Sonography 2014 - Breast Ultrasound

BREAST ULTRASOUND
LOUIS J. MANQUEN M.D.
Director of Breast Imaging
Advocate-Condell Medical Center
BREAST ULTRASOUND:
FROM THE BASICS, TO THE
ADVANCED…AND A LOOK INTO
THE FUTURE!!
INDICATIONS FOR BREAST
ULTRASOUND
• ADJUNCT TO MAMMOGRAPHY(DIAGNOSTIC)
• EVALUATE WOMEN WHO ARE PREGNANT,
LACTATING OR LESS THAN 30 Y.O.
• EVALUATE SYMPTOMS (I.E LUMPS, PAIN)
• GUIDE BIOPSIES AND OTHER PROCEDURES
ADDITIONAL INDICATIONS
• 2ND look US after abnormal Breast MRI
• Abnormal nipple discharge
• Suspected gynecomastia in men
• Suspected breast abscess/infection
• Screening for breast cancer????
BENEFITS OF BREAST
ULTRASOUND
• NO IONIZING RADIATION
• WELL TOLERATED BY PATIENTS
• RELATIVE LOW COST
• LESS TIME CONSUMING THAN MRI OR
MOLECULAR BREAST IMAGING
DISADVANTAGES OF BREAST
ULTRASOUND
• OPERATOR SKILL DEPENDENCE
• LIMITED DETECTION OF D.C.I.S./CA++
• HIGH FALSE POSITIVES/BIOPSY RATES
• POOR REPRODUCIBILTY BETWEEN DIFFERENT
EXAMINERS AND FACILITIES
TECHNICAL FACTORS
• LINEAR TRANSDUCER, CENTER OF
FREQUENCY(>12MHZ), 192-256 ELEMENTS
• TISSUE HARMONICS AND SPATIAL
COMPOUNDING- improves contrast resolution
• DOPPLER-color, Power and spectral
quantitative analysis-not mandatory
TECHNICAL FACTORS
• TISSUE HARMONICS:
Filters out harmonic frequencies that are
created when the US pulse is distorted as it
passes through breast tissue.
- Improves contrast resolution(esp. between fat
and subtle lesions)
- Decreases reverberation artifacts in cysts
TECHNICAL FACTORS
• SPATIAL COMPOUNDING:
Electronic beam steering forming multiple
images from different angles. One composite
image created by averaging frames.
- Reduces artifactual echos, speckles and
-
spurious noise
Improve contrast resolution; lateral edges
Improves resolution of mCa++
THE PATIENT EXAM
• Supine positioning with the are raised on the
side being examined.
• Slight elevation on the side for lateral/axillary
lesions.
• Observe for breast scars, dimpling, bruises,
skin lesions and for symmetry.
THE PATIENT EXAM
-Depth set to see pectoralis m. during the
initial scan.
-Gain set so that fat is mid gray.
-Multiple focal zones, decreases frame rate.
-Single zone when an abnormality is being
evaluated.
NORMAL ANATOMY
• SKIN-white
• FAT LOBULES-gray
• COOPERS LIGAMENTS-white
• FIBROGLANDULAR TISSUE-white
• DUCTS-not visible or black if dilated
• CHEST WALL-ribs white with shadowing
• FASCIA-white
NORMAL BREAST ANATOMY
NORMAL BREAST ANATOMY
FATTY BREAST PATTERN
MIXED FIBROGLANDULAR
PATTERN
DENSE FIBROGLANDULAR
SUBAREOLAR REGION AND
DUCTS
WHAT IS THE ANATOMIC
STRUCTURE DEPICTED?
ULTRASOUND-MAMMOGRAPHIC
CORRELATION
• CLOCK LOCATION
• DEPTH RELATIVE TO THE SKIN AND CHEST
•
•
•
WALL OR DISTANCE FROM NIPPLE
USE OF INTRINSIC LANDMARKS
US SIZE TO MAMMOGRAPHIC LESION- NO
MORE THAN 20% US DIAMETER.
MAMMOGRAPHIC SHAPE SHOULD CORRELATE
WITH US SHAPE
CLOCKFACE
MAMMO-US CORRELATION
MAMMO-US CORRELATION
BENIGN VS MALIGNANT MASSES
• LANDMARK STUDY BY STAVROS ET AL,
RADIOLOGY. JUL1995;196(1): 123-34
• PROSPECTIVELY CLASSIFIED LESIONS AS
BENIGN OR MALIGNANT
• USED SPECIFIC US CRITERIA TO CLASSIFY
LESIONS
STAVROS PROPOSED US
CRITERIA FOR SOLID NODULES
• 3 CATEGORIES: B9, INDETERMINATE
AND MALIGNANT
• DEFINITION FOR B9 NODULE: NO
MALIGNANT FEATURES AND AT LEAST 1
B9 CHARACTERISTIC
CRITERIA FOR SOLID NODULES,
CONT.
• BENIGN FEATURES:
- INTENSE UNIFORM HYPERECHOGENICITY
- ELLIPSOID/WIDER THAN TALL(PARALLEL)
WITH A THIN ECHOGENIC CAPSULE
- 2-3 GENTLE LOBULATIONS
CRITERIA FOR SOLID NODULES,
CONT.
• MALIGNANT FEATURES:
-SPICULATED
-TALLER THAN WIDE
-ANGULAR MARGINS
-MARKED HYPOECHOGENICITY
-POSTERIOR ACOUSTIC SHADOWING
-PUNCTATE CALCIFICATIONS
-MICROLOBULATIONS
-DUCT EXTENSION AND BRANCH PATTERN
RESULTS OF STUDY-1995
• 750 Solid Breast Lesions:
-625 B9 and 125 Malignant
• 98.4 Sensitivity
• 99.5% Negative Predictive Value
INDENTIFICATION AND
DESCRIPTION OF BREAST LESIONS
ACR BIRADS-US LEXICON
• HELPS TO STANDARDIZE ULTRASOUND
TERMINOLOGY FOR CHARACTERIZING AND
REPORTING BREAST LESIONS
• DESCRIBES 7 ASSESSMENT CATEGORIES
US LEXICON CLASSIFICATION
• MASSES
-SHAPE: OVAL, ROUND, IRREGULAR
-ORIENTATION: PARALLEL/NON-PARALLEL
“TALLER THAN WIDE”
-MARGIN: CIRCUMSCRIBED, SPICULATED
INDISTINCT,ANGULAR, MICROLOBULATED
US LEXICON CLASSIFICATION
• MASSES
- BOUNDARY: ABRUPT, ECHOGENIC HALO
- ECHOPATTERN: ISO/ANECHOIC,
HYPOECHOIC, HYPERECHOIC, COMPLEX
- POSTERIOR ACOUSTIC FEATURES:
SHADOWING, ENHANCEMENT, COMBINED
NO POSTERIOR ACOUSTIC FEATURES
THE ULTRASOUND OF BREAST
CANCER
• CONFIRM AND BETTER CHARACTERIZE A
SUSPICIOUS BREAST LESION
• FIND ADDITIONAL LESIONS
• EVALUATE THE AXILLA
• HELP GUIDE A NEEDLE BIOPSY
DUCTAL CARCINOMA IN SITU
(D.C.I.S.)
INVASIVE DUCTAL AND LOBULAR
CARCINOMA
FINDINGS IN BREAST CANCER
• ECHOPATTERN:
- USUALLY HETEROGENEOUS
- MOSTLY HYPOECHOIC
- SOMETIMES MARKEDLY HYPOECHOIC
FINDINGS IN BREAST CANCER
• LESION CHARACTERISTICS
-SHAPE:
COMMON- IRREGULAR
UNCOMMON- CIRCUMSCRIBED
-MARGINS: SPICULATED, ANGULAR,
MICROLOBULATED, INDISTINCT
FINDINGS IN BREAST CANCER
• ORIENTATION:
-TALLER THAN WIDE
• POSTERIOR ACOUSTIC FEATURES:
- OFTEN CAUSES SHADOWING
• BOUNDARY:
ECHOGENIC HALO
FINDINGS IN BREAST CANCER
• VASCULARITY: VARIABLE/INCREASED
• MICROCALCIFICATIONS
• INVADES ADJACENT FASCIAL PLANES
OR EXTENDS INTO DUCTS
• INCREASED STIFFNESS/STRAIN PATTERN
BREAST CANCER
BREAST CANCER
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INVASIVE DUCTAL CARCINOMA
INTRACYSTIC PAPILLARY
CARCINOMA
METAPLASTIC CARCINOMA
MEDULLARY CARCINOMA
MUCINOUS CARCINOMA
SUBTLE INVASIVE DUCTAL
CANCER
VERY SMALL INVASIVE DUCTAL
CANCER
VERY SMALL INVASIVE DUCTAL
CANCER
LARGE INVASIVE CARCINOMA
PALPABLE LUMP
NEW PALPABLE LUMP
LARGE INVASIVE DUCTAL CA
MULTIPLICITY OF LESIONS
• 5-10% OF BREAST CANCERS ARE EITHER
MULTICENTRIC OR MULTIFOCAL
• 2-4% HAVE CANCER FOUND IN THE
CONTRALATERAL BREAST
• ULTRASOUND CAN BE USED TO FIND
ADDITIONAL LESIONS
THE AXILLA
• WHEN A SUSPICIOUS BREAST LESION IS FOUND
LOOK IN THE AXILLA
- LOOK FOR ABNORMAL LYMPH NODES:
1) THE LYMPH NODE LOSES ITS
NORMAL OVOID SHAPE
2) THE CORTEX BECOMES IRREGULAR
AND THICK(>3mm)
3) THE HILUS IS EFFACED OR REPLACED
4) PENETRATING NON-HILAR VASCULARITY
PATIENT POSTIONING FOR
ULTRASOUND OF AXILLA
NORMAL LYMPH NODE
NORMAL LYMPH NODE
ABNORMAL LYMPH NODE
ABNORMAL LYMPH NODE
BREAST CANCER AND
ABNORMAL LYMPH NODE
BENIGN OR PROBABLY BENIGN
LESIONS
• FIBROADENOMAS/FIBROEPITHELIAL LESIONS
• CYSTS-SIMPLE AND COMPLICATED
• MICROCYSTIC NODULES
• LYMPH NODES
• SEBACEOUS AND EPIDERMAL INCLUSION
•
•
•
CYST/GALACTOCELES
HAMARTOMAS
FAT NECROSIS
HEMATOMA/SEROMA/ABSCESS
SIMPLE CYST
COMPLICATED CYST
FIBROADENOMA
FIBROADENOMA
GROUP OF MICROCYSTS
SEBACEOUS OR EPIDERMAL
INCLUSION CYSTS
FAT NECROSIS
GALACTOCELE AND ABSCESS
PHYLLOIDES TUMOR
INTRADUCTAL PAPILLOMA
… TO THE ADVANCED
AUTOMATED WHOLE BREAST US
- SCANS ENTIRE BREAST VOLUME
- LARGE FIELD OF VIEW TRANSDUCER
- 3D, FAST, NOT SONOGRAPHER DEPENDENT
ELASTOGRAPHY
- MEASURES ‘STIFFNESS’ OF BREAST LESIONS
- HELPS TO DIFFERENTIATE SOLID VS CYSTIC
- AN ADDITIONAL TOOL, SIMILAR TO COLOR
DOPPLER
AUTOMATED WHOLE BREAST
ULTRASOUND-FOR SCREENING?
Breast Density and
Intermediate Risk Women
• Screening breast US is currently not considered
standard of care.
• Increases in breast density decreases the
mammographic detection of cancer and has
been attributed to an increase risk for
developing breast cancer.
WHOLE BREAST SCREENING
ULTRASOUND
BREAST DENSITY REPORTING LAWS:
• Several states have enacted or considering laws
requiring Radiologists to inform women
of their mammographic breast density and
supplemental screening tests such as US or
MRI.(Conn., CA and Texas).
• H.R. 3102 –October 2011. Proposed Federal
Law that died in Congress!
ARE YOU DENSE ADVOCACY, INC
• The story of Nancy Cappello, PhD
• Connecticut resident diagnosed with
•
•
advanced breast Ca in 2003 after a normal
screening mammogram.
Told by her doctor she had ‘extremely dense
breast tissue’.
Worked with Conn. state Senators to pass 1st
breast density notification legislation in USA
(May 2009).
THE STATE OF ILLINOIS
-The state of Illinois mandates insurance
coverage for bilateral screening breast US;
required by law since 2009, if certain criteria are
satisfied (i.e. breast density)
- Bill 2314 enacted 8/2013. Within this Bill,
providers of mammography services must
inform women of the meaning and
consequences of “dense breast tissue”.
WHOLE BREAST SCREENING
ULTRASOUND
• ACRIN 6666 TRIAL; JAMA 2008
Hand held with Radiologist scanning
• EUROPEAN RADIOLOGY 2010
Automated breast US scanner-SonoCine
• SOMA-INSIGHT CLINICAL STUDY-CLOSED
Automated breast US scanner-U-Systems
AUTOMATED WHOLE BREAST US
AUTOMATED WHOLE BREAST US
AUTOMATED WHOLE BREAST US
AUTOMATED WHOLE BREAST US
BREAST ELASTOGRAPHY
• Measures tissue deformity(strain) and
stiffness(elasticity)
• Strain- measures tissue displacement
- stiff tissue,
strain
- soft tissue/fluid, strain
- qualitative information
BREAST ELASTOGRAPHY
• Shear Wave- US pulses creates shear
waves in breast tissue whose velocities
differ depending on the stiffness of the
tissue.
- velocities in stiff tissue compared to
soft tissue or fluid.
- quantitative information
- measure in kPa-pressure(<80kPa, more
likely B9 masses)
BREAST ELASTOGRAPHY
• Certain strain patterns can help delineate
between solid vs cystic lesions.
• Most breast cancers are ‘hard’ on the strain
images due to the greater stiffness of the
tumor and adjacent tissue.
• Simple and complicated cysts are ‘soft’
and appear to have some typical elastogram
features(i.e. Bull’s eye sign)
BREAST ELASTOGRAPHY
BREAST ELASTOGRAPHY
BREAST CANCER-ELASTOGRAPHY
SMALL CYSTS-ELASTOGRAPHY
BREAST ELASTOGRAPHY
…AND A LOOK INTO THE FUTURE.
• US BREAST COMPUTER AIDED
DETECTION(C.A.D.)
• US FUSION IMAGING WITH MRI
• INTRAVENOUS MICROBUBBLE CONTRAST
OR THERAPUTIC AGENTS
US BREAST C.A.D.
• B-C.A.D software performs lesion
segmentation(finds the lesions edge) and
characterizes them using the BIRADS lexicon.
• Automated and Interactive Modes Used
• A BIRADS score is given
US BREAST C.A.D.
• A retrospective study at the Univ. of
•
•
•
•
Toronto:
-reviewed 320 US guided biopsied breast
lesions with a 2 year f/u
- 54 excluded, 164 Ca, 102 B9 lesions
-Sensitivity-98% Specificity-83%
-NPV-94% PPV-93% Accuracy-97%
could have avoided biopsy of 95 of the
102 B9 lesions
US BREAST C.A.D.
INTRAVENOUS MICROBUBBLE
AGENTS
• Evaluate/Identify Neovascularity
• Characterize Enhancement Patterns
• Measure Rates of Uptake and Washout
• Deliver Targeted Chemo or Gene Therapy
ULTRASOUND/MRI FUSION
• Use MRI fusion second look US
• Breast MRI performed supine and images are
loaded into an US-MRI Scanner(Hitachi)
• Small study presented at British Society of
Breast Radiology Meeting 2012
- using the US-MRI fusion, 9 of 10 patients
incidental lesions were confidently seen
Bibliography
• A.T. Stavros et al, Radiology, Jul
1995;196(1):123-34 Solid Breast Nodules: The
Use of Sonography to Distinguish between
Benign and Malignant
• K.M Kelly et al, Eur Radiology(2010) 20:734-42
Breast Cancer Detection using automated
whole breast US and Mammography in Dense
Breasts
Bibliography(cont.)
• Robert Schmidt, et al Radiographics 2007;
27:S91-S99, US Guided Core Needle Biopsy
of Axillary Lymph Nodes in Patients with
Breast Cancer: Why and How to do It.
• SOMA-INSIGHT CLINICAL STUDY BY U-
SYSTEMS; 11 Centers in the U.S.A.-CLOSED
15,000 Women with Dense Breasts Enrolled
Screening using both Automated Whole
Breast US and Mammography
Bibliography(cont.)
• JAMA 2008 May 14th;299(18): 2151-2163.
Combined Screening with US and
Mammography Compared with Mammography
Alone in Women with an Elevated Risk of
Breast Cancer: Results of the First year Screen
in ACRIN 6666.
• Radiology 2012 Feb.;262(2) 435-449
Shear-wave Elastography Improves the
Specificity of Breast US: The BE1 Multinational
Study of 939 Masses.