Presentation is loading. Please wait.

Presentation is loading. Please wait.

Mrozin,md BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers.

Similar presentations


Presentation on theme: "Mrozin,md BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers."— Presentation transcript:

1 mrozin,md BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers

2 mrozin,md Goal of Breast Ultrasound SOLID VS CYSTIC

3 mrozin,md Goal of Breast Ultrasound Make a more specific diagnosis than clinical and mammographic findings alone. Prevent unnecessary biopsies. Find cancers missed by mammography.

4 mrozin,md Breast cancer is extremely heterogeneous therefore we CANNOT distinguish benign from malignant on the basis of only a single sonographic finding. Breast cancer varies greatly not only from one mass to another but even WITHIN an individual mass.

5 mrozin,md Ultrasound shows morphology and not histology / biology ONE suspicious finding requires further evaluation -----> that is biopsy and should be given BIRAD 4A up to 5

6 mrozin,md BIRADS for U/S BIRAD 1 – normal BIRAD 2 – benign finding BIRAD 3 – probably benign

7 mrozin,md BIRADS for U/S BIRAD 4A – abnormal finding – low suspicion BIRAD 4B – abnormal finding – intermediate suspicion BIRAD 4C – abnormal finding – probably malignant BIRAD 5 – highly suspicious for malignancy BIRAD 6 – known malignancy

8 mrozin,md Spectrum of masses

9 mrozin,md Circumscribed vs Spiculated malignant masses – a spectrum of ultrasound features I.Desmoplastic vs. inflammatory reaction II.Cellularity III. Vascularity

10 mrozin,md Desmoplastic Reaction Host response to tumor – attempt to wall off the tumor with fibrosis and elastosis to keep it from spreading. Develops slowly Therefore spiculated lesions are usually slow growing GRADE 1 – 2 tumors

11 mrozin,md Inflammatory Response GRADE 3 tumors may be circumscribed and grow so fast that desmoplasia has no time to develop. These carcinomas incite an inflammatory response with lymphocytes and plasma cells.

12 mrozin,md Cellularity Circumscribed masses are much more cellular than spiculated masses. They have lots of tumor cells, lymph cells and plasma cells – this causes posterior enhancement. Spiculated masses have much fewer cells and very hypocellular desmoplasia – this causes posterior shadowing.

13 mrozin,md Vascularity Circumscribed masses are usually very vascular – lots of cells and divisions require more blood – more angiogenetic factors; inflammatory response also creates hypervascularity. Spiculated masses may have same vascularity as normal tissue or benign masses because of the smaller amount of cells and angiogenetic factors.

14 mrozin,md

15 BIRADS for Ultrasound Masses I.Shape II.Margin III.Orientation IV.Lesion boundary V.Echogenic pattern VI.Posterior acoustic features VII.Effect on surrounding parenchyma VIII.Calcifications IX.Vascularity

16 mrozin,md Background Breast Pattern Homogenous Fatty Heterogeneous – focally or diffusely variable Homogenous Fibroglandular

17 mrozin,md Fatty

18 mrozin,md Heterogeneous

19 mrozin,md Fibroglandular

20 mrozin,md I. Shape Oval – includes tear drop shape 2-3 macrolobulations may be with thin echogenic capsule Round – cysts, mets, IDC (high grade) Irregular – NOT round or oval

21 mrozin,md Oval fibroadenoma DCIS

22 mrozin,md Round cyst DCIS

23 mrozin,md Irregular IDC radial scar

24 mrozin,md II. Margin Circumscribed – smooth, distinct margin Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS Indistinct – NO abrupt interface with surrounding tissue

25 mrozin,md Circumscribed

26 mrozin,md II. Margin Circumscribed – smooth, distinct margin Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS Indistinct – NO abrupt interface with surrounding tissue

27 mrozin,md Microlobulated

28 mrozin,md

29 II. Margin Circumscribed – smooth, distinct margin Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS Indistinct – NO abrupt interface with surrounding tissue

30 mrozin,md Indistinct

31 mrozin,md Margin – cont. Angular – part of margin has sharp corners; most accurate of all signs of malignancy; invasion follows path of least resistance – in fat: many angles; in fibrosis: horizontal and then along Coopers ligaments Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings

32 mrozin,md Angular

33 mrozin,md

34 Margin – cont. Angular – part of margin has sharp corners; most accurate of all signs of malignancy; invasion follows path of least resistance – in fat: many angles; in fibrosis: horizontal and then along Coopers ligaments Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings

35 mrozin,md Spiculated

36 mrozin,md Mixed

37 mrozin,md III. Orientation Parallel – wider than tall – long axis parallel to skin NOT parallel – taller than wide – long axis perpendicular to skin includes ROUND masses

38 mrozin,md TDLU

39 mrozin,md CA FA

40 mrozin,md

41

42 ant.post.terminal

43 mrozin,md

44 Wider than tall !! ant. lobule terminal lobules distended duct with invasion

45 mrozin,md IV. Lesion Boundary Abrupt interface – no transition zone between mass and surrounding tissue Echogenic rim – variant of spicules too small to resolve on U/S; some masses have a very thick echogenic rim with a tiny hypoechogenic nidus – must examine carefully; peritumoral edema usually occurs btw. mass and skin

46 mrozin,md Abrupt Interface echogenic capsule FACA

47 mrozin,md IV. Lesion Boundary Abrupt interface – no transition zone between mass and surrounding tissue Echogenic rim – variant of spicules too small to resolve on U/S; some masses have a very thick echogenic rim with a tiny hypoechogenic nidus – must examine carefully; peritumoral edema usually occurs btw. mass and skin

48 mrozin,md Echogenic Rim

49 mrozin,md Echogenic Rim Same mass – with & without Sono-CT

50 mrozin,md V. Echogenic Pattern Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma Isoechoic – equal to fat Hypoechoic – less than fat Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC Anechoic – absence of internal echoes; mets, IDC- high grade.

51 mrozin,md normal fibrotic tisssue silicone fat necrosis

52 mrozin,md hyper with iso 4 mo later hyper?NOT

53 mrozin,md V. Echogenic Pattern Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma Isoechoic – equal to fat Hypoechoic – less than fat Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC Anechoic – absence of internal echoes; mets, IDC- high grade.

54 mrozin,md

55 Mucinous CA

56 mrozin,md V. Echogenic Pattern Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma Isoechoic – equal to fat Hypoechoic – less than fat Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC Anechoic – absence of internal echoes; mets, IDC- high grade.

57 mrozin,md IDC seroma FA

58 mrozin,md V. Echogenic Pattern Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma Isoechoic – equal to fat Hypoechoic – less than fat Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC Anechoic – absence of internal echoes; mets, IDC- high grade.

59 mrozin,md hematomaphylloides Intracystic papillary CA

60 mrozin,md V. Echogenic Pattern Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma Isoechoic – equal to fat Hypoechoic – less than fat Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC Anechoic – absence of internal echoes; cysts mets, IDC- high grade.

61 mrozin,md cysts

62 mrozin,md VI. Posterior Acoustic Features None Enhancement – highly cellular lesions Shadowing – seen in desmoplasia Combined Can use this finding to try and predict GRADE; very small lesions (< 5 mm) may have no transmission because havent had time to develop desmoplasia or inflammatory reaction

63 mrozin,md Shadowing

64 mrozin,md enhancement normal CA cyst

65 mrozin,md DO NOT FORGET - May see artifactual shadowing from steep Coopers ligaments – can be removed with compression !

66 mrozin,md artifact compression

67 mrozin,md DD of Enhancement 1)IDC – high GRADE 2)Mucinous CA 3)Medullary CA 4)Metaplastic CA 5)Papillary CA 6)FA 7)Cysts

68 mrozin,md DD of Shadowing 1)IDC – low GRADE 2)ILC 3)Tubular CA 4)Scar 5)Fat necrosis 6)Radial scar 7)Calcified FA 8)Calcified oil cysts

69 mrozin,md VII. Effect on Surrounding Tissue Straightening of Coopers ligaments Architectural distortion Skin thickening – normal 2 mm Skin retraction Edema – mastitis, radiation Tx, inflammatory CA, CHF Ducts – abnormal size, branching

70 mrozin,md Architectural distortion Thickening & straightening of coopers ligaments

71 mrozin,md VII. Effect on Surrounding Tissue Straightening of Coopers ligaments Architectural distortion Skin thickening – normal 2 mm Skin retraction Edema – mastitis, radiation Tx, inflammatory CA, CHF Ducts – abnormal size, branching

72 mrozin,md Inflammatory CA Skin thickening

73 mrozin,md Skin retraction in scar with seroma

74 mrozin,md VII. Effect on Surrounding Tissue Straightening of Coopers ligaments Architectural distortion Skin thickening – normal 2 mm Skin retraction Edema – mastitis, radiation Tx, inflammatory CA, CHF Ducts – abnormal size, branching

75 mrozin,md focal edema Edema with dilated lymphatics

76 mrozin,md VII. Effect on Surrounding Tissue Straightening of Coopers ligaments Architectural distortion Skin thickening – normal 2 mm Skin retraction Edema – mastitis, radiation Tx, inflammatory CA, CHF Ducts – abnormal size, branching

77 mrozin,md

78 Duct extension Branch pattern

79 mrozin,md IDC 1 st lumpectomy with + margin 2 nd lumpectomy with + margin Duct extension

80 mrozin,md VIII. Calcifications Macrocalcifications Microcalcifications outside a mass Microcalcifications inside a mass

81 mrozin,md FA Oil cyst

82 mrozin,md IDC DCIS

83 mrozin,md IX. Vascularity Absent Present Adjacent to lesion In surrounding tissue

84 mrozin,md IDC-Grade I Feeding vessel

85 mrozin,md IDC-GradeII

86 mrozin,md FA

87 mrozin,md FACyst

88 mrozin,md

89

90 Suspicious for Malignancy I.Hard spiculations, thick rim angular margins (shadowing) II.Intermediate hypoechoic microlobulation taller than wide Stavaros

91 mrozin,md III. Soft duct extension branching pattern calcifications Stavaros

92 mrozin,md Most likely benign Oval Circumscribed – echogenic capsule Parallel Abrupt interface Hyperechogenic

93 mrozin,md Algorithm for Sonographic Evaluation 1)Look for malignant findings and if there are any – give BIRADS 4-5 and biopsy 2)If there are NO malignant findings look for benign findings and if there are any give BIRADS 2-3 and suggest follow-up 3)If NO benign findings found – give BIRADS 4A and biopsy

94 mrozin,md Sine Qua Non (without which there is nothing) technique, technique, technique Must always base management on the worst feature present !!!!

95 mrozin,md


Download ppt "Mrozin,md BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers."

Similar presentations


Ads by Google