BREAST SONOGRAPHY

GOPAL KHANAL
 Application of breast USG
1. Primary screening
2. Secondary screening(following
mammography)
3. Diagnosis
4. Guiding Biopsies and
5. Treatment planning for radiotherapy
 Indication
1. Palpable mass
2. Discharge
3. Mammographic abnormality

 Specific goals of targeted diagnostic breast

ultrasound-
1. To prevent unnecessary biopsies & short interval
follow-up of mammogram of benign lesion
2. To guide intervention
3. To find malignancies missed on mammography
 Role of US in diagnosis

• Women with dense breasts

• Women with fibrocystic disease
• When mammography alone cannot classify
lesion
• Young women with masses
• Pregnant women with masses
• Women with implants
• Women who refuse mammography
 Sonographic equipment
• High frequency transducer optimized for near field
imaging i.e. electronically focussed linear arrays.
• All organizations involved in accreditation of breast USG
(ACS, ACR, AIUM), require minimum transducer frequency
of 7Mhz.
• Focal Length – 1.5-2 cm
• Lesions just under the skin on the mammogram, or that
are palpable and “pea sized”- with acoustic stand off. (
volume averaging)
• Split-screen images -to compare mirror-image -
asymmetrical fibroglandular tissue
• Volume averaging with 5Mhz transducer
 Fundamentals
• Acoustic standoff
- thick layer of gel as standoff for superficial lesion like
sebaceous cyst
• Controlling depth of focal zone position
- to reduce volume averaging with surrounding tissue
• Split screen imaging
- for comparision
• Extended FOV imaging
- for large lesion
• Tissue harmonic imaging
- improves lesion conspicuity with high image contrast and
lateral resolution .
Anatomy
• Modified sweat gland
• 15-20 lobes not well
deliniated from each
other.
– Parenchyma- lobar duct,
smaller branch ducts, and
lobules
– stromal tissues -compact
interlobular stromal
fibrous tissue, loose
periductal and intralobular
stromal fibrous tissue, and
fat
 Terminal ductolobular unit(TDLU)
• Functional unit of breast
• Consist of lobule & its extralobular
terminal duct
• Lobule- intralobular segment of
terminal duct , ductules & intralobular
stromal fibrous tissue
• Site of origin of most breast pathology &
ANDIs.
• Most breast ca arise in terminal duct at
junction of Intra & extralobar segment.
• Lobar duct- site for development of
large duct papillomas, duct ectasia-
periductal mastitis complex
• Location – anterior and posterior TDLU
• Oriented in taller than wider axis.
Anterior TDLU Posterior TDLU

Long extralobular terminal duct Shorter extralobular term duct

More numerous Less numerous

Don’t regress Tend to regress over time

•Since anterior TDLU greatly outnumber posterior TDLU ,

most breast pathology that arise from TDLU occur in
superficial half of mammary zone, just deep to ant
mammary fascia
•TDLU may be sonographically visible as isoechoic
structure 2mm, may be upto 5mm in fibrocytic disease,
adenosis & ANDI
•TDLU increased in size & no.- pregnancy, lactation,
adenosis.
 TDLU

Terminal ductolobular units (TDLUs). The TDLU includes the extralobular terminal duct
and the lobule,
TDLUs present as an isoechoic structure similar to a tennis racket; the head of the racket
(asterisk) represents the lobule, and the handle and neck of the racket (arrows) represent
the extralobular terminal duct.
Zones of breast
 Mammary fascia & Cooper’s ligament

Two layers of anterior mammary

fascia (arrows) form the bases of
a Cooper’s ligament (white
arrowhead), which inserts into
superficial fascia (open arrow).

Invasive malignancies
often develop angles as they
invade the base of Cooper’s
ligaments.
 Lymphatic drainage
• Lymphatic drainage is from deep to superficial
toward subdermal lymphatic network, then to
periareolar plexus(Sappey’s plexus) & finally to
axilla.
• Some deep portion of breast, particularly
medial, preferentially drain along chest wall to
internal mammary lymph nodes.
• Most drainage of breast is to axillary lymph
nodes.
• 3 levels of axillary lymph nodes with respect to
pectoralis minor muscle-
 Level 1- periphery to inferolateral edge of Pectoralis
minor
 Level 2- posterior to Pectoralis minor
 Level 3- prox. to superomedial border of pectoralis
minor

• Lymphatic drainage from axilla pass through level

1→level 2→level 3
• Rotter nodes lie between pectoralis major & minor
muscle
• It is important to recognize level 2, 3 & Rotter node
because unrecognized metastasis to these lymph nodes
are source of chest wall recurrences.
Pectoralis minor muscle and levels of axillary lymph nodes. Extended-FOV sonogram shows
metastases to all three axillary lymph node levels on the left. The level of axillary lymph nodes
is determined by the pectoralis minor muscle. Lymph nodes that lie inferior and lateral to the
inferolateral edge of the pectoralis minor muscle are level 1 nodes; those that lie deep to the
pectoralis minor muscle are level 2 lymph nodes; and those that lie superior and medial to
the superomedialedge of the pectoralis minor muscles are level 3 (infraclavicular) lymph
nodes.
 TECHNIQUES
Aims -to
• Maximize tissue thinness
• Reduce reflective and refractive attenuation
• Maintain ultrasound transducer parallel to
breast surface
• Maintain ultrasound beam perpendicular to
breast tissue
 Technique-Scanning
• Coupling Gel
– liberal quantity
– use gel warmer
• Apply gentle uniform pressure with the
ultrasound transducer
• Increase transducer pressure for:
– greater penetration
– scanning the subareolar region
 Special breast USG technique
Dynamic & positional maneuvers
• Dynamic maneuvers
1. Varying compression- to assess compressibility &
mobility. > 30% compressible lesions are fatty; either
benign lipoma or normal fat lobule.
Superficial venous thrombosis(Mondor’s disease)
require incompressibility & lack of flow on Doppler for
diagnosis.
2. Ballotment – alternating compression & compression
release to demonstrate mobility of echoes with ectatic
ducts or complex cysts.
3. Heeling & toeing of transducer – minimize critical
angle shadowing from Cooper’s ligament , better
demonstrate thin, echogenic capsule on ends of
solid nodules, better delineation of ductal anatomy
& pathology esp. in subareolar region
4. Doppler ultrasound assessment – depends on using
as little compression as possible. Blood flow from
breast lesion can be decreased/absent if
compression is vigorous.
• Positional changes- for complex cysts. Fluid-debris
level, milk of calcium, fat-fluid level changes
position between supine, upright or lateral
position.
Maneuvers for demonstrating subareolar and intranipple mammary ducts. A, Left image,
The subareolar ducts are difficult to assess from a straight anterior approach because
shadowing arises from the nipple and areola and the tissue planes of the nipple are parallel
to the ultrasound beam. Right image, Peripheral compression technique. With vigorous
compression on the peripheral end of the transducer and sliding it over the nipple to push
the nipple to the side, shadowing can be minimized, and the angle of incidence of the beam
with the subareolar ducts can be improved. Lesions that lie in the immediate subareolar
region (arrow) can often be demonstrated.
Left image, Rolled nipple technique is the best way to demonstrate the ducts within the nipple
and if a lesion extends into the nipple from the subareolar ducts. B, Right image, Two-handed
compression technique further improves the angle of incidence with the subareolar ducts and
helps assess the compressibility of the ducts. This can help to distinguish echogenic, inspissated
secretions from intraductal papillary lesions and determine whether the lesion (arrows) has
penetrated through the duct wall (arrowheads). The rolled nipple technique shows that this
malignant intraductal papillary lesion does not extend into the intranipple segment of the duct,
but the two-handed compression maneuver shows that it has invaded through the posterior
duct wall and is forming angles within the periductal tissues.
 Echogenicity spectrum
• Hyperechoic-compact interlobular stromal fibrous
tissue, ant & post mammary fascia, cooper’s ligament,
skin and ducts wall(when visible)
• Isoechoic- fat, epithelial tissue in duct & lobules, loose
intralobular & periductal stromal fibrous tissue
• Mammary duct- isoechoic because of poor angle of
incidence, central bright echo surrounded by isoechoic
stromal tissue when optimally demonstrated.
 Annotation
Annotation of location of a sonographic breast images.
• Side- left/right
• Clock face position
• Distance from nipple
• Transducer orientation – long, trans, radial or antiradial
• 5 zones to record the distance from the nipple
-SA- subareolar
-AX- axillary segment
-1,2 and 3 of equal width rings starting at the areolar
margin and extending to the edge of the breast.
• For depth 3 zones – A for superficial third, B for middle
third and C for deep third
 6cm

Alternative, instead for zone 1,2,3, distance from nipple to the lesion is measured

RIGHT 12:00, N + 6, C
 Solid Breast Lesions
• Benign Vs Malignant Solid Lesions
• Cannot distinguish all benign from malignant
solid lesions
• Goal- To identify subgroup of lesions that are
likely to be benign that the patient can be
offered the option of follow-up in addition to
the option of biopsy.- BIRADS -3 (<2% Risk)
 Comparision of suspicious
mammographic & sonographic findings
Suspicious mammographic findings Suspicious sonographic findings

spiculation Spiculation (thick echogenic halo)

Irregular or poorly defined margin Angular margins

Microlobulation Microlobulation

Calcifications Calcification

Linear calcification pattern Duct extension

Branching calcification pattern Branch pattern

Mass or nodule Taller than wide*

Assymetric density Acoustic shadowing*

Developing density Hypoechogenicity*

 Comparision of morphologic & histologic features of
suspicious sonographic findings
Morphologic features Histologic features
Surface characteristics Hard findings
spiculations Spiculations(halo)
Angular margins Angular margin
lobulation Acoustic shadowing
Shapes Mixed findings
Taller than wide Hypoechogenicity
Duct extension Taller than wide
Branch pattern Soft findings
Internal characteristics Microlobulation
Calcifications Duct extension
Acoustic shadowing Branch pattern
Hypoechogenicity Microcalcification
 Spiculation or thick echogenic halo
• Invasion of surrounding tissue & desmoplastic host
response to the lesion.
• Course spiculation- alternating hypoechoic (fingers of
invasive tumour or DCIS component of tumour in
surrounding Tissue) & hyperechoic(interface between
spicules & breast tissue) lines that radiate
perpendicular to surface of nodule
• Fine spiculation- single echogenicity, depending on
echogenicity of tissue whithin which lesion lies.
• The thick echogenic halo that surround some
malignant nodules represent spiculations that are too
small to demonstrate sonographically.
Spiculation. A, Spiculation is a “hard” mammographic finding that indicates invasion. B, Coarse
spiculations (between arrows) present as alternating hypoechoic and hyperechoic lines radiating
from the nodule on ultrasound. The hypoechoic parts represent fingers of invasive tumor or
ductal carcinoma in situ, and the hyperechoic lines represent the interface between the tumor
and surrounding tissue.
Fine Spiculations: The spiculated lesions surrounded by hyperechoic fibrous tissues
are hypoechoic; where as that surrounded by fat are hyperechoic
Echogenic halo with hyperechoic spicules. The thick, poorly defined echogenic halo that can be seen
around some invasive malignant lesions surrounded by fat represents hyperechoic spicules too small to
be resolved individually. The halo is more often seen and is thicker along the sides of the nodule within
the coronal plane (arrows) because spicules are more common in the coronal plane and because the
spicules that lie within the coronal plane are perpendicular to the ultrasound beam, where they make
strong spicular reflectors.
Angular margins
• Indicates invasion
• Acute, right angle or obtuse
angulations tend to occur at
points where Cooper’s
ligaments intersect the
surface of the nodule
• A single angle of any type-
suspicious

Angular margins represent invasion of carcinoma into low-resistance pathways.

A, Fat offers little resistance to invasion, so malignant nodules surrounded by fat
can develop angles along any surface (arrows).
B, In lesions surrounded by hyperechoic fibrous tissues, paths of low resistance are
along the periductal tissues (arrowhead) and horizontally along the tissue planes
within the fibrous tissue (arrows). C, Following Cooper’s ligaments (arrowheads) down
to their base, where they intersect the surface of the nodule, is the best way to detect
angles (arrows) on the surface of malignant solid nodules.
 Microlobulations (Soft Findings)
• 1mm – 2mm lobulations along surface & within substance of nodule
• Seen in both invasive &DCIS components of tumour
• When angular & are associated with thick echogenic halo- fingers of
invasive carcinoma
• When round & associated with thin echogenic capsule- DCIS
• With increasing size of microlobulation, grade of tumour increases.

Microlobulations -pointed or angular

(arrows) and associated with spiculations
or thick, echogenic halo (asterisks), they
represent fingers of invasive tumor.
B, When microlobulations appear as small “tennis rackets” (arrows) projecting from
the surface of the nodule, they represent surrounding lobules distended with DCIS or cancerous
lobules. Microlobulations that are round or oval shaped with thin, echogenic capsules represent
tumor-distended ducts. The thin capsule represents the intact duct wall.
D, Large microlobulations(arrows) correspond to grossly distended ducts that contain high–
nuclear-grade DCIS.
 Shape Taller than wide
• Lesions that are larger in the AP dimension than in any horizontal
dimension are suspicious for malignancy.
• Primary feature of small solid malignant nodules of volume 1cc or
less
• As lesion enlarge, they become more wider than tall
• Shape of carcinoma reflects the shape of TDLUs within which
carcinoma arise. Most TDLUs lie in anterior aspect of mammary zone
& are oriented in a taller than wider axis. As lesion expand into lobar
ductal system, which is oriented horizontally, they then become
wider than taller.
• About 70% of malignant nodules with maximum diameters less than
10 mm are taller than wide. Only 20% of malignant nodules over 2.0
cm in maximum diameter are taller than wide.
B, Small, intermediate-nuclear-grade DCIS grossly distends the lobule (asterisk)
and its extralobular terminal duct, remaining oriented in the taller-than-wide axis of
the lobule from which it arose.
 Duct extension & branch pattern (Soft)
• Duct extension manifest as single projection of
solid growth toward nipple from main nodule.
• Branch pattern manifest as projection of solid
nodule into multiple small ducts peripherally.
• Size of branch pattern correlates with histologic
grade. High grade tumour tend to have large
branch patterns
• Presence of duct extension is not specific for
malignancy , rather suggest intraductal growth
pattern
Duct extension of ductal carcinoma in situ. DCIS growing within the lobar duct toward
nipple. Most invasive duct carcinomas contain DCIS components. In some cases the DCIS
growing away from the tumor toward the nipple within the lobar duct may grossly
distend the duct enough to allow recognition of duct extension sonographically (arrows).
 Acoustic shadowing
• Suggests presence of invasive malignancy
• Due to desmoplastic component & spiculation of
tumour
• If tumor is heterogeneous- only a part of tumour
show acoustic shadowing, other part of lesion may
show normal or enhanced sound transmission.
• D/D of malignant lesion showing acoustic
shadowing
– Low grade to intermediate invasive ductal carcinoma,
– Invasive lobular carcinoma,
– Tubulolobular carcinoma,
– Tubular carcinoma
Cancer causing acoustic shadowing. Acoustic shadowing is a “hard” finding that suggests the
presence of desmoplastic invasive tumor. Any acoustic shadowing should be considered
suspicious—whether A, complete, or B, partial. Tumors that are becoming progressively more
de-differentiated and that are polyclonal or that contain mixtures of low-grade and
intermediate-grade or high-grade components tend to create partial shadows.
 Acoustic enhancement
• However high grade invasive ductal carcinomas, the
most common circumscribed malignant nodules, do
not usually cause shadowing. In fact, they most often
have associated enhanced sound transmission
• D/D of malignant lesion showing enhanced sound
transmission-
– High grade invasive ductal carcinoma,
– high nuclear grade DCIS,
– colloid ca,
– medullary ca,
– invasive papillary ca
 High-grade invasive ductal carcinomas tend to be associated with enhanced sound
transmission. About one third of malignant nodules cause acoustic shadowing, the other
two-thirds have either normal sound transmission or enhanced sound transmission.
 Calcifications
• Benign calcification lie within echogenic
background, so after vol. averaging with
surrounding tissue, they are not enough
echogenic to be identified sonographically.
• Malignant calcifications lie within hypoechoic
tumour ,so remain visible even after vol.
averaging.
• So USG can demonstrate higher % of malignant
calcification than benign.
 Hypoechogenicity
• High cellularity , abundant hyaluronic acid in ECM
(high water content), necrosis, secretions and
intense acoustic shadowing.
 Benign findings
• Only if no suspicious finding are present, one
of three benign findings should be sought.
1. Pure and marked hyperechogenicity
2. Elliptical shape with wider than taller
orientation with lesion completely
encompassed by a thin ,echogenic capsule.
3. Gently lobulated shape with wider than
taller orientation with 3 or fewer lobulation,
with complete thin echogenic capsule
Benign
Findings
 Simple cyst
• anechoic, surrounded completely by thin, echogenic wall
or capsule with enhanced sound transmission & thin edge
shadows
• benign (BIRADS 2) and
require no aspiration or
follow-up.
 Complicated & complex cyst
Complex cyst – thick irregular walls, mural
nodules, thick septations & internal blood flow.
• Increased risk of containing papillomas &
carcinomas.

Complicated cyst – echogenic fluid, fluid debris

level, or fat-fluid level.
• Most non simple cyst fall within benign FCC
spectrum & malignant cysts are relatively
uncommon.
Septations within cystic masses. A, Thick, isoechoic septations within complex cysts are
suspicious for intracystic papilloma or intracystic papillary carcinoma. B, Thin, echogenic
septations within complex cysts are not suspicious. Such septations represent residual
walls of cystically dilated acini within a single TDLU and can be thought of as clusters of
simple cysts.
• Complex cysts are classified as BIRADS 4a &
should not undergo fluid cytology but evaluated
histologically by USG guided DVAB.
• Cysts that are characterized as BIRADS 2
include-
– cysts with mobile cholesterol crystals,
– cysts with milk of calcium,
– cyst with fat-fluid level,
– lipid cysts,
– cysts with calcified wall,
– cyst with thin echogenic septations
– cysts of skin origin.
 Niche application for breast USG
Nipple discharge
• Cause- large duct papillomas, carcinoma, duct
ectasia, benign fibrocystic change with
communicating cysts & hyperprolactemia
• Galactography is procedure of choice for nipple
discharge evaluation.
• When intraductal papillary lesion is demonstrated
by galactography ,USG is required because it is much
more practical to do USG guided DVAB of
intraductal lesion than to do stereotactic biopsy
with galactographic demonstration of affected duct
& lesion.
High-risk intraductal papillary lesions. A, lesions that expand the duct or breach
(arrows) its wall
2.Infection
• Mastitis- to dermine whether there is abscess,
maturity, loculations & to guide aspiration & to put
drain in abscess .
3.Implants
• To identify type of implant, implantation site, intra
or extracapsular rupture , silcon granuloma,
herniation, capsule infection
Breast implant rupture. A, Classic findings of intracapsular rupture of a single-lumen silicone
gel implant are the “stepladder sign” (arrows) and hyperechoic silicone gel (asterisk) in the
right breast. Several linear, horizontally oriented echoes represent folds in a collapsed shell.
Several of these are double echogenic lines that represent the inner and outer surfaces of
each fold of the shell (arrows). The extravasated gel that lies outside the implant shell has
become hyperechoic (asterisk). Note that only a single echogenic line that represents the peri-
implant capsule can be seen on the right (arrowhead).
 Regional lymph node assessment
1. Size
• minimum diam. > 1cm considered abnormal.
• Poor criteria for metastasis
2. Shape
• Metastatic lymph node is abnormally round-
late finding
• Eccentric cortical thickening is much more
sensitive than roundening
• Abnormally hypoechoic cortex.
 Lymph nodes: spectrum of normal appearance
A, In young patients the mediastinum of the lymph node tends to be uniformly hyperechoic
because the medullary cords and sinuses fill the entire mediastinum (m).
B, In older patients who have had repeated episodes of inflammation, the center of the
mediastinum (m) becomes infiltrated with isoechoic fat, and the medulla (arrowhead) becomes
compressed into a thin band just deep to the hypoechoic cortex (c).
• Morphologic assessment of lymphnode is more
effective than size, shape or echogenicity.
• Hallmark of metastasis- cortical thickening
• Pattern of thickening depend on implantation site:
1. Centre of cortical sinusoid- widen cortex focally &
equally in outward & inward directions.
2. Subcapsular sinusoid- bulge outward, “mickey ear”
3. Innerside of cortical sinusoid- bulge into lymph node
mediastinum, “rat bite” defect in hilum
4. Cortical sinusoid throughout entire lymph node-
uniform cortical thickening simulating reactive LN.
 spectrum of cortical thickening.
A, Metastases that implant near the midcortical sinusoids tend to thicken the cortex
focally and equally in inward and outward directions.
B, Metastases that implant within the subcapsular sinusoids tend to cause focal,
outwardly bulging cortical thickening (“mouse ear”).
C, Metastases that implant toward the inner part of the cortical sinusoids cause focal
cortical thickenings that bulge inwardly into the lymph node mediastinum (“rat bite”
defect).
D, Metastases that implant extensively throughout the cortical sinusoids can cause
symmetrical cortical thickening indistinguishable from the cortical thickening caused by
inflammation.
E, Cortical thickening so severe that the hilum is obliterated is usually caused by metastasis
and is strongly against the node being benign and reactive.
F, Microcalcifications within a lymph node indicate metastasis until proved otherwise,
especially if the primary breast lesion presents with microcalcifications.
• In case of uniform cortical thickening, comparing to
adjacent LN is best way to differentiate benign
reactive LN & metastatic LN. In inflammation all LNs
show uniform cortical thickening, however in
metastasis, adjacent LN is normal.
• Assessment of adjacent LN is not necessary when
thickening is so severe that hilum is completely
obliterated, because it is more frequent in
metastasis than reactive LN.
• LNs should be routinely seen in BIRADS 4 & 5
lesions.
• Sentinel lymph node- level 1, rarely level 2
• If level 3 LNs involved- assess supraclavicular &
jugular LNs.
• Internal mammary LNs should be evaluated in all
cases, specially when lesion is medial & deep.
• Internal mammary LNs are important to radiation
oncologists because internal mammary LNs are not
routinely treated with radiation for potential long
term cardiac complication. But if internal mammary
LNs are involved , it is included in radiation field.
• Internal mammary LNs metastasis is most common
in first 3 interspaces just lateral to sternum.
Advances in USG imaging of Breast
• Sonoelastography
• 3D USG
• Contrast Enhanced US
 Sonoelastography
• Noninvasive imaging technique that can be used to
depict relative tissue stiffness or displacement (strain)
in response to an imparted force. Stiff tissues deform
less and exhibit less strain than compliant tissues in
response to the same applied force.
• Sonoelastography is based on the comparison of signals
acquired before and after tissue displacement. Several
sonoelastographic techniques have been devised,
including compression strain imaging , vibration
sonoelastography , acoustic radiation force generated
by the ultrasound pulse , and real-time shear velocity
 Tissue compression(force)

Tissue strain (displacement)

Soft tissue Hard tissue

(Benign) ( malignant)

More displacement Less displacement

Elasticity image reconstruction according to strain(displacement) distribution

Elasticity image
• Compression elastography involves calculating a
strain profile in a direction perpendicular to the
tissue surface in response to an externally applied
force.
• Specialized software is used to calculate the
relative difference in tissue movement from one
frame to another and then to estimate the tissue
deformation.
• The deformation measurements are mapped onto
an elastogram, on which stiffer areas are depicted
as dark and more-elastic areas are lighter, according
to convention. This permits depiction of a lesion
that is otherwise isoechoic on gray-scale US images
• Lesions that have only one discordant feature
between the B-mode US image and the elastogram
may be considered indeterminate on the
elastogram.
• Overall, US elastography is reported to have a
sensitivity greater than 95% and a specificity of
about 85% for differentiating between benign and
malignant breast lesions
 Interpretation:
• Score 1: Even strain for entire lesion: Benign lesions

• Score 2: mosaic strain: mostly benign lesion/ DCIS

• Score 3: strain only in peripheral: benign(intraductal papillma)

>> malignant.

• Score 4: no strain in entire lesion: characteristics of malignancy

• Score 5: no strain even in surronding : infiltrating malignant

lesion.
 Score 2
Score 1

Score 5
 3D Ultrasound
• Enables reconstruction of image in coronal plane
which is otherwise not obtainable by 2D imaging.
• Coronal plane image is better for delineation of
spiculations and architectural distortion.
• Automated Breast Volume scanning is a
technique which acquires volume data of the
whole breast and permits MPR of the image in
coronal and sagittal planes
• 3D USG to guide biopsy
3D scanning and
coronal
reconstructed image
demonstrating
spiculations in a
lesion which showed
only thick echogenic
halo on axial scan.
 Contrast-enhanced ultrasonography
• The finding that Doppler signals may be difficult to
detect either because of small vessel size or
inadequate equipment has led to the development of
ultrasound contrast agents.
• They are encapsulated microbubbles, which increase
the acoustic scattering from the tissues through which
they.
• Contrast enhancement improves detection of small
vessels with slow and low-volume blood flow. It
reduces equipment dependence and could
theoretically improve standardization by also providing
dynamic flow information which can be quantified.
THANK YOU
1. Fundamentals in breast imaging
2. Breast anatomy
3. TDLU & its significance
4. Technique to demonstrate intranipple & subareolar ducts.
5. BIRADS category & expected risk of malignancy
6. Management of BIRADS category
7. Dynamic & positional maneuvres
8. Morphologic & histologic feature of suspicious sonographic findings
9. D/D of malignant lesion showing acoustic shadowing
10. D/D of malignant lesion showing enhanced sound transmission
11. sonographic finding in benign lesions
12. Simple, complex & complicated cysts
13. Cysts characterized as BIRADS 2 category
14. Niche application of breast ultrasound
15. Features of malignant lymph nodes
16. Doppler findings in benign & malignant lesions
17. Sonoelastography principle
 False –ve finding in invasive ductal carcinoma
(a) B-mode US image shows a hypoechoic lesion that is wider than tall but has
microlobulations. (b) US elastogram shows that the lesion does not appear
particularly stiff, and the boundaries are difficult to discern.
 Fibroadenoma
(a) B-mode US image of the left breast shows a lobulated hypoechoic lesion that is
taller than wide, with posterior acoustic shadowing. (b) US elastogram, however,
shows the lesion to be smaller than on the B-mode image
 False-positive finding of malignancy in fibroadenoma
The fibroadenoma measures smaller on the B-mode US image (a) than on the
elastogram
 Hematoma
(a) B-mode US image of the breast demonstrates a superficial heterogeneous mass.
(b) US elastogram shows that the lesion is stiff but measures smaller than on the B-
mode image. At physical examination, skin discoloration was noted in the
corresponding area, a finding consistent with a hematoma
 Metastatic lymph node
(a) B-mode US image demonstrates a lymph node that appears benign
on the basis of its reniform shape and echogenicity. . (b) Corresponding
US elastogram, however, shows a stiff area that turned out to be a
metastatic focus (arrows)& larger diameter than B mode.
 Lobar duct

Parenchymal
Smaller branch duct
elements

lobules

Lobe
Compact interlobular
stromal fibrous
tissue

Loose periductal &

Supporting stromal
intralobular stromal
tissue
fibrous tissue

fat
• Elastography:
– Score 1: Even strain over the entire low echo area
– Score 2: Strain over most of the low echo area
– Score 3: Strain at the periphery, the low echo area
spared
– Score 4: No strain over the entire low echo area
– Score 5: No strain over the entire low echo area or
surrounding area
Score 1: Even strain over the entire low echo area

Score 2: Strain over most of the low echo area

Score 3: Strain at the periphery, the low echo area spared

Score 4: No strain over the entire low echo area

• Score 5: No strain over the entire low echo area or
surrounding area