Hyperechoic breast images: all that glitters is not gold!
Hyperechogenicity is a sign classically reported to be in favour of a benign lesion and can be observed in many types of benign breast lesions such as hamartoma, lipoma, angiolipoma, haemangioma, haematoma, fat necrosis, fibrosis and galactocele, among others. However, some rare malignant breast lesions can also present a hyperechoic appearance. Most of these hyperechoic malignant lesions present other characteristics that are more typically suggestive of malignancy such as posterior shadowing, a more vertical axis or irregular margins that help to guide the diagnosis. Post magnetic resonance imaging, second-look ultrasound may visualise hyperechoic malignant lesions that would not have been identified at first sight and radiologists must know how to recognise these lesions.
• Some rare malignant breast lesions can present a hyperechoic appearance.
• Malignant lesions present other characteristics that are suggestive of malignancy.
• An echogenic mass with fat density on mammography does not require biopsy.
KeywordsBreast cancer Breast ultrasound Histology Hyperechogenicity Malignancy
Densely grouped adipocytes
Thick bands of fibrosis
Multiple vascular spaces
A heterogeneous and invasive tumour cell contingent
In their original study published in 1995, based on a series of 750 breast nodules detected by ultrasound, Stavros et al.  reported that 42 nodules were hyperechoic and all of them were benign. Hyperechogenicity was the ultrasound parameter in favour of a benign lesion with the highest negative predictive value (100%). In a more recent study published by Linda et al. , retrospective review of a series of 4511 biopsied lesions revealed that 25 (0.6%) were hyperechoic and 9 (0.4%) were malignant.
The differential diagnosis of hyperechoic breast images is based on knowledge of the clinical setting, detailed analysis of morphological features, and comparison with mammography and possibly magnetic resonance imaging (MRI). In this paper, we propose a review of the various hyperechoic breast lesions.
Harmonic mode: reduces artefacts, improves spatial resolution and the contrast between glandular tissue, fat and breast lesions by increasing the echogenicity of fat, and enhances posterior ultrasound modifications.
Compound mode or real-time spatial compound imaging: improves the signal-to-noise ratio and optimises analysis of lesion margins and the internal echostructure of breast masses. Posterior ultrasound modifications are attenuated.
Benign hyperechoic lesions
Lipoma is a proliferation of mature adipocytes forming a lobular mass clearly circumscribed by a fine fibrous capsule. Lipoma is a common lesion, often unilateral and solitary, and can present as a soft, mobile palpable mass.
Just-developed hematomas can also be ill-defined and hyperechoic.
The mammographic appearance can be misleading and may mimic malignancy. Correlation with the clinical context and clinical interview are therefore essential for diagnosis.
Diseases of lactating women
Galactocele corresponds to milk retention in a dilated lactiferous duct proximal to duct obstruction, generally occurring during breastfeeding or shortly after stopping breastfeeding.
Galactocele can also occur in the absence of breastfeeding in women treated by neuroleptic drugs. The appearance of galactocele depends on the fat and protein content.
Lactating adenoma is a benign tumour occurring during the last trimester of pregnancy, composed of dilated tubular structures, forming alveoli of variable size, lined by vacuolated cells containing lipid-rich foamy material in their centres. Mammography shows an oval-shaped mass containing zones of fat, while ultrasound reveals a well-circumscribed, homogeneous, hypoechoic (67%), isoechoic (20%) or hyperechoic (13%) oval-shaped mass. Lactating adenoma usually resolves spontaneously after stopping breastfeeding .
Pseudoangiomatous stromal hyperplasia (PASH)
Pseudoangiomatous stromal hyperplasia is a benign mesenchymal lesion, more commonly observed in premenopausal women or in women treated by hormonal therapy. PASH consists of proliferation of myofibroblasts induced by a high density of progesterone receptors, leading to the development of fibroblastic hyperplasia. PASH is characterised by the presence of a network of anastomotic channels lined by flat, endothelium-like cells, simulating a vascular tumour. These empty channels, devoid of erythrocytes, predominantly present a concentric pattern around lobules and are typically situated in a dense collagen stroma.
Mastitis and breast abscess
Complex sclerosing lesion
Possibly hyperechoic malignant lesions
Breast cancers, regardless of their histology, are typically hypoechoic. Breast cancer can rarely be hyperechoic, but other ultrasound features are usually also present, suggesting the diagnosis, such as poorly circumscribed margins, irregular shape, posterior attenuation, a more vertical axis . Ultrasound characterisation must take the most pejorative parameter into account.
Invasive ductal carcinoma (IDC)
Invasive lobular carcinoma (ILC)
Angiosarcoma is a rare, aggressive malignant tumour, accounting for less than 1% of all breast cancers. Two forms are distinguished: primary angiosarcoma, which is sporadic in young women, and secondary angiosarcoma in an irradiated breast, occurring an average of 6 years after radiotherapy.
Primary lymphoma of the breast is very rare, accounting for less than 0.5% of all breast cancers and less than 1% of non-Hodgkin’s malignant lymphomas, predominantly corresponding to diffuse B-cell lymphoma. Secondary lymphoma, more frequent, is associated with extramammary involvement at diagnosis.
The very great majority of hyperechoic masses of the breast are benign, and the diagnosis is often guided by the clinical setting. Most malignant lesions are hypoechoic compared to fat, especially when using the harmonic mode. However, malignant lesions can sometimes present in the form of hyperechoic or mixed echogenicity images, in which case other signs suggestive of malignancy are generally present: a more vertical axis, irregular shape, spiculated margins, posterior attenuation or hypervascularisation. Second-look post-MRI ultrasound may visualise hyperechoic malignant lesions that would not have been identified at first sight.
- 1.American College of Radiology (1998) Illustrated breast imaging reporting and data system (BI-RADS), 3rd edn. American College of Radiology, RestonGoogle Scholar
- 5.Mendelson EB, Böhm-Vélez M, Berg WA et al (2013) ACR BI-RADS® ultrasound. In: ACR BI-RADS® atlas, breast imaging reporting and data system. American College of Radiology, RestonGoogle Scholar
- 8.Kim SY, Kim HH, Kim EH, Kim SY, Jou SS, Han JK, (2009) Angiolipoma of the breast: a case report. J Breast Cancer 12(4):344–346Google Scholar
- 10.Raut P, Lillemoe TJ, Carlson A (2017) Myofibroblastoma of the breast. Appl Radiol 46:42–44Google Scholar
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