ULTRASOUND OF ULTRASOUND OF BREASTBREAST

By Dr AttiyaBy Dr Attiya

Breast ultrasound uses high-frequency Breast ultrasound uses high-frequency sound waves to map the internal sound waves to map the internal structures of the breast.structures of the breast.

Applications Applications Though ultrasound is successfully used to aid assessment of Though ultrasound is successfully used to aid assessment of

abnormalities detected by mammography, it should not be used abnormalities detected by mammography, it should not be used as a sole modality for screening as ultrasound does not always as a sole modality for screening as ultrasound does not always detect cancers that are visualised mammographically. detect cancers that are visualised mammographically.

Conversely, used in conjunction with mammography, ultrasound Conversely, used in conjunction with mammography, ultrasound can detect clinically and mammographically occult cancers can detect clinically and mammographically occult cancers particularly when there is a higher possibility of cancer.particularly when there is a higher possibility of cancer.

With new high-frequency transducers, it is also possible to detect With new high-frequency transducers, it is also possible to detect malignancy associated with mammographically detected malignancy associated with mammographically detected clustered microcalcifications.clustered microcalcifications.

These lesions may be evident as irregular masses, abnormal These lesions may be evident as irregular masses, abnormal dilated ducts or clustered foci of increased echogenicity with dilated ducts or clustered foci of increased echogenicity with increased Doppler vascularity.increased Doppler vascularity.

ULTRASOUND OF BREASTULTRASOUND OF BREAST

TechniqueTechnique High-quality images of the normal and High-quality images of the normal and

abnormal breast can be obtained with modern abnormal breast can be obtained with modern ultrasound equipmentultrasound equipment. .

Initial examinationInitial examination

– – Machine to patient’s rightMachine to patient’s right

– – Image with right handImage with right hand

– – Operate machine with left hand.Operate machine with left hand.

Patient PositionPatient Position

MEDIAL LESIONSMEDIAL LESIONS patient is supinepatient is supine ipsilateral arm is placed over the patient’s ipsilateral arm is placed over the patient’s

head.head.

LATERAL LESIONSLATERAL LESIONS patient is opposite.patient is opposite.

SUPERIOR LESIONSSUPERIOR LESIONS patient is SITTINGpatient is SITTING

Equipment selection:Equipment selection:

TransducerTransducer At the minimum, a 7.5 At the minimum, a 7.5

MHz linear array probe MHz linear array probe should be used.should be used.

Apply gentle uniform pressure Apply gentle uniform pressure with the ultrasound with the ultrasound transducertransducer

Increase transducer pressure for:Increase transducer pressure for:

– – greater penetrationgreater penetration

– – scanning the subareolar region.scanning the subareolar region.

Scanning is done inScanning is done in three directions.three directions.

1.1. Radial Radial

2.2. Transverse Transverse

3.3. Longitudinal Longitudinal

Localization is by the Localization is by the clock face.clock face.

12

3

66

39

Ultrasound of the BreastUltrasound of the Breast

Recent studies show if strict criteria for Recent studies show if strict criteria for lesion analysis are followed, specificity of lesion analysis are followed, specificity of ultrasound in determining benign or ultrasound in determining benign or malignant reaches 70%.malignant reaches 70%.

All macroscopic breast structures can be easily All macroscopic breast structures can be easily imaged with adequate sonographic equipment.imaged with adequate sonographic equipment.

The breast can be divided into four regions The breast can be divided into four regions skin, nipple, subareolar tissuesskin, nipple, subareolar tissues subcutaneous regionsubcutaneous region parenchymaparenchyma (between the subcutaneous (between the subcutaneous

and retromammary regions)and retromammary regions) retromammary region.retromammary region.

Sonographic Breast Sonographic Breast AnatomyAnatomy

Ultrasound interpretationUltrasound interpretation The The subcutaneous fat layersubcutaneous fat layer is demonstrated is demonstrated

superficially as hypoechoic tissue compared to the superficially as hypoechoic tissue compared to the glandular tissue from which it is separated by a well-glandular tissue from which it is separated by a well-defined scalloped margin.defined scalloped margin.

Normal Normal ducts ducts are often visible, particularly in the are often visible, particularly in the subareolar region, as anechoic tubular structures. subareolar region, as anechoic tubular structures.

Deep to the glandular tissue, Deep to the glandular tissue, a retromammary fat a retromammary fat layerlayer is usually visible and, behind this, the structures is usually visible and, behind this, the structures of the of the chest wallchest wall. .

Sonographic Breast Sonographic Breast AnatomyAnatomy

SkinSkin Subcutaneous fatSubcutaneous fat Cooper’s LigamentsCooper’s Ligaments Breast parenchymaBreast parenchyma Retromammary fatRetromammary fat Pectoralis musclePectoralis muscle RibsRibs PleuraPleura NippleNipple

Cooper's ligamentskin

fibroglandular tissue

Nipple

• Consists of both denseconnective tissue andconnective tissue ofthe duct which cancause posterioracoustic shadowing

Ribs• Easily identified bone attenuates causing an acoustic shadow

Duct• Tubular branchingstructures

Ultrasound showing dilated ducts (lactating)The duct appears as branching hypoechoic structure within echogenic glandular tissue.

Intramammary vessel running branching under the skin.

Lymph Node

• Solid nodule• Ovoid• Echogenic fatty hilum

INDICATIONSINDICATIONS

Symptomatic breast lumps in women aged less than 35 Symptomatic breast lumps in women aged less than 35 years.years.

Breast lump developing during pregnancy or lactation.Breast lump developing during pregnancy or lactation. Assessment of mammographic abnormality (± further Assessment of mammographic abnormality (± further

mammographic views)mammographic views) Assessment of MRI or scintimammography detected Assessment of MRI or scintimammography detected

lesions.lesions. Clinical breast mass with negative mammograms.Clinical breast mass with negative mammograms. Breast inflammation.Breast inflammation. The augmented breast (together with MRI).The augmented breast (together with MRI). Breast lump in a male (together with mammography).Breast lump in a male (together with mammography). Guidance of needle biopsy or localisation.Guidance of needle biopsy or localisation. Follow-up of breast cancer treated with adjuvant Follow-up of breast cancer treated with adjuvant

chemotherapy.chemotherapy.

INDICATIONSINDICATIONS

The original role of breast sonography is in The original role of breast sonography is in the differentiation of the differentiation of cysticcystic and and solidsolid lesions. lesions.

Ultrasound complements both clinical Ultrasound complements both clinical examination and mammography.examination and mammography.

It is also successfully used as a 'second-look' It is also successfully used as a 'second-look' procedure where an abnormality has been procedure where an abnormality has been identified using MRI or scintimammography.identified using MRI or scintimammography.

INDICATIONSINDICATIONS Because it does not use ionising radiation, it is Because it does not use ionising radiation, it is

the examination of choice in young women and the examination of choice in young women and is valuable in the assessment of the is valuable in the assessment of the mammographically mammographically `̀dense'dense' breast. breast.

Ultrasound plays an important role in the triple Ultrasound plays an important role in the triple assessment of symptomatic lesions. assessment of symptomatic lesions.

Being the only `real-time' imaging modality also Being the only `real-time' imaging modality also means it can be used to accurately localise or means it can be used to accurately localise or biopsy breast lesions. biopsy breast lesions.

Breast Ultrasound andBreast Ultrasound andMammographic CorrelationMammographic Correlation

Dense breast

Fatty breast

The echotexture of any lesion is compared The echotexture of any lesion is compared relative to the echotexture of the relative to the echotexture of the intramammary fat.intramammary fat.

CystsCysts are typically well-defined rounded are typically well-defined rounded anechoic lesions with posterior acoustic anechoic lesions with posterior acoustic enhancement, though the presence of debris enhancement, though the presence of debris can increase the overall internal echogenicity. can increase the overall internal echogenicity.

Wall thickening, irregularity or mural nodules Wall thickening, irregularity or mural nodules should be treated with suspicion and should be treated with suspicion and aspiration should be performed. aspiration should be performed.

Simple Cysts– anechoic– smooth, thin margins– posterior acousticenhancement

In practice, In practice, needle biopsyneedle biopsy should be performed as should be performed as part of triple assessment in the presence of a discrete part of triple assessment in the presence of a discrete solid mass. solid mass.

Not all breast pathology presents as a discrete lesion. Not all breast pathology presents as a discrete lesion. Inflammatory or lobular cancers may present as areas Inflammatory or lobular cancers may present as areas of scattered indeterminate attenuation.of scattered indeterminate attenuation.

The use of colour and power Doppler can also aid in The use of colour and power Doppler can also aid in benign-malignant differentiation of solid masses. benign-malignant differentiation of solid masses.

In general, malignant masses tend to show an In general, malignant masses tend to show an increased number of vessels that penetrate deep into increased number of vessels that penetrate deep into the tumour with a branching morphology.the tumour with a branching morphology.

Breast UltrasoundBreast UltrasoundImaging CharacteristicsImaging Characteristics sizesize shapeshape border definitionborder definition internal echogenicityinternal echogenicity posterior enhancementposterior enhancement architectural changesarchitectural changes

Analytic CriteriaAnalytic Criteria

• • MarginsMargins

• • Retrotumoral acoustic phenomenaRetrotumoral acoustic phenomena

• • Internal echo patternInternal echo pattern

• • EchogenicityEchogenicity

• • Compression effect on Compression effect on SHAPESHAPE

• • Compression effect on Compression effect on INTERNAL INTERNAL ECHOESECHOES

Benign CharacteristicsBenign Characteristics

Ellipsoid shapeEllipsoid shape Thin definable Thin definable

capsulecapsule Two or three Two or three

lobulationslobulations Hyperechogenicity.Hyperechogenicity.

Solid Mass - MalignantSolid Mass - Malignant

• Irregular shape• Irregular/ill-defined borders• Almost anechoic• Angular margin• Taller than wide

Irregular shape• Irregular/ill-defined borders• Almost anechoic• Thick echogenic rim• Posterior shadowing

BenignBenign MalignantMalignantShapeShape Oval/ellipsoidOval/ellipsoid VariableVariable

AlignmentAlignment Wider than deep; aligned parallel to Wider than deep; aligned parallel to tissue planestissue planes

Deeper than wideDeeper than wide

MarginsMargins Smooth/thinSmooth/thin

echogenic pseudocapsule withechogenic pseudocapsule with

2-3 gentle lobulations2-3 gentle lobulations

Irregular or spiculated; echogenic 'halo'Irregular or spiculated; echogenic 'halo'

EchotextureEchotexture Variable to intense Variable to intense hyperechogenicityhyperechogenicity

Low-levelLow-levelMarked hypoechogenicityMarked hypoechogenicity

Homogeneity of Homogeneity of internal echoesinternal echoes

UniformUniform Non-uniformNon-uniform

Lateral Lateral shadowingshadowing

PresentPresent AbsentAbsent

Posterior effectPosterior effect Minimum attenuation/posterior Minimum attenuation/posterior enhancementenhancement

Attenuation with obscured posterior Attenuation with obscured posterior marginmargin

Other signsOther signs ---------------------------- CalcificationCalcificationMicrolobulationMicrolobulationIntraductal extensionIntraductal extensionInfiltration across tissue planes and increasedInfiltration across tissue planes and increasedechogenicity of surrounding fatechogenicity of surrounding fat

A typical fibroadenoma with homogeneous internal echoes with an ovoid shape and

circumscribed margins -- benign. There is posterior acoustic enhancement..

A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.

An invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.

Inflammatory breast cancer with secondary signs.increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.

A power Doppler image of an invasive grade 3 breast cancer.

irregular tortuous and branching vessels penetrating into the centre of the lesion.

The sonographic pattern varies with age The sonographic pattern varies with age and individually, and depends on the and individually, and depends on the amount and type of contents, i.e. fat, amount and type of contents, i.e. fat, fibrous and glandular tissues. fibrous and glandular tissues.

The fibrous and glandular components The fibrous and glandular components are variably echogenic, while fat is are variably echogenic, while fat is hypoechoic.hypoechoic.

Benign ??Benign ??Malignant ??Malignant ??

Benign vs. MalignantBenign vs. Malignant

Benign ??Benign ??Malignant??Malignant??

THANKYOUTHANKYOU