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Case 2

Breast Carcinoma

35 year old female with a breast lump

This 35 year old lady presented with a lump in her left breast. A needle aspiration performed in the assessment clinic produced fluid, which was a little blood-stained. She was referred for an ultrasound to confirm the initial clinical impression of a benign cyst.

Findings

The lesion demonstrates a central cystic component, echo free with acoustic enhancement posteriorly. This lies within a relatively well defined round 2cm diameter low echogenicity lesion. In parts (particularly anteriorly) this extends out into the breast in a more irregular fashion.

Diagnosis

Carcinoma of the breast

Discussion

Ultrasound is a poor screening test for breast carcinoma, being neither sensitive nor specific. However it has a more useful role when directed towards a specific lesion felt clinically or seen mammographically. In particular it is very specific for simple cysts, which require no further investigation if they fulfil the appropriate criteria.

While benign and malignant solid lesions (eg. fibroadenomas and carcinomas) have certain characteristic features, there is considerable overlap, which reduces the specificity of ultrasound. In this situation fine needle aspiration cytology (FNAC) or biopsy will often be required.

Some of the typical appearances are indicated below:

Simple cysts

In order to diagnose a simple cyst, it should be well defined, with a smooth regular border and an echo free centre. There should be acoustic enhancement behind it. There should be no solid component.

Fibroadenomas

Fibroadenomas are usually well defined oval structures of low echogenicity, which often contain focal calcifications. They usually cause acoustic enhancement posteriorly.

Carcinomas

These are usually of low echogenicity, but with more irregular and ill defined margins. They often cause acoustic shadowing behind the lesion, and may distort the surrounding tissues. However a carcinoma may resemble a fibroadenoma and vice versa.

Malignant microcalcifications

These are frequently invisible on ultrasound and are best demonstrated on mammograms. They indicate ductal carcinoma.

In this particular case the lesion is cystic, but otherwise does not fulfil the criteria listed above. There is a large irregular low echogenicity soft tissue component. A cystic malignant lesion is unusual but well recognised and must be differentiated from simple cysts which are many times more common.

On this occasion the diagnosis was confirmed by the cyst aspiration cytology report, which described malignant cells in the fluid. The patient underwent surgical excision of the lesion.

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