1. BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND
Dr. Mona Rozin
Director of Breast Imaging
Assuta Medical Centers
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2. Goal of Breast Ultrasound
SOLID VS CYSTIC
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3. Goal of Breast Ultrasound
Make a more specific diagnosis than clinical and mammographic findings alone.
Prevent unnecessary biopsies.
Find cancers missed by mammography.
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4. 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.
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5. 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
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6. BIRADS for U/S BIRAD 1 – normal BIRAD 2 – benign finding
BIRAD 3 – probably benign
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7. 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
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8. Spectrum of masses
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9. Circumscribed vs Spiculated malignant masses – a spectrum of ultrasound features
Desmoplastic vs. inflammatory reaction
Cellularity
III. Vascularity
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10. 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
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11. 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.
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12. 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.
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13. 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.
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15. BIRADS for Ultrasound Masses
Shape
Margin
Orientation
Lesion boundary
Echogenic pattern
Posterior acoustic features
Effect on surrounding parenchyma
Calcifications
Vascularity
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16. Background Breast Pattern
Homogenous Fatty
Heterogeneous – focally or diffusely variable
Homogenous Fibroglandular
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17. Fatty
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18. Heterogeneous
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19. Fibroglandular
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20. I. Shape
Oval – includes tear drop shape macrolobulations may be with thin echogenic capsule
Round – cysts, mets, IDC (high grade)
Irregular – NOT round or oval
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21. Oval
fibroadenoma
DCIS
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22. Round
cyst
DCIS
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23. Irregular
radial scar
IDC
IDC
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24. 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
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25. Circumscribed
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26. 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
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27. Microlobulated
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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
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30. Indistinct
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31. 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 Cooper’s ligaments
Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings
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32. Angular
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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 Cooper’s ligaments
Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings
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35. Spiculated
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36. Mixed
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37. III. Orientation
Parallel – wider than tall – long axis parallel to skin
NOT parallel – taller than wide – long axis perpendicular to skin
includes ROUND masses
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38. TDLU
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39. CA FA
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42. post.
ant.
terminal
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44. Wider than tall !! ant. lobule terminal lobules
distended duct with invasion
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45. 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
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46. Abrupt Interface FA CA
echogenic capsule
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47. 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
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48. Echogenic Rim
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49. Echogenic Rim
Same mass – with & without Sono-CT
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50. 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.
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51. normal fibrotic tisssue
fat necrosis
silicone
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52. hyper?
NOT
hyper with iso mo later
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53. 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.
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55. Mucinous CA
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56. 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.
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57. IDC
seroma FA
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58. 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.
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59. Intracystic papillary CA
phylloides
hematoma
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60. 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.
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61. cysts
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62. 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 haven’t had time to develop desmoplasia or inflammatory reaction
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63. Shadowing
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64. enhancement
normal
cyst CA
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65. DO NOT FORGET -
May see artifactual shadowing from steep Cooper’s ligaments – can be removed with compression !
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66. artifact
compression
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67. DD of Enhancement IDC – high GRADE Mucinous CA Medullary CA
Metaplastic CA
Papillary CA FA
Cysts
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68. DD of Shadowing IDC – low GRADE ILC Tubular CA Scar Fat necrosis
Radial scar
Calcified FA
Calcified oil cysts
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69. VII. Effect on Surrounding Tissue
Straightening of Cooper’s ligaments
Architectural distortion
Skin thickening – normal 2 mm
Skin retraction
Edema – mastitis, radiation Tx, inflammatory CA, CHF
Ducts – abnormal size, branching
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70. Architectural distortion
Thickening & straightening of cooper’s ligaments
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71. VII. Effect on Surrounding Tissue
Straightening of Cooper’s ligaments
Architectural distortion
Skin thickening – normal 2 mm
Skin retraction
Edema – mastitis, radiation Tx, inflammatory CA, CHF
Ducts – abnormal size, branching
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72. Skin thickening
Inflammatory CA
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73. Skin retraction in scar with seroma
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74. VII. Effect on Surrounding Tissue
Straightening of Cooper’s ligaments
Architectural distortion
Skin thickening – normal 2 mm
Skin retraction
Edema – mastitis, radiation Tx, inflammatory CA, CHF
Ducts – abnormal size, branching
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75. Edema with dilated lymphatics
focal edema
Edema with dilated lymphatics
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76. VII. Effect on Surrounding Tissue
Straightening of Cooper’s ligaments
Architectural distortion
Skin thickening – normal 2 mm
Skin retraction
Edema – mastitis, radiation Tx, inflammatory CA, CHF
Ducts – abnormal size, branching
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78. Duct extension
Branch pattern
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79. 2nd lumpectomy with + margin
IDC
Duct extension
2nd lumpectomy with + margin
1st lumpectomy with + margin
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80. VIII. Calcifications Macrocalcifications
Microcalcifications outside a mass
Microcalcifications inside a mass
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81. FA
Oil cyst
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82. IDC
DCIS
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83. IX. Vascularity Absent Present Adjacent to lesion
In surrounding tissue
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84. Feeding vessel
IDC-Grade I
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85. IDC-GradeII
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86. FA
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87. FA
Cyst
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90. Suspicious for Malignancy
Hard spiculations, thick rim angular margins (shadowing)
Intermediate hypoechoic microlobulation taller than wide
Stavaros
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91. III. Soft duct extension branching pattern calcifications
Stavaros
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92. Most likely benign Oval Circumscribed – echogenic capsule Parallel
Abrupt interface
Hyperechogenic
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93. Algorithm for Sonographic Evaluation
Look for malignant findings and if there are any – give BIRADS 4-5 and biopsy
If there are NO malignant findings look for benign findings and if there are any give BIRADS 2-3 and suggest follow-up
If NO benign findings found – give BIRADS 4A and biopsy
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94. (without which there is nothing) technique, technique, technique
Sine Qua Non
(without which there is nothing) technique, technique, technique
Must always base management on the worst feature present !!!!
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95. Thank You !
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