Non-tumorous changes in the mammary gland

Dysplasia

Dysplasia is characterized by a violation of symmetry, the size of the configuration of the mammary glands and is caused by hypertrophic, hyperplastic and hypoplastic processes. Hypertrophy of the breast is diagnosed with an increase in the volume of the breast by more than 50%. The severity of hypertrophy is estimated by the size of the breast in height and by the increase in the front projection. Hypertrophy of the mammary glands can be bilateral and one-sided. The need for an echographic evaluation arises with unilateral hypertrophy of the mammary gland to exclude the tumor etiology of the process.

The increase in the mammary gland due to the growth of all the components forming it is a true hypertrophy. As a rule, this process is associated with an increased content of sex hormones. A particular example is the 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 disturbing the echostructure.

The increase in the mammary gland due to the growth of the fatty component is fatty (false) hypertrophy. At the same time on the echogram of an enlarged mammary gland the fatty component predominates in the form of multiple hypoechoic structures forming the entire array of enlarged breast tissue. This type of hypertrophy is characteristic of involutive processes.

True and false hypertrophy should be differentiated with specific processes of proliferation of connective tissue 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 determines the alternation of hyperechoic fibrous structures and areas of the glandular tissue with a somewhat reduced echogenicity.

Dyshormonal hyperplasia of the breast

Dyshormonal hyperplasia is characterized by varying degrees of severity of hyperplastic processes in the mammary glands. Conditionally they can be divided into:

1. hyperplasia of the protocol epithelium by increasing the terminal tubular branches and the number of cell layers of the duct wall;
2. sclerosis of connective tissue.

Sclerosis of connective tissue is a severe form of premature involution of the breast and leads to the development of cysts (multiple microcysts or one cyst, sometimes of considerable size), expressed by tissue fibrosis. These processes characterize diffuse dyshormonal hyperplasia (diffuse fibrocystic mastopathy). With echography, there is a thickening of the walls, an enlarged lumen, an uneven contour of the ducts. Pocket extensions in the form of hypoechoic zones along the main axis of the duct are often determined. These protrusions of ducts are difficult to differentiate with cysts. With dyshormonal hyperplasia, the parenchyma may acquire a higher echogenicity due to the alternation of hyperechoic connective tissue elements among the less echogenic glandular structures. Often behind the areas of fibrosis appears an acoustic shadow, which does not allow you to clearly differentiate the structures located below. Diffuse forms of dyshormonal hyperplasia require dynamic control and treatment aimed at normalizing the hormonal background.

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

Cysts

Cysts - this is one of the most common diseases of the breast. Typical for the occurrence of cysts is 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 the menopause against hormonal therapy with estrogens, steroids, when taking medications that reduce blood pressure, derivatives of digitalis. The size of the cysts can be from a few millimeters to 5-6 cm. Cysts can be either unilateral or bilateral; single and multiple. More common are multiple bilateral cysts. Close-lying cysts of the breast tend to merge, unite into a single cavity. This process can be traced with dynamic observation - in the place of several closely located cysts a multi-chamber cystic formation with septa is formed; Later, in connection with the lysis of the septa, a single-cell cyst is formed. The regression period of the partitions usually lasts several months. The most common cysts are formed in the terminal part of the milk duct (the first 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. Cysts of the breast can have typical signs of fluid-containing formations, characteristic for cysts of other localizations:

• round or oval shape;
• compressibility;
• no reflections from internal contents;
• distal reinforcement;
• a clear differentiation of the inner and outer contours;
• bright rear wall;
• bilateral lateral acoustic shadows.

In the presence of all the above echographic features, the accuracy of ultrasound diagnosis of cysts is from 98 to 100%.

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

Distal pseudo enhancement is absent:

• at small sizes of cysts;
• behind cysts located among structures that have high echogenicity;
• behind the cysts located near the pectoral muscle;
• with the severity of the fibrous capsule of the cysts.

With rounded cysts, lateral acoustic shadows are noted. Often, the cyst determines visible echostructures, the appearance of which is due to improper adjustment of the equipment. It is necessary to regulate and adjust the overall gain and focus area in each particular case. Very superficially located cysts may need to be examined using a special silicone gasket or water nozzle. The compression mode allows to determine the compressibility or stress of the cyst walls. Changing the plane of the position of the sensor makes it possible to assess the state of the internal and external contour of the cyst walls and to reveal intracavitary proliferation. Cystic formations of the breast do not always have an ideal rounded shape and even outlines. This is due to the degree of fullness of the cyst and the internal pressure on its walls. Multicomponent structures of the mammary gland have a great elasticity, which requires sufficient pressure from the contents of the cyst to spread the walls. The shape of the unfilled cyst can be varied: from rounded to irregular, oblate, polygonal.

Hyperechoic image of internal contents.

Echographic signs of a cyst:

• Round or oval shape.
• Clear smooth contours.
• Anechogenous ehostruktura without reflections.
• Distal acoustic effects - can determine the effect of distal pseudo-amplification, lateral acoustic shadows.
• The effect of compression on the form of education is a pronounced change in form.
• Changing the internal structure against the background of compression - no change.

Atypical cysts

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

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

The prolonged existence of the 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. The ultrasound image of atypical cysts without distal reinforcement is practically impossible to distinguish from the image of a solid volumetric formation. Only the movement of structures within the cyst during bullying can indicate the liquid nature of the formation. With very thick content, these movements become practically indistinguishable to the eye, and then the nature of the changes in the mammary gland can only be established by aspiration under ultrasound control.

Hemorrhagic secret, like the contents of an infected cyst, is characterized by the appearance of internal reflections. The walls of such a cyst are often thickened. Atypical cyst can have hyperechoic inclusions in the cavity due to the content of calcifications. Calculation of the cyst walls hinders the evaluation of the structure of the cyst due to the appearance of an acoustic shade. Atypicality of cysts can be caused by intracavitary growths. Intracereous growths in 75% of cases are benign in nature and are usually papillomas. 20% are malignant tumors. The remaining 5% constitute other changes in the cyst wall. The combination of cancer cyst is very rare (0.5% of all breast cancers), but with intracavitary vegetation it must always be kept in mind.

Identification of atypical cysts suggests a completely different management tactics than with simple cysts. Puncture biopsy under ultrasound control with cytological examination is mandatory when an atypical cyst is detected.

Echographic features of the atypical cyst:

• Round or oval shape.
• Clear contours (smooth or uneven).
• Homogeneous ehostruktura with internal reflections of different intensity.
• Distal acoustic effects - can be expressed the effect of distal pseudo amplification, lateral acoustic shadows.
• The effect of compression on the form of education is a pronounced change in form.
• Changing the internal structure against the background of compression - reflections from the inner content become more orderly.

Galactocele

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 several milk ducts. Stasis of milk can very quickly lead to mastitis and an abscess. Continuing to exist and after the end of the lactation period galactocele is transformed into a chocolate cyst. Palpation of galactocele against the background of an enlarged lactating gland is difficult. In this regard, the formation of galactocele can be mistakenly regarded as a compaction of the mammary gland tissue against the background of mastitis. When ULM galactocele is visualized as a cyst with echogenic content or in the form of a dilated (spherical) milky duct with a well-pronounced effect of distal pseudo-enhancement.

Echographic signs of galactocele

• Round or oval shape.
• Clear smooth contours.
• Hypoechoic or anechogenous ehostruktura.
• Distal acoustic effects - distal pseudo amplification, lateral acoustic shadows can be determined.
• The effect of compression on the form of education is a varying degree of change in form.
• Changing the internal structure against the background of compression - reflections from the inner content become more orderly.

Seborrheic cysts

Sebaceous (seborrheic), or epidermal, cysts can reach a size of up to 1.5 cm, which makes it possible to diagnose them with ultrasound. This formation contains an oily secret, fat and in some cases can be calcified. The subcutaneous location of the formation allows you to correctly diagnose. The ultrasound picture corresponds to a rounded or oval volumetric formation with a large number of reflections of medium and low intensity. The effect of distal pseudo-enhancement can be either expressed or not determined. Often marked lateral acoustic shadows.

Echographic signs of seborrheic cysts

• Round or oval shape.
• Clear smooth contours.
• Hypoechoic or anechogenous ehostruktura.
• Distal acoustic effects - distal pseudo amplification, lateral acoustic shadows can be determined.
• The effect of compression on the form of education is a varying degree of change in form.
• Changing the internal structure of education against a background of compression - reflections from internal contents become more orderly.

Expansion of the milk ducts of the breast

Expansion of the milk ducts of the breast can proceed latent. The clinical manifestation of the widening of the main and lobar ducts can be discomfort sensations in the mammary glands, usually in the nasal region, as well as discharge from the nipple of a different nature. There are several situations in which duct dilatation is a reflection of the natural physiological state:

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

The cause of the pathological expansion of the milk ducts can be inflammatory processes against the background of nipple cracks and intra-cellular mastitis. Dilatation of the milk ducts can occur due to disruption of the processes of physiological resorption by the protocol epithelium. As a result, a liquid secret accumulates in the lumen of the duct. Single extensions of the main excretory ducts in the region of the lacteal sinus can be detected at different periods of a woman's life. As a kind of ductal involution, dilatation of the milk ducts occurs after 50 years.

Picture of an atypical milky duct. When the echography is determined by multiple dilated milk ducts, the diameter of which exceeds 2.5-3.0 mm. The walls of the ducts can be even or crimped with pocket-like extensions. Thickness or roughness of the duct wall may be due to its deformation from the outside or expansion along the inner contour. Milky ducts, located near the cysts in the form of elongated anechoic structures, can themselves imitate cysts.

Determination of the hyperechoic structure along the inner contour.

With obturation of the lumen of the duct, a tumor may reveal an enlargement of its distal sections. The contents of the dilated part of the duct will be anechogenous in the presence of fluid and hypoechoic when the tumor mass is distributed internally. The echography allows to reveal not only persistent dilations 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". Such a picture takes place with various dysfunctional and inflammatory processes of the pelvic organs, the thyroid gland, the background of taking contraceptives, etc. The same changes can be detected in women with clinically defined conditions, such as mastosis, mastalgia, fibrocystic mastopathy. When adequate treatment of diseases of the uterus and ovaries, as well as liver diseases (disruption of estrogen utilization), there is a disappearance of echographic signs of duct enlargement. If the normalization of the size of the ducts is not observed against the background of the therapy, then they speak not of dysfunctional dilatation, but of the permanent expansion of the milk ducts, which is already of an organic nature. Persistent dilatation 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 can 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. Inflammatory process affects one or more lobules of the breast, very rarely all the gland is involved in the process. Inflammation may be due to stasis of milk, nipple cracks, may occur against the background of the ectasia of the milk ducts in women with diabetes and against a background of decreased immunity, and also for no apparent reason. The most common symptoms of the inflammatory process in the mammary gland are compaction, pain and swelling, local fever and erythema, weakness, chills and fever and / or discharge from the nipple. There are diffuse and focal forms of mastitis with an outcome in an abscess.

In acute inflammation, X-ray mammography demonstrates nonspecific darkening, characteristic of edema and infiltration, sometimes accompanied by thickening of the skin and loss of transparency of the subcutaneous tissue. Impossibility of compression of the breast due to severe pain reduces the diagnostic value of X-ray mammography.

Diffuse form of mastitis

Diffuse form of mastitis is characterized by thickening of the skin, increased echogenicity of subcutaneous tissue and parenchyma with loss of clarity of their differentiation. Thick skin may be hypo- or hyperechoic. Its thickness exceeds the thickness of the skin of a symmetrical segment in the contralateral mammary gland. Often, on the periphery of the altered tissue, dilated milk ducts (up to 3-4 mm in diameter) are determined. The compression of the ducts can lead to the formation of a galactocele. The milky ducts (protocol mastitis) involved in the inflammatory process are characterized by the presence of hypoechoic purulent contents. Against the backdrop of inflammation, the subcutaneous network of numerous dilated lymphatic vessels in the form of multidirectional anechoic tubular structures can be well visualized. These echographic changes in the breast are non-specific, since they can accompany both mastitis and edematous-infiltrative form of breast cancer. Neither with RM nor with echography can diffuse diffuse inflammation and edematous-infiltrative form of breast cancer. However, on the 1 - 2 day after taking antibiotics in the diffuse form of mastitis, there is a marked improvement in the ultrasound differentiation of the mammary gland tissues.

Nodal form of mastitis

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

Depending on the age of the abscess, the ultrasound pattern will be different. So, at the stage of the capsule formation around the periphery of the diffusely altered tissues, the hypoechoic edema zone first begins to be determined first, followed by the fragmentary hyperechoic sections of the capsule. By the time of the completion of the formation of the abscess, a hyperechoic capsule of various thickness is clearly visualized. The internal structure of the abscess also changes and becomes more heterogeneous with the appearance of anechogenous areas - necrosis zones and purulent melting, hyperechoic zones - detritus sites. Dynamic monitoring of the development of mastitis allows you to exclude a significant number of unnecessary surgical interventions.

With 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 breast tissue or visualization of the walls of thin vessels. The inflammatory process in the mammary glands is usually accompanied by a reaction from the side of the lymph nodes. Ultrasound of the mammary glands has a much higher sensitivity compared to the PM in identifying the abscess cavity. In addition, ultrasound can determine the prevalence of the inflammatory process, prevent the appearance of fistulae before the obvious skin manifestations. With the help of echography, you can observe various stages of mastitis before their resolution. Echography is also used to conduct diagnostic and therapeutic aspiration of abscesses, while taking a cytological material in patients with unclear focal changes in the mammary gland. X-ray mammography with slow processes is prescribed 1 to 2 weeks after the start of treatment to exclude a malignant tumor.

[1], [2], [3], [4], [5], [6]