Journ al of the Korean Radiol ogica l Society 1995 : 33(3) : 443- 447

Ultrasonographic Findings of Diseases During Pregnancy and Lactating Period1

Yeon Hee Lee, M.D2., Yong Hyun Park, M.D., Tae Hee Kwon, M.D.

Purpose: To evaluate ultrasonographic findingsand usefulness in the diagnosis of breast diseases during pregnancy and lactating period. Methods and Materials: The authors evaluated the ultrasonographic findings of 18 breast diseases during pregnancy and lactation retrospectively. The ultr­ asonographic examinations were performed with linear-array 5 MHz transducer (AT 니. Final diagnoses were obtained by the excisional biopsy, fine needle aspir­ ation and clinical follow-up. Results: Total 18 cases of breast diseases were consisted of 8 cases of gala­ ctocele, 4 cases of fibroadenoma, 3 cases ofaxillary accessory breast, 2 cases of lactating adenoma, and 1 case of phylloidestumor. The ultrasonographic findings of the above breast diseases were valuable in the diagnosis and therapeutic plan­ nlng. Conclusion: Ultrasonography is the initial and useful method of diagnosing breast diseases during pregnancy and lactating period.

Index Words: Breast. US Breast neoplasms, US

INTROCUCTION MATERIALS and METHODS

During pregnancy, patients complain of breast dis­ The authors reviewed the ultrasonographic findings comfort, pain or mass but cannot be of 18 breast lesions of 17 female patients retrospe­ taken due to possible radiation hazard to the fetus ctively. Mean age ofthe patients was 29.5 years and the After delivery, mammography of lactating breast is lim­ age range was 24 - 35 years. Five patients were preg­ ited in detecting a mass lesion due to hypertrophied, nant and 13 patients were postpartum within one year dense breast parencymal tissue which can mask the at the time of examination. The most common symptom mass density. was palpable breast mass(72.2 % ) (Table 1). Ultrasonogram has no radiation hazard(1) and is ef­ The exam inations were performed with a hand - held, fective in the detection of the mass especially in dense linear -array 5 MHz transducer( ATL Ultramark 9, 80- , so it is of great use in the exam ination of breast thell , Washington , U.S.A) and a sonopad was used wh­ diseases during pregnancy and lactating period. enever a lesion is located superficially. The authors have experienced various breast dis­ Final diagnoses wer e obtained by means of surgical eases during pregnancy and lactation and these tried excision in 11 cases, fine needle aspiration in 4 cases to find the usefulness of ultrasonography in these pa­ of galactoceles, and combination of clinical and sono­ patients graphic findings in 3 cases ofaxillary accessory bre­ asts. In five pregnancies, the excision was performed after del ivery.

' D epart m e nt 이 D i a gn ostic Radiology , ChaWo men’ s Hospi tal olSeoul RESULTS 2Department ofDiagnostic Radio logy , Dan kook Uni versityCo llege 01 Medi cine Rece ived October 14, 1994; AcceptedAugu st28 , 1995 Address reprint requests to :Yeon Hee Lee , M.D. , Department 01 Radi ology Total of 18 breast lesions were examined by ultra­ Dankook Un iversityH ospital sonography due to subjective symptoms. The final di ­ ~ 29 Anseodong Chonan Choong nam 330-714 Korea agnoses were 8 cases of galactoceles, 4 cases of Tel. 82-417- 550-6921 Fax. 82-417- 552-9674 fibroadenomas, 3 cases ofaxillary accessory breà. sts, - 443 - Journal of the Korean Radiological Society 1995 ; 33(3) : 443 - 447

2 cases of lactating adenomas, 1 case of benign phy­ (25%) but which was not confirmed by pathology (Fig. Iloides tumor. 2b). In 4 cases, after aspiration of mildly greenish fluid, Patients with accessory breast of axilla (3 cases) the masses disappeared in palpation. In the other 4 complained swelling of the axillary area with or without cases, the excision of the masses was performed pain. Ultrasonographic findings showed brease paren­ In 2 cases of lactating adenoma, roughly 3 cm sized chymal echoes in axillary area without a definite mass isoechoic mass was noted with ill defined border, mim­ or Iymphadenopathy. After delivery, swelling of both icking breast parencymal echogenicity adjacent to it. axillary area disappeared and so did the symptoms. There was no characterirstic findings such as posterior Three patients with fibroadenomas showed a well de­ enhancement, posterior shadowing, and calcification fined, low echogenic, oval shaped mass lesions, but (Fig. 3) the lateral shadowing was not seen(Fig. 1). One case One patient with phylloides tumor(1 case) showed showed a well defined mass which had a lobulated bor­ hypoech 이 c oval shaped mass (13.5 X 10 X 6.5cm) der and dense central calcification. The diameter ofthe with well defined border but definite clefts or cysts fibroadenomas were less than 2 cm in all cases. Micro­ were not seen (Fig. 4). scopic findings showed variable parenchymatous du­ ctal hyperplasia corresponding to those of the sur­ DISCUSSION rounding breast. Ultrasonographic findings of galactoceles(8 cases) In the evaluation of breast diseases, combined mo­ were cystic masses with variable internal echoes In 5 dalities are used such as mammography, ultrasono­ cases, well defined, single chambered, purely cystic graphy, xeromammography, and re­ mass lesions were noted. One case showed 3.1 X 1.2 cently MRI(2 -4). cm sized purely cystic mass with multilocular cham­ The usefulness of mammography in women less bers and the pathology showed multiple ductectasias then 35 years of age is controversial. Mammography is without inflammatory changes (Fig. 2a). Two, relatively apparently less effective in the evaluation of the radio­ large (3.5 X 2.1 cm and 2.8 X 2.0 cm in size in each) dense breasts of younger women than of the less ra­ cystic masses contained highly echogenic. nodular diodense breasts of older women. According to Ba­ densities with posterior shadowing suggesting curds ssett et al(5) , in women less than 35 years of age, at

Table 1. Summary of 18 Breast Diseases During Pregnancy and Lactation Period Diagnosis Age Symptom onset Symptom Physical Exam Axillary 30 IUP24wk pai nl ess 1eft axi 11 ary left axiliary sweliing accessory breast mass 27 IUP 19 wk painless bilateral bilateral axillary axillary mass swelling 24 IUP 8wk painfulleft axillary left axillary swelling mass Fibroadenoma 30 IUP 6wk breast discomfort nodular breast *35 P.P. 12m breast mass tender mass 29 P.P. 3m breastmass firm movable mass 27 P.P. 3m breastmass firm movable mass Gal actocel e 30 P.P. 3m left breast mass semifirm mass 25 P.P. 3m 1eft breast mass cysticmass

34 P.P. 1 m leftbreastpain firm πlO vable πlass 32 P.P .12 m left breast mass firm movable mass 26 P.P. 1 m ri ght breast mass soft movable mass 30 P.P. 4m right breast mass firm movable mass *35 P.P. 12 m breastmass tender mass 30 P.P.12m ri ght breast mass nodular mass Lactating adenoma 28 P.P. 1 m right breast mass solidmass 33 P.P. 1 m 1eft breast mass firm movable mass Pylioides tumor 31 IUP28wk rapidly growing solidmass

painf비 mass IUP : Intrauterine pregnancy, P.P. : Postpartum , wk: weeks , m : months *T he same patient showed both a fibroadenoma and a galactocele

444- Yeon Hee Lee, et al: Ultrasonographic Findin gs of Breast Di seases During Pregnancy and La ctating Period

2a 2b Fig . 1. fibroadenomas A homogenous hypoechoic mass is well identified just beneath the skin . Fig. 2. galactoceles a. Multiseptated cystic mass is demonstrated and confirmed as multipl e ductectasias b. 111 defined hypoechoic mass with posterior enhancement is defined on ultrasonography that represents cystic mass. Multiple echogenic nodules with posterior shadowing are demonstrated at posterior wall ofthe mass suggesting curds

Fig. 3. Lactating adenoma Ultrasonography reveal s an ill- defined and oval shaped isoechogenic mass that inter­ mingled with normal parenchymal echoge­ nicities Fig. 4. phylloides tumors Ultrasonogram shows large, re latively well defined hypoechoic mass without charac­ teristic internal cl efts or cysts

3 4 leasttwothirds ofthe breastwas radiodense. the mass. Therefore, the ultrasonography is recommended as During pregnancy and lactating period, striking ch­ a primary imaging technique for the young women with anges take place in the mammary gland. The ductal ­ breast pro 비 ems. The rationale for this approach in lobular- alveolar system undergoes considerable hy­ younger women includes the lower prevalence of br­ pertrophy and prominent lobules are formed. Estrogen east cancer, the great likelihood that the breasts will be and progesterone secretion from the placenta is elev­ dense and poorly suited for mammography(6). Ultra­ ated and these are considered to be the major hor­ sonography may be also the initial mode of examin­ mones responsible for full breast development(7, 8). ation in lactation or pregnant women, because the T,herefore on ultrasonography, the glandular compo­ increased breast parenchymal density may obscure nent dominates, giving a finely granular pattern and

-445 ./ Journ al of th e Korean Radiological Society 1995; 33(3) : 443-447 highly reflective appearance with extreme compre­ eves et al. (18) suggest phylloides tumors are related ssion of the subcutaneous and retromammary fat. The with pregnancy and lactation. In our case, the mass lactiferous ducts are also dilated and may reach a di­ was rapidly growing during pregnancy. ameter of 7 -8 mm during lactation and are seen as The axillary accessary breasts were the cause of cystic spaces(9). These changes are also noted within swelling and pain ofaxillary area in the pregnant wo­ the tumor mass corresponding to those of breast pa­ men and were easily recognized by ultrasonogrphy renchyme. Moran (8) reported that fibroadenomas are without any further work - up. After delivery, the symp­ histologically modified at pregnancy and lactation. toms were subsided Var i"able amounts of parenchymal hyerplasia deve­ In conclusion , ultrasonography should be the initial lops and rarely the early pregnancy changes might be and probably sole imaging modality in patients with mistaken for cancer. And for this reason the tumor breast diseases during pregnancy and lactating pe­ have probably grown rapidly during this period. As we riod. However, the limitations of sonography include expected, postpartum diseases were lactation related inability to depict microcalcifications, difficulty in pathologies such as galactoceles, lactating adenomas, imaging fatty breasts, inability to differentiate benign rapidly growing fibroadenomas, and phylloides tumor from malignant solid masses, and unreliable depiction A galactocele is a milk containing cystthat develops 。 f solid mass smaller than 1 cm(19). So if solid mass during lactation and shows variable ultrasonographic lesions are detected during pregnancy and lactating findings which include a pure cyst, a multiseptated cyst period by ultrasonography that persist after delivery, and echogenic debris floating within the cysts. Accord­ excision ofthe masses is definitely needed ing to Salvador(1 0) , the echolucency of the upper fluid and the high echogenicity of lower component was the REFERENCES characteristic finding , but in this study such finding was not seen. The presence of the line separating both 1. Whang IS, Kim YS , Suh HS. Ultrasonographic lindings 01 breast components suggests two fluids with the upper having lesions. Journal of Korean Radiologic Society 1990 ; 26 ‘ 581-588 a lower specific gravity (fat) than the lower (milk). The 2. Teixidor HS, Kaszam E. Combined mammographic , sonog raphi c presence of solid, mobile echogenic contents with dis­ evaluation ofbreast masses. AJR 1977; 128 : 409-417 tal acoustic shadowing in fluid cavity was the charac­ 3. Fleicher AC. Palpable breast masses: Evaluation by high fre­ quency, hand-held real time sonography and xeromammo­ teristic findings of galactocele in this study and the graphy. Radiology 1983 ; 148 : 81 3-817 nodules may be cholesterol crystal or curded milk(1 1). 4. Oh KK , Lee KS , Sohn SK. Variable complementary combined Ultrasonography was useful and easy modality for fol­ radiologic imaging methods for breast disease Journal of low-up after the aspiration whether the cyst remained Korean Radiologic Society 1985 ; 21( 5) : 223-236 ornot. 5. Bassett LW, Ysrael M, Gold RH , Ysrael C. Usefulness of ma­ Fibroadenomas are readily detectable during this mmography and sonography in women less than 35 years of age period due to development of pain or growing mass (8) Radiology 1991 ; 180 : 831-835 caused by the hormonal changes and high prevalence 6. Harper AP , Kelly-Fry E, Noe S. Ultrasound -the rate(12, 13, 14, 8) in young ages. Ultrasonographic fin­ method of choice for examining the young patien t. Ultrasound dings of fibroadenomas during pregnancy and lac­ Med Bio/1981 ; 7 : 231-237 tating period showed no different findings as compared 7. Smith MS. Lactation. Patton HD , Fuchs AF , Hille B, Scher AM , Steiner R‘ Textbook of Physiology. 21st edition Philadelphia with those of conventional fibroadenomas, but lateral Saunders 1989 ; 1408-1421 shadowing was not noted at al l. 8. Moran CS. Fibroadenoma of the breast during pregnancy and Lactating adenomas are circumscribed benign tu­ lactation. Arch Surg 1935 ; 31 : 688-708 mors composed predominantly of glandular structures 9. Guyer PB , Dewbury KC. Clinical ultrasound-a comprehensive with scanty stroma with promineht secretary changes text, vol 11 , Abdominal and general ultrasound : Breast Ultra­ in the ducts. Therefore the histologic findings raise the sound 1989 ; 709-735 question of whether these are unique tumors or focally 10. Salvador R, Salvdor M, Jinenez JA , Martinez M, Casas L. Ga­ hyperplastic lobules(15). In our study the masses sh­ lactoc ele of the breast: radiologic and ultrasonographic finding s owed isoechogenicity with hy The British Journal of Radiology 1990 ; 63 : 140-142 11 . Jokich PM , Monticciolo DL , Adler YT. Breast ultrasonography. In Silver B ed. Ultrasonography of small parts. Radiol Clin North Am 1992; 30 (5) : 993-1 009 12. Yoon CS, Kim MH , Ahn CS, Oh KK. Ultrason ographic evaluation 。 1 libroadenoma in the breast : primary signs of mass. Journal of Korean Radiological Society 1994 ; 30(1) : 193-196 13. Fornage BD ‘ Lorigan JG , Andry E. Fibroadenoma of the breast sonographi c appe arance. Radiology 1989 ; 172: 671-675 14. Oavid Lp , Thomas JA. Diagnostic histopathology of the breast 3rd series. Washigton: AFIP(Armed Forces Institute of Pathol 。gyJ, 1987 ; 80-83

- 446 - \ Yeon Hee Lee, et al : Ultrasonographic Findings of Breast Diseases During Pregnancy and Lactating Period

15. Buchberger W, Strasser K, Heim K, Muller E, Schrocksnadel H. 17. Treves N, Sutherland DA. Cystosarcoma phylloides olthe Breast Phylloides tumor: Findings on mammography, sonography, and : a malignant and a benign tumor, a clinicopathologic study 01 aspiration cytology in 10 cases. AJR 1991 ; 157 : 715-719 seventy seven cases. Cancer 1951 ; 4: 1286-1332 16. Oh KK , Ji H, Lee KS , Jeong HJ. Evaluation 01 Cystosarcoma 18. Bassett LW, Kimme-Smith C. Breast Sonography. AJR 1991 ; 156 : phylloides in Korean women. Journal of Korean Radiologic So- 449-455 ciety 1988 ; 24(5) : 795-807

대 한 방사선 의 학회 지 1995 ; 33(3) : 443- 447

임신 및 수유기 유방 질환의 초음파 소견 1

1 차병원진단방사선과 2 단국대 학교 의 과대학 진 단방사선과학교실

이연희 2 .박용현·권태희

목 적 : 임신 및 수유기의 유방 검사는 태아에 미칠 방사선의 영향에 대한 우려와 유방실질의 비후로 인해 증가된 실질 음

영때문에 필름 유방촬영보다는 초음파 검사가 유용하게 이용된다.

임신 및 수유기에 호발하는 유방질환과 초음파 소견에 대해 알아보고자 하였다.

대상 및 방법 :임신 및 수유기에 유방의 통증 혹은 종괴로 내원하여 초음파검사를 시행하고 수술， 서|침흘입 및 추적검사로

확진된 18 예의 유방질환을 대상으로 후향적으로 분석하였다.

결 과:총 18 예의 유방질환 중 유선 낭종 (Oalactocele)OI 8 예로 가장 많았고 섬유선종(tibroadenoma) 4 예， 액와부유방

(axillary accessory breast) 3 예， 수유성 선종 (Iactating adenoma)2예， 양성 엽상 낭상 육종 (benign‘ phylloides tumor) 1 예

였다.

상기 유방질환의 초음파 소견은 비임신 비수유기의 유방 초음파 소견과 유사하였으며， 특히 수유기에 많은 유선 낭종의

진 단 및 추적 검사에 초음파검사가 유용하였다.

결 론:유방초음파검사는임신과수유기의 유방질환진단에 유용한검사법이라생각된다.

-447- 국제 학술대회 일정표 [III]

1996/04/14-19 9th World Congress of the Int. Radiation Protection Association(l RPA) venue: Hofburg Congress Center Vienna, Austria contact: IRPA9 Congress Org. Ct. , Austropa-Interconvention, P.O. Box 30, A-1043 Vienna, Austria. (te! : 43 - 1 - 58800 - 299 ; fax: 43 -1 - 5867 127)

1996/04/18- 25 Annual Meeting Society of Magnetic Resonance venue: Vancouver, Canada. contact: SMRI., 213 West Institute Place, Suite 501 Chicago, I1Iinois 60610, USA. (tel: 1-312-7512590 ; fax: 1-312-9516474)

1996/04/ 23-26 The 6th Int. Symposium of Interventional Radiology & Newvascular Imaging venue: Amori, Japan contact: Prof. S.D. Takekawa, M .D., Hirosaki Univ. Sch. of Med, Dept. of Radio1ogy, Hirosaki 036, Japan. (teI: 81 -172 - 335 111 ; fax: 81 -172 - 335627)

1996/04/ 23-26 Pragomedica ’ 96 : Int. Exhibition of Medical Engineering, Diagnosis & Therapy venue: Exhibition Grounds Prague, Czech RequbIic contact: Mr. Jaros1av Cepek, INCHERA Company Ltd., 28. rijna 13, P.O. Box 555, 111 21 Praha 1, Czech Republic. (tel : 42 -2 - 24195358 ; fax: 42 -2 - 24195286)

1996/04/ 24-26 Esdir Seminar-Non Invasive Vascular Imaging venue : Bordeaux, France. contact: Prof. N. Grenier, Service de Radio1ogie, P1ace AmeIie Raba Leon, F-33076 Bordeaux, France. (teI : 33 - 56795599 ; fax: 33 - 56795639)

1996/04/25-28 MR11996: Neuro Weekend Review venue: The Westin Hotel Cincinnati, Ohio, USA contact: Stephen J. Pomeranz, M.D., MRI Education Foundation, 2600 Euc1id Avenue, Cincinnati, OH 45219-2199, USA (teI: 1-513 -2813400 ; fax: 1 -513 -2813420)

1996/04/27-03 Annual Meeting of the Society of Magnetic Resonance ven ue : New York Hi 1ton & Towews New York, NY, USA contact : SMR Centra1 Offoce, 2118 Mivia Street, Suite 20 1, Berki1ey, CA 94704, USA (te1: 1 - 510 - 841 1899; fax: 1 - 510 -8412340)

1996/05/00-00 33RD Annual Congress European Society of Paediatric Radiology venue: Boston, MA, USA. contact: Prof. F. Brunel1e, Hop. des Enfants Ma1ades, 149 Rue de Sevres, F-75730 Paris cedex 15, France. (tel : 33 -1 -44495173 ; fax: 33 -1 -444951 70)

제공:대한방사선의학회 국제협력위원회

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