|Ahead of print
Diagnostic dilemma in hyperechoic breast masses
Rajesh R Shah1, Maharra S Hussain2
1 Department of Radiology, Mediclinic Welcare Hospital, Dubai, UAE
2 Department of General Surgery, Mediclinic Welcare Hospital, Dubai, UAE
|Date of Submission||14-Sep-2020|
|Date of Decision||19-Jan-2021|
|Date of Acceptance||10-Feb-2021|
|Date of Web Publication||29-Jun-2022|
Rajesh R Shah,
Department of Radiology, Mediclinic Welcare Hospital, Dubai
Source of Support: None, Conflict of Interest: None
Hyperechoic breast lesions are relatively uncommon, constituting only 0.6–6% of all breast masses and 0.6% of all biopsied lesions. The majority of these lesions are benign. There are rare malignancies that can present as hyperechoic masses and careful ultrasonographic assessment must be employed to avoid misdiagnosis. We discuss the case of a 67-year-old female patient with a strong family history of breast and ovarian cancer, who presented with one such rare breast cancer in a hyperechoic mass.
Keywords: Breast, hyperechoic, ultrasonography
| » Case Report|| |
A 67-year-old post-menopausal Caucasian woman was an active aerobics instructor with a family history of breast cancer in a younger sister and ovarian cancer in her mother. She was asymptomatic for breast diseases and came for routine screening mammography and breast ultrasonography examination, 10 years after her last imaging. She had no co-morbidities and was not on hormonal treatment. Both breasts and axillae did not reveal any abnormality on clinical examination.
A mammogram showed benign calcifications in the breast (non-progressive over 10 years) without any defined mass lesion or architectural distortion [Figure 1].
|Figure 1: CC Mammographic view showing no spiculated mass or architectural distortion|
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Ultrasonography was performed on a GE LOGIQ E9 (USA) scanner with a high-frequency linear transducer (6–15 MHz). The ultrasonography showed a left breast 6 'o clock' poorly marginated, heterogeneously hyperechoic, irregular lesion with no significant internal vascularity [Figure 2]a. At first, a diagnosis of focal fat necrosis or pseudoangiomatous stromal hyperplasia (PASH) was considered given that the mammogram was unremarkable.
|Figure 2: (a) Initial Ultrasound showing the ill-circumscribed, irregular, heterogeneously echogenic lesion at 6 o clock of the left breast. (b) Ultrasound exam 3 months later showing the changes and vascularity in the echogenic lesion at 6 o clock of the left breast|
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In view of the ill-defined breast lesion seen on ultrasonography, with no clear history of trauma, it was decided to follow-up with repeat ultrasonography at a short-term 3-month interval with BIRADS III grading.
On the follow-up ultrasonography, the lesion had not resolved but had marginally grown in size and showed some new internal vascularity with progressive non-parallel orientation [Figure 2]b. With the given morphological features it was decided to biopsy the lesion under ultrasonography guidance. A 14-gauge needle was used for the core biopsy and the histopathology showed an invasive ductal carcinoma Grade II with estrogen receptor positivity (ER 8/8), progesterone receptor positivity (PR 7/8), HER 2/neu (human epidermal growth factor receptor 2) negative and Ki-67 index of 15% [Figure 3].
|Figure 3: Invasive ductal carcinoma and Ductal carcinoma in-situ (DCIS), core biopsy, H and E 2×. Section shows an invasive ductal carcinoma with nests and sheets of moderately pleomorphic cells with mitotic activity which qualifies the carcinoma for grade II (Tubule formation score 3, Nuclear pleomorphism score 2, Mitosis score 1) Score 6. There is associated intermediate grade ductal carcinoma in situ which has solid architecture and central calcification. No vascular invasion or tumor necrosis noted|
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| » Discussion|| |
The ACR BI-RADS (American College of Radiology Breast Imaging Reporting and Data System) lexicon describes a hyperechoic (bright appearance on ultrasonography) breast lesion on ultrasonography (USG) as having an echogenicity greater than subcutaneous fat or equal to fibro glandular tissue. This hyperechoic sonographic appearance is attributable histologically to the fat, fibrous content, vascularity, and high cellularity of the lesions.
Stavros et al. in their study noted that hyperechoic breast masses usually tend to be benign and rarely malignant. A hyperechoic lesion had a 99.5% negative predictive value for cancer. This negative predictive value can only be applied if the lesion is homogeneously hyperechoic.
It has been observed that hyperechoic breast cancers reflect the heterogeneity of the tumor in contrast with the homogeneous breast parenchyma. Thus, certain polymorphous histologic patterns, such as cribriform, tubular, solid nests, and scirrhous patterns, may present as hyperechoic breast tumors. Densely packed tumor cells in invasive and in situ ductal carcinoma can appear hyperechoic on ultrasonography.
Noncircumscribed margins, an irregular shape, and a nonparallel orientation occur significantly more frequently in malignant as compared to benign lesions, as has been demonstrated by Linda et al. and Nam et al. Masses with heterogeneous internal echotexture also occur relatively more frequently in malignant lesions, and are likely to show corresponding mammographic abnormalities.
What is remarkable, however, is that the three statistically significant features that correlate with malignancy among the studied hypoechoic masses (irregular shape, nonparallel orientation, and non circumscribed margins) are also well-demonstrated risk factors for malignancy among hyperechoic breast lesions.
In our case since there was no palpable mass and the mammographic features were not suspicious, the lesion was primarily evaluated on its ultrasonographic features such as orientation, size, margins, echogenicity and echotexture, vascularity, posterior acoustic shadowing, and associated features.
Elastography was not performed as the lesion was predominantly echogenic and poorly circumscribed with inflammatory features which often demonstrate inconsistent findings and also to emphasize the importance of the B-mode features which warranted a biopsy in this case.
Our ultrasonography findings show that regardless of the echogenicity of the lesion, the method of assessment should always be the same, emphasizing the importance of the above three criteria to correctly categorize these lesions especially when mammographic findings are not significant. A high index of suspicion must always be maintained; however, small the incidence of cancers in hyperechoic breast lesions, and these masses should be carefully evaluated on ultrasonography and biopsied keeping a low threshold when all the criteria for benignity are not fully satisfied.
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Conflicts of interest
There are no conflicts of interest.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3]