 You as a doctor give hope and health to many each day, there are many more to give hope and health to. And with Fujifilm, we are doing that together. My topic for today is lesions associated with pregnancy and lactation. And during this talk, I would be focusing more on the entities which are specific to this period of pregnancy and lactation. We'll have an overview of the modalities that can be used. We look at some benign entities and of course, we will look at some cancers as well. It's not unusual to have a pregnant or a lactating woman present with breast symptoms. As we do for a workup of any symptomatic woman, we must do a triple assessment. However, the physiological changes that occur during pregnancy and lactation can make the breast feel very nodular or lumpy and that can limit a good clinical exam. Similarly, the appearance of the breast on imaging, ultrasound, mammogram, MRI is also altered. And we'll see more as we go ahead in this talk. Ultrasound with its very high sensitivity to demonstrate an abnormality is the first line of investigation. It also has a very high negative predictive value for pregnancy associated breast cancer. So let's go to the first case. This is not open for polling, but this is a pregnant lady with increasing heaviness in both breasts. This is her breast at 14 weeks at the end of the first trimester and this is at 35 weeks. What do we see here? We see that the glandular component in the breast has increased and there is a little bit of ductal prominence which is coming about as we would observe with ductal sprouting which starts around the first trimester. Along with that, there is proliferation of the lobules, but by the third trimester, the lobule epithelium changes into a secretary epithelium and it starts secreting colostrum. And what does colostrum look like? It looks hypoechoic within the prominent and dilated ducts and therefore the look of the breast in the third trimester is one of a hypoechogenicity with dilated prominent ducts with homogeneous hypoechoic contents. What is a normal appearance of lactating breast? This is a lactating breast where you see that there is a lot of fibro glandular component, very little fatty component, but the breast appears diffusely hyperechoic with increased echogenicity and why is that? Because now under the unrestricted influence of prolactin, milk is flowing through the ducts and that contains fat, it contains protein and it contains water. This all these elements together imparted a very diffusely hyperechoic look. Along with that, because there is so much proliferation and activity in the ducts, we expect that there would be a generalized hypervascularity in the lactating breast. The question often asked is, can we do a mammogram in a pregnant lady? In the last lecture, Dr. Shilpa has already clarified and I will not go through this slide again, but what I would like to add is that it is safe when indicated to do a mammogram in a pregnant lady. If we were to use an abdominal shield, in fact, there is no significant dose that is delivered to the fetus, let alone a minimal dose. So what are the indications for mammography? If there is a lactate woman who is over 30 years of age with a palpable lump, after an ultrasound you will proceed to do a mammogram. If there is a lactating lady under 30 years of age or if there is a pregnant woman, you will do a mammogram only if there is a suspicious ultrasound abnormality or sometimes a mammogram is also done in biopsy proven cancer in these states to look at the extent of disease and to assess the contralateral breast. But it's always after an ultrasound. Now, what do we expect the look to be on a normal mammogram? Of course, there's going to be increase of the glandular tissue. So the breasts are going to be heterogeneously dense like we see in both these patients here. Is there a way to reduce the overall breast density? Yes, milking out the breast before the mammogram can be helpful. And what is most important is that we must place a marker in the region of the palpable concern. It just helps us detect or look at that region better when we are assessing a heterogeneously dense breast on mammogram. So this is the first case that is coming up for pole. This is a 36 year old lactating lady who feels a lump in the outer quadrant of her left breast. This mammogram has been done after a negative ultrasound. I'm going to zoom up these images. A marker has been placed in the region of the palpable concern. That's the CC view and that's the MLO view. Zooming out again and zooming in again on the view. The question is, what are the findings on mammogram? Casting type calcification, grouped fine pleomorphic calcification, suspicious axillary node. Is it casting type with a suspicious axillary node or is it fine pleomorphic grouped calcifications with a suspicious axillary node? So most of you have answered B or D. Let's look at what B was. That is the correct answer. You see grouped fine pleomorphic calcification, micro calcification. But the correct answer in this case is 2 and 3, which is grouped fine pleomorphic micro calcification along with the suspicious axillary lymph node. Did you see that there? That is the suspicious axillary lymph node. So this is the correct answer. A second look ultrasound was then done after this mammogram and what do we see here? We see these ill-defined hypoechoic areas which are more like architectural distortion on ultrasound and we see increased vascularity focally around this lesion. This lesion was biopsied. This area was biopsied under ultrasound guidance and the result was an invasive ductal carcinoma with extensive vascular invasion. So this is how we will work out a case. We'll first do an ultrasound. You don't see anything but there is a palpable concern. The lady is over 30 years of age. She's lactating. We will do a mammogram and then look at a possibility of an ultrasound guided biopsy with a second look ultrasound. What about MRI? It is not recommended by ACR during pregnancy. However, it is completely safe during lactation. In fact, you don't need to suspend lactation as the dose of gadolinium, which is excreted in the breast milk, is miniscule. You can pump and discard for 24 hours if the woman is really apprehensive. But what really helps is if you empty out the breast before the MRI, just like you did for the mammogram. This is the next case coming up for poll. This is a 30-year-old lactating lady with a nodular feel in her right breast. The question here is on this sequence is a mass seen. Mass is seen true or false? A or B? I don't see the results, Mithusha. Okay. So 46% of you feel that there is a mass and the majority feel that there is no mass. Okay. Firstly, what is this sequence? It's a T2 weighted sequence. In a lactating breast, you'll see hyperintensity within the ducts on a T2 weighted non-contrast image. And against that, a mass which is a low signal intensity will be conspicuous. So this is the mass seen, and this is the post-contrast image for this patient. And what you see here is an irregular mass with heterogeneous enhancement, some non-uniform cystic spaces there, and you see abnormal lymph nodes. And of course, this was a malignancy. So how does a normal lactating breast behave on MRI? The normal tissue will show a diffuse high T2 signal intensity and rapid moderate enhancement followed by a plateau. Against that, the cancer will have a lower T2 signal intensity and will have a more intense initial enhancement with an early washout. So the normal breast, which is not lactating, what would you expect? You'll expect that the normal tissue will show a mild progressive enhancement, but the lactating breast will show a rapid moderate enhancement followed by the plateau. This is the next case that is coming up for polling. This is a 32-year-old lactating lady with a painless lump. I'm going to, yeah, with a painless lump felt in right breast since six weeks. She reports a slight decrease in size in the last two to three weeks. The options are fibroadenoma with cystic change, galactosil, lactating adenoma, abscess. It's open for poll now. Mithusha, could you show me the poll results because I seem to have minimized the poll screen. Okay, so the majority feel that this is a lactating adenoma and you are absolutely correct. This is the scan from four weeks earlier. Do you see how many cystic spaces you see there? What are these? These are just hyperplastic lobules in the duct, which are filled with secretion and these ecogenic lines are just the intervening connective tissue. But how do you differentiate between this and maybe a galactosil or a fibroadenoma? Well, a lactating adenoma has no capsule. You never see a discernible margin. You don't see a clear-cut margin. A galactosil will show a thin smooth margin and a fibroadenoma, of course, will show a thicker capsule. And of course, for excluding an abscess, you need to take everything in a clinical perspective. So it's very important yesterday we heard in the talks that when you start your reporting, you should put a clinical history which should have been elicited from the patient if it is not there on the doctor's notes. What else can lactational change or adenoma look like? Well, sometimes it just looks like an oval, hypoechoic mass with tiny cystic areas with posterior acoustic enhancement and variable vascularity that we see here. Again, see there is no real capsule that you can see around this lesion. Lactational change can present as a lump and when you see this kind of a picture, this is nothing but very diffuse lactational change. You will not get any other contents in the ducts. You won't see anything suspicious in these dilated ducts. Another thing that we must remember is that whatever changes we can see during lactation in the breast can also be seen in accessory breast parenchyma. And this was one such case where the lady presented with a lump in the axilla and this is nothing but a lactational adenoma in the accessory breast parenchyma in the axilla. Okay, next case, these are just images. There's no history. Both patients are lactating. Two separate patients, two separate images, options are both are galactoseals, both are abscesses, both are lactating adenomas. Image one is a galactoseal and image two is a fibroadenoma. It's open to poll. Mitushal, you'll have to share the screen for the poll because I've minimized it. It's gone somewhere. Okay, so most people think that the first image is a galactoseal, but the second image is a fibroadenoma. Some of you about 30% feel that both are galactoseals. The correct answer is that both are galactoseals. This is the image. Now, this is a fresh galactoseal. It has a cystic component and what is this ecogenic area here? It's the fat which is seen in the non-dependent part of the cystic region that is characteristic for a galactoseal. If you have something so cystic and you turn the patient into a lateral decubitus and wait for about 10 minutes, you may find that the fat fluid level shifts like you see here. So very, very characteristic. If you were to do a mammogram which you want in this case because it's very clearly benign, but if you were to do a mammogram and you take a true lateral view, what will you see? You will see again a fat fluid level. Okay, now what is open for discussion is this. This is a lesion. It has a capsule, so it doesn't appear to be a lactating adenoma. Could it be an atypical fibroadenoma with cystic change? Yes, that is the closest DD. But in a fibroadenoma, you usually see a thicker capsule like we see here and you do see some amount of vascularity within the lesion on low flow imaging. However, in a galactoseal, because why is this appearance coming? It's all curdled milk. You are never going to get vascularity within a galactoseal. Sometimes a galactoseal may rupture, it may release its contents and if there's fat necrosis surrounding, you may get irregular margins. But then of course, there's no way to differentiate on an ultrasound whether this is a malignancy, is it a fibroadenoma, is it a galactoseal and this will go to a biopsy and usually you just aspirate curdled milk. Abscess, a lot more hypervascularity and of course an appropriate clinical setting. So that option was not correct either. Okay, this is history, but this is not open for poll. We'll just go through this case. This is a lactating lady with focal pain in the right upper inner quadrant and these are the images. What is this? What is happening here? There are, there's a focally dilated duct, ectatic duct and it is showing thickened walls like we see here. On par Doppler, we see increased periductal vascularity. WHO defines mastitis as inflammation with or without infection. Should this remain and if it is not treated with anti-inflammatory and there is a crack nipple which causes bacterial seeding inside this duct, it can progress to a full form abscess. What is this? Very smooth walls. These are not thickened walls, but this too is an obstructed duct. It's just a simple obstructed duct with a fat fluid level within it. This usually does not require treatment. The woman reports with a pea-sized lump and you just need to give some warm compresses. However, should this get infected or inflamed, it can progress to this. Now, sometimes when you're looking at an appropriate clinical setting and you know, you're concerned whether these kind of ducts that you're seeing, a focal dilatation of the ducts with increased vascularity, could it be DCIS? Well, one of the pointers is that in DCIS, you'll see a lot of more irregularity of the ducts and if you look at the vascular signals, you see that they're coming in perpendicular to the wall of the ducts as against inflammation where the vascular signals are parallel to the walls of the ducts. So that may be a clue that may help you differentiate that this is not a DCIS and we definitely don't want to miss a DCIS. Okay, so this is the next question which is open to poll. It's two weeks apart, the same lady, two weeks apart images, post-antibiotics. In a 22-week pregnant lady, she's Gravita 2, Para 1. Last childbirth was three years ago. The clue is look at the pointers, look at the pointers, what's happening there? And the options are tubercular mastitis, staphilococcal mastitis, idiopathic granulomatis mastitis or is this a very high suspicion for malignancy? Okay, so we have 33% who think that this is IgM and about 28% think that this is could be its high suspicion for a malignancy. And I think most of you who based your answer on point four is because you feel that there has been no resolution. Well, that is the correct thought process, but this was a case of idiopathic granulomatis mastitis. And when I said look at the markers, what exactly is happening here? What is IgM? It's a lobular centric non-casiating granulomatis problem. So the lobules, there's insinuation of the process around the lobules. The process is going around the lobules. And what is pathognomic is that you will see tubular extensions like you see here, you may get irregular hypoechoic masses, you may get masses with angular or indistinct margins on ultrasound, and these can closely mimic a malignancy. What was done for this patient, we aspirated the contents and a biopsy was done from the deeper part from the wall, and it came out to be idiopathic granulomatis mastitis. We are seeing a lot of this, the history is classic last childbirth in the last five years, and I won't go into the details on mammogram, etc. Because I think Dr. Vino would be taking this entity in detail. So it looks the same and can present the same as it would in a non-pregnant, non-lactating woman as well. What about staph mastitis? The other option that was there, when staph mastitis, you will have a unilocular or a multi-locular thick wall lesion, but usually the hypervascularity is very, very intense. In the byrath descriptors, this is what we call as the rim vascularity, the rim pattern of vascularity in the atlas. IGM, it is hypervascular, but not as much. What about tubercular? These will usually show no vascularity, but what you have to look out for is when you see dilated ducts, you should look out for fistulus communications, which are the hallmark. This is a six o'clock duct and a nine o'clock duct, and that's the fistulus communication. Also look for sinus tracts. This is a duct which is draining into a subcutaneous collection, and you see that this is a sinus tract. So this is the hallmark of tubercular mastitis. Well, for any mastitis or what appears to be a benign mastitis, again I reiterate, if there's no response to antibiotics, for two to three weeks a biopsy is mandated. Another common problem that does come up is that the woman presents and she says she has a painful swelling in the axilla. What is this? This is an enlarged hyperplastic lymph node in which you see a very clear cut echogenic hyalum. If you were to put on vascularity, you will see that it has a hyalurvascular pattern. You see a central vessel coming in, and then these branches going from the center to the periphery. Contrast that with this very abnormal looking lymph node, which there is a loss of the fatty hyalum, and you see the blood vessels coming in from the cortex into the center in a very haphazard manner. Now, supposing you saw this, nothing needs to be done. But what if the lady presented only with this lump in the axilla? What would your workup comprise of? You would scan the breast and look for an occult primary. That is mandatory. If you don't see anything on ultrasound and you have this abnormal looking node, you have to do a mammogram and look for a primary on the mammogram. So, you have to use further imaging to make sure whether this node is linked to a primary in the breast. Sometimes, of course, this node can be with a large breast primary that we see here. This is the node that we saw in the axilla. And this, on first look, seemed to be a very well circumscribed mass with posterior enhancement. But meticulous scanning of its margins, and you can see that there is slight irregularity and a little bit of extension along the Cooper's ligaments anteriorly. And this was biopsy because it was suspicious for malignancy, and it turned out to be an invasive duct carcinoma and it was a triple negative tumor. In fact, this case went to Bombay and I think Dr. Mandar Nadkarni has operated on this case. Okay. The next is intraductal papilloma can give you bloody nipple discharge during pregnancy or lactation. We've had the most amazing lecture this morning by Dr. Burma where he's shown amazing images. Needless to say that you can get papillomas in any part of the ductal tree and one needs to look at them very, very carefully with a lot of jelly and with high-resolution probes. So this is one in the lactiferous sinus there in a segmental duct and in a central duct. Having gone through the benign entities, let's move on to PABC or pregnancy-associated breast cancer. By definition, it is cancer which is diagnosed during pregnancy or in the first 12 months postpartum. Now we realize that because of the altered feel of the breast and we don't know what's going on, there's a lactating lady or a pregnant lady, a lot of times the lumps that the lady reports with are dismissed as physiological lumps not only by the clinician or the lady but also by the relatives and she's told nothing needs to be done. Because of which usually these women actually have a delayed diagnosis. In fact, one Indian study has reported that there may be a delay of up to 11.5 months between the presentation or the lady reporting a lump and the actual diagnosis. What does this delayed diagnosis translate into? Of course it translates into advanced stage at diagnosis. It also translates into node positive disease and in fact up to about 80% of these women with a delayed diagnosis have node positive disease. So really we are sitting on a time bomb and we need to understand that just because the lady is pregnant if she presents with a palpable lump that persists we have to do a full follow up even if it means doing a mammogram if we have suspicious findings on an ultrasound. What does PABC look like? Well it can show you typical features. These are typical ultrasound byrads, five lesions, you see speculated masses, you see calcifications within, you see duct extension, another case where you see angular margins and irregular mass with calcifications within. So yes you can get what looks like a typical byrads five lesion and these are no-brainers and you know that you have to do a mammogram and then follow up with a biopsy and take it to completion. But what about these cases? You see a very well circumscribed mass. It almost appears cystic or complex you know with a complicated cyst kind of an appearance. There is posterior acoustic enhancement again and other lesion. It appears circumscribed but it has some minimal vascularity posterior acoustic enhancement, another mass in parallel orientation. So all these if we've heard our byrads lectures these are all descriptors for benignity. Yes but in pregnancy associated breast cancer these are very very aggressive tumors because they are aggressive tumors. There's not much time for the speculations to develop for the angular margins to develop and therefore you may not get typical features that you would see in the non lactating non pregnant woman. In fact about 40 percent of them are well circumscribed about half of them are in parallel orientation and more than 60 percent actually show posterior acoustic enhancement and these features mimic biologically aggressive tumors like the triple negative breast cancers. So this is the last case for pole. It's not the last case of this talk but it's the last case for pole. 28 year pregnant lady she's 30 weeks pregnant with a palpable lump in the right breast upper outer quadrant she noticed it a month ago then she sat on it because she was told and then she started feeling a little pain and then also felt that the size was increasing. So she decided to bypass the clinician and come directly for an ultrasound during her pregnancy. So when she came for the pregnancy ultrasound she mentioned it and she said I feel a lump and that's when we did this ultrasound. Your options are is this a galactosil? Is this likely to be a malignancy? An abscess or is this just a hyperplastic intramamory node? 90 percent of you have got this correct which also means that pre perennial we are still not we are still holding on to that lunch right? Okay branch actually. Okay so the answer is malignant and why would I say that? Let's do a quick revision of the Bayrads descriptors. So what will you describe this as? This is an oval mass. It's circumscribed because it has only three gentle lobulations. What about the echogenicity? How will you describe it? The term used is complex solid cystic. It's in parallel orientation. The long axis is parallel to the skin and it shows posterior enhancement like we see here and there is internal vascularity in the solid component. Now that is where we have to start thinking about malignancy. Galactosil we thought that we can get atypical appearances but we will never get vascularity within what appears to be the solid component. Abscess likewise, never get vascularity inside. There's cystic contents, there are liquefied contents and of course nah this just doesn't appear to be a hyperplastic intramammary lymph node. So a biopsy was done from the solid component and this turned out to be a papillary carcinoma. This is the image we saw about two slides ago. So again well circumscribed posterior enhancement almost appears like a complicated cyst. This was a 32 year old lactating lady with a tender lump in the right breast. She was treated with antibiotics. There was no resolution. It was a large lump but she decided she didn't want anything else. With great difficulty we convinced her that your 32 years of age there's no resolution. You need to get a mammogram. So here comes the mammogram picture. Again a circumscribed mass, high density that we see here on both the views. Again it has a pretty benign appearance but because there was no resolution a biopsy was advised. After much ado and after discussing with multiple radiologists and going shopping, she said I don't want a biopsy but I am okay to get a MRI done and this is the picture. Again revising what we should see on MRI, T2 weighted image, diffuse increase in signal intensity, conspicuous against that hyperintensity is this low signal intensity mass but you do see some hyperintensities inside and this was on post contrast images an irregular mass with non-uniform cystic spaces that we see here and a heterogeneous pattern of enhancement. What you also see is non-mass enhancement anterior to this lesion. Of course then we convinced her that it has to be biopsied and it turned out to be in case of double carcinoma grade 3 and it was a triple negative tumor again. So large tumors with necrosis, non-uniform cystic spaces, please please think of very aggressive tumors like the triple negative breast cancers. And this is my last case this is curtsy Dr. Shilpa Lard, 36 year old woman she is 34 weeks pregnant and presents with an enlarging left breast since the last 10 days. So it's actually a very very short history. So an ultrasound was done by Dr. Lard and you see that at five o'clock you do see a circumscribed lesion with few gentle lobulations. Well could this be a fibroadenoma? Is it okay to put this onto a follow-up and that is what was decided at that time. However two weeks later the lady reports that know my breast is still enlarging and now I can feel bigger lumps. So she comes back earlier in two weeks time and as you see just visually you can make out that the lump has increased to about three times the size, original size. It's hypervascular and newer lumps have appeared. Now because she had come in and they were thinking of a biopsy they decided to do a CBC and what they found was that there was along with the doubling of the size and suspicious findings a falling platelet count and therefore they started suspecting whether they were dealing with a hematological malignancy. A word about increase in size of fibroadenomas during pregnancy and lactation they will increase but even if you have a garden variety of a fibroadenoma during pregnancy of lactation if that increases by over 20% in its longest dimension over a period of six months it is mandatory to biopsy that lesion it could be an atypical malignancy. So biopsy was performed at the time of LSCS which was done at 34 weeks immediately and it came out to be a diffused large cell large B cell lymphoma. NHL diagnosed during pregnancy is extremely fast-growing and a very high grade type and it is not really that uncommon and the prognosis is variable. If you are interested in reading this is a very good article about this entity and you should actually look it up. So the take-home message is we of course like Dr. Shilpa said when a lady lactating or pregnant walks in you think about all the benign entities first sure we should but we must remember that cancers may also show reassuring benign characteristics and so if there is any new solid or complex solid cystic mass even if it has a benign appearance but does not resolve for two to three weeks after medical treatment a biopsy must be done. These are some of the references that are used to make this talk the first one is particularly insightful and a very easy read. Thank you for your kind attention.