What is the next step for a 40-year-old woman with three oval (shaped) lesions on breast ultrasound that are hyperechoic, parallel to the skin, with light posterior enhancement and no vascularity?

Management of Hyperechoic Breast Lesions on Ultrasound

For a 40-year-old woman with three oval lesions that are hyperechoic, parallel to the skin, with light posterior enhancement and no vascularity on breast ultrasound, short-interval follow-up ultrasound in 6 months is the most appropriate next step. 1

Characteristics of the Described Lesions

• The described lesions have multiple features consistent with BI-RADS 3 (probably benign) classification:
  • Oval shape 1
  • Hyperechoic appearance 2
  • Parallel orientation to the skin 1
  • Light posterior enhancement 1
  • Absence of vascularity 1

Risk Assessment

• Hyperechoic breast masses are very rare (0.6% of all breast lesions) and mostly benign 2
• Lesions with oval shape, parallel orientation, and circumscribed margins have a low risk of malignancy 1
• The absence of suspicious features (irregular shape, non-parallel orientation, non-circumscribed margins, or hypoechoic areas) further supports a benign etiology 2
• The probability of malignancy for lesions with these characteristics is less than 2% 1

Management Algorithm

For Probably Benign (BI-RADS 3) Lesions:

1. Short-interval follow-up ultrasound

   • Recommended interval: 6 months initially, then annually if stable 1
   • This is appropriate for solid masses with benign features identified on ultrasound 1

2. When to consider biopsy instead of follow-up:

   • If the mass is new or enlarging (>20% increase in volume or diameter in a 6-month period) 1
   • In high-risk patients 1
   • In patients awaiting organ transplant 1
   • In patients with known synchronous cancers 1
   • In patients trying to get pregnant 1
   • To alleviate extreme patient anxiety 1

Differential Diagnosis

• Benign entities that can appear as hyperechoic masses include:
  • Fibroadenoma 2, 3
  • Fat necrosis 2
  • Hamartoma 3
  • Lipoma 3
  • Benign skin lesions 4

Important Considerations

• Careful correlation between clinical and imaging findings is essential 1
• If the lesions increase in size during follow-up (>20% in volume or diameter), image-guided core biopsy should be performed 1
• If the lesions remain stable over 1-2 years, the patient can return to routine screening 1, 5

Common Pitfalls to Avoid

• Overtreatment of asymptomatic, stable benign-appearing lesions - most require only observation 5
• Misclassifying a small superficial breast cancer as a benign dermal lesion - ensure proper assessment of the lesion's location (dermal vs. parenchymal) 4
• Failing to recognize that some hyperechoic lesions can be malignant, particularly those with irregular shape, non-parallel orientation, or non-circumscribed margins 2

When to Consider Additional Imaging

• MRI is not indicated as the next step in evaluating these probably benign findings 1
• Diagnostic mammography may be appropriate depending on the patient's age and clinical context, but is not necessary as the immediate next step for these benign-appearing lesions 1