Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Breast Hamartoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Breast hamartomas:
    • Most likely result from an overgrowth of a portion of normal breast tissue, or from fibrous and glandular elements becoming incorporated into a lipomatous growth:
      • Thus, they are sometimes called a “breast within a breast”
    • They are also variously called:
      • Adenolipofibroma
      • Lipofibroadenoma
      • Adenolipofibroma
      • Fibroadenolipoma:
        • Because they contain fibrous, fatty, and epithelial tissues
    • They may present as palpable masses:
      • But are more commonly discovered on routine imaging
    • They are round, oval, or lobulated, and usually are well-circumscribed:
      • They have a mixture of water density and fatty elements and frequently have either a capsule or the appearance of a capsule resulting from surrounding compressed breast tissue
    • A mammographically classic hamartoma does not require further imaging:
      • Short interval follow-up, or biopsy
  • The presence of a breast hamartoma should prompt further questioning of the patient to be sure there is nothing to suggest she has multiple hamartoma syndrome (Cowden syndrome):
    • A rare disorder caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene:
      • Patients with this disorder have an increased head circumference, multiple trichilemmoma skin lesions, intestinal hamartomas, and an increased risk of cancer of the breast, thyroid, endometrium, and kidney
      • Genetic testing should be done if there is a personal or family history suggestive of the disorder
  • References
    • Crothers JG, Butler NF, Fortt RW, Gravelle IH. Fibroadenolipoma of the breast. Br J Radiol. 1985;58(687):191-202.
    • Daya D, Trus T, D’Souza TJ, Minuk T, Yemen B. Hamartoma of the breast, an underrecognized breast lesion. A clinicopathological and radiographic study of 25 cases. Am J Clin Pathol. 1995;103(6):685-689.
    • Murat, A, Ozdemir H, Yildirim H, Poyraz AK, Ozercan R. Hamartoma of the breast. Australas Radiol. 2007;51(Spec No.):B37-B39.
    • Schrager CA, Schneider D, Gruener AC, Tsou HC, Peacocke M. Clinical and pathological features of breast disease in Cowden’s syndrome: an underrecognized syndrome with an increased risk of breast cancer. Hum Pathol. 1998;29(1):47-53.
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Simple Breast Cyst

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The patient has a BIRADS 2 simple cyst:
    • To be regarded as a simple cyst, a mass must meet three criteria:
    • The margins must be circumscribed:
      • i.e., a margin “that is well defined or sharp, with an abrupt transition between the lesion and surrounding tissue”
    • It must be anechoic:
      • i.e., “without internal echoes”
    • It must show posterior acoustical enhancement:
      • i.e., “a column that is more echogenic deep to the mass”
  • Simple cysts are almost never associated with cancer in the absence of other abnormalities seen on mammogram or ultrasound
  • There are numerous reflectors in breast tissue:
    • All of the sound waves that are reflected do not make it back to the transducer:
      • Many of them bounce back and forth (reverberate) between reflectors in the tissue, and with each reverberation, part of the echoes return to the transducer, are recorded, and part undergo another excursion between the reflectors
    • Most of these echoes are obscured by all of the other echoes in the tissue, but when an otherwise anechoic window (a cyst) is present:
      • The reverberation echoes can be seen in the anterior part of the cyst:
        • In the image shown, a hyperechoic band can be seen within or just above the anterior wall of the cyst, especially on the left side of the image
      • The acoustic mismatches between this band and the less echogenic tissue superficial to it and the anechoic fluid deep to it, cause echoes that reverberate, creating the artifact in the near field of the cyst
  • References
    • D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas: Breast Imaging Reporting and Data System, 5th ed. Reston, VA: American College of Radiology; 2013.
    • Kremkau FW. Diagnostic Ultrasound: Principles and Instruments, 7th ed. Elsevier; 2006:274-292.
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Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • There are two main groups of diffuse breast cancers:
    • That present as large areas of architectural distortion on the mammogram:
      • One is neoductgenesis
      • The other is a diffusely infiltrating carcinoma:
        • Which makes up approximately
Bilateral diagnostic mammogram images
  • When the tumor is e-cadherin negative:
    • It is usually called invasive “lobular” carcinoma
  • When it is e-cadherin positive:
    • It is called infiltrating “ductal” carcinoma:
      • The designation based on e-cadherin staining is arbitrary:
        • Because the behavior of diffusely invasive carcinoma is the same regardless of the staining
  • Lacking calcifications and a central tumor mass:
    • These cancers are notoriously difficult to perceive on mammogram:
      • Even when they are large and palpable or when they occur in fatty involuted breasts:
        • However, the associated connective tissue response:
          • Makes this type of cancer quite visible with ultrasound
Hand-held ultrasound image
  • In contrast to diffusely infiltrating cancers:
    • Circular (Image) and spiculated (Image) tumors arising in the terminal ductal lobular units (TDLU):
      • Have bulging, convex contours protruding into the adipose tissue
Lobulated spherical tumor mass
Multifocal stellate invasive breast cancer
  • The solid variety of infiltrating lobular carcinoma:
    • Most probably arises within the TDLU and has a circular / oval shape on breast imaging
  • There are two other variants of invasive lobular carcinoma that arise in the TDLUs:
    • The tubulolobular variant:
      • Is either a unifocal or multifocal spiculated lesion on the mammogram (Image 5a-b)
    • The alveolar type of invasive lobular carcinoma:
      • Is usually mammographically occult, or it can be seen as a subtle, asymmetric density (Image)
Mammogram (a) and large format histology (b) alveolar type invasive lobular carcinoma
  • The various forms of invasive lobular carcinoma that develop in the TDLUs and present as localized lesions:
    • Have a significantly better prognosis than the diffusely infiltrating type breast cancer
  • Complex sclerosing lesions:
    • Present mammographically as nonpalpable architectural distortion with no central tumor mass and lucent radiating structures, the so called “black star”:
      • As opposed to cancers originating from the TDLU:
        • Which have a dense central tumor mass surrounded by radiopaque spiculation, giving the impression of looking at a “white star”
  • Malignant phyllodes tumors:
    • Present as large, high density masses:
      • The borders may be circumscribed or ill defined
  • Fat necrosis:
    • Also presents as a hypoechoic, high-density mass
  • References:
    • Tot T. Diffuse invasive breast carcinoma of no special type. Virchows Arch. 2016;468(2):199-206.
    • Tabár L, Dean PB. Teaching Atlas of Mammography. New York, NY: Thieme; 2011.
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Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • This axilla ultrasound shows a case of severe eccentric compression and displacement of the hilum to the edge of the node:
    • Favoring metastatic disease:
      • Biopsy of the node provides pathology staging:
        • Which may influence treatment options
  • Typical lymph node ultrasound appearances include:
    • Uniformly mildly thickened cortex:
      • Typical of inflamed or reactive lymph node
    • Eccentric cortical thickening:
      • Favors metastatic disease
Severe eccentric compression and displacement of the mediastinum to the edge of the node
  • Convex indentations of the hilum:
    • Favors metastatic diseased
  • Severe compression of the hilum to slit-like configuration:
    • Can occur in metastatic or severely inflamed lymph node
  • Severe eccentric compression and displacement of the hilum to the edge of the node:
    • Favors metastatic disease
  • Complete obliteration of the hilum and rounding of the node:
    • Favors metastatic disease (can also occur in severe necrotizing lymphadenitis)
  • Perinodal invasion by metastasis:
    • The outer thin echogenic capsule cannot be identified
    • Angular margins
  • References
    • Stavros AT. Evaluation of regional lymph nodes in breast cancer patients. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:858-859.
    • AIUM curriculum for fundamentals of ultrasound physics and instrumentation. JUltrasound Med 2019;38(8):1933-1935. https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15088. Accessed July 16, 2020.
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Tissue Harmonic Imaging of the Breast

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Tissue harmonic imaging (THI):
    • Creates images derived solely from higher frequencies
  • The ultrasound beam:
    • Is transmitted centered at 1 frequency, e.g., 6 MHz, and received centered at a multiple of the transmitted frequency, e.g., 12 MHz
  • Different techniques can be used to process the received signals so that only the returning high-frequency harmonic signal is used to produce the image:
    • Whereas echoes from the fundamental / lower frequencies are rejected
  • THI increases signal-to-noise ratio:
    • Resulting in better tissue contrast
  • THI:
    • Reduces reverberation, clutter, and speckle artifacts:
      • Improving contrast resolution
    • It accentuates real echoes in addition to suppressing artifactual echoes
    • The suppression of speckle artifact by coded harmonics makes solid nodules more hypoechoic and conspicuous than they are with fundamental imaging (Images)
    • It makes the thin, echogenic capsule that surrounds most benign lesions appear to be thinner, more echogenic and more complete than with fundamental imaging
  • THI cannot be combined with simultaneous color Doppler imaging because the resulting frame rate would be unacceptable:
    • When Doppler is required, the image that is interlaced with Doppler must be constructed at fundamental rather than harmonic frequencies
  • THI is of limited value in differentiating benign from malignant lesions
  • Another method of reducing artifactual echoes, improving contrast, and making the thin, echogenic capsule more conspicuous is real time spatial compounding of images
  • In conventional imaging, each frame is created by a single sweep of the beam at a 90 degree angle to the long axis of the transducer:
    • In compound imaging, there are multiple sweeps of the beam from different angles, creating a spatially and temporally compounded image from multiple angles over time
    • Among other things, the lateral borders of lesions can be seen better with compound imaging
Infiltrating ductal carcinoma with fundamental imaging.
The same infiltrating ductal carcinoma as above with coded harmonic imaging
  • References:
    • Mesurolle B, Helou T, El-Khoury M, Edwardes M, Sutton EJ, Kao E. Tissue harmonic imaging, frequency compound imaging, and conventional imaging use and benefit in breast sonography. J Ultrasound Med. 2007;26(8):1041-1051.
    • Cha JH, Moon WK, Cho N, Kim SM, Park SH, Han BK, et al. Characterization of benign and malignant solid breast masses: comparison of conventional US and tissue harmonic imaging. Radiology. 2007;242(1):63-69.
    • Stavros AT. Breast ultrasound equipment requirements. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:16-41.
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Breast Calcifications

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Screening mammography:
    • Is important in identifying breast cancer at an early stage
  • Calcifications have many forms:
    • The characteristics of the calcifications:
      • Help identify whether they are associated with a benign or malignant process
    • Smooth, round, large and layering calcium:
      • Are generally associated with benign findings
Round and punctate calcifications. Lobular. This group of calcifications is characterized by relatively monomorphic round and punctate calcifications having some variation in density. No linear forms or linear orientation is seen. BI-RADS 2: Benign finding
  • Fine, irregular, punctate, linear and branching, and pleomorphic calcifications:
    • Are characteristics generally associated with malignant findings
Fine Linear or Fine Linear Branching
These are thin, linear or curvilinear irregular calcifications.
They may be discontinuous.
Their appearance suggests filling of the lumen of a duct, i.e. ‘casting’ calcifications.
These calcifications are classified as Bi-RADS 4C.
On the left calcifications in a segmental distribution.
Some have a linear distribution and some have a branching morphology.
This is highly suggestive of malignancy (Bi-RADS 4C)
  • Magnification views of the calcifications are essential in helping to evaluate the calcifications to determine the appearance and to be able to accurately interpret the findings
  • References:
    • Brant W, Helms C. Fundamentals of Diagnostic Radiology, 5th Edition. Lippincott, Williams & Wilkins; 2019
    • Baldwin P. Breast calcification imaging. Radiol Technol. 2013;84(4):383M-404M.

Breast Nodules on Ultrasound

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Targeted ultrasound of mammographic abnormality
  • At first glance, the rounded, almost anechoic sonographic mass could be mistaken for a simple cyst:
    • However, closer inspection shows some small spiculations, angular margins, and a suggestion of an echogenic halo
      • These findings alone make it a BIRADS 4 lesion
    • Even if they were not present:
      • The lesion is rounded and, therefore, does not meet any of the 3 benign definitions:
        • That would allow it to be classified BIRADS 3
    • Although the lesion is small, homogeneous, and does not cause worrisome posterior acoustical artifacts:
      • Cancers this small frequently have no shadowing or enhancement
    • It could be benign:
      • But it has the appearance that a high-grade carcinoma would have when it is less than a centimeter in diameter
  • When a nodule seen on mammogram and ultrasound are in the same location, have the same size and shape, and the same surrounding tissue:
    • They can be confidently assumed to be the same
  • If it were going to be followed, mammograms would expose this young woman to ionizing radiation and thus a small but real risk of developing a radiation-induced malignancy:
    • So a 6-month follow-up ultrasound would be the modality of choice
  • Because the lesion cannot be confidently considered to be less than BIRADS 4a:
    • Evaluation with a needle is required:
      • It is possible aspiration would collapse a small cyst:
        • If not, percutaneous biopsy should be done with a spring-loaded, vacuum-assisted, or intact-removal device, depending on the experience and expertise of the surgeon
  • Steps in the evaluation of breast nodules by ultrasound:
    • You first evaluate the lesion for any of the 10 malignant signs:
      • Shadowing
      • Hypoechoic echotexture
      • Spiculation
      • Angular margins
      • Thick echogenic halo
      • Microlobulation
      • Taller than wide
      • Duct extension
      • Branching pattern
      • Calcifications)
    • Finding none:
      • You move on to the second step in the evaluation process and specifically look for one of the three strictly defined benign signs:
        • If any of them are found:
          • The lesion can be considered BIRADS 3:
            • The three benign findings defined by Stavros are:
              • A purely hyperechoic lesion with no hypoechoic area larger than a normal duct or lobule
              • Elliptical, wider than tall, well-circumscribed and thin echogenic capsule
              • Gently lobulated, wider than tall, well-circumscribed and thin echogenic capsule
          • Combining the elliptical or gently lobulated shapes with the presence of a complete, thin echogenic capsule:
            • Is necessary because many circumscribed carcinomas and most ductal carcinoma in situ are encompassed in a thin, echogenic capsule:
              • However, the shape of circumscribed invasive carcinoma or pure ductal carcinoma in situ:
              • Is rarely elliptical or gently lobulated
      • Because this lesion is elliptical, wider-than-tall, well-circumscribed, and has a thin, echogenic capsule:
        • It is BIRADS 3:
          • A 6-month follow-up ultrasound would be appropriate unless the anxiety of the patient makes core biopsy a better option
  • References
    • D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System, 5th ed. Reston, VA, American College of Radiology, 2013.
    • Madjar H, Mendelson EB. The Practice of Breast Ultrasound. 2nd ed. Thieme; 2008;141-144.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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Ten Signs of Malignancy During Breast Ultrasound

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Marked hypoechogenicity with immobile echogenic foci:
    • Representing calcifications
Ultrasound imaging of the palpable breast lesion.
  • The 10 signs of malignancy in breast ultrasound include:
    • Shadowing
    • Hypoechoic echotexture
    • Spiculation
    • Angular margins
    • Thick echogenic halo
    • Microlobulation
    • Taller than wide dimensions
    • Duct extension
    • Branching pattern
    • Calcifications
  • Well-defined smooth border and posterior acoustic enhancement:
    • Are found in both malignant and nonmalignant lesions
  • Layering / teacup mammographic microcalcifications:
    • Are usually associated with benign disease
  • Sonographic mass with a benign mammographic imaging:
    • Is managed based on ultrasound features
  • References
    • Evaluation and imaging features of malignant breast masses. In: Cardenosa G. Clinical Breast Imaging: The Essentials. Philadelphia, PA: Wolters Kluwer; 2015:234-282.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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Trabecular Thickening and Skin Thickening in Mammograms

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Right mediolateral oblique image
  • The mammogram shows trabecular thickening and an increased thickness of the skin:
    • Trabecular thickening is an increased prominence of linear structures in the breast:
      • Primarily corresponding to Cooper’s ligaments
    • It is almost always seen in conjunction with skin thickening:
      • It indicates significant breast edema
    • It has a number of different causes, including:
      • Congestive heart failure
      • Renal failure
      • Venous or lymphatic obstruction
      • Diffusely infiltrating carcinoma
      • Radiation
    • When the cause is lymphatic obstruction:
      • The obstruction can be the result of surgery, radiation, or lymphatic invasion by cancer
  • Unilateral breast edema with increased trabecular and skin thickening:
    • Sometimes occurs with congestive heart failure:
      • The pedal edema that develops during the daytime decreases at night:
        • And the fluid accumulates in the dependent breast in patients who sleep on their side
  • References
    • Berg, WA, Birdwell RL, Kennedy A. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006.
    • Verbelen H, Gebruers N, Beyers T, De Monie AC, Tjalma W. Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: a systematic review. Breast Cancer Res Treat. 2014;147(3):463-471.
    • Wratten CR, O’Brien PC, Hamilton CS, Bill D, Kilmurray J, Denham JW. Breast edema in patients undergoing breast-conserving treatment for breast cancer: assessment via high frequency ultrasound. Breast J. 2007;13(3):266-273.
    • Menta A, Fouad TM, Lucci A, Le-Petross H, Stauder MC, Woodward WA, et al. Inflammatory breast cancer: what to know about this unique, aggressive breast cancer. Surg Clin North Am. 2018;98(4):787-800.
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Atypical Ductal Hyperplasia (ADH)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Excisional biopsy:
    • Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB):
      • The chance of upgrade at excision to ductal carcinoma in situ (DCIS) or invasive carcinoma:
        • Is generally in the 12% to 22% range in the literature
    • The need for routine excision of pure flat epithelial atypia (FEA) has been less clear:
      • Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH:
        • When the vast majority of biopsies were done with a 14-gauge spring-loaded core biopsy device
    • It is not clear that biopsy with a vacuum-assisted device would yield the same results:
      • In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device:
        • Pure FEA never resulted in an upgrade to malignancy
      • An article from the Mayo Clinic:
        • Showed that FEA does not seem to convey an independent risk of breast cancer beyond that of associated proliferative disease without atypia or associated ADH
  • The risk of upgrade at surgical excision for ADH:
    • Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
      • With 2 or fewer foci of involvement:
        • There was no upgrade on excision
      • With 4 or more foci of involvement:
        • There was a strong probability of upgrade to ductal carcinoma in situ or invasive carcinoma at excision
  • Work continues to try to define a low-risk group who could potentially avoid excisional biopsy:
    • Particularly those with small areas of calcifications completely removed with core needle biopsy and only focal ADH on pathology
  • Apocrine metaplasia, florid epithelial hyperplasia of the usual variety, and columnar cell change without atypia:
    • Do not confer a significant risk of upgrade and do not require excision
  • References
    • Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Is surgical excision necessary for focal atypical ductal hyperplasia found at stereotactic vacuum-assisted breast biopsy? Ann Surg Oncol. 2008;15(11):3232-3238.
    • Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol. 2001;25(8):1017-1021.
    • Khoumais NA, Scaranelo AM, Moshonov H, Kulkarni SR, Miller N, McCready DR, et al. Incidence of breast cancer in patients with pure flat epithelial atypia diagnosed at core-needle biopsy of the breast. Ann Surg Oncol. 2013;20(1):133-138.
    • Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, et al. Flat epithelial atypia and risk of breast cancer: a Mayo cohort study. Cancer. 2015;121(10):1548-1555.
    • McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ. Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol. 2012;19(10):3264-3269.
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