ULTRASOUND OF

BREAST

By Dr Attiya
 Breast ultrasound uses high-frequency
sound waves to map the internal
structures of the breast.
Applications
 Though 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 visualised 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 as irregular masses, abnormal

dilated ducts or clustered foci of increased echogenicity with
increased Doppler vascularity.
ULTRASOUND OF BREAST
 Technique
 High-quality images of the normal and
abnormal breast can be obtained with modern
ultrasound equipment.

Initial examination
– Machine to patient’s right
– Image with right hand
– Operate machine with left hand.
Patient Position
MEDIAL LESIONS
 patient is supine
 ipsilateral arm is placed over the patient’s
head.

LATERAL LESIONS
 patient is opposite.

SUPERIOR LESIONS
 patient is SITTING
Equipment selection:

 Transducer
 At the minimum, a 7.5
MHz linear array probe
should be used.
Apply gentle uniform pressure
with the ultrasound
transducer
Increase transducer pressure for:
– greater penetration
– scanning the subareolar region.

Scanning is done in three directions.

1. Radial
2. Transverse
3. Longitudinal
 12
 Localization is by the
clock face.

9 33

66
Ultrasound of the Breast
 Recent studies show if strict criteria for
lesion analysis are followed, specificity of
ultrasound in determining benign or
malignant reaches 70%.
Sonographic Breast
Anatomy
 All macroscopic breast structures 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 regions)
 retromammary region.
Ultrasound interpretation
 The subcutaneous fat layer is demonstrated
superficially as hypoechoic tissue compared to the
glandular tissue from which it is separated by a well-
defined scalloped margin.

 Normal ducts are often visible, particularly in the

subareolar region, as anechoic tubular structures.

 Deep to the glandular tissue, a retromammary fat

layer is usually visible and, behind this, the structures
of the chest wall.
Sonographic Breast
Anatomy
 Skin
 Subcutaneous fat
 Cooper’s Ligaments
 Breast parenchyma
 Retromammary fat
 Pectoralis muscle
 Ribs
 Pleura
 Nipple
skin Cooper's ligament

fibroglandular tissue
Nipple

• Consists of both dense

connective tissue and
connective tissue of
the duct which can
cause posterior
acoustic shadowing
Ribs
• Easily identified bone
attenuates causing an
acoustic shadow
Duct
• Tubular branching
structures
Ultrasound showing dilated ducts (lactating)
The duct appears as branching hypoechoic structure within
echogenic glandular tissue.
Intramammary vessel running branching under
the skin.
Lymph Node

• Solid nodule
• Ovoid
• Echogenic fatty hilum
INDICATIONS
 Symptomatic breast lumps in women aged less than 35
years.
 Breast lump developing during pregnancy or lactation.
 Assessment of mammographic abnormality (± further
mammographic views)
 Assessment of MRI or scintimammography detected
lesions.
 Clinical breast 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 localisation.
 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 complements 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 an important role in the triple

assessment of symptomatic lesions.

 Being the only `real-time' imaging modality also

means it can be used to accurately localise or
biopsy breast lesions.
Breast Ultrasound and
Mammographic Correlation

Dense breast
Fatty breast
 The echotexture of any lesion is compared
relative to the echotexture of the
intramammary fat.

 Cysts are typically well-defined rounded

anechoic lesions with posterior acoustic
enhancement, though the presence of debris
can increase the overall internal echogenicity.

 Wall thickening, irregularity or mural nodules

should be treated with suspicion and
aspiration should be performed.
Simple Cysts
– anechoic
– smooth, thin
margins
– posterior acoustic
enhancement
 In practice, needle biopsy should be performed as
part of triple assessment in the presence of a discrete
solid mass.

 Not all breast pathology presents as a discrete lesion.

Inflammatory or lobular cancers may present as areas
of scattered indeterminate attenuation.

 The use of colour and power Doppler can also aid in

benign-malignant differentiation of solid masses.

 In general, malignant masses tend to show an

increased number of vessels that penetrate deep into
the tumour with a branching morphology.
Breast Ultrasound
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 Characteristics

 Ellipsoid shape
 Thin definable
capsule
 Two or three
lobulations
 Hyperechogenicity.
Solid Mass -
Malignant

• Irregularshape
• Irregular/ill-defined
borders
• Almost anechoic
• Angular margin
• Taller than wide
Irregular shape
• Irregular/ill-defined borders
• Almost anechoic
• Thick echogenic rim
• Posterior shadowing
 Benign Malignant
Shape Oval/ellipsoid Variable

Alignment Wider than deep; aligned parallel to Deeper than wide

tissue planes

Margins Smooth/thin Irregular or spiculated; echogenic 'halo'

echogenic pseudocapsule with
2-3 gentle lobulations

Echotexture Variable to intense Low-level

hyperechogenicity Marked hypoechogenicity
Homogeneity of Uniform Non-uniform
internal echoes

Lateral Present Absent

shadowing

Posterior effect Minimum attenuation/posterior Attenuation with obscured posterior

enhancement margin

Other signs -------------- Calcification

Microlobulation
Intraductal extension
Infiltration across tissue planes and increased
echogenicity of surrounding fat
A typical fibroadenoma with homogeneous
internal echoes with an ovoid shape and
circumscribed margins -- benign.
There is posterior acoustic enhancement..
A typical 'tall' irregular spiculated hypoechoic
attenuating mass in keeping with a malignant
breast tumour.
An invasive lobular carcinoma presenting as areas of
scattered indeterminate attenuation.
Inflammatory breast cancer with secondary signs.
increased hyperechogenicity of the intramammary fat resulting in
loss of the normal glandular adipose differentiation Lymphatic
dilation is also apparent under the thickened subcutaneous layer.
A power Doppler image of an invasive grade 3 breast
cancer.
irregular tortuous and branching vessels penetrating into the
centre of the lesion.
 The sonographic pattern varies with age
and individually, and depends on the
amount and type of contents, i.e. fat,
fibrous and glandular tissues.

 The fibrous and glandular components

are variably echogenic, while fat is
hypoechoic.
Benign ??
Malignant ??
Benign vs. Malignant
Benign ??
Malignant??
THANKYOU