Journal of Medical Imaging and Radiation Oncology 60 (2016) 506–513

MEDICAL IMAGING—PICTORIAL ESSAY

Malignant hyperechoic breast lesions at ultrasound: A pictorial

essay

Journal of Medical Imaging and Radiation Oncology

Stephen Tiang,1 Cecily Metcalf,3 Deepthi Dissanayake1 and Elizabeth Wylie1,2
1 Radiology Department, Royal Perth Hospital, Perth, Western Australia, Australia
2 University of Western Australia, Crawley, Western Australia, Australia
3 PathWest, Royal Perth Hospital, Perth, Western Australia, Australia

S Tiang MBBS; C Metcalf MBBS, FRCPA, Summary

FIAC; D Dissanayake MBBS, FRANZCR; E
Wylie MBBS, FRANZCR.
Correspondence
Dr Elizabeth Wylie, Radiology Department,
Royal Perth Hospital, Wellington Street, Perth
6000, WA, Australia.
Email: liz.wylie@health.wa.gov.au
Conflict of interest: None declared.
Malignant breast lesions are typically hypoechoic at sonography. However, a
small subgroup of hyperechoic malignant breast lesions is encountered in clini-
cal practice. We present a pictorial essay of a number of different hyperechoic
breast malignancies with mammographic, sonographic and histopathologic cor-
relation. Suspicious sonographic features in a hyperechoic lesion include inho-
mogeneity in echogenic pattern, an irregular margin, posterior acoustic
shadowing and internal vascularity. A hyperechoic lesion at ultrasound does not
discount the need to undertake histological assessment of a mammographically
suspicious lesion.

Key words: breast imaging; hyperechoic; malignancy; ultrasound.

Submitted 30 November 2015; accepted 6
April 2016.

doi:10.1111/1754-9485.12468

hyperechoic nodules among 393 screen detected breast

Introduction
On ultrasound, a hyperechoic breast mass is defined as
a lesion that is of increased echogenicity compared to
the subcutaneous adipose tissues. Approximately 0.6–
5.6% of breast masses are hyperechoic.1–3 In 1995,
Stavros et al.1 described lesions that were uniformly
hyperechoic with no isoechoic or hypoechoic areas as
benign, reporting a negative predictive value of 100%
after 42 biopsies of hyperechoic nodules. One of the
most common benign hyperechoic breast lesion is fat
necrosis from previous breast trauma. Other benign
entities include lesions containing adipose tissue
(lipoma), lesions containing fibrotic tissue (pseudoan-
giomatous stromal hyperplasia and others), vascular
lesions (haemangioma) and a combination of tissue
types such as a hamartoma and angiomyolipoma. A
number of authors have published data indicating that a
very small proportion of hyperechoic lesions are malig-
nant. Linda et al.2 reported 9 (0.5%) hyperechoic
malignant lesions out of 1849 biopsied malignancies.
Nam et al.3 reported 103 hyperechoic lesions out of
16416, of which 27 were biopsied, five (4.9%) were
malignant, and Soon et al.4 found two (0.5%)
cancers.
Background
The cases in this pictorial essay are patients that were
referred to the breast assessment centre at Royal Perth
Hospital from 2011 to 2015.
Primary breast carcinoma
Invasive ductal carcinoma
Invasive ductal carcinoma (IDC) is the most common
invasive primary breast malignancy. Clinically, the carci-
noma may present as a palpable mass with features such
as skin retraction and nipple discharge, or as an assymp-
tomatic screen detected lesion.
The characteristic mammographic appearances are of
an irregular, spiculated mass (Fig. 1a) with or without
pleomorphic calcifications and architectural distortion.
The typical sonographic appearance of a primary
breast malignancy is that of a hypoechoic mass with irreg-
ular margins and variable posterior acoustic shadowing.

506 © 2016 The Royal Australian and New Zealand College of Radiologists
 Hyperechoic breast malignancy on ultrasound

(a) (b) (c)

(d) (e)

Fig. 1. Invasive ductal carcinoma. A 68-year-old woman presented with a palpable lump in the left breast. (a) An irregular mass is shown at mammography.
(b) Ultrasound showed an 8.4 mm hyperechoic and irregular mass with parenchymal distortion. (c) Examining the lesion from another plane reveals a hypoe-
choic component and posterior acoustic shadowing, further suspicious features. (d) The lesion has internal vascularity. (e) Excision biopsy of breast shows
infiltrating duct carcinoma within stroma and fat. The tumour forms ill-defined nodules imparting a vague multilobulated appearance. Original magnification
91.0. Haematoxylin & Eosin. The insert shows a solid sheet of large, pleomorphic tumour cells with abundant pale cytoplasm. Original magnification 940.
Haematoxylin & Eosin.

Malignant hyperechoic lesions are more likely than
benign lesions to have an irregular shape (Fig. 1–3),
non-parallel orientation and a hypoechoic component.2,3
A lesion that is not completely hyperechoic and has small
hypoechoic areas should be regarded as suspicious.1,2
Other predictive features of malignancy include a spicu-
lated shape, posterior shadowing and distortion of sur-
rounding tissues3 (Fig. 1–3).
Nam et al.3 reported that all five hyperechoic carcino-
mas had corresponding suspicious mammographic find-
ings such as spiculated margins, interval enlargement,
suspicious microcalcification and lymphadenopathy.
Invasive lobular carcinoma
Invasive lobular carcinoma (ILC) is a tumour composed
of small, usually bland cells arranged in poorly cohesive
aggregates or in single files surrounding ducts and not
destroying normal parenchyma, with minimal
desmoplastic response. The commonest appearance on
mammography is a spiculated mass. However, many
present as an isolated architectural distortion or focal
asymmetry or are seen on one mammographic view
(Fig. 5) only or are radiographically occult. On ultra-
sound, they are usually hypoechoic with typical suspi-
cious features of irregular margins and posterior
acoustic shadowing (Fig. 4,5).
The literature suggests that hyperechoic malignancies
may be more commonly associated with ILC.4–6 In a ser-
ies by Cawson et al.6, 21 (57%) out of the 37 ILCs were
at least partly hyperechoic, concluding that ILC was 9.94
times more likely to be hyperechoic than IDC. Waterman
et al.6 who studied sonographic appearances of 406
invasive breast carcinomas reported that a hyperechoic
or isoechoic pattern was more frequent in ILC. Jones
et al.7 conducted a retrospective review of 509 ILCs and
concluded that 27 (5%) were hyperechoic. The periduc-
tal infiltration by ILCs with formation of concentric rings

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S Tiang et al.

(a) (b)

(c)

Fig. 2. Invasive ductal carcinoma. (a) This 65-year-old woman presented with a screen detected opacity which persists on compression in the left upper
outer quadrant of breast. There is no prior history of trauma. (b) Ultrasound shows a 6 mm predominantly hyperechoic lesion with small central hypoe-
chogenicity and posterior shadowing. (c) Excision biopsy of breast shows an infiltrating duct carcinoma within stroma and fat and extending close to the sur-
gical margin (blue ink). Original magnification 91. Haematoxylin & Eosin. The insert shows several solid nests of large, pleomorphic tumour cells surrounding
several fat cells. Original magnification 940. Haematoxylin & Eosin.

may act as acoustic reflectors5 causing the bright hyper-
ehoic halo around the small hypoechoic tumour nidus to
become the predominant ultrasound finding.
Mucinous (colloid) carcinoma
This is an uncommon breast malignancy which comprises
0.5–3% of breast carcinomas.8 These mucin producing
tumours can be pure or mixed, with the pure subtype
conferring a better prognosis. Microscopically, the
tumour cells occur within large mucinous lakes which
may result in a core biopsy finding of mucinous pools
with a paucicellular tumour.
On mammography, the tumour may be round, oval,
irregular or dense with circumscribed or partially
indistinct margins (Fig. 6a). On sonography (Fig. 6b),
the tumour is frequently isoechoic or hypoechoic to sur-
rounding adipose tissues but may occasionally be hyper-
echoic.8 Because of their wide ranging appearances and
occasional well-defined margins, they may mimic a
fibroadenoma or hamartoma. Posterior enhancement is a
common association and posterior shadowing is rare
(Fig. 6b). A homogeneous appearance to the lesion is
usually associated with a pure subtype and conversely
lesional heterogeneity at ultrasound is more predictive of
a mixed subtype.8

508 © 2016 The Royal Australian and New Zealand College of Radiologists

(a) (b)
Fig. 3. Invasive duct carcinoma. This 63-year-old woman with a screen detected, non-palpable solid nodule in the right upper outer quadrant of breast.
There is no history of trauma. (a) Mammogram left breast, mediolateral oblique (MLO). (b) Ultrasound shows a heterogenous hyperechoic and hypoechoic
mass with posterior acoustic shadowing. (c) Several core biopsies of breast tissue show infiltration of adipose tissue and stroma by tumour. Original magnifi-
cation 91.3. Haematoxylin & Eosin. The insert shows small and large solid nests of large, pleomorphic tumour cells separated by small amounts of fibrous
stroma. Original magnification 940. Haematoxylin & Eosin.
Fig. 4. Invasive lobular carcinoma. This 60-year-old woman has bilateral
retropectoral silicone implants. She presented with a palpable mass in the
left breast. Ultrasound of the left breast (transverse view) shows a small
hyperechoic mass with ill-defined margins superficial to the implants. At
the time of examination, this was felt to be silicone extravasation due to
the “snowstorm” appearance of the mass. This prompted a silicone implant
exchange. At surgery the mass was excised and subsequently shown to be
a lobular breast carcinoma
Metastasis
Metastases to the breast are uncommon but should be
considered as a differential diagnosis for multiple breast
masses in the setting of a known malignancy. The com-
monest malignancies that metastasize to the breast are
melanoma (skin) and lung adenocarcinoma.9 Other
primaries to consider include small cell carcinoma, sar-
coma, neuroendocrine tumours and squamous cell
© 2016 The Royal Australian and New Zealand College of Radiologists
Hyperechoic breast malignancy on ultrasound
(c)
carcinomas. Rarely metastases may originate from a
contralateral breast primary.
When the tumour spread is haematogeneous, the
mammographic findings include round, circumscribed,
non-calcified masses (Fig. 7a). If the spread is lymphan-
gitic, there may be breast enlargement, skin thickening,
asymmetric density and axillary adenopathy. Although
metastases to the breast are most commonly hypoe-
choic, they can rarely present as hyperechoic masses
(Fig. 7c). Lesional hypervascularity is seen in the major-
ity of melanoma metastases.8
Lymphoma
Breast lymphoma is the second most common (after
melanoma) non-mammary malignancy of the breast.
Breast lymphoma may be primary or secondary. The
diagnostic criteria for primary breast lymphoma include
the breast as the site of clinical presentation of the dis-
ease, absence of prior lymphoma or absence of wide-
spread disease at diagnosis, close association of
mammary tissue with lymphomatous infiltrate and dis-
ease limited to the breast and/or ipsilateral lymph nodes
at the time of diagnosis.10 Secondary breast lymphoma
occurs in setting of systemic lymphoma.
The mammographic appearance is usually a solitary,
non-calcified mass with no overt spiculation (Fig. 8a,b).
In secondary breast lymphoma, axillary adenopathy is a
common mammographic presentation, with asymmetry
of the breast and skin thickening. On sonography, the
appearance is variable, ranging from hypoechoic, mixed
echogenicity to near completely hyperechoic lesions11
(Fig. 8c). There is usually marked vascular flow9 in the
lymphoma mass.
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S Tiang et al.

(a) (b) (c)

(d)

Fig. 5. Invasive lobular carcinoma. This 68-year-old woman with a history of prior breast reduction surgery presented with a left sided palpable lump. (a) Craniocau-
dal (CC) mammogram of the left breast does not show any abnormality. (b) Mediolateral oblique (MLO) mammogram of the left breast also does not show any abnor-
mality. The lesion was occult on both mammographic views. (c) The ultrasound showed a 20 mm region of increased echogenicity in the subcutaneous adipose
tissues. The lesion has ill-defined margins. (d) Excision biopsy of breast shows a lobular carcinoma widely infiltrating adipose tissue and stroma. Original magnification
91. Haematoxylin & Eosin. The insert shows small, regular tumour cells infiltrating around fat cells. Original magnification 940. Haematoxylin & Eosin.

(a) (b) (c)

Fig. 6. Mucinous (colloid) carcinoma. This 79-year-old woman presented with a palpable lump. (a) Mammogram of the left breast, craniocaudal (CC) view
shows a non-calcified mass in the upper inner quadrant. (b) Ultrasound examination found a corresponding lesion measuring 2.5 cm at the left upper inner
quadrant at 10 o’clock. It is well-defined, heterogenous, with hypo- and hyperechoic components. There is posterior enhancement. (c) Excision biopsy of
breast shows a large well circumscribed mucinous carcinoma. Most of the tumour consists of mucin with central haemorrhage and with necrosis of the
tumour cells but a small component in the lower part of the tumour shows viable tumour cells admixed with mucin. Original magnification 90.6. Haema-
toxylin & Eosin. The insert shows small aggregates of tumour cells floating in mucin. Original magnification 940. Haematoxylin & Eosin.

510 © 2016 The Royal Australian and New Zealand College of Radiologists
 Hyperechoic breast malignancy on ultrasound

R L

(a) (b) (c)

(d) (e)

(f)

Fig. 7. Metastatic adenocarcinoma. This 63-year-old woman had a screen detected non-calcified opacity in both breasts. Soon after the mammogram, she
was admitted to hospital with obstructive jaundice, where a CT abdomen showed a common bile duct stricture. During ERCP, the stricture was felt to be
malignant, although formal brushings were not performed. Core biopsies of the breast lesions revealed well-differentiated adenocarcinoma, considered meta-
static and consistent with a tumour of foregut origin. (a) Mammogram right breast, craniocaudal (CC) view shows a round, well-defined mass with no calcifi-
cation or stromal distortion. (b) Mammogram left breast, carniocaudal (CC) view shows a solitary mass similar to the right breast. (c) Ultrasound of the left
breast shows a 17 mm lesion which appears completely hyperechoic but with suspicious features including an ill-defined margin and posterior acoustic shad-
owing. (d) Ultrasound of the same lesion in a different plane reveals a hypoechoic area with posterior shadowing. (e) Doppler ultrasound of the lesion
demonstrates internal vascularity. (f) Several cores of breast tissue showing tumour infiltrating adipose tissue and stroma. Large areas of necrosis are also
present. Original magnification 92.0. Haematoxylin & Eosin. The insert shows small nests of intermediate, pleomorphic tumour cells arranged around small
glandular spaces and separated by small amounts of fibrous stroma. Original magnification 940. Haematoxylin & Eosin.

© 2016 The Royal Australian and New Zealand College of Radiologists 511
S Tiang et al.

(a) (b) (c)

(d) (e)

Fig. 8. Secondary breast lymphoma. This 60-year-old had a screen detected solitary nodule on mammogram. There is a prior history of low grade follicular
lymphoma. (a) Digital tomosynthesis of the left breast, craniocaudal (CC) view shows a solitary, well-defined, lobulated nodule, without calcification and stro-
mal distortion. (b) The lesion is also identified on the mediolateral oblique (MLO) left breast mammogram. No evidence of axillary lymphadenopathy. (c) Ultra-
sound shows a heterogeneous lesion with hypoechoic area centrally and a hyperechoic halo. (d) There is a vascular flow within the lesion. (e) Core biopsy of
breast consisting of lymphoid cells with a small amount of residual fat infiltrate Original magnification 92.4. Haematoxylin & Eosin. The upper middle insert
shows diffuse infiltrating lymphocytes in small ill-defined nodules (arrows). Original magnification 910. Haematoxylin & Eosin. The lower right hand insert
shows a mixture of small cleaved cells and large lymphocytes. Original magnification 940. Haematoxylin & Eosin. The upper right hand insert show tumours
cells labelled with a B cell marker. Original magnification 98. CD20 immunohistochemistry.

necrosis may ultimately require a biopsy for a definitive

Pitfalls for detection
Stavros et al.1 recommended that a lesion should be
homogeneous in echogenicity and more hyperechoic
than adipose tissue for it to be considered benign on
ultrasound.
Some infiltrating malignancies can have a small
hypoechoic central nidus surrounded by a larger hypere-
choic halo. Scanning through the thick hyperechoic halo
and not appreciating the hypoechoic central focus can
cause such lesions to be misinterpreted as purely hyper-
echoic.12
In conclusion, approximately 0.5%2,11 of malignant
breast lesions appear hyperechoic. Correlation with
mammographic findings and clinical history should deter-
mine the need for biopsy. A hyperechoic lesion in the
absence of a preceding history of trauma and character-
istic mammographic radiolucent appearances of fat
assessment.
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