2.1　Breast Invasive Ductal Carcinoma and Breast In...

2.1　Breast Invasive Ductal Carcinoma and Breast Invasive Lobular Carcinoma

Invasive ductal carcinoma of breast，one of the most common types，belongs to breast cancer.Its histology is diverse in morphology.The arrangement of cancer cells shows nests and cord shape.Cancer cells can break through the basement membrane of the catheter and infiltrate the stroma.Clinically，it is mainly diagnosed middle-aged and elderly women finding breast mass or abnormal nipple.The main manifestations of two-dimensional ultrasound are hypoechoic lesions with irregular shapes and unclear edges.Fine calcification can be found in the lesions，posterior echo attenuation，rich blood flow，etc.Invasive lobular carcinoma of breast is a common type of breast cancer，and the ultrasonographic features of most invasive lobular carcinoma of breast are the same as the above signs.

Case 1：female，45 years old，has been found a left breast mass for 5 years and the mass has enlarged for 6 months.Specialized examination：the mass can be touched at 11 point in the upper quadrant of the left breast.The texture is hard，the boundary is unclear，and the activity is poor.The left armpit can be touched the swollen lymph node.The texture is hard，and it can move.

Fig.A　Maximum diameter section with irregular shape and angled edge.

Fig.B　Transverse section，hypoechoic lesion

Fig.C　Alder grade Ⅱ

Fig.D　RI：0.73

Fig.E　Elasticity score：4 points

Fig.F　CEUS 17S

Fig.G　CEUS 19S

Fig.F CEUS 17S：rich in blood supply，high enhancement lesion，and its scope has expanded.

Fig.G CEUS 19S：unclear boundary after enhancement.

Fig.H　CEUS 26S

Fig.I　Time intensity curve

Fig.H CEUS 26S：feeding blood vessels are seen around.

Fig.I Time intensity curve：the lesion is enhanced before the surroundings with high peak value.

Analysis：middle-aged woman，left breast is touched with tough lump.Ultrasonic manifestations：hypoechoic nodule，irregular shape，unclear edge and burr shape.Stripe blood flow signals can be seen in peripheral part，Alder grade 3，RI：0.73，elasticity score：4.Contrast-enhanced ultrasound shows high enhancement and fast-forwarding to the blood-rich lesions，with unclear boundary and slightly enlarged scope after enhancement.There are nourishing blood vessels.The lesion conforms to the manifestation of breast malignant tumor.

Pathological results：The capsule is intact and the size of the tumor is about 2.5×3×3cm.The section is fish-like.It supports invasive ductal carcinoma.

Case 2：female，50 years old，has been found right breast lump for 2 months.Specialized examination：the upper quadrant of the right breast can touch the mass at 12 point，with hard quality，unclear boundary，poor activity，skin adhesion（-），no swelling and ulceration，and bilateral axillary and supraclavicular lymph nodes can not touch the swelling.

Fig.A　Maximum transection，hypoechoic lesion，regular shape

Fig.B　The local edge is slightly rough and the echo behind is slightly enhanced.

Fig.C　Alder grade Ⅱ

Fig.D　RI：0.81

Fig.E　Elasticity score：4 points

Fig.F　CEUS 17S

Fig.G　CEUS 20S

Fig.F CEUS 17S：high enhancement lesion，and its scope has not been significantly expanded.

Fig.G CEUS 20S：flake enhancement defect area is seen in the interior.

Fig.H　CEUS 26S

Fig.I　Time intensity curve：

Fig.H CEUS 26S：feeding blood vessels are seen around.

Fig.I Time intensity curve：the lesion is enhanced before the surroundings with high peak value.

Analysis and differential diagnosis：a middle-aged and elderly female，the right breast touches a hard mass.Ultrasonic manifestations：hypoecho，irregular local shape，unclear edge，abundant blood flow signals visible in the periphery and inside，Alder grade 3，RI：0.73，elasticity score：4.Contrast-enhanced ultrasound shows that the fast forwarded，high enhancement lesions with rich blood supply，the border is unclear after enhancement，and there are locally enhanced defect areas and nourishing vessels.However，the blood flow of this lesion is relatively rich，the elasticity score is relatively high，high enhancement，and there are feeding vessels.It should be considered as malignant.The edge burr or angle of this lesion is not obvious，and the local shape is regular.No obvious calcification is found in it，which is easily misdiagnosed as benign lesion.

Pathological results：before operation，the patient has underwent ultrasound-guided puncture biopsy.It supports invasive ductal carcinoma.

Case 3：female，55 years old，has been found with left breast mass for more than 1 month.Specialized examination：the mass can be touched at 3 points in the outer quadrant of the left breast，which is hard and has unclear boundary，poor activity，skin adhesion（+），no redness and ulceration，and the left armpit touches swollen lymph nodes，which is hard and without fusion.

Fig.A　The longitudinal and transverse sections of the lesion are irregular in shape.Edges are burred and angled，with fine calcification inside and cooper ligament is pulled.

Fig.B　Alder grade 2

Fig.C　RI：0.67

Fig.D　The elasticity score is 4 points.

Analysis：a middle-aged woman，a hard mass is found in her left breast.Ultrasonic manifestations：hypoechoic mass with irregular shape and unclear boundary.Fine calcifications are common in it，the surrounding structure is slightly distorted，cooper ligament is invaded，and the echo behind it is slightly weakened.Strip blood flow signals can be seen in it，Alder grade 2，elasticity score：4.It conforms with the ultrasonic manifestation of breast malignant tumor.

Pathological results：During the operation，the tumor has no complete capsule，and the sectional tissue is grayish white.It supports invasive ductal carcinoma.

Case 4：female，59 years old，has been found right breast mass for more than 2 weeks.Specialized examination：the upper quadrant of the right breast can touch the mass with hard quality，unclear boundary，poor activity，no swelling and ulceration，and the right armpit can touch the swollen lymph nodes with tough quality and fusion.

Fig.A　Transverse section，hypoechoic lesion，irregular shape.

Fig.B　The edge is fuzzy and the part is burr.

Fig.C　Alder grade 3

Fig.D　RI：0.65

Fig.E　The elasticity score is 4 points.

Fig.F　CEUS 16S：high enhancement lesion with irregular shape

Fig.G　CEUS 19S：The scope has expanded and the boundary is unclear

Fig.H　CEUS 22S：Feeding blood vessels are seen in the periphery.

Fig.I　CEUS 30S：After descending，the lesion shows moderate and slight high enhancement.

Analysis：The left breast of the elderly woman touches a hard mass.Ultrasonic manifestations：hypoechoic mass with irregular shape，unclear edge，burr-like local edge，abundant blood flow signals and perforating vessels visible inside，Alder grade 3，RI：0.65，elasticity score 4.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.After enhancement，the boundary is unclear and the scope is slightly enlarged，where there are feeding blood vessels.The lesion is consistent with the ultrasound findings of breast malignant tumors.

Pathological results：During the operation，the tumor has no complete capsule and its section is grayish white.It supports invasive ductal carcinoma.

Case 5：female，37 years old，has been found with left breast mass for more than 4 years.The mass has enlarged for more than one year.Specialized examination：the left breast outer quadrant can touch the mass，with hard quality，unclear boundary and poor activity.

Fig.A　Transverse section，hypoechoic lesion，calcification in it

Fig.B　Maximum diameter section，irregular shape，angled edge

Fig.C　Alder grade 3

Fig.D　The elasticity score is 3 points.

Fig.E　CEUS 13S：High enhancement lesion with regular shape

Fig.G　CEUS 20S：Feeding vessels are found around the lesion.

Fig.H　CEUS 15S：After lesion enhancement decreases，it shows moderate enhancement.

Fig.F　CEUS 17S：Enlargement of enhanced range of lesion

Analysis：The left breast of the young and middle-aged woman touches a hard mass.Ultrasonic manifestations：hypoechoic mass with irregular shape，unclear edge，burr-like local edge，abundant blood flow signals and perforating vessels visible inside，Alder grade 3，RI：0.65，elasticity score 4.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.After enhancement，the boundary is unclear and the scope is slightly enlarged，where there are feeding blood vessels.The lesion is consistent with the ultrasound findings of breast malignant tumors.

Pathological results：Before operation，the patient has undergone ultrasound-guided puncture biopsy.It supports invasive lobular carcinoma.

Case 6：female，50 years old，has been found with left breast mass for more than half a year and the mass has increased for more than 2 months.Specialized examination：In the inner quadrant of the left breast，a mass about 3×3cm in size can be touched，with good mobility，regular shape and toughness.

Fig.A　Maximum diameter section，hypoechoic lesion，irregular shape，angled edge

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Fig.B　Maximum diameter section，calcification in it

Fig.C　Alder grade 2

Fig.F　CEUS 16S：Enlargement of lesion and lesion with regular shape enhanced range

Fig.D　The elasticity score is 4 points.

Fig.E　CEUS 12S：Uneven high enhancement

Fig.G　CEUS 20S：Feeding vessels are found decreases，it shows moderate slight high enhancement.

Fig.H　CEUS 26S：After lesion enhancement around the lesion.

Analysis：The left breast of the middle-aged and elderly woman touches a hard mass.Ultrasonic manifestations：hypoechoic mass with irregular shape，unclear edge，burr-like local edge，abundant blood flow signals visible inside，Alder grade 2，elasticity score 4.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.After enhancement，the boundary is unclear and the scope is slightly enlarged，locally there is an area of enhanced defect and feeding blood vessels.The lesion is consistent with the ultrasound findings of breast malignant tumors.

Pathological results：During the operation，we has found that the tumor has no complete capsule and its section is grayish white.It supports invasive ductal carcinoma.

Case 7：female，42 years old，has been found left breast mass for more than 1 month.Specialized examination：A mass about 2×3cm in size can be touched at 1 to 2 points in the upper quadrant of the left breast，hard quality，unclear boundary and poor activity.

Fig.A　Maximum diameter section，hypoechoic lesion，irregular shape，angled edge

Fig.B　Maximum diameter section，calcification in it

Fig.C　Alder grade 2

Fig.D　The elasticity score is 3 to 4 points.

Fig.E　CEUS 13S：Uneven high enhancement lesion with regular shape

Fig.F　CEUS 16S：Enlargement range of lesion increases

Fig.G　CEUS 21S：Feeding vessels are found around the lesion.

Fig.H　CEUS 25S：After lesion enhancement decreases，it shows moderate slight high enhancement.

Analysis：The left breast of middle-aged woman touches a hard mass.Ultrasonic manifestations：hypoechoic mass with irregular shape and unclear edge，with fine calcification visible in it，local edge angles，strip-shaped blood flow signal visible in it，Alder grade 2，elasticity score：3 to 4.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.After contrast-enhanced，the boundary between the lesion and the surrounding tissues is not clear，with slightly enlarged scope and feeding vessels.It conforms with the ultrasonic manifestation of breast malignant tumor.

Pathological results：Before operation，the patient has undergone ultrasound-guided biopsy.It supports invasive ductal carcinoma.

Case 8：female，55 years old，has been found with left breast mass for more than 1 year.Specialized examination：The mass can be touched from 12 point in the upper quadrant to 3 point in the outer quadrant of the left breast，with hard mass，unclear boundary and poor activity.A fresh surgical scar about 4cm long can be seen in the left armpit.No obvious abnormality is found in the right breast，and the right armpit and supraclavicular lymph nodes are not enlarged.

Fig.A　Transverse section，hypoechoic lesion，irregular shape，rough edge

Fig.B　Maximum diameter section，calcification in it

Fig.C　Alder grade 3

Fig.D　RI：0.69

Fig.E　Elasticity score：3 points

Analysis：For middle-aged and elderly women，left breast touches a hard mass.Ultrasonography shows a hypoechoic mass with irregular shape and unclear margin.Multiple fine calcifications can be seen in the mass.Abundant blood flow signals can be seen in the mass.Alder grade 3 and elasticity score：3.The lesion grows in parallel with low elasticity score，but multiple fine calcifications are found in the lesions.So it conforms with the ultrasonic manifestation of breast malignant tumor.

Pathological results：Before operation，the patient has undergone ultrasound-guided biopsy.Pathology suggests that high-grade ductal carcinoma in situ with the possibility of interstitial infiltration.

Case 9：female，46 years old，has been found right breast lump for more than 2 months.Specialized examination：the mass can be touched in the outer quadrant of the right breast from 10 point to 12 point，hard mass，unclear boundary and poor activity.The right armpit touches the swollen lymph node，hard mass，unclear boundary and poor activity.

Fig.A　Transverse section，hypoechoic lesion，structure disorder

Fig.B　Maximum diameter section，disordered irregular shape，rough edge

Fig.C　Alder grade 2

Fig.D　RI：0.68

Fig.E　System score：3 points

Fig.F　CEUS 16S：Uneven high enhancement lesion with regular shape

Fig.G　CEUS 19S：Enlargement range of lesion increases，unclear boundary.

Analysis and differential diagnosis：Right breast of middle-aged woman touches hard mass.Ultrasonic manifestations：flaky echo area，irregular shape，unclear boundary，disordered structure，and no obvious change in echo behind.Abundant blood flow signals can be seen in it，Alder grade 3，elasticity score：3.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.After enhancement，the boundary is unclear and the shape is irregular.It conforms with the ultrasonographic manifestations of breast malignant tumors.However，it still needs to be differentiated from sclerosing gonadism and mastitis.

Pathological results：Before operation，the patient has underwent ultrasound-guided puncture biopsy.It supports invasive ductal carcinoma.

Case 10：male，44 years old，has been found with left breast mass for more than 2 months.Specialized examination：The central area of the left breast can touch the mass，which is hard，has unclear boundary and poor activity.

Fig.A　Maximum diameter section，mixed echo lesion

Fig.B　Transverse section，regular shape，clear boundary，the rear echo is enhanced.

Fig.C　Alder grade 2

Fig.D　Elasticity score：3 points

Fig.E　CEUS 20S：Uneven high enhancement lesion with regular shape

Fig.F　CEUS 23S：Enlargement range of lesion is not increased，clear boundary.

Analysis and differential diagnosis：Left breast of middle-aged male touches hard mass.Ultrasonic manifestations：cystic-solid mixed echo，regular shape，clear boundary，posterior echo enhancement，abundant blood flow signals visible in substantial part，Alder grade 3，elasticity score：3.Contrast-enhanced ultrasound：the fast forwarded，high enhancement lesions with rich blood supply.The border is clear after enhancement，and there are local enhancement defect areas.The shape of the lesionis regular，the boundary is clear，and no obvious calcification is found in the solid.It is easily misdiagnosed as benign duct lesions.Male breast cancer is a very rare male malignant tumor，and its incidence rate is far lower than that of female breast cancer.

Pathological results：The tumor is found in the central area of the left breast during the operation and does not invade the pectoralis major fascia.It supports invasive ductal carcinoma.

Case 11：female，62 years old，has been found with left breast mass for 4 days.Specialized examination：The mass can be touched at 2 point in the upper quadrant outside the left breast，with hard quality，unclear boundary and poor activity.

Fig.A　Maximum diameter section，mixed echo lesion，regular shape

Fig.B　Transverse section，clear boundary，the rear echo is enhanced.

Fig.C　Alder grade 1

Fig.D　Elasticity score：4

Fig.E　CEUS 12S：Annular high enhancement around lesion

Fig.F　CEUS 16S：Clear boundary，range is not increased，no enhancement inside it

Fig.G　CEUS 20S：Regular shape，clear boundary

Fig.H　CEUS 37S：After the enhancement decreases，the peripheral part of the lesion was still enhanced.

Analysis and differential diagnosis：Left breast of elderly women touches hard mass.Ultrasonography shows cystic mixed echogenicity，regular shape，clear boundary，posterior echo enhancement，flake blood flow signals around the lesion，Alder grade 1，elasticity score：4.Contrast-enhanced ultrasound shows a ring-shaped high enhancement at the edge of the lesion，and most areas inside the lesion remains unreinforced.After enhancement，the lesion has regular shape and clear boundary.The edge shape of this lesion is regular，the boundary is clear，and no obvious calcification is found in the solid.It is easily misdiagnosed as benign lesions.It needs to be differentiated from complicated cyst with cyst wall infection and interductal papilloma.

Pathological results：During the operation，the capsule is seen with homogeneous white section.It supports intraductal cancer with invasive cancer.

Case 12：female，55 years old，has been found left breast mass for more than 10 days.Specialized examination：The mass can be touched at 3 point in the outer quadrant of the left breast，with hard quality，unclear boundary and mobility.

Fig.A　Maximum diameter section，solid hypoechoic lesion，regular shape，rough fuzzy

Fig.B　Alder grade 1，local edge slightly

Analysis and differential diagnosis：Left breast of middle-aged woman touches hard mass.U1-trasonic manifestations：hypoechoic mass with regular shape，slightly rough local edge，uneven distribution，and no obvious change in posterior echo.CDFI：striped blood flow signals can be seen around and inside the mass，Alder grade 1.

The malignant sign of this lesion is not obvious.It is easily misdiagnosed as adenopathy with fibroadenoma.

Pathological results：During the operation，the gray-white solid nature of the mass section is found.Pathology shows solid papillary carcinoma with invasive carcinoma.