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BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND. Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers. Goal of Breast Ultrasound. SOLID VS CYSTIC. Goal of Breast Ultrasound. Make a more specific diagnosis than clinical and mammographic findings alone.

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benign vs malignant masses in breast ultrasound

BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND

Dr. Mona Rozin

Director of Breast Imaging

Assuta Medical Centers

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goal of breast ultrasound
Goal of Breast Ultrasound

SOLID VS CYSTIC

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goal of breast ultrasound1
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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slide4
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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slide5
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
BIRADS for U/S

BIRAD 1 – normal

BIRAD 2 – benign finding

BIRAD 3 – probably benign

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birads for u s1
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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circumscribed vs spiculated malignant masses a spectrum of ultrasound features
Circumscribed vs Spiculated malignant masses – a spectrum of ultrasound features
  • Desmoplastic vs. inflammatory reaction
  • Cellularity

III. Vascularity

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desmoplastic reaction
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
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
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
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
BIRADS for Ultrasound Masses
  • Shape
  • Margin
  • Orientation
  • Lesion boundary
  • Echogenic pattern
  • Posterior acoustic features
  • Effect on surrounding parenchyma
  • Calcifications
  • Vascularity

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background breast pattern
Background Breast Pattern
  • Homogenous Fatty
  • Heterogeneous – focally or diffusely variable
  • Homogenous Fibroglandular

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fatty
Fatty

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heterogeneous
Heterogeneous

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i shape
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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slide21
Oval

fibroadenoma

DCIS

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round
Round

cyst

DCIS

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irregular
Irregular

radial scar

IDC

IDC

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ii margin
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
Circumscribed

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ii margin1
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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ii margin2
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
Indistinct

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margin cont
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
Angular

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margin cont1
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
Spiculated

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mixed
Mixed

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iii orientation
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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slide38
TDLU

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slide39

CA

FA

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slide42

post.

ant.

terminal

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wider than tall
Wider than tall !!

ant. lobule

terminal lobules

distended duct with invasion

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iv lesion boundary
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
Abrupt Interface

FA

CA

echogenic capsule

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iv lesion boundary1
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
Echogenic Rim

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echogenic rim1
Echogenic Rim

Same mass – with & without Sono-CT

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v echogenic pattern
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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slide51

normal fibrotic tisssue

fat necrosis

silicone

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slide52

hyper?

NOT

hyper with iso 4 mo later

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v echogenic pattern1
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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slide55

Mucinous CA

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v echogenic pattern2
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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slide57

IDC

seroma

FA

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v echogenic pattern3
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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slide59

Intracystic papillary CA

phylloides

hematoma

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v echogenic pattern4
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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slide61

cysts

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vi posterior acoustic features
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
Shadowing

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slide64

enhancement

normal

cyst

CA

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slide65
DO NOT FORGET -

May see artifactual shadowing from steep Cooper’s ligaments – can be removed with compression !

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slide66

artifact

compression

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dd of enhancement
DD of Enhancement
  • IDC – high GRADE
  • Mucinous CA
  • Medullary CA
  • Metaplastic CA
  • Papillary CA
  • FA
  • Cysts

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dd of shadowing
DD of Shadowing
  • IDC – low GRADE
  • ILC
  • TubularCA
  • Scar
  • Fat necrosis
  • Radial scar
  • Calcified FA
  • Calcified oil cysts

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vii effect on surrounding tissue
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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slide70

Architectural distortion

Thickening & straightening of cooper’s ligaments

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vii effect on surrounding tissue1
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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slide72

Skin thickening

Inflammatory CA

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vii effect on surrounding tissue2
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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slide75

focal edema

Edema with dilated lymphatics

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vii effect on surrounding tissue3
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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slide78

Duct extension

Branch pattern

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slide79

IDC

Duct extension

2nd lumpectomy with + margin

1st lumpectomy with + margin

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viii calcifications
VIII. Calcifications
  • Macrocalcifications
  • Microcalcifications outside a mass
  • Microcalcifications inside a mass

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slide81

FA

Oil cyst

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slide82

IDC

DCIS

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ix vascularity
IX. Vascularity
  • Absent
  • Present
  • Adjacent to lesion
  • In surrounding tissue

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slide84

Feeding vessel

IDC-Grade I

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slide85

IDC-GradeII

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slide86

FA

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slide87

FA

Cyst

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suspicious for malignancy
Suspicious for Malignancy
  • Hard spiculations, thick rim angular margins (shadowing)
  • Intermediate hypoechoic microlobulation taller than wide

Stavaros

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slide91
III. Soft duct extension branching pattern calcifications

Stavaros

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most likely benign
Most likely benign
  • Oval
  • Circumscribed – echogenic capsule
  • Parallel
  • Abrupt interface
  • Hyperechogenic

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algorithm for sonographic evaluation
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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slide94
Sine Qua Non

(without which there is nothing) technique, technique, technique

Must always base management on the worst feature present !!!!

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slide95

Thank You !

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