Breast ultrasound lecture for medical only

Breast ultrasonography for medical use especially radiologist

1. Sonographic evaluation of Breast

2. Introduction Probe selection Anatomy Scanning techniques Indications BIRADS Benign vs malignant lesion characteristics

3. Introduction Ultrasound has high sensitivity (95.7%) Sonography is gaining popularity as a screening tool especially in ladies below 40 years so can be regarded as primary imaging modality of choice. Its role in conjunction with mammography is well established fact now. Limitation- calcifications

4. Equipment selection: Transducer 12-18 MHz probe

5. SCRANNING TECHNIQUES- RADIAL APPROACH

6. SCRANNING TECHNIQUES- QAUDRANT APPROACH

7. SCRANNING TECHNIQUES- NOTE LOCATION How would you report this lesions location?

8. Sonographic Breast Anatomy skin, nipple, subareolar tissues subcutaneous region Glandular tissue/ parenchyma retromammary region. Axillary tail

9. BREAST ANATAOMY

10. BREAST ANATOMY

11. Cooper's ligament BREAST ANATOMY

12. BREAST ANATOMY

13. NIPPLE

14. RIBS

15. DUCTS

16. INTRAMAMMARY VESSELS

17. INTRAMAMMARY LYMPH NODE

18. INDICATIONS Symptomatic breast lumps in women aged less than 35 years. Skin or nipple changes Breast lump developing during pregnancy or lactation. Assessment of mammographic abnormality (± further mammographic views) Clinical breast mass with negative mammograms.

19. INDICATIONS Breast inflammation The augmented breast (together with MRI). Breast lump in a male (together with mammography) Dense breasts volpara C +D

20. BI-RADS assessment categories can be summarized as follows: Category 0 - Need additional imaging evaluation Category 1 - Negative Category 2 - Benign finding, noncancerous Category 3 - Probably benign finding, short-interval follow-up suggested Category 4 - Suspicious abnormality, biopsy considered Category 5 - Highly suggestive of malignancy, appropriate action needed Category 6 – Biopsy proven cancer Category 0 is a temporary category that means additional imaging is needed before assigning a permanent BI-RADS assessment category. BI-RADS

21. Simple Cysts Most common masses seen at mammography. Result from dilatation and effacement of the TDLU. Frequently multiple and fluctuate in size on serial examinations.

22. Simple Cysts Mammographic findings: Circumscribed round or oval mass. Ultrasound: Sonographic criteria set forth by Stavros: Anechoic. Well circumscribed with a thin echogenic capsule. Increased through-transmission. Thin edge shadows. BI-RADS 2

23. Simple Cyst

24. Simple Cysts Aspiration may be performed if : Symptomatic. The cyst prevents adequate compression for mammography.

25. Complicated Cysts A cyst that meets all criteria of simple cyst except contains internal echoes or fluid-fluid levels. Appropriate classification of complicated cyst Because there is only a <2% chance of malignancy. Aspiration or short-interval follow-up should be offered. BI-RADS 3

26. Complicated Cyst Breast abscess Galactocele Lipid cyst

27. Thick walls Some discrete solid component Septa greater than 0.5 mm thick Mural nodules. BIRADS 3 or 4 Complex Cyst

28. Simple cyst Complicated cyst Complex cyst Simple cyst Galactocele Hematoma Oil cyst. Galactocele Hematoma Oil cyst. Abscess . Galactocele Hematoma Fat necrosis. Abscess. Necrotic tumor. Papillary tumor. Atypical ductal hyperplasia. DCIS

29. Solid Lesions Benign Malignant Indeterminate

30. Benign Malignant Shape Oval/ellipsoid Variable Alignment Wider than tall; aligned parallel to tissue planes Taller than wide Margins Smooth/thin echogenic pseudocapsule with 2-3 gentle lobulations Irregular or spiculated; echogenic 'halo’ >3 lobulations or microlobulations angular borders Echotexture Variable to intense hyperechogenicity Low-level Marked hypoechogenicity Homogeneity of internal echoes Uniform Non-uniform Lateral shadowing Present Absent Posterior effect Minimum attenuation/posterior enhancement Attenuation with obscured posterior margin Other signs -------------- Calcification Microlobulation Intraductal extension Infiltration across tissue planes and increased echogenicity of surrounding fat

31. Benign Characteristics Round or oval shape Smooth defined borders Uniformly low/medium level internal echoes Through transmission 2-3 gentle lobulations

32. Solid Mass - Malignant Irregular shape Irregular/ill-defined borders Almost anechoic Angular margin Taller than wide

33. Solid Mass - Malignant Irregular shape Irregular/ill-defined borders Almost anechoic Angular margin Taller than wide

34. Solid Mass - Malignant Ductal extension Spiculations

35. BIRADS II BI-RADS Category 2: Mass seen on mammogram proved to be a cyst. Smooth well defined lesion in the right breast. Uniformly hypoechoic, transverse diameter > AP, posterior acoustic enhancement, no micro/ Macro calcifications -

36. BIRADS III BIRADS 3 refers to a lesion that is probably benign. There is an 1.5 cm mass on mammogram. US was recommended and  showed a solid, well-circumscribed parallel mass suggesting  a probably benign lesion. Fibroadenoma

37. BIRADS IV The ultrasound does not show all the features of a fibroadenoma . There is no definite posterior acoustic enhancement. This feature categorizes the lesion in the BIRADS IV category.

38. BIRADS V

39. What BIRADS Score? 17-year-old female with a palpable breast lump

40. What BIRADS Score? 3 years later Changes?

41. What BIRADS Score? 6 months later

42. What BIRADS Score?

43. CLOSE ATTENTION TO BORDERS

44. Correlating Mammography and Ultrasound

45. Correlating Mammography and Ultrasound

46. Correlating Mammography and Ultrasound

47. Correlating Mammography and Ultrasound

48. RIGHT BREAST 5:00 BIRADS score?

49. Scanning Technique Tricks Fremitus Compression Scanning positions Scanning planes/angles Slow flow doppler

50. Fremitus Power Doppler and vocal fremitus to help distinguish solid masses vs normal breast tissue get patient to say " ahhh " very loud not a useful test in superficial lesions or large breasts

51. Scanning techniques – Fremitus

52. Scanning techniques – Fremitus

53. Scanning Pitfall- Fat lobules

54. Scanning Pitfalls- Copper’s Ligaments

55. Scanning Angles

56. Compression Very important to distinguish between ductal debris vs solid lesions within Malignant masses will be less compressible

57. Patient Position

58. Benign pathology that mimic malignant lesions Mastitis Radial scars Fat necrosis

59. Mastitis vs Inflammatory Breast Cancer

60. Dense Breasts- Higher Risk Patient’s with dense breasts have a higher risk of breast cancer