26th July 2021

ICRI CASE OF THE WEEK

Contributed By : Dr Jwala Srikala DMRD, DNB

Senior Consultant Radiologist
Krishna Institute of Medical Sciences, Hyderabad

Copyright of the Case belongs to : Dr Jwala Srikala

History

40 year old woman with a history of palpable lump in right
breast since 1 week
No associated nipple discharge
Not associated with pain
Mother had breast cancer at 55 years of age





Do you find any abnormality ?

Mammogram shows –

An area of architectural
distortion in the retro-areolar
region of right breast

USG of the right breast shows an irregular hypoechoic lesion in the
superficial planes of the right breast, extending into the nipple

Elastography of the lesion shows that it is a hard
lesion showing blooming, and measuring much
larger on elastography than on B mode

What is your diagnosis ?

A) Sebaceous cyst
B) Epidermal lesion
C) Papillary lesion of breast
D) Superficial breast carcinoma

USG guided core biopsy was done from the lesion

Diagnosis

INVASIVE DUCTAL CARCINOMA

Discussion

SUPERFICIAL BREAST CANCERS

• Superficial lesions are commonly encountered in the breast and may be located
in the dermis, hypodermis (subcutaneous fat), or parenchyma. The differential
diagnosis varies for each anatomic layer. Dermal lesions that are seen by breast
imagers are usually benign skin cysts.

• Hypodermal lesions, although usually benign, may include lesions that arise
from anterior terminal duct lobular units and include papilloma, adenosis,
fibroadenoma, and breast cancer.

• The skin overlying the breast is connected to the breast tissue by way of
ligaments (known as Cooper ligaments), which provide structural support.

• TDLUs, which are located in anterior or superficial breast tissue, may extend
into the Cooper ligaments at the base of the hypodermis or become entrapped
within the ligaments over time as the fibroglandular tissue atrophies.

• Hence, breast lesions that arise from TDLUs may be located within
subcutaneous fat. Such lesions include fibroadenomas, papillomas, adenosis,
and breast cancer and should be part of the differential diagnosis for lesions

• The tissue volume is typically thinner in the subareolar area, and lesions are
anatomically closer to the skin surface than they are elsewhere in the breast,
most retroareolar lesions are relatively superficial.

• Epidermal inclusion cysts and sebaceous cysts (including obstructed Montgomery
glands) may occur in the areolar area.

• Ruptured or inflamed, epidermal inclusion cysts in the subareolar area are
known to have imaging features that overlap with those of malignant lesions.

• US is the optimal modality for localizing superficial palpable or nonpalpable
breast masses. Imaging of superficial lesions is often improved with the use of
high-frequency (L17–5) transducers and a step-off pad or a blob of acoustic
gel.

• When lesions are located completely within the echogenic dermal layer, they
may be confidently identified as dermal.

• For lesions that are located either partially or wholly within the hypodermal layer,
evaluating the angles that are made between the lesion margin and the dermis may be
helpful; typically, lesions that are completely within the hypodermis form an obtuse
angle with the dermis as they push upward, whereas lesions that are partially within the
dermis and partially within the subcutaneous fat form an acute or 90 angle with the
dermis.

• The presence of a tract—which represents extension of the hair follicle from the dermis
up through the epidermis—that extends from the lesion to the epidermal skin surface
also confirms a dermal origin and is indicative of a sebaceous or epidermal inclusion
cyst.

• US findings that are indicative of a dermal origin include a completely intradermal
location, a claw of dermis wrapping around the margin of the lesion, and a tract leading
from the lesion to the skin surface. In the absence of these findings, a superficial breast
cancer should be considered.

• Core needle biopsy may be successfully performed in most superficial lesions, although
increased skin bruising may occur, a result of tunneling the biopsy needle just beneath

References

1. Fornage BD. Sonography of the skin and subcutaneous tissues. Radiol Med (Torino)
1993;85(5,suppl 1):149–155.
2. Kopans D. Anatomy, histology, physiology, and pathology. In: Kopans D, ed. Breast
imaging. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 1998; 3–27.
3.Stavros AT. Breast anatomy: the basis for understanding sonography. In: Stavros AT, ed.
Breast ultrasound. Philadelphia, Pa: Lippincott Williams & Wilkins, 2004; 56–108.
4. Distinguishing Breast Skin Lesions from Superficial Breast Parenchymal Lesions:
Diagnostic Criteria, Imaging Characteristics, and Pitfalls Catherine S. Giess, MD • Sughra
Raza, MD • Robyn L. Birdwell, MD RadioGraphics 2011; 31:1959–1972