CASE 919, 920, 921, 922: BREAST PAPILLARY LESIONS: Dr PHAN THANH HẢI, Dr TRẦN THÙY TRANG, MEDIC MEDICAL CENTER, VIETNAM.

 Four cases of papillary lesions of the breast were detected by breast ultrasound.

CASE 1

32 yo multiple papillary lesions in 2 breasts, BI-RADS 4A,B.

Bilateral breasts show multiple hypoechoic structures; duct-associated, lobulated margins, horizontal orientation, non-calcified, measuring 5x4mm to 14x6mm, with increased vascularity. Right breast mass at the 11 o'clock position (3cm from the nipple) shows micro-lobulated margins and orientation perpendicular to the skin surface, measuring 11x7mm.
➔ Conclusion: Bilateral multiple papillomas, BI-RADS 4A–4B.

Breast MRI

Core biopsy and IHCS

Intraductal papillary lesions

CASE 2: 47 yo L breast plaque like lesion,  BI-RADS 4B 

Left breast: Located at the 5–6 o'clock position, 3 cm from the nipple, there is a hypoechoic plaque-like lesion; it is unencapsulated with spiculated and micro-lobulated margins, measuring 31 x 37 x 10 mm, and shows marked hypervascularity.
Conclusion: Plaque-like lesion in the left breast (BI-RADS 4B).
➔ Core biopsy of the left breast

Intraductal Papillary Carcinoma .

CASE 3: 43 yo R papillary tumor.

Right breast: 8 o'clock position,

1 cm from the nipple; hypoechoic nodule,

lobulated margins, horizontal orientation,

dimensions 4x5 mm and 4x6 mm;

associated with a duct, showing increased vascularity.

➔ Suggestive of right breast papilloma (BI-RADS 4a).

➔ Recommendation: FNA of the right breast nodule.

Papillary lesions of the right breast.

Intraductal papillary Carcinoma. 

Histopathology: Composed of hyperplastic mammary ductal epithelial cells arranged in clusters, exhibiting nuclear atypia, hyperchromasia, and atypical mitoses. The cells remain confined within the ducts; there is no evidence of stromal invasion.
➔ Suspicion of an intraductal breast lesion. Immunohistochemical staining recommended to assist in confirming the diagnosis: p63, CK5/6, ER, Ki-67 (Block 1).
Immunohistochemistry results (April 2, 2025): p63 negative (with focal p63 positivity at the periphery of epithelial cell clusters), CK5/6 positive, ER positive (30% of tumor cells), Ki-67 positive (20%).
➔ Post-immunohistochemistry conclusion: Intraductal carcinoma of the breast.

CASE 4: 46 yo L breast adenocarcinoma. 

LEFT BREAST: At the 3 o'clock position, 4 cm from the nipple, there is a hypoechoic nodule with regular margins and a horizontal orientation (D = 5x5 mm); it appears associated with a duct and shows no increased vascularity. + At the 2 o'clock position, 1 cm from the nipple, there is a hypoechoic area with irregular margins (D = 9x7 mm) and no increased vascularity.

➔ Left breast lesions at 2 o'clock (BI-RADS 4a) and 3 o'clock (BI-RADS 3).

Recommendation: FNA.

Intraductal papillary Carcinoma (C50).

DISCUSSION 

Papillary lesions in the breast are a heterogeneous group of lesions that may include benign tumors (such as papillomas, papillomas with atypical epithelial hyperplasia (ADH)) or cancerous tumors (DCIS, papillary carcinoma in situ or invasive, encapsulated papillary carcinoma, papillary carcinoma of the body, papillary carcinoma of the breast).

• Benign papillomas also present with diverse imaging findings: 

Mass-like form: a tumor within the duct lumen or cyst, possibly accompanied by duct dilation. 

Plaque form: a flattened tumor that spreads along the duct wall, not forming a distinct round mass;.it may thicken the duct wall or create a dense area adhering to the duct wall, forming an ill-defined plaque with increased vascularity.

Intraductal branching form: spreading along the duct lumen, developing into multiple branching papillae within the duct lumen, occupying many branches of the duct system. 

---->Overlapping appearance, indistinguishable from types of cancer within the ducts.

On SWE ultrasound:

• Papillomas are the most common histological type causing false positives on elastography.

Diagnostic traps:

• Fibrovascular core: Papilloma has a connective tissue and blood vessel axis > Increased central stiffness > False positive

• Stromal fibrosis: Increased collagen around the lesion → increased stiffness > False positive

• Hyalinization: Common in long-standing papillomas > increased stiffness > False positive.  

. Hemorrhage within the tumor > decreased stiffness > False negative. 

. Lesions that are too small: ROI includes surrounding tissue → Inaccurate assessment of lesion stiffness.

• Encapsulated papillary carcinoma: Minimal stromal reaction, may not be excessively firm → False negative

For avoiding mistakes please keep in mind:

1. Risk factors:

  Age: >55 years-old 

  Large lesion: > 1cm. Peripheral papillary lesions (> 3cm) or multiple lesions.

  History of breast cancer or high-risk lesions: ADH (Atypical ductal hyperplasia), LCIS, DCIS, history of contralateral breast cancer.

  Family history and gene mutations. 

2. High BI-RADS classification lesion. 

3. Lesions with ADH pathology.

CASE 918: MADELUNG DISEASE in a Young Asian Woman, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER and Dr NGUYỄN PHAN TÚ DUNG, VIETNAM.

A 24 year-old nurse with height 1600cm, weight 90kg is suffering from her big size of butt circumference # 136cm.

 Symmetrical hypertrophy of the butt, firmly palpable and painless. 

She would like to reduce her butt size by cosmetic management.

Ultrasound notes hypertrophy of fatty tissue which was hypoechoic homogeneous pattern without capsule of her butt, no tumor inside.

MSCT confirmed symmetric fatty tissue of the subcutanous layer of the butt and nothing abnormal detected in the abdomen and bone or vessels.

Surgery with ultrasound knife removed the fatty tissue masses # 2.5kg each side.

Right mass # 18x16mm. Left mass 22x16cm

Post-op removing two masses of the butt using vacuum-assisted closure.

Specimen were benign lipoma. 

Madelung disease, also known as Madelung-Launois-Bensaude syndrome or neck lipomatosis or multiple symmetric lipomatosis. That is a rare benign entity clinically characterized by the presence of multiple and symmetric, non-encapsulated masses of fatty tissue. The extra fatty tissues are usually involving the neck and the upper region of the trunk, mainly in the posterior aspect. Limb involvement is usually proximal and around the shoulder and hip girdles.

Madelung’s disease causes fatty tissue to grow on neck, upper back and shoulders. It can cause symptoms like difficulty swallowing, talking or moving the head.

Madelung’s disease is a rare condition where extra fatty tissue builds up in places it normally wouldn’t, like around the neck and shoulders. It causes painless, fatty masses that grow over time. If the lumps get too big, they can affect nearby body functions. 

Less commonly, fatty deposits appear on Abdomen, Chest, Hips, Thighs.

This fatty tissue is different than a fatty lump (lipoma) or typical body fat. It spreads and mixes under the skin — looking like jelly spread on a piece of bread. It also grows evenly. For example, it will be on both the left and right sides of the shoulders.

Risk factors

Alcohol use disorder is one of the biggest risk factors. Between 60% and 90% of people with this disease also have cirrhosis of the liver from heavy alcohol use.

Other risk factors include:

Being male and between the ages of 30 and 70

Having a biological family history of the disease

Having a metabolic disorder, like diabetes or hyperlipidemia

May classify the type of Madelung’s disease based on where the fat has built up:

Type 1 (classic type): This type is most common in men. Fat builds up in only the neck, shoulders and upper body. It can sometimes give someone athletic-looking appearance. It’s strongly associated with alcohol use disorder.

Type 2: This type is more common in women, but rarer overall. Fat builds up in the upper body, like Type 1. It also builds up in the abdomen, thighs and hips. It doesn’t have a strong connection to alcohol use disorder.

So our case may be classified in type 2 of Madelung disease based on: no alcohol intake,  symmetric lipomatosis  at the butt.

REFERENCES:

1/ https://rarediseases.org/rare-diseases/madelungs-diseases

2/

3/ Việt Đức Hospital: A 45 yo woman with a lipoma at her posterior neck and two fatty masses at her back. A published Madelung disease case of female patient.

4/ Some 24 other cases in drunken men in Vietnam from northern hospitals were published on Internet.

https://tapchiyhocvietnam.vn/index.php/vmj/article/view/7064

CASE 917: ABSCESSES post FILLING of BREAST AUGMENTATION for 24 years, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr VÕ THỊ PHƯƠNG TRINH, Dr LÊ HỮU LINH, MEDIC MEDICAL CENTER and Dr NGUYỄN PHAN TÚ DUNG, VIETNAM.

A 48 year-old with two huge breasts due to filling breast augmentation by artificial fat liquid for 24 year in oversea. She got painful breast for one month.

X-ray saw no breast abscess.

Ultrasound detected  intricate fluid into breasts which were not like abscess fluid.

Because MRI with breast coil could not fit with the huge breast, MSCT was done in note the  filling fluid was not silicone.

WBC: 16,3×10^9/L

Emergency surgery was done in the same day to remove the breast complex contents which were amount # 2.5 liters each breast.

In surgery, many granulomata inside the breast fields were many amorphous nodules into breast fluid on ultrasound. 

Specimen was the inflamed tissue with reaction  of foreign body phagocytosis of macrophages.

The female patient remains well and discharges after two days in hospital. 

Major medical regulators like the FDA strongly warn against using any liquid injectable fillers (including silicone, hydrogels, or facial dermal fillers) for breast augmentation due to severe safety risks:  

• Product Migration: Free liquid fillers can travel into other parts of the body, causing chronic pain, hard lumps (granulomas), and severe inflammation.  

• Vascular Occlusion: Injected fluid can enter blood vessels, leading to tissue death (necrosis) or life-threatening embolisms.  

• Mammogram Interference: Foreign liquid materials obscure breast tissue, making early detection of breast cancer extremely difficult.

• Removal Difficulty: Unlike solid breast implants, free fluid cannot simply be "taken out" if something goes wrong; it bonds with natural tissue and often requires destructive surgery to excise.

CASE 916: COMPLICATED DIVERTICULITIS, Dr PHAN THANH HẢI, Dr NGUYỄN QUANG HUẤN, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 71 year-old diabetic man with lower abdominal pain for one week.

Ultrasound detected an # 46x57mm abscess close by the sigmoid colon and above the urinary bladder.

Lab data: HbA1c: 7.79 H, FBS: 5.49mmol/L , WBC: 9.03x10^9/L, CRP: 26.78g/L.

MSCT confirmed an abscess which connected with one of diverticula.

Abscess of a inflamed diverticule of colon is a rare entity. 

Complicated diverticulitis occurs when inflammation of small inflamed pouche (diverticulitis) of the colon leads to secondary structural issues—such as an abscess, perforation, fistula,  or stricture.

Key Ultrasound Findings in Diverticulitis

When assessing suspected diverticulitis, transabdominal ultrasound typically looks for:

• Colon Wall Thickening: Colonic wall thickness greater than 4 mm over a segment.
• Outpouchings: Outpouchings (diverticula) sticking out from the colon wall.
• Inflamed Fat: Non-compressible, bright (hyperechoic) fat surrounding the affected colon segment.
• Localized Tenderness: Direct tenderness when pressure is applied with the transducer over the affected colon segment.

CASE 915: LIVER CANCER post 10 year-treated -HCV- infection, Dr PHAN THANH HẢI, Dr PHAN HỮU BỘI HOÀN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 A 70 year-old woman with history of 10 year-infected HCV. She underwent a treated HCV process  in three months and well remaining.

Ultrasound has been followed her liver at her local province. But in an ultrasound examination at Medic Center she was noted her METAVIR in F4 classified with micronodular pattern and a node of the right lobe and an one another in the left lobe.

  

Lab data showed AntiHCV positive, platelets low result  and GAAD score positive.

MRI confirmed a #19x18mm HCC of the right liver  on a liver of cirrhosis and a # 2, 3mm nodule in the left lobe.

The patient went through a RFA  (radio frequency ablation) for the liver tumor and chemotherapy in hospital. She was under a treated liver cancer management.

Liver cancer may appear whenever post antivirus 

management.

REFERENCE;