Non-tumor changes in the breast

Dysplasia

Dysplasia is characterized by a violation of symmetry, size and configuration of the mammary glands and is caused by hypertrophic, hyperplastic and hypoplastic processes. Hypertrophy of the mammary gland is diagnosed when the volume of the mammary gland increases by more than 50%. The severity of hypertrophy is assessed by the size of the mammary gland in height and by its increase in the anterior projection. Hypertrophy of the mammary glands can be bilateral and unilateral. The need for echographic assessment arises in case of unilateral hypertrophy of the mammary gland to exclude the tumor etiology of the process.

Enlargement of the mammary gland due to the growth of all its forming components is true hypertrophy. As a rule, this process is associated with an increased content of sex hormones. A particular example is physiological asymmetric hypertrophy of one of the mammary glands in girls aged 8-9 years. Echograms show an increase in the size of the organ without disruption of the echostructure.

Enlargement of the mammary gland due to the growth of the fat component is fatty (false) hypertrophy. In this case, the echogram of the enlarged mammary gland is dominated by the fat component in the form of multiple hypoechoic structures that form the entire mass of enlarged mammary gland tissue. This type of hypertrophy is characteristic of involutional processes.

True and false hypertrophy should be differentiated from specific processes of connective tissue proliferation and edema in the mammary glands after repeated erysipelas. In this case, the thickness of the skin of the altered mammary gland is increased.

The echogram of the gland shows alternation of hyperechoic fibrous structures and areas of glandular tissue with slightly reduced echogenicity.

Dyshormonal hyperplasia of the mammary gland

Dyshormonal hyperplasias are characterized by varying degrees of expression of hyperplastic processes in the mammary glands. They can be conditionally divided into:

1. hyperplasia of the ductal epithelium due to an increase in terminal tubular branches and the number of cell layers of the duct wall;
2. connective tissue sclerosis.

Connective tissue sclerosis is a severe form of premature involution of the mammary gland and leads to the development of cysts (numerous microcysts or one cyst, sometimes of significant size), pronounced tissue fibrosis. These processes characterize diffuse dyshormonal hyperplasia (diffuse fibrocystic mastopathy). Echography reveals thickening of the walls, enlargement of the lumen, and uneven contours of the ducts. Pocket-like expansions in the form of hypoechoic zones along the main axis of the duct are often determined. These protrusions of the ducts are difficult to differentiate from cysts. In dyshormonal hyperplasia, the parenchyma can acquire higher echogenicity due to the alternation of hyperechoic connective tissue elements among less echogenic glandular structures. An acoustic shadow often appears behind the areas of fibrosis, which does not allow for a clear differentiation of the structures located below. Diffuse forms of dyshormonal hyperplasia require dynamic monitoring and treatment aimed at normalizing hormonal levels.

Often the term "dyshormonal hyperplasia" includes such pathological processes (known for their risk of degeneration into cancer) as adenosis, adenomatosis, intratubular papillomas and atypical hyperplasia. All of them are variants of nodular hyperplasia (nodular fibrocystic mastopathy). Echography of nodular forms of dyshormonal hyperplasia is characterized by the appearance of single or multiple areas of reduced echogenicity without clear contours and boundaries, often of a bizarre shape. According to the ultrasound examination data, it is impossible to clearly differentiate an area of adenosis from an early stage of breast cancer. According to the decision of the American Congress of Pathologists (1968), all types of nodular hyperplasia must have morphological verification. To determine the nature of the changes, a puncture is performed under ultrasound control followed by a cytological or histological examination.

Cysts

Cysts are one of the most common diseases of the mammary gland. Typically, cysts appear at the age of menstruating women (between 35 and 50 years). With the onset of menopause, cysts usually regress, but they can appear and even increase in size during menopause against the background of hormone therapy with estrogens, steroids, when taking drugs that reduce blood pressure, digitalis derivatives. The size of cysts can be from a few millimeters to 5-6 cm. Cysts can be both unilateral and bilateral; single and multiple. Multiple bilateral cysts are more common. Closely located cysts of the mammary gland tend to merge, unite into a single cavity. This process can be traced during dynamic observation - in place of several closely located cysts, a multi-chamber cystic formation with septa is formed; later, due to lysis of the septa, a single-chamber cyst is formed. The period of regression of the septa usually lasts several months. Most often, cysts form in the terminal part of the milk duct (1st order galactophore). Some authors distinguish microcysts (less than 3 mm in diameter) with a low risk of degeneration into cancer and larger cysts (more than 3 mm) - with a high risk of degeneration. Breast cysts may have typical signs of fluid-containing formations, characteristic of cysts in other locations:

• round or oval shape;
• compressibility;
• absence of reflections from internal contents;
• distal enhancement;
• clear differentiation between internal and external contours;
• bright back wall;
• Double-sided side acoustic shadows.

In the presence of all the above-mentioned echographic signs, the accuracy of ultrasound diagnostics of cysts ranges from 98 to 100%.

The echographic sign of distal pseudo-enhancement behind a cyst in the mammary gland is not always determined.

Distal pseudo-enhancement is absent:

• for small cysts;
• behind cysts located among structures with high echogenicity;
• behind cysts located near the pectoral muscle;
• if the fibrous capsule of the cysts is pronounced.

In the case of a round cyst, lateral acoustic shadows are observed. Visible echo structures are often detected in the cyst, the appearance of which is caused by improper equipment settings. Regulation and adjustment of the overall gain and focus area are required in each specific case. Very superficial cysts may need to be examined using a special silicone pad or a water nozzle. The compression mode allows determining the compressibility or tension of the cyst walls. Changing the plane of the sensor position makes it possible to assess the condition of the internal and external contour of the cyst walls and identify intracavitary growths. Cystic formations of the mammary gland do not always have an ideal round shape and smooth contours. This is due to the degree of cyst filling and internal pressure on its walls. Multicomponent structures of the mammary gland have high elasticity, which requires sufficient pressure from the cyst contents to straighten the walls. The shape of an unfilled cyst can be varied: from round to irregular, flattened, polygonal.

Hyperechoic image of the internal contents.

Echographic signs of a cyst:

• Round or oval shape.
• Clear, even contours.
• Anechoic echostructure without reflections.
• Distal acoustic effects - the effect of distal pseudo-amplification and lateral acoustic shadows can be determined.
• The effect of compression on the shape of the formation is a pronounced change in shape.
• Changes in internal structure due to compression - no changes.

Atypical cysts

Atypical cysts are characterized by thickening of the walls and the presence of reflections from the internal contents. The most common atypical structures are:

• long-standing cysts;
• recurrent cysts;
• calcium-containing cysts.

Long-term existence of a cyst is often accompanied by an inflammatory process, which is characterized by the appearance of reflections from the internal structure, varying degrees of wall thickening, and the lack of expression of the effect of distal pseudo-enhancement. Ultrasound images of atypical cysts without distal enhancement are almost impossible to distinguish from images of solid volumetric formations. Only the movement of structures inside the cyst during swamping can indicate the liquid nature of the formation. With very thick contents, these movements become almost indistinguishable to the eye, and then the nature of changes in the mammary gland can be determined only by aspiration under ultrasound control.

Hemorrhagic secretion, as well as the contents of an infected cyst, is characterized by the appearance of internal reflections. The walls of such a cyst are often thickened. An atypical cyst may have hyperechoic inclusions in the cavity due to the content of calcifications. Calcification of the cyst walls makes it difficult to assess the structure of the cyst due to the appearance of an acoustic shadow. Atypicality of cysts may also be due to intracavitary growths. Intracavitary growths in 75% of cases are benign in nature and are usually papillomas. 20% are malignant tumors. The remaining 5% are other changes in the cyst wall. The cancer-cyst combination is very rare (0.5% of all breast cancers), but in the presence of intracavitary vegetations it should always be kept in mind.

The detection of atypical cysts requires a completely different patient management strategy than in the case of simple cysts. Ultrasound-guided puncture biopsy with cytological examination is mandatory when detecting an atypical cyst.

Echographic signs of an atypical cyst:

• Round or oval shape.
• Clear contours (even or uneven).
• Homogeneous echo structure with internal reflections of varying intensity.
• Distal acoustic effects - the effect of distal pseudo-amplification and lateral acoustic shadows may be pronounced.
• The effect of compression on the shape of the formation is a pronounced change in shape.
• Changes in internal structure due to compression - reflections from internal contents become more orderly.

Galactocele

A galactocele is a cyst that forms in the mammary gland during pregnancy or lactation and contains milk. Galactocele is formed as a result of obstruction of one or more milk ducts. Milk stasis can very quickly lead to mastitis and abscess. A galactocele that continues to exist after the end of the lactation period transforms into a chocolate cyst. Palpation of a galactocele against the background of an enlarged lactating gland can be difficult. In this regard, the formation of a galactocele can be mistakenly assessed as a compaction of the mammary gland tissue against the background of mastitis. With ultrasound, galactocele is visualized as a cyst with echogenic contents or as a dilated (spherical) milk duct with a well-defined effect of distal pseudo-enhancement.

Sonographic signs of galactocele

• Round or oval shape.
• Clear, even contours.
• Hypoechoic or anechoic echostructure.
• Distal acoustic effects - distal pseudo-enhancement, lateral acoustic shadows can be detected.
• The effect of compression on the shape of the formation is varying degrees of shape change.
• Changes in internal structure due to compression - reflections from internal contents become more orderly.

Seborrheic cysts

Sebaceous (seborrheic) or epidermal cysts can reach sizes of up to 1.5 cm, which makes it possible to diagnose them using ultrasound. This formation contains an oily secretion, fat, and in some cases can calcify. The subcutaneous location of the formation allows for a correct diagnosis. The ultrasound image corresponds to a round or oval volumetric formation with a large number of reflections of medium and low intensity. The effect of distal pseudo-enhancement may be either pronounced or not determined. Lateral acoustic shadows are often noted.

Sonographic signs of seborrheic cysts

• Round or oval shape.
• Clear, even contours.
• Hypoechoic or anechoic echostructure.
• Distal acoustic effects - distal pseudo-enhancement, lateral acoustic shadows can be detected.
• The effect of compression on the shape of the formation is varying degrees of shape change.
• Changes in the internal structure of the formation against the background of compression - reflections from the internal contents become more orderly.

Dilation of milk ducts in the mammary gland

Dilation of the milk ducts of the mammary gland may occur latently. Clinical manifestations of dilation of the main and lobar ducts may include discomfort in the mammary glands, usually in the areola, as well as discharge from the nipple of various natures. There are several situations in which dilation of the ducts is a reflection of the natural physiological state:

1. during lactation and pregnancy;
2. in the 2nd phase of the menstrual cycle (as a reflection of the hormonal status of sex hormones).

Pathological dilation of the milk ducts can be caused by inflammatory processes against the background of nipple cracks and intraductal mastitis. Dilation of the milk ducts can occur due to disruption of physiological resorption processes by the ductal epithelium. As a result, liquid secretion accumulates in the lumen of the duct. Single dilations of the main excretory ducts in the area of the milk sinus can be detected at different periods of a woman's life. As a type of ductal involution, dilation of the milk ducts occurs after 50 years.

Image of an atypical milk duct. Echography reveals multiple dilated milk ducts with a diameter exceeding 2.5-3.0 mm. The walls of the ducts may be smooth or tortuous with pocket-like dilations. Thickening or unevenness of the duct wall may be due to its deformation from the outside or growth along the internal contour. Milk ducts located near cysts in the form of elongated anechoic structures may themselves imitate cysts.

Determination of the hyperechoic structure along the internal contour.

When the duct lumen is obstructed by a tumor, its distal parts may be dilated. The contents of the dilated part of the duct will be anechoic if there is fluid and hypoechoic if tumor masses spread intraductally. Echography allows us to detect not only persistent dilatations of the ducts, but also transient or functional dilatations of the ducts.

The detection of dilated (more than 2.5 mm) milk ducts in the first phase of the menstrual cycle may indicate a "dysfunctional mammary gland". This picture occurs with various dysfunctional and inflammatory processes of the pelvic organs, thyroid gland, against the background of taking contraceptives, etc. The same changes can be detected in women with such clinically determined conditions as mastosis, mastalgia, fibrocystic mastopathy. With adequate treatment of diseases of the uterus and ovaries, as well as liver diseases (impaired utilization of estrogens), the disappearance of echographic signs of duct dilation is observed. If normalization of the duct sizes is not observed against the background of the therapy, then we speak not of dysfunctional dilation, but of persistent dilation of the milk ducts, which is already of an organic nature. Persistent dilation of the ducts, as a rule, is combined with deformation of the surrounding tissues and is a sign of diffuse dyshormonal hyperplasia. The detection of dilated ducts in the mammary gland in a woman in deep menopause may serve as an indirect sign of a hormone-producing tumor of the ovaries or endometrium.

Acute inflammation of the mammary gland (mastitis)

Inflammation of the breast tissue, regardless of the nature of the process, unites a large group of diseases called mastitis. The inflammatory process affects one or more lobes of the mammary gland, very rarely the entire gland is involved in the process. Inflammation can be a consequence of milk stasis, cracks in the nipple, can occur against the background of ectasia of the milk ducts in women with diabetes and against the background of decreased immunity, as well as for no apparent reason. The most common symptoms of the inflammatory process in the mammary gland are compaction, pain and swelling, local increase in temperature and erythema, weakness, chills and fever and / or discharge from the nipple. A distinction is made between diffuse and focal forms of mastitis with an outcome in an abscess.

In acute inflammation, X-ray mammography demonstrates non-specific darkening characteristic of edema and infiltration, sometimes accompanied by thickening of the skin and loss of transparency of the subcutaneous tissue. The impossibility of performing compression of the mammary gland due to severe pain syndrome reduces the diagnostic value of X-ray mammography.

Diffuse form of mastitis

The diffuse form of mastitis is characterized by thickening of the skin, increased echogenicity of the subcutaneous tissue and parenchyma with loss of clarity of their differentiation. Thickened skin can be hypo- or hyperechoic. Its thickness exceeds the thickness of the skin of the symmetrical area in the contralateral mammary gland. Dilated milk ducts (up to 3-4 mm in diameter) are often determined along the periphery of the altered tissue. Compression of the ducts can lead to the formation of galactocele. Milk ducts involved in the inflammatory process (ductal mastitis) are characterized by the presence of hypoechoic purulent contents. Against the background of inflammation, the subcutaneous network of numerous dilated lymphatic vessels can be clearly visualized in the form of multidirectional anechoic tubular structures. These echographic changes in the mammary gland are non-specific, since they can accompany both mastitis and the edematous-infiltrative form of mammary gland cancer. Neither RM nor echography can differentiate diffuse inflammation and the edematous-infiltrative form of mammary gland cancer. However, 1-2 days after taking antibiotics in the diffuse form of mastitis, a significant improvement in ultrasound differentiation of mammary gland tissue is noted.

Nodular form of mastitis

The nodular form of mastitis is characterized by the formation of an abscess. Most abscesses form behind the nipple. However, the inflammation site can be located under the skin, inside the mammary gland, in front of the pectoral muscle. The formation of an abscess is accompanied by various painful sensations, redness and tension of the skin, and palpation of the formation.

Depending on the age of the abscess, the ultrasound picture will be different. Thus, at the stage of capsule formation, a hypoechoic zone of edema begins to be determined along the periphery of diffusely changed tissues, then fragmentary hyperechoic areas of the capsule. By the time the abscess formation is complete, a hyperechoic capsule of varying thickness is clearly visualized. The internal structure of the abscess also changes and becomes more heterogeneous with the appearance of anechoic areas - areas of necrosis and purulent melting, hyperechoic zones - areas of detritus. Dynamic monitoring of the development of mastitis allows to exclude a significant number of unnecessary surgical interventions.

In long-term chronic inflammatory processes in the mammary gland, hyperechoic linear structures appear. The appearance of these structures can be explained by the processes of fibrosis of the tissues of the mammary gland or visualization of the walls of thin vessels. The inflammatory process in the mammary glands is usually accompanied by a reaction from the lymph nodes. Ultrasound of the mammary glands has a much higher sensitivity compared to RM in detecting the abscess cavity. In addition, ultrasound can determine the prevalence of the inflammatory process, prevent the occurrence of a fistula even before obvious skin manifestations. With the help of echography, it is possible to observe various stages of mastitis until their resolution. Echography is also used for diagnostic and therapeutic aspiration of abscesses, when collecting cytological material from patients with unclear focal changes in the mammary gland. X-ray mammography for sluggish processes is prescribed 1 - 2 weeks after the start of treatment to exclude a malignant tumor.

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