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Solid Nodules

Cindy Rapp BS, RDMS, FAIUM, FSDMS

National Sales ManagerCanon Medical

Disclosure

Employee – Canon Medical

Pathologic Results Type of CA

IDC (81.6%)

first, seek malignant findings– if present, classify as malignant– if absent.....

then look for benign findings– if present, classify as benign– if absent.....

then classify as indeterminate

Sonography of Solid Breast Nodulesmethods (old 750 nodules)

Sonography of Solid Breast Nodulesurface characteristics

scan entire surface of nodule in 2 planes ..…surface characteristics heterogeneous

if mixture of benign and malignant surface findings……exclude nodule from benign classification.

Breast Cancer is Heterogeneous

from nodule to nodule often within a single nodule

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Circumscribed• cellular• high grade• inflammatory hr• enhanced transmission• Doppler +• elastography -

Spiculated• paucicellular• low grade• desmoplastic• shadowing• Doppler -• elastography +

Breast Cancer is Heterogeneous

...and mixed circumscribed& spiculated between ...

solid breast nodulescomplex spectrum of gross morphology for both benign and

malignant nodules that overlap extensively

single criterion -- high true negatives, high false negativesa single finding cannot identify a group of benign nodules

with an acceptable false negative rate

= bx’s prevented

= false negatives

need to havefalse negative rate of < 2%

When enough findings have been added to the algorithm to achieve a false negative rate of 2% or less, follow-up option can be offered.

=

Carlsbad Caverns

spiculation angular margins acoustic shadowing microlobulation taller-than-wide hypoechogenicity duct extension branch pattern calcifications

BUS algorithm for evaluation of solid breast nodules – step 1 –

search for suspicious findings

“hard” findingsinvasive

“soft” findingsDCIS

“nonspecific” findingsinvasive &/or DCIS

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Malignant Findingspiculation

“hard finding”

Spiculation“hard finding”

Breast Cancer can be heterogeneous within nodule

only part of surface may be spiculated

Spiculation

alternating hypoechoic and hyperechoic spiculesTabar

magnification helps evaluate surface characteristics

variant of spiculations = thick, echogenic halo

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thick, echogenic halohalo thicker on edges ,

Variant of Spiculations

less apparent ant. and post.

thick, echogenic halo = unresolved spiculationssame lesion, same examination

Malignant Findingangular margins

“hard finding”

Angular Margins

long trans

CA can be heterogeneous within a single nodule-- even circumscribed carcinomas have some --

angular and/or microlobulated margins.

1) cannot simply look at 2 “random slices” through nodule

2) must scan entire surface and volume of nodule in 2 planes (radial and anti-radial)

3) if mixture of benign and malignant findings, ignore benign findings

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radial

anti- radial

angular margins – heterogeneous within one nodule

A

AB

B

Angular Margins

Angular Margins

paths oflow resistance to

invasion

in bases of

Cooper’s ligaments

Malignant Findingmicrolobulation

“invasive or DCIS”

fingers of invasive tumor intraductal components cancerized lobules

Microlobulationmicrolobulation margins

invasive fingers of tumor

1) angular 2) associated with thick haloTabar

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**

* *

microlobulation marginsDCIS components of tumor

**

*

*

85% of ductal CA is mixed invasive and DCIS1) invasive cords central (I) 2) DCIS peripheral (*)

(I)

microlobulation marginscancerized lobules

Microlobulation Sizerelated to tumor grade

LNG DCISsmall microlobulations

HNG DCISlarge lobulations

Malignant Finding“taller-than-wide”

James Bond Island – Phuket Thailand

Malignant Finding“taller-than-wide”

FAFA CACA

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Wider-than-tall Taller-than-wide

Benign Malignant

theories about why malignant nodules are taller-than-wide

growth across tissue planes lack of rotation of fixed malignant nodules only measuring central nidus incompressibility of malignant nodules reflection of axis of orientation of the TDLU in

which a small CA arose

Spread of Cancer

1 2

= cancerization of lobules= Pagetoid spread

typical small carcinomas of breast arising from…

Posterior TDLU - 2 Anterior TDLU - 1 Terminal TDLU - 3

taller-than-widea feature of small malignant nodules,

not of large malignant nodules

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Malignant Findingduct extension

Duct Extensionextensive intraductal components

important not just for dx, but staging and rx

Malignant Findingbranch pattern

branch pattern – “soft” finding

isolated duct extension or branch pattern indicates benign IDP 87% of time…

…but 6% are DCIS and another 7% ADH……therefore, cannot qualify for BIRADS 3 !

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Malignant Findingacoustic shadowing

“hard finding”

Acoustic Shadowing hard finding

proportional to degree of desmoplasia

complete shadowing partial shadowing

IDC histologic gradevs. sound transmission

BRS grade 3 (I) BRS grade 9 (III)

sound transmission in 409 solid malignant nodules

acoustic shadowing (complete or partial) 35%

normal through transmission 32%

enhanced through transmission 28%

mixed sound transmission 5%

TOTAL 100%

enhanced through transmission

HNG DCIS

= poor man’s CDIindicates cellular,

metabolically active lesions

acoustic shadowing & enhanced transmission are features of special type tumors as well as indicators

of histologic grade

shadowing (diff dx)– low grade IDC– invasive lobular CA– tubular CA (> 1.5 cm)

enhanced (diff dx)– high grade IDC– colloid CA (>1.5 cm)– medullary CA– invasive papillary CA

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Malignant Findingcalcification“soft finding”

Malignant Findingcalcification

mixed IDC and DCIS

Malignant Findingmarkedly hypoehoic*

* vs.fat

Malignant Findingmarkedly hypoechoic

hypoechogenicity intermediate finding

compared to fat

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hypoechogenicitydependent upon dynamic range

isoechoic at 90 dB

hypoechoic at 69 dB

Malignant Findingssensitivity

in order of sensitivity

individual findings have low to moderately good sensitivity

98.4 % of cancers detected because ....... the average malignant nodules cancer had 5.3 malignant findings.

benign grouped findingssought only if no suspicious findings1 of 3 must be present for BIRADS 3

Benign Findings

Benign Findings

marked hyperechogenicity ellipsoid shape 2 or 3 gentle lobulations thin echogenic capsule

* Must combine complete thin capsule with shapes to avoid missing pure DCIS & circumscribed invasive CA

Benign Findinghyperechogenicity

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hyperechogenicity must be purely hyperechoic

no isoechoic areas larger than ducts

purely hyperechoic not purely hyperechoic

Benign Findinghyperechogenicity

hyperechogenicity must be purely hyperechoic

can be no isoechoic areas larger than ducts

palpable lumpnot purely hyperechoic

4 months later

13 mm mammographic nodule

not purely hyperechoic – tangential image thru halo

Benign Findingelliptical shape

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Benign Findingelliptical shape Benign Finding

2 or 3 gentle lobulations

Benign Finding2 or 3 gentle lobulations

Benign Findingstear-drop shape

Benign Findingthin, echogenic pseudocapsule

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Benign Findingthin, echogenic pseudocapsule

use lighter scan pressure to show capsule

normal scan pressure light pressure

lighter scan pressure to show capsule bettermay lead to artifactual shadowing

need a combination of light and heavy scan pressure

“heeling and toeing” thetransducer to show the capsule on the ends of

lesions

circumscribed cancers can have thin, echogenic capsules…but capsule is either incomplete or shape is not elliptical

or gently lobulated, wider-than-tall…

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in order of NPV

we have never seen a purely hyperechoic CA !!!

Benign Findingsnegative predictive value

left palpable lump – pure fibrous tissue?lesion too superficial need standoff

Not pure fibrous tissueVolume averaging

normal sonographic lymph node appearancereniform appearance – but thinner cortex

long axis short axis

range of normal sonographic LN appearances

late

abnormal LN’shandle FB’s differently from tumor/infection

FB’s accumulate from medullary sinusoids outwardly

early

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metastasisfrom cortical sinusoids in

siliconefrom medullary sinusoids out

abnormal lymph nodesforeign bodies vs. tumor

range of abnormal sonographic LN appearances

malignant LN’sgrossly abnormal LN right next to morphology WNL LN

LN distributionright to left asymmetry favors mets

WNL or benign LNa single feeding artery

color Doppler of LN metastasestranscapsular feeding vessels

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Sonography of Solid Breast Nodules

patient chooses follow-up in 3 of every 5 cases

radiologist does not make decision about whether a solid, benign breast nodule is biopsied.

patient is told that we cannot be 100% sure the lesion is benign, but that we are more than 98% sure it is benign.

She is told she has 3 choices…

1. follow-up ultrasound in 6 months*

2. large core needle or vacuum assisted biopsy3. excisional biopsy