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Sonographic Evaluation of Solid

Breast Masses

ANNINA N. WILKES MD

History

Solid Breast Nodules: Use of Sonography to Distinguish between Benign and Malignant lesions

A T Stavros, D Thickman, C L Rapp, M A Dennis, S H Parker, and G A Sisney Radiology 1995

Ultrasound as a Complement to Mammography and Breast Examination to Characterize Breast Masses

Kenneth J.W Taylor, Christopher Merritt ,Catherine Piccoli, Robert Schmidt,Glenn Rouse, Bruno Fornage, Eva Rubin, Dianne Georgian-Smith,Fred Winsberg,,Barry Goldberg ,Ellen Mendelson, Radiology 2002

Characterizing Breast Lesions Using Quantitative Parametric 3D Subharmonic Imaging: A Multicenter Study

Anush Sridharan 1, John R Eisenbrey 2, Maria Stanczak 2, Priscilla Machado 2, Daniel A Merton 2, Annina Wilkes 2, Alexander Sevrukov 2, Haydee Ojeda-Fournier 3, Robert F Mattrey 3, Kirk Wallace 4, Flemming Forsberg 5 AcadRadiol. 2020

A Prospective Study of Automated Breast Ultrasound Screening of Women with Dense Breasts in a Digital Breast Tomosynthesis-based Practice

Denise M Chough, MD, Wendie A Berg, MD, PhD, Andriy I Bandos, PhD, Grace Y Rathfon, MD, Christiane M Hakim, MD, Amy H Lu, MD, Terri-Ann Gizienski, MD, Marie A Ganott, MD, David Gur, ScD Journal of Breast Imaging, Volume 2, Issue 2, March/April 2020, Pages 125–133

Computer-aided Diagnosis System for Breast Ultrasound Images Using Deep Learning

Hiroki Tanaka1,4, Shih-Wei Chiu1, Takanori Watanabe2, Setsuko Kaoku3 and Takuhiro Yamaguchi1 5 December 2019 • © 2019 Institute of Physics and Engineering in MedicinePhysics in Medicine & Biology, Volume 64, Number 23

History

Sonography can accurately classify solid lesions as benign, allowing

imaging follow up rather than biopsy

NPV 99.5% ( when something has benign characteristics, it is)

Sensitivity of 98.4% ( when something has malignant characteristics,

it is)

BIRADS

1 Negative

2 Benign

3 Probably Benign <2%

4 Suspicious. 2-95%

4a low suspicion 2-10%

4b moderate suspicion 10-50%

4c high suspicion 50-95%

5 Highly Suggestive of Malignancy

Benign – BIRADS 2

intramammary lymph nodes

lipomas

fat necrosis

post surgical scar

trauma - bruise

fibroadenolipoma/hamartoma

probable fibroadenomas that have been stable for

at least 2 years or have characteristic calcifications

associated on mammo

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2

lymph nodes lipoma

trauma bruise/hemorrhage

fat necrosis Post surgical scar

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3

fibroadenolipoma/hamartoma

silicone

Probably benign BIRADS 3

Benign characteristics of solid masses

circumscribed margins

oval/elliptical shape

parallel orientation ( wider than tall)

less than 3 gentle lobulations

thin echogenic pseudo capsule

iso or hypoechoic to fat

Probably Benign- BIRADS 3

Combination of benign characteristics

ABSENCE OF MALIGNANT FEATURES

Periodic imaging surveillance/follow up

– 6 mos - 6 mos -1 yr

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Juvenile fibroadenoma-children and teenage girls (10-16yo)- 5 cm

Sonography of Solid Breast Nodulesurface characteristics

scan entire of nodule in 2 planes

cine loops

if mixture of benign and malignant surface

findings……exclude from benign classification.

cine

cinecine

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cine cine

Breast Cancer is Heterogeneous

from nodule to nodule

often within a single nodule

Suspicious- BIRADS 4,5

Spiculations – most specific

Angular margins-most common

Irregular shape

Marked hypoechogenicity

Non parallel orientation to skin

Posterior acoustic shadowing

Microcalcifications

Ductal extension

Branching Pattern

Malignant FindingSpiculations

Spiculation

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Breast Cancer can be heterogeneous within nodule

only part of surface may be spiculated

Magnification helps evaluate surface

characteristics

thick, echogenic halo

halo thicker on edges ,

Variant of Spiculations

less apparent ant. and post.

Irregular Shape – not round or oval

Malignant Findingangular margins radial

anti- radial

Angular margins – heterogeneous within one nodule

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Angular Margins

paths of

low resistance to

invasion

in bases of

Cooper’s ligaments

Malignant Findingmicrolobulation

“invasive or DCIS”

fingers of invasive tumor

intraductal components

cancerized lobules

Microlobulationmicrolobulation margins

invasive fingers of tumor

1) angular 2) associated with thick halo

Tabar

**

* *

microlobulation margins

DCIS components of tumor

*

*

*

*

1) invasive cords central (I)2) DCIS peripheral (*)

(I)

Malignant Findingnon parallel

FA CA

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Wider-than-tall Taller-than-wide

Benign Malignant

taller-than-wide

a feature of small malignant nodules,

not of large malignant nodules

0

10

20

30

40

50

60

70

80

% o

f ca

ses

< 10 mm 11-15 mm 16-20 mm > 20 mm

size groups

< 10 mm

11-15 mm

16-20 mm

> 20 mm

Malignant Findingduct extension

Duct Extension

extensive intraductal components

important not just for dx, but staging and rx

Malignant Findingbranch pattern

Malignant Findingcalcification

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Malignant Findingmarkedly hypoechoic- relative to fat

vs.fat

Intraductal Masses

Papilloma

DCIS

IDC

Duct ectasia

Fibroadenoma

ADH

Duct ectasia/debris

Intraductal Masses suspicious characteristics

Intraductal Mass on Breast Ultrasound: Final Outcomes and Predictors of Malignancy. Won Hwa Kim, Jung Min Chang et al ALR 2013

• Large size>15 mm

• Irregular shape

• Peripheral duct- > 15 mm from nipple

• Causes duct expansion

• Spread into branch duct

atypical papilloma

Tools Color Doppler

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thick walled cyst?

cyst with debris?

Metastatic Melanoma

Tools -Posterior Acoustic Shadowing

• Cancers• Fibroadenomas• Scars

• Fat necrosis• Calcification• Free silicone – dirty shadowing

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Tools - Posterior Acoustic Enhancement

Indicates cellular, metabolically active cancers

High grade IDC

Colloid CA

Medullary CA

Invasive papillary CA

Cysts, Hematomas, Abscess

enhancing fibroadenoma shadowing fibroadenomamammographically stable

Elastography – based on tissue stiffness, resistance Contrast Enhanced Subharmonic Breast Ultrasound

BIRADS Positive Predictive Value (PPV) ACR

benchmarks

1 Negative 0%

2 Benign 0%

3 Probably Benign <2% chance of malignancy

4 Suspicious 2-95%

4a low suspicion 2-10%

4b moderate suspicion 0-50%

4c high suspicion 50-95%

5 Highly Suggestive of Malignancy

TI-RADS

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Proposed guidelines for BI-RADS 4 sub-categorization

BIRADS 3: No suspicious findings, one of two benign patterns: 1)oval shape, parallel orientation, circumscribed, abrupt interface with complete thin hyperechoic capsule 2)three or fewer lobulations, parallel orientation, circumscribed, abrupt interface with complete thin hyperechoic

capsule

BIRADS 4a: Three or fewer suspicious findings, all ‘weak’ non-mass findings… OR presence of a single angle… OR four total findings, none ‘strong’, with one or two nonspecific findings… OR two total findings, both nonspecific findings

BIRADS 4b: Four total suspicious findings with one ‘strong’ mass finding… Or three total suspicious

findings with two ‘strong’ mass findings

BIRADS 4c: Either five or six total suspicious findings… OR 4 total findings with two ‘strong’ mass

findings

BIRADS 5: Six or more findings… OR three or more ‘strong’ mass findings

Proposed guidelines did not improve overall reader performanceUltrasound positive predictive values by BI -RADS categories 3–5 for solid masses: An independent reader study A. Thomas Stavros1 & Andrea G. Freitas 2 & Giselle G. N. deMello2 & Lora Barke 3 &

Dennis McDonald4,5 & Terese Kaske 3,6 & Ducly Wolverton3,7 & Arnold Honick4,8 & Daniela Stanzani2 & Adriana H. Padovan2 & Ana Paula C. Moura2 10 April 2017 # European

Society of Radiology 2017

BIRADS 4 a,b,c

4a

Partially circumscribed mass suggestive of fibroadenoma

Complex cyst

4b

Calcifications -moderate suspicion for malignancy, some benign

characteristics

4c

.Highly suspicious but not classic

US of Breast Masses Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing Clinical Management, Sughra Raza, MD, Allison L. Goldkamp, MD, Sona A. Chikarmane, MD, and Robyn L. Birdwell, MD Radiographics 2010

Ultrasound

Technology-continuing study

Elastography

3D/4D= volumetric imaging

Whole Breast Imaging

Improved Lesion Detection/Characterization – vascularity-contrast, calcifications

Computer Aided Detection - AI

Guidance for tumor ablation -cryotherapy