Image Presentation

Posterior Acoustic Shadowing

in Benign Breast Lesions
Sonographic-Pathologic Correlation

Susan P. Weinstein, MD, Emily F. Conant, MD, Carolyn Mies, MD,

Geza Acs MD, PhD, Steven Lee, MD, Chandra Sehgal, PhD

Objective. To show a variety of benign breast lesions that exhibit posterior acoustic shadowing on
sonography. Methods. The cases illustrate a variety of pathologic breast conditions that were collected
at a referral breast center at a tertiary medical center. Results. A variety of pathologic conditions are dis-
cussed, with pathologic-imaging correlation. Conclusions. Although posterior acoustic shadowing is a
sonographic feature that is most commonly associated with mammary malignancies, this sonographic
finding may also be seen with benign breast lesions. Key words: breast; posterior acoustic shadowing;
sonography.

B
Received July 2, 2003, from the Departments of
Radiology (S.P.W., E.F.C., S.L., C.S.) and Pathology
(C.M., G.A.), University of Pennsylvania Medical
Center, Philadelphia, Pennsylvania USA. Revision
requested August 4, 2003. Revised manuscript
accepted for publication August 13, 2003.
Address correspondence and reprint requests to
Susan P. Weinstein, MD, Department of Radiology,
University of Pennsylvania Medical Center, 1
Silverstein Building, 3400 Spruce St, Philadelphia,
PA 19104-4283 USA.
E-mail: weinstei@oasis.rad.upenn.edu.
reast sonography has become an indispensable
tool in the evaluation of breast lesions. Although
breast sonography may play many different roles
in breast imaging, perhaps one of the more
important roles it plays is in lesion characterization.
There are sonographic criteria that help guide in differen-
tiating benign lesions from questionable ones that need
to undergo biopsy. Some of the typical sonographic fea-
tures of breast carcinoma include irregular margins, a
long axis perpendicular to the skin, a heterogeneous echo
texture, and posterior acoustic shadowing.1,2 Although 1
or more of these sonographic features may be seen with
breast carcinoma, it is important to note that there is an
overlap of the sonographic features, and some of these
sonographic findings may be seen with benign breast
lesions.
In this article, we present a spectrum of benign lesions
that exhibit posterior acoustic shadowing. Although
some benign lesions cannot be distinguished from
malignant lesions on the basis of sonography alone,
many of the lesions may be accurately diagnosed on the
basis of a combination of sonography, mammography,
and history. If biopsy is necessary, with the increased use
of percutaneous breast biopsies, understanding the over-

© 2004 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 23:73–83, 2004 • 0278-4297/04/$3.50
Posterior Acoustic Shadowing in Benign Breast Lesions

lap in the sonographic appearance of benign and Granular Cell Tumors

malignant lesions is particularly important when Granular cell tumors are uncommon neoplasms
assessing concordance of the imaging appear- that may arise at any anatomic site; 16% occur in
ance with the pathologic results. mammary parenchyma or associated soft
tissue.4 Granular cell tumors, first called “granu-
Materials and Methods lar cell myoblastoma,” are now known to express
markers of neural (Schwann cell) differentiation.
Cases showing a wide variety of pathologic breast Although nearly always benign in behavior, they
conditions were collected from a busy breast can mimic breast malignancies both clinically
imaging center. The cases were evaluated by and on imaging evaluation. On physical exami-
mammography and sonography. All the cases had nation, they are palpably firm and, because of an
various benign breast conditions that exhibit pos-
terior acoustic shadowing on breast sonography.
Figure 1. Biopsy-proved fibroadenoma in a 57-year-old woman.
Shadowing Lesions A, Sonogram showing a hypoechoic nodule with posterior
acoustic shadowing. The echogenic sharp posterior margin of
Fibroadenomas the mass (arrow) is shown through the region of shadowing.
Typically, the posterior margin is not visible in malignancies that
Fibroadenomas are perhaps the most common have posterior acoustic shadowing. B, Medium-power view
solid breast masses that undergo biopsy. They showing a fibroadenoma with hyalinized stroma. The lesion is
may vary greatly in size from microscopic mass- well circumscribed (original magnification ×100). The epithelium
es to lesions that are larger than 10 cm. shows mild hyperplasia without atypia. The stroma shows scant
Fibroadenomas arise from the terminal ductal cellularity composed of abundant collagen material and bland
spindled stromal cells.
lobular unit. The usual fibroadenoma is com-
A
posed of a benign neoplastic proliferation of
stroma balanced by the expansion and stretch-
ing of non-neoplastic ductules. It forms a sharply
circumscribed mass with an expansile character
that compresses adjacent mammary parenchy-
ma. As a consequence of generalized mammary
involution, fibroadenomas in postmenopausal
women often show atrophy, hyalinizing sclerosis,
and calcification.
Typically on sonography, fibroadenomas are
well circumscribed and have an ovoid or lobular
shape. The internal architecture may vary from
homogeneous to heterogeneous3 on sonographic
evaluation. Once the fibroadenoma begins to
undergo hyalinization, posterior acoustic shad-
owing may be seen (Figure 1). Up to 30% of non-
calcified fibroadenomas may exhibit posterior
acoustic shadowing.1 This sonographic shadow- B
ing may be confusing to the imager if not recog-
nized as part of a spectrum of sonographic
findings of hyalinized fibroadenomas. In some
cases, the shadowing is seen from the margin of
the lesion, giving a slightly different appearance
than the more typical central shadowing of can-
cer. Additionally, the degree of shadowing does
not appear to be as dense as in the case of some
malignancies that exhibit this characteristic, and
the posterior wall of the fibroadenoma is often
visible as a thin echogenic margin, as shown in
our example.

74 J Ultrasound Med 23:73–83, 2004

 Weinstein et al

infiltrative character, may become fixed to sur-
rounding tissue and may cause skin retraction or
dimpling.5 Local wide excision is the therapy of
choice given the infiltrative and locally aggres-
sive nature of these benign lesions.
At pathologic review, sheets and clusters of
bland tumor cells are seen. The tumor cells are
characterized by bland uniform nuclei with
evenly distributed chromatin and conspicuous
nucleoli and abundant granular eosinophilic
cytoplasm.6 There should be a lack of mitotic
activity in the lesion.6
Mammographically, an irregular spiculated
mass may be seen,4 as shown in Figure 2,
although circumscribed masses also have been
described.5 Sonographically, a hypoechoic mass
with posterior acoustic shadowing is often seen.5
The sonographic image shows an echogenic
interface anterior to the hypoechoic lesion.
The combination of the mammographic and
sonographic features may suggest the diagnosis.
Even though imaging features may suggest the
diagnosis of a radial scar, biopsy is recommend-
ed because a definitive diagnosis may not be
made on the basis of the imaging findings alone.
Figure 2. Granular cell tumor in a 25-year-old woman.
A, Sonogram showing an irregular mass with posterior acoustic
shadowing. B, Pathologic specimen showing a stellate-shaped,
0.8-cm mass that arose in a very fatty region of the breast (orig-
inal magnification ×200). The microscopic pattern is typical:
cytologically bland-appearing cells with abundant granular cyto-
plasm and petite nuclei (arrows) embedded in a dense fibrous
stroma. There is a lack of mitotic activity. These features are con-
sistent with the diagnosis of a granular cell tumor. There was
subtle spiny infiltration of fat at the periphery, but there was no
necrosis or mitotic activity.
A

Radial Scars
Radial scars are common, seen in up to 28% of
mastectomy and large excisional biopsy speci-
mens. Most are microscopic, multiple, and
scattered, but some merge into a confluent
mass-forming aggregate. Solitary larger (≥1.0-
cm) examples may form a palpable mass or
one that appears as a discrete lesion on a mam-
mogram. Radial scars are benign lesions of
unknown etiology that can mimic a malignan-
cy on imaging and pathologic evaluation.
Mammographically, these lesions show spicules
originating from a central nidus (Figure 3).
Unlike a carcinoma, with spicules originating
from a central mass, the radial scar does not have
a central mass but rather has a central area of
architectural distortion.7 At times, there may be
fat entrapped in the central nidus, resulting in an
area of lucency, which may suggest the diagnosis
of a radial scar.7 At pathologic evaluation, the B
characteristic feature is a central fibroelastotic
area, which is surrounded by distorted ducts in a
stellate pattern.8 The microscopic appearance
may vary depending on the amount of sclerosis,
epithelial proliferation, and ductal distortion
and entrapment.8 Unlike a typical invasive duc-
tal carcinoma, a radial scar may vary in appear-
ance greatly depending on the mammographic
projection.
At sonographic evaluation, a hypoechoic mass
with dense posterior acoustic shadowing may
be seen. There are no sonographic features
that would distinguish this from a malignancy.9

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Posterior Acoustic Shadowing in Benign Breast Lesions

Excisional biopsy, rather than core needle biopsy,
is recommended because of the risk of associat-
ed lesions with this entity, such as atypical ductal
hyperplasia, intraductal carcinoma in situ, lobu-
lar neoplasia, and tubular carcinoma.10
Diabetic Mastopathy
Diabetic mastopathy was first described in the
context of thyroiditis and arthropathy in 1984 by
Soler and Khardori.11 It is an uncommon condi-
tion occurring in patients with long-standing
diabetes mellitus, although similar pathologic
findings occur in nondiabetic persons. It is most
often diagnosed in premenopausal women.
Patients usually have a poorly defined, firm-to-
hard, nontender breast mass that can mimic car-
cinoma. The size may vary considerably from
millimeters to several centimeters.12
Mammographically, a mass is often not seen
because of the presence of dense breast tissue.
Therefore, sonography is helpful in characteriz-
ing the breast mass. At sonographic evaluation,
an irregular hypoechoic mass with posterior
acoustic shadowing may be seen (Figure 4).
Given the clinical history and the sonographic
features, the diagnosis of diabetic mastopathy
may be suggested, but tissue diagnosis is recom-
mended for confirmation.
At gross pathologic evaluation, a discrete mass
is usually palpable without being visible. The
mass is caused by the dense hyalinized collage-
nization of intralobular and interlobular stroma
populated by sparse enlarged, epithelioid fibrob-
A

Figure 3. Radial scar in a 38-year-old woman. A, A spiculated

mass is shown on a spot magnification view in the craniocaudal
position. B, Sonogram showing a small hypoechoic mass with
dense posterior acoustic shadowing. There is suggestion of spic-
ulations arising from the hypoechoic mass. A radial scar was sus-
pected on the basis of the patient’s mammographic and sono-
graphic findings. Gross examination of the tissue showed it to be
predominantly fibrous in character, with a firm 0.3-cm nodule at
the radiologically identified site. C, This nodule corresponds to a
fibroelastotic center (arrow) from which radiates a corona of con-
nective tissue bands and stretched terminal duct-lobular units,
typical of a radial scar (original magnification ×25). Some of the
small ducts are cystically dilated because of local obstruction by
this fibrosing process.
B

76 J Ultrasound Med 23:73–83, 2004


lasts and myofibroblasts; a ductocentric and lob-
ulocentric lymphocytic infiltrate is often, but not
invariably, seen.4,11
Fat Necrosis
Fat necrosis is a benign condition related to prior
trauma or surgery. The condition is usually
asymptomatic, although patients may have
palpable breast masses. The mammographic
appearance may be varied depending partly on
Figure 4. Diabetic mastopathy in a 37-year-old woman with a
17-year history of insulin-dependent diabetes mellitus. On phys-
ical examination, a mobile 3-cm mass was palpated within the
left upper inner quadrant. The patient’s mammogram showed
dense breast tissue without a focal mammographic abnormality.
A, Sonogram showing a poorly marginated mass with posterior
acoustic shadowing. Biopsy revealed diabetic mastopathy.
B, Medium-power view showing dense, keloidlike fibrosis and a
perilobular chronic inflammatory infiltrate composed of small
lymphocytes (original magnification ×100). Scattered epithelioid
myofibroblasts are also present. The combination of these histo-
logic features is consistent with diabetic mastopathy.
B B
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Weinstein et al
the remoteness of the inciting event relative to
the time of the imaging evaluation. An irregular
spiculated mass with or without calcifications,
calcifications alone, an oil cyst, or no findings
may be seen at mammographic evaluation. On
sonography a hypoechoic mass with posterior
acoustic shadowing may be seen (Figure 5).
In the case of oil cysts, late in the evolution of
Figure 5. Fat necrosis in a 43-year-old woman who had a
recent history of a left mastectomy and a right breast reduction.
The patient had a palpable right breast mass. The mammo-
graphic examination revealed no questionable findings.
A, Sonogram showing an area of posterior acoustic shadowing.
Given the clinical appearance and the sonographic finding, the
patient underwent an excisional biopsy, and the diagnosis of fat
necrosis was made. B, Medium-power view of fat necrosis
showing chronic inflammation composed of lymphocytes
admixed with foamy macrophages and a giant cell reaction
(original magnification ×100).
A
77
Posterior Acoustic Shadowing in Benign Breast Lesions

fat necrosis, a circumscribed hypoechoic mass
with or without posterior acoustic shadowing
may be seen. The thin echogenic rim is usually
visible regardless of the presence of the shadow-
ing. Other sonographic appearances of fat necro-
sis include a complex mass with a mixed echo
texture and an intracystic soft tissue mass.13
Although the sonographic findings may be quite
alarming, the mammographic findings typically
are benign appearing and suggestive of the diag-
nosis (Figure 6).
The histologic appearance of fat necrosis similar-
ly varies with the age of the process. Mass-forming
lesions are characterized by lymphoplasmacytic
inflammation, foamy macrophages, foreign body-
type giant cells, and reparative fibrosis.
years and speculated on a hormonal etiology. In
fact, this process may have several causes, region-
al or partial mammary involution probably being
the most common.16
Figure 6. Fat necrosis in a 24-year-old woman with a palpable
left breast mass. Directed breast sonography was initially per-
formed, revealing several hypoechoic masses with posterior
acoustic shadowing. A, Sonogram showing one of the masses.
B, Mammogram showing several peripherally calcified masses,
clearly consistent with fat necrosis. The patient did not recall a
history of trauma. Careful correlation with limited mammo-
graphic imaging in this young woman helped clarify the exact
etiology of the benign yet palpable breast changes.
A

Postsurgical Scars
After a benign breast biopsy, the breast tissue
usually heals without residual perceptible
changes. For patients who undergo breast con-
servation therapy for cancer, there is an
increased likelihood of distortion and scarring
after surgery and radiation therapy. These find-
ings may be confusing if the appropriate clinical
history is not provided. Likewise, for patients
who have undergone benign excisional biopsy,
the changes seen on the mammogram are usual-
ly obvious given the appropriate clinical history, B
prior comparison films, and even the images
from the needle localization procedure. In cases
when the appropriate history is not available, a
postsurgical scar may mimic a malignancy.
At sonographic evaluation, an area of posterior
acoustic shadowing may be seen.1 It has been
our experience that the shadowing associated
with a scar often has shadowing without a central
mass. This lack of a central mass helps differenti-
ate a scar from a carcinoma, which has shadow-
ing arising from a central mass. With scars, the
degree of posterior acoustic shadowing may be
more prominent in certain planes than in others,
as in our example (Figure 7). Occasionally, on
sonography a hypoechoic surgical plane margin
may be seen extending from the surgical bed to
the skin surface.

Focal Fibrosis
Focal fibrosis is a fairly common condition,
accounting for as many as 9% of lesions diag-
nosed on the basis of core needle biospy.14 It was
first described as a distinct entity by Haagensen,15
who noted its occurrence during the reproductive

78 J Ultrasound Med 23:73–83, 2004


Focal fibrosis manifests with a range of mam-
mographic and sonographic findings. The mam-
mographic findings include circumscribed
masses, asymmetric densities, architectural dis-
tortion, and irregular masses.14,17 Similarly, on
sonography the appearance may vary from cir-
cumscribed hypoechoic masses to questionable
hypoechoic masses with or without posterior
acoustic shadowing and posterior acoustic shad-
owing without definite masses.14,17 Examples of
Figure 7. Postsurgical scar in a 57-year-old woman with a his-
tory of benign left breast biopsy. A and B, Sonograms of the scar
site showing dense posterior acoustic shadowing. During
dynamic scanning, no central mass was shown. The degree of
posterior acoustic shadowing is more prominent in the antiradi-
al direction (A) than in the radial position (B).
A
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Weinstein et al
fibrosis are shown in Figures 8 and 9. Pathologic
studies of this entity differ in only 1 respect: the
character of the interface of the lesion with sur-
rounding breast. Most describe the process as
forming a clinically dominant mass that has
microscopically indistinct margins; others say
the mass is discrete and sharply circum-
scribed.15,18 In fact, both configurations are seen,
in parallel with the range of imaging features.
Figure 8. Focal fibrosis in a 32-year-old woman with a palpable
breast mass. The mammogram revealed dense breast tissue with-
out a questionable focal abnormality. A, Directed sonogram over
the palpable area of concern showing a hypoechoic region with
posterior acoustic shadowing. Excisional biopsy was performed,
revealing fibrosis. B, Pathologic examination revealed a discrete
mass that was not grossly or microscopically visible; the tissue was
composed of paucicellular fibrous tissue with completely atrophic
parenchymal structures (original magnification ×100). Some fat is
evident at the edges of the resected tissue as well as in interposed
wispy streaks and small pockets.
A
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Posterior Acoustic Shadowing in Benign Breast Lesions
By definition, the epithelial components of the
fibrocystic change complex are absent. At
pathologic evaluation the key features include
dense stromal fibrosis with atrophy of ducts and
lobules. A variable amount of chronic inflam-
matory infiltrate may be present, composed of
small lymphocytes.13
A
80
Sclerosing Adenosis
Sclerosing adenosis is a component of the pro-
liferative fibrocystic change complex that is
usually spotty but may coalesce to form a dom-
inant mass on its own (so-called adenosis
Figure 9. Focal fibrosis in an 87-year-old woman with a palpa-
ble mass in the left breast. A, Craniocaudal mammograms
showing developing density (arrows) in the central breast,
which was not seen on a mammogram obtained 2 years earlier
(B). C, Sonogram showing a poorly defined hypoechoic area
with posterior acoustic shadowing. Biopsy revealed fibrosis.
D, Medium-power view showing dense fibrosis with bundles of
collagen and bland spindled stromal cells (original magnification
×100). There is a sparse chronic inflammatory infiltrate com-
posed of small lymphocytes.
B
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 Weinstein et al

tumor). It also may occur in the context of radi-
al scars and sclerosing papillomas to create a
highly complex imaging and pathologic picture.
The condition typically manifests as a mammo-
graphic abnormality, although rarely it may
manifest as a palpable breast finding.19 The
most common appearance on mammography
is a focal group of punctate or amorphous calci-
fications or a regional cluster of powdery calci-
fications. However, sclerosing adenosis may
also appear as a nodule or a spiculated mass.20
Although there is limited information on the
sonographic evaluation of sclerosing adenosis,
at sonography, posterior acoustic shadowing
may be seen,1,3 as shown in Figure 10. The shad-
owing may be due to the fibrotic response
elicited by this entity.3
At pathologic evaluation, closely packed
benign lobules are seen, composed of distorted
acini with surrounding fibrosis. The fibrotic stro-
ma compresses, elongates, and distorts the acini.
The normal 2-cell layer of the ductules is
retained, although the myoepithelial cell layer is
usually hyperplastic.7
Normal Breast Tissue
Real-time sonographic evaluation of normal
breast tissue may exhibit posterior acoustic
shadowing.1 Because the ultrasonic transducer
scans over the multiple tissue interfaces, such
as Cooper ligaments and other connective tis-
sue, posterior acoustic shadowing may result.
However, on rescanning and dynamic imaging of
the area, particularly in a different plane, the
shadowing may resolve or may appear less
prominent. Additionally, because the posterior
acoustic shadowing is generated by interfaces,
there should be no associated mass. This exam-
ple shows the importance of dynamic real-time
scanning in the evaluation of subtle breast
lesions. Figure 11 shows shadowing as an artifact
that may be seen in normal breast tissue.

A
Figure 10. Sclerosing adenosis in a 45-year-old woman with an
area of architectural distortion in the upper outer quadrant. A,
Sonogram showing a vague hypoechoic area with posterior
acoustic shadowing (arrows). The degree of posterior acoustic
shadowing is not as dense as in carcinomas that have shadows.
Wire localization biopsy showed irregularly fibrotic breast tissue
without a discrete mass. B and C, Microscopic specimens show-
ing a complex combination of proliferative fibrocystic changes
dominated by sclerosing adenosis and multiple microscopic
radial scars forming confluent nodules and bands of dense
fibrosis (B and C, respectively, original magnification ×50).
Sclerosing adenosis consists of a micronodular proliferation of
small mammary acini with prominent spindling myoepithelial
cells and fibrosis. The fibrotic stroma compresses, elongates,
and distorts the acini.

B C

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Posterior Acoustic Shadowing in Benign Breast Lesions
Conclusions
Sonography is an indispensable tool in the eval-
uation of breast abnormalities. Posterior acoustic
shadowing is a sonographic characteristic that is
most commonly associated with breast malig-
nancies. However, it is important to keep in mind
that this sonographic finding may also be seen in
benign breast masses. The clinical history and
mammographic findings, in conjunction with
the sonographic findings, will often lead to the
correct diagnosis. If core needle biopsy is per-
formed on a lesion with posterior acoustic shad-
owing, it is important to keep in mind that a
specific benign diagnosis, such as a fibroadeno-
ma or diabetic mastopathy, may indeed be con-
cordant with the imaging findings.
Figure 11. A, Sonogram of normal breast tissue showing pos-
terior acoustic shadowing. B, On reevaluation on the same area,
the shadowing is no longer seen.
A Unusual breast lesions: radiologic-pathologic corre-
B
82
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