, which causes a segmental hyperecho-genicity of the tissue distal to the cyst (arrows). d If the cyst has been punctured and evacuated, air is frequently injected into it again. This is done for two reasons: On the one hand, a subsequent mammogram can now image the cyst wall and any tissue previously masked by the cyst content because of potentially equal radiographic density. This is particularly important in large cysts. On the other hand, it is hoped that the air instillation will support the shrinking of the cyst and prevent recurrence. e This patient had a breast carcinoma removed two years ago. The patient history makes an oil cyst the most likely diagnosis for this lesion in the tumor bed. The lesion is of fat density and shows a thin capsule (arrow). A lipoma of the breast could also look like this.

Cyst: A cyst often has its origin in dilated glandular ducts or lobules. It can gain size quickly, can become inflamed, and also—but very rarely—contain a cancer. Mammogra-phically it appears in most instances as a well-marginated rounded mass (Fig. 12.4a). The cysts may contain "milk of calcium," which causes a characteristic interface between the cyst fluid and small calcific particles layering along the dependent portion of the cyst: this is best observed on mammograms taken with a horizontal beam. This so-called "tea-cup" phenomenon is seen on strictly lateral projections (Fig. 12.4b). Occasionally the cyst wall may calcify. On ultrasound a clear-cut cyst shows no internal echogenicity at all and a strong through-transmission of sound (a sector of higher echogenicity directly distal to the cyst; Fig. 12.4c). Absolute proof, of course, is provided by the ultrasound-guided puncture and aspiration of the cyst fluid. If any blood residua are perceived within the aspirated fluid, it should be sent to the pathologist for cy-tological analysis. In older women and in otherwise very dense breasts, the cyst fluid should be replaced by air before the mammography is repeated. On this immediate follow-up mammogram the cyst wall and the immediate neighborhood of the cyst are scrutinized again with special care (Fig. 12.4d).

An oil cyst is a remnant of an injury to the breast that has caused a hematoma and some focal fatty tissue necrosis. The patient history is, of course, the clearest hint at the true nature of the process. On the mammogram the oil cyst appears as a round mass of fatty density (Fig. 12.4e). Sonographically it cannot be distinguished from a simple cyst.

• Diagnosis: The ultrasound examination has been the definitive modality in Mrs. Dyan's case. Hannah is abso-

Much Mas Radiogrpah
Fig. 12.5 The cyst content has a dark coloring, much like Coca Cola. From the look in Mrs. Dyan's eyes you can tell she's been through 2 days of worry and feels a great relief after the diagnosis and aspiration of this benign cyst.
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Responses

  • Kelvin
    What is "fatty density" on a mammogram?
    5 years ago

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