mrozin,md benign vs malignant masses in breast ultrasound dr. mona rozin director of breast imaging...
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BENIGN VS MALIGNANT MASSES IN BREAST
ULTRASOUND
Dr. Mona RozinDirector of Breast Imaging
Assuta Medical Centers
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Goal of Breast Ultrasound
SOLID VS CYSTIC
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Goal of Breast Ultrasound
• Make a more specific diagnosis than clinical and mammographic findingsalone.
• Prevent unnecessary biopsies.• Find cancers missed by mammography.
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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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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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BIRADS for U/S
BIRAD 1 – normal
BIRAD 2 – benign finding
BIRAD 3 – probably benign
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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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Spectrum of masses
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Circumscribed vs Spiculated malignant masses – a
spectrum of ultrasound features
I. Desmoplastic vs. inflammatory reaction
II. Cellularity
III. Vascularity
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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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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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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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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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BIRADS for Ultrasound Masses
I. ShapeII. MarginIII. OrientationIV. Lesion boundaryV. Echogenic patternVI. Posterior acoustic featuresVII. Effect on surrounding
parenchymaVIII.Calcifications IX. Vascularity
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Background Breast Pattern
• Homogenous Fatty• Heterogeneous – focally or
diffusely variable• Homogenous Fibroglandular
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Fatty
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Heterogeneous
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Fibroglandular
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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
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Oval
fibroadenoma
DCIS
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Round
cyst
DCIS
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Irregular
IDC
IDC
radial scar
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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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Circumscribed
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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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Microlobulated
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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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Indistinct
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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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Angular
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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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Spiculated
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Mixed
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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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TDLU
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CA
FA
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ant.post. terminal
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Wider than tall !!
ant. lobule
terminal lobulesdistended duct
with invasion
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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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Abrupt Interface
echogenic capsule
FA CA
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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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Echogenic Rim
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Echogenic Rim
Same mass – with & without Sono-CT
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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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normal fibrotic tisssue
siliconefat necrosis
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hyper with iso 4 mo later
hyper?
NOT
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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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Mucinous CA
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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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IDC
seroma
FA
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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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hematoma
phylloides
Intracystic papillary CA
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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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cysts
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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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Shadowing
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enhancement
normal
CA
cyst
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DO NOT FORGET - May see artifactual shadowing from
steep Cooper’s ligaments – can be removed with compression !
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artifact
compression
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DD of Enhancement
1) IDC – high GRADE2) Mucinous CA3) Medullary CA4) Metaplastic CA5) Papillary CA
6) FA7) Cysts
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DD of Shadowing
1) IDC – low GRADE2) ILC3) Tubular CA
4) Scar5) Fat necrosis6) Radial scar7) Calcified FA8) Calcified oil cysts
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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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Architectural distortion
Thickening & straightening of cooper’s ligaments
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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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Inflammatory CA
Skin thickening
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Skin retraction in scar with seroma
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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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focal edema
Edema with dilated lymphatics
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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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Duct extension
Branch pattern
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IDC
1st lumpectomy with + margin
2nd lumpectomy with + margin
Duct extension
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VIII. Calcifications
• Macrocalcifications • Microcalcifications outside a
mass• Microcalcifications inside a mass
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FAOil cyst
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IDC
DCIS
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IX. Vascularity
• Absent • Present• Adjacent to lesion• In surrounding tissue
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IDC-Grade I
Feeding vessel
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IDC-GradeII
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FA
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FA Cyst
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Suspicious for Malignancy
I. Hard spiculations, thick rim angular margins (shadowing)
II. Intermediate hypoechoic microlobulation taller than wide
Stavaros
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III. Soft duct extension branching pattern calcifications
Stavaros
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Most likely benign
• Oval• Circumscribed – echogenic
capsule• Parallel• Abrupt interface• Hyperechogenic
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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
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Sine Qua Non (without which there is nothing) technique, technique, technique
Must always base management on the worst feature present !!!!
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