Applications

•Through ultrasound is successfully used to aid assessment of abnormalities

detected by mammography, it should not be used as a sole modality for
screening as ultrasound does not always detect cancers that are visualized
Mammographically.

• Conversely, used in conjunction with mammography, ultrasound can detect

clinically and mammographically occult cancers particularly when there is a
higher possibility of cancer.

• with new high-frequency transducers, it is also possible to detect malignancy

associated with mammographically detected clustered microcalcifications.

•These lesions may be evident is irregular masses, abnormal dilated ducts or

clustered foci of increased echogenicity with increased Doppler vascularity.
 Brest Ultrasound

• High quality images of the normal and

abnormal breast can be
Technique: • Obtained with modern ultrasound
equipment.

• Lightning
Initial • Patient positioning : support elbow, flat, supine
• Machine to patient’s right
examination: • Image with right hand
• Operate machine with left hand.
 Patient’s Position

MEDIAL LESIONS LATERAL SUPERIOR

• Patient is supine LESIONS LESIONS
• Ipsilateral arm is
placed over the • Patient is • Patient is
patient’s head. opposite. SITTING
 Equipment Selection

•Transducer
§ At the minimum a 7.5 MHz linear
array Probe should be used

•Brest Ultrasound uses high frequency

sound wave (linear probe 7 – 13 MHz) to
map the internal structures of breast.
•Apply gentle uniform pressure
with the ultrasound transducer.

§ Increased Transducer pressure for:

§Greater penetration
§Scanning the sub-areolar region.

§Scanning is done in three directions

1. Radial
2. Transverse
3. longitudinal
 Radial Anti-Radial

Transverse (Axial) Longitudinal (Sagittal)

•LOCALIZATION IS BY THE CLOCK FACE
 Anatomy
•The breast is located on the chest wall between the second and the sixth ribs
within layers of the superficial pectoral fascia.

•The fat and fibroglandular tissues of the breast are between the superficial
layer of this fascia just beneath the skin and the deep fascial layer that lies
just anterior to the pectoral muscle.
•A few as seven or eight and as many as 20 lobes, loosely associated duct
segments, are the anatomic components of the breast.
•Each segments starts in the fine peripheral branches and ends in a large
collecting duct, its punctum visible on the nipple.
•The most peripheral ducts, the intralobular terminal ducts, end in the
terminal duct lobular units that give rise to common malignant and
beginning pathologies.
•The subclavian and axillary arteries and their lateral thoracic,
thoracoacromial and internal mammary branches provide arterial supply to
the breast.
•The venous plexus lies just beneath the nipple. Over 90% of the lymphatics
of the breast drain in to the epsilateral axilla, with a small percentage of
drainage in to the internal mammary chain.
•In women who have had axillary dissection or mastectomy extending in to
the axilla, lymphatic drainage may cross to the contralateral axilla.
 AXILLA

•The axilla contains lymph nodes, the brachail plexus, and axillary artery and
vein.
•The number and size of normal axillary lymph node varies widely from
individual to individual.
•Side to side symmetry of size, shape and number of nodes may help
distinguish normal from abnormal.
•Nodes may be depicted in the axillae on mammograpms; commonly two,
three or more can be identified as circumscribed oval (often reniform)
masses with hilar fat and cortices of fibroglandular tissues density.
•With us normal axillary or intramammary lymph nodes have echogenic fatty
hila and cortices that are hypoechoic to anechoic.
 NIPPLE AND AREOLA

• The nipple- areolar complex is quit variable, with areolar width narrow in
some women or extending for 1 or 2 cm in other, making the nipple a more
reliable landmark than the areola.
• Normal nipples can be prominent, flat, or inverted.
• If an abnormality is suspected, or for interpretive confidence, look at
contralateral
• Breast as you would for any other paired organ.
• The nipple’s cervices and irregular surface cause posterior attenuation, an
offset pad or thick layer of gel can provide a medium for clear depiction.
• The skin of the areola tapers as the areola extends to either side of the
nipple.
• The width of normal skin over the breast is 0.2 cm except for the region of
the inframammary fold and the areola, where the skin is normally a little
thicker.
 ULTRASOUND

Recent studies shows if strict

criteria for lesion analysis are
followed, specificity of ultrasound
in determining benign or malignant
reaches 70%
 SONOGRAPHIC ANATOMY

• All macroscopic breast structure can be easily imaged with adequate

sonographic equipment.
The breast can be divided into four regions
• skin, nipple, subareolar tissues
• subcutaneous region
• parenchyma (between the subcutaneous and retromammary region)
• Retromammary region.
 INTERPRETATION

• The subcutaneous fat layer is demonstrated superficially as hypoechoic

tissue compared to the glandular tissues from which it is separted by a wall-
defined scalloped margin.
• Normal ducts are often visible, particularly in the subareolar region, as
anechoic tubular structures.
• Deep to the glandular tissues, a retromammary fat layer is usually visible
and, behind this, the structures of the chest wall.
Sonographic Anatomy

Skin
Subcutaneous fat
Cooper ligaments
Breast parenchyma
Retromammary fat
Pectoralis muscle
Ribs
Pleura
nipple
 NIPPLE
Skin
Consists of both dense connective
tissue and connective tissue of the
duct which can cause posterior Nipple
acoustic shadowing. shadow
 RIBS

Easily identified bone attenuates

causing an acoustic shadow
 DUCT

Tubular branching structures

 LYMPH NODE

•Solid nodule
•Ovoid
•Echogenic fatty hilum
•Near the midline the ribs are only composed of
cartilage and are not calcified.
•The cartilage does not produce a white echo on the
anterior side or posterior shadowing.
•Instead a hypoechoic structure is seen anterior the
lungs.
•Do not mistake this structure for a breast tumor.
•At first glance this may look like a fibroadenoma when
you image the rib on cross section.
•By turning the transducer you will notice that it is a
long structure connected to the calcified part of the rib.
 INDICATIONS

•Symptomatic breast lump in women ages less than 35 years.

•Breast lump developing during pregnancy or location.
•Assessment of mammographic abnormality (+ further mammographic
views)
•Assessment of MRI or scintimammography detected lesions.
•Clinical breasts mass with Negative mammograms.
•Breast inflammation.
•The augmented breast (together with MRI)
•Breast lump in a male (together with mammography).
•Guidance of needle biopsy or localization.
•Follow up of breast cancer treated with adjuvant chemotherapy.
 INDICATIONS

•The original role of breast sonography is in the differentiation

of Cystic and Solid lesions.
•Ultrasound complemetnts both clinical examination and
mammography.
•It is also successfully used as a ‘second look’ procedure where
an abnormality has been identified using MRI or
scintimammography.
 INDICATIONS

•Because it does not use ionising radiation, it is the examination

of choice in young women and is valuable in the assessment of
the mammographically ‘dense’ breast.

•Ultrasound plays and important role in the triple assessment of

symptomatic lesions.

•Beginning the only ‘Real time’ imaging modality also means it

can be used to accurately localized or biopsy breast lesions.
•In practice, needle biopsy should be performed as part of triple
assessment in the presence of a discrete solid mass.

•Not all breast pathology presence as a discreate lesion. inflammatory

or lobular cancers may present as areas of scattered in determined
attenuation.

•The use of color ad power Doppler can also aid in benign malignant
differentiation of solid masses.

•In general, malignant masses tend to so and increased number of

vessels that penetrate deep in to the tumor with a branching
morphology.
ABNORMAL PARENCHYMAL PATTERN

Simple cyst
Complex Cyst

Chronic abscess
Galactocoel

Fibrocystic disease
Duct ectasia

Fibroadenoma
Cystosarcoma phyllodes
Lipoma
 SIMPLE CYST

•Breast cysts are the commonest cause of

breast lumps in women between 35 and 50
years of age.
•A cyst occurs when fluid accumulates due
to obstruction of the extra lobular terminal
ducts, either due to fibrosis or because of
intra ductal epithelial proliferation.
•A cyst is seen on USG as a well defined,
round or oval, single or multiple anechoic
structure with a thin wall.
 COMPLEX CYST
•When internal echoes or debris are seen,
the cyst is called a complex cyst.

•These internal echoes may be caused by

floating cholesterol crystals, pus, blood
or milk of calcium crystals
 SIMPLE CYST

•Anechoic
•Smooth, thin margins
•Posterior acoustic enhancement
 ABSCESS OF THE BREAST
•Patients may present with fever, pain,
tenderness to touch and increased white
cell count.

•Abscesses are most commonly located in

the central or subareolar area.

•An abscess may show an ill-defined or

a well-defined outline. It may be
anechoic or may reveal low-level internal
echoes and posterior enhancement
 GALACTOCOEL (lacteal cyst or milk cyst)

•It is a retention cyst containing milk or a

milky substance that is usually located in the
mammary gland

•It is caused by protein plug that blocks off the

outlet

•It is seen in lactating women on cessation of

lactation

•Patient typically presents with a painless

breast lump occurring over weeks to month
 FIBROCYSTIC DISEASE
•This condition is referred by many different names:
fibrocystic disease, fibrocystic change, cystic disease, chronic
cystic mastitis or mammary dysplasia.

•About half of these breast masses are usually classified as indeterminate and
will eventually require a biopsy’.
Extremely variable depends on the stage and extent of
morphological
•In the early stage, the USG appearance may be normal, even though lumps
may be palpable on clinical examination

•There may be focal areas of thickening of the parenchyma, with or without

patchy increase in echogenicity.

•Discrete single cysts or clusters of small cysts may be seen in some

•Focal fibrocystic change may appear as solid masses or thin walled cysts.
 DUCT ECTASIA

•This lesion has a variable appearance.

•Typically, duct ectasia may appear as a

single or multiple tubular structure
filled with fluid

• Old cellular debris may appear as

echogenic content. If the debris fills
the lumen , it can be sometimes
mistaken for a solid mass, unless the
tubular shape is identified
 FIBROADENOMA

•Fibroadenoma is an estrogen-induced tumor that form in

adolescence.

•It is the third most common breast lesion after fibrocystic

disease and carcinoma

•It usually presents as a firm, smooth oval-shaped, freely

moveable mass on palpation.

•It is rarely tender or painful. The size is usually under 5 cm,

though larger fibroadenomas are know. Fibroadenomas are
multiple in 10-20% and bilateral in 4% of cases. Calcifications
may occur.
 FIBROADENOMA

•A well-defined lesion. A capsule can

usually be identified.

•The echotexture is usually

homogenous and hypoechoic as
compared to the breast parenchyma,
and there may be low-level internal
echoes.

•Typically, the transverse diameter is

greater than the antero-posterior
diameter
 CYSTOSARCOMA PHYLLODES

•This is a large lesion that presents in older women.

•Some authors consider it to be a giant fibroadenoma.

•The mass may involve the whole of the breast. It

usually reveals well defined margins and an
inhomogeneous echotexture, sometimes with
variable cystic areas.
 LIPOMA

•Lipoma is a slow-growing, well-defined tumor.

•It may be a chance finding or the patient may

present with complaints of increase in the size
of the involved breast, though no discretely
palpable mass can be made out.

•The tumor is soft and can be deformed by

compression with the transducer.
 U/S Criteria for benign lesion

•Smooth and well circumscribed.

•Hyperechoic, isoehoic or mildly hypoechoic.

•Thin echogenic capsule

•Ellipsoid shape, with the maximum diameter being in the

transverse plane.

•Three or fewer gentle lobulations.

•Absence of any malignant finding.

 U/S Criteria for Malignant lesion

•Malignant lesion are commonly hypoechoic nodular lesion

with ill-defined borders, which is ‘taller than broader’ and has
spiculated margins, posterior acoustic shadowing and micro
calcifications.

•Three-dimensional scanners with the capability of reproducing

high-resolution image in the capability of reproducing
important information.

•It was initially believed that color Doppler scanning would add
to the specificity of USG examination, but this has not proven
to be very efficacious.
 CLASSIFICATION
BREAST CARCINOMA

Carcinoma in situ Invasive Carcinoma

1. Ductal carcinoma in situ 1. Invasive ductal carcinoma

2. Lobular carcinoma in situ 2. Invasive lobular carcinoma
3. Medullary carcinoma
4. Mucinous (colloid) carcinoma
5. Papillary carcinoma
6. Tubular carcinoma
7. Paget’s disease of the nipple
8. Rare cancers (adenoid, cystic,
squamous cell apocrine).
 INVASIVE DUCTAL CARCINOMA

ULTRASOUND
• Ill-defined lesion
• Hypoechoic mass
• Hyperechoic angular margins
• Posterior acoustic shadowing
• Ductal extension may be seen
which is extension of the lesion
into surrounding parenchyma
• Branched or spiculated pattern
• Microcalcifications
 DUCTAL CARCINOMA IN SITU

•A microlobulated mild hypoechoic mass with

ductal extension and normal acoustic transmission
is considered the most common feature in
sonographically detected detected DCIS.

•It is possible in everyday practice to identify the

DCIS process as it grows in the ductal system of
the breast.
 INVASIVE LOBULAR CARCINOMA

•Heterogeneous, hypo echoic mass with angular or ill-

defined margins and posterior acoustic shadowing.

•An ill-defined heterogenous infiltrating area of low

echogenicity with disproportionate posterior shadowing
is one of the sonographic characteristics of invasive
lobular carcinoma.
 MEASTASES TO THE BREAST

•Lymphoma/leukemia: •On ultrasound, metastatic

most common extra masses tend to have
mammary source circumscribed margins
•Melanoma with low-level internal
•Sarcoma echoes and, occasionally
•Lung cancer posterior acoustic
•Gastric enhancement.
•Ovarian
•Renal cell cancer •Color Doppler
•Malignant mesothelioma interrogation most often
•Ca cervix shows increased
•Rectal cancer vascularity.
•Papillary thyroid cancer
 GYNECOMASTIA

Enlarged male breast tissue due to

hormonal imbalance

•It could be uni or bilateral

•Oestrogen and Testosterone

are not adequately balance
Imaging Characteristics

•Size
•Shape
•Border definition
•Internal echogenicity
•Posterior enhancement
•Architectural changes
 ANALYTIC CRITERIA

•Margins
•Retrotumoral acoustic phenomena
•Internal echo pattern
•Echogenicity
•Compression effect on SHAPE
•Compression effect on INTERNAL
ECHOES
 BENIGN CHARACTERISTIC

•Ellipsoid shape

•Thin definable capsule

•Two or three lobulations

•Hyperechogenicity.
 SOLID MASS MALIGNANT

•Irregular shape Irregular shape

•Irregular/ ill-defined borders
•Irregular/ ill-defined borders
•Almost anechoic
•Almost anechoic
•Angular margin
•Thick echogenic rim
•Taller than wide
•Posterior shadowing
 Benign Malignant
Shape Oval/Ellipsoid Variable
Alignment Wider than deep; aligned parallel to Deeper than wide
tissue planes.
Margins Smooth/thin echogenic pseudo- Irregular or spiculated; echogenic
capsule with 2-3 gentle lobulations halo

Echotexture Variable of intense hyperechogenicity Low level marked hypo-

echogenicity, Non uniform
Lateral shadowing Present absent

Posterior effect Minimum attenuation/ posterior Attenuation with obscured

enhancement posterior margin
Other sign ----------------- Calcification, microlobulation ,
intraductal extension, infiltration
across tissue planes and increased
echogenicity of surrounding fat
2
Breast imaging and reporting data system (BI-RADS)

• BI-RADS is designed to standardize breast imaging reporting

and to reduce confusion in breast imaging interpretations.

•It also facilitates outcome monitoring and quality assessment.

•It contains a lexicon for standardized terminology (descriptors)

for mammography, breast US and MRI.

•All mammographic, ultrasound, and breast MRI findings and .

reports should closely adhere to the BI-RADS lexicon and .
assessment categories.
 BIRADS

• Latest version classifies lesions into 0 – 6 categories:

• BIRADS 0: Incomplete, further imaging or information is

required. Eg: compression, magnification, special
mammographic views, ultrasound. This is also used when
previous image not available at the time of reading.
 BIRADS

• BIRADS I: Negative, symmetrical and no masses,

architectural disturbances or suspicious calcification present.

•BIRADS II: benign finding, interpreter may wish to describe a

benign appearing finding, Eg: calcified fibroadenomas, multiple
secretory calcifications, fat containing lesions like Oil cyst,
breast lipomas, galactocele and mixed density hemartomas,
simple breast cysts.

•These lesions should have characteristic appearances and may

be labeled with confidence and make sure there is no
mammographic evidence suggesting malignancy.
 BIRADS

• BIRADS III: probably benign, short interval follow up

suggested.

•BIRADS IV: suspicious abnormality.

•There is mammographic appearance which is sucpicious of
malignancy.
•Biopsy should be considered.

•BIRADS IV (A): low level of suspicion.

•BIRADS IV (B): intermediate level of suspicion.
•BIRADS IV (A): moderate level of suspicion for malignancy.
 BIRADS

• BIRADS V: there is a mammographic appearance which is

highly suggestive of malignancy, action should be taken.

• BIRADS VI: known biopsy proven malignancy.

•The vast majority of mammograms fall in to BIRADS I or II

• Risk of Cancer:
•BIRADS III: ~ 02%
•BIRADS IV: ~ 30%
•BIRADS V : ~ 95%
 STANDARD REPORTING

1. Indication

2. Breast Composition
Composition
Mass
Asymmetry
3. Important
Architectural distortion
findings
Calcification
Associated features
4. Comparison
to previous
studies

5. Final Assessment category

6. Give Management recommendations

7. Communicate unsuspected findings with the referring clinician