BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND

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BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Powered By Docstoc
					BENIGN VS MALIGNANT
  MASSES IN BREAST
    ULTRASOUND

          Dr. Mona Rozin
    Director of Breast Imaging
     Assuta Medical Centers


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Goal of Breast Ultrasound

  SOLID VS CYSTIC




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   Goal of Breast Ultrasound
• Make a more specific diagnosis than
  clinical and mammographic findings
  alone.
• Prevent unnecessary biopsies.
• Find cancers missed by mammography.




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Breast cancer is extremely heterogeneous
  therefore we CANNOT distinguish
  benign from malignant on the basis of
  only a single sonographic finding.

Breast cancer varies greatly not only from
  one mass to another but even WITHIN
  an individual mass.



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Ultrasound shows morphology and not
  histology / biology

ONE suspicious finding requires further
 evaluation -----> that is biopsy and
 should be given BIRAD 4A up to 5




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   BIRADS for U/S
BIRAD 1 – normal

BIRAD 2 – benign finding

BIRAD 3 – probably benign




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         BIRADS for U/S
BIRAD 4A – abnormal finding – low
           suspicion
BIRAD 4B – abnormal finding –
           intermediate suspicion
BIRAD 4C – abnormal finding – probably
           malignant
BIRAD 5 – highly suspicious for malignancy
BIRAD 6 – known malignancy

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Spectrum of masses




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  Circumscribed vs Spiculated
 malignant masses – a spectrum
      of ultrasound features
I.   Desmoplastic vs. inflammatory reaction

II. Cellularity

III. Vascularity


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     Desmoplastic Reaction
• Host response to tumor – attempt to
  wall off the tumor with fibrosis and
  elastosis to keep it from spreading.
• Develops slowly
• Therefore spiculated lesions are usually
  slow growing GRADE 1 – 2 tumors




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    Inflammatory Response
• GRADE 3 tumors may be circumscribed
  and grow so fast that desmoplasia has no
  time to develop.
• These carcinomas incite an inflammatory
  response with lymphocytes and plasma
  cells.




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              Cellularity
• Circumscribed masses are much more
  cellular than spiculated masses.
• They have lots of tumor cells, lymph
  cells and plasma cells – this causes
  posterior enhancement.
• Spiculated masses have much fewer
  cells and very hypocellular desmoplasia
  – this causes posterior shadowing.


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             Vascularity
• Circumscribed masses are usually very
  vascular – lots of cells and divisions
  require more blood – more angiogenetic
  factors; inflammatory response also
  creates hypervascularity.
• Spiculated masses may have same
  vascularity as normal tissue or benign
  masses because of the smaller amount
  of cells and angiogenetic factors.

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BIRADS for Ultrasound Masses
I. Shape
II. Margin
III. Orientation
IV. Lesion boundary
V. Echogenic pattern
VI. Posterior acoustic features
VII. Effect on surrounding parenchyma
VIII.Calcifications
IX. Vascularity
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Background Breast Pattern

• Homogenous Fatty
• Heterogeneous – focally or
  diffusely variable
• Homogenous Fibroglandular




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Fatty




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Heterogeneous




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Fibroglandular




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                 I. Shape

• Oval – includes tear drop shape
         2-3 macrolobulations
         may be with thin echogenic capsule

• Round – cysts, mets, IDC (high grade)

• Irregular – NOT round or oval


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               Oval




fibroadenoma

                      DCIS




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       Round




cyst



               DCIS




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              Irregular



radial scar




                          IDC

        IDC


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                II. Margin
• Circumscribed – smooth, distinct margin

• Microlobulated – may be the expression of
  extended lobules filled with DCIS; 80% of
  all IDC have a component of DCIS

• Indistinct – NO abrupt interface with
  surrounding tissue

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Circumscribed




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                II. Margin
• Circumscribed – smooth, distinct margin

• Microlobulated – may be the expression
  of extended lobules filled with DCIS; 80% of
  all IDC have a component of DCIS

• Indistinct – NO abrupt interface with
  surrounding tissue

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Microlobulated




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               II. Margin
• Circumscribed – smooth, distinct margin

• Microlobulated – may be the expression of
  extended lobules filled with DCIS; 80% of
  all IDC have a component of DCIS

• Indistinct – NO abrupt interface with
  surrounding tissue

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Indistinct




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              Margin – cont.
• Angular – part of margin has sharp corners;
  most accurate of all signs of malignancy;
  invasion follows path of least resistance – in
  fat: many angles; in fibrosis: horizontal and
  then along Cooper’s ligaments

• Spiculated – sharp projecting lines; use U/S
  MAG views to see surface characteristics

 This is a spectrum of findings

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Angular




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              Margin – cont.
• Angular – part of margin has sharp corners;
  most accurate of all signs of malignancy;
  invasion follows path of least resistance – in
  fat: many angles; in fibrosis: horizontal and
  then along Cooper’s ligaments

• Spiculated – sharp projecting lines; use U/S
  MAG views to see surface characteristics

 This is a spectrum of findings

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Spiculated




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Mixed




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           III. Orientation

• Parallel – wider than tall – long axis
  parallel to skin

• NOT parallel – taller than wide – long
  axis perpendicular to skin
  includes ROUND masses



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TDLU




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CA




FA


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post.   ant.   terminal



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  Wider than tall !!

         ant. lobule




                       terminal lobules
distended duct with
invasion




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        IV. Lesion Boundary
• Abrupt interface – no transition zone
  between mass and surrounding tissue

• Echogenic rim – variant of spicules too
  small to resolve on U/S;
  some masses have a very thick echogenic
  rim with a tiny hypoechogenic nidus –
  must examine carefully;
  peritumoral edema usually occurs btw.
  mass and skin
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 Abrupt Interface



FA                         CA




       echogenic capsule

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        IV. Lesion Boundary
• Abrupt interface – no transition zone
  between mass and surrounding tissue

• Echogenic rim – variant of spicules too
  small to resolve on U/S;
  some masses have a very thick echogenic
  rim with a tiny hypoechogenic nidus –
  must examine carefully;
  peritumoral edema usually occurs btw.
  mass and skin
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Echogenic Rim




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            Echogenic Rim




Same mass – with &
without Sono-CT




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        V. Echogenic Pattern
• Hyperechoic – more than fat; very rarely
  can be angiosarcoma, ILC, lymphoma
• Isoechoic – equal to fat
• Hypoechoic – less than fat
• Mixed – hyper and hypo; can be fibrosis, fat
  necrosis, FA, IDC
• Anechoic – absence of internal echoes;
  mets, IDC- high grade.


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     normal fibrotic tisssue




                               fat necrosis
silicone


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hyper?                    NOT




         hyper with iso         4 mo later

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        V. Echogenic Pattern
• Hyperechoic – more than fat; very rarely
  can be angiosarcoma, ILC, lymphoma
• Isoechoic – equal to fat
• Hypoechoic – less than fat
• Mixed – hyper and hypo; can be fibrosis, fat
  necrosis, FA, IDC
• Anechoic – absence of internal echoes;
  mets, IDC- high grade.


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Mucinous CA




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        V. Echogenic Pattern
• Hyperechoic – more than fat; very rarely
  can be angiosarcoma, ILC, lymphoma
• Isoechoic – equal to fat
• Hypoechoic – less than fat
• Mixed – hyper and hypo; can be fibrosis, fat
  necrosis, FA, IDC
• Anechoic – absence of internal echoes;
  mets, IDC- high grade.


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IDC




           seroma


      FA




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        V. Echogenic Pattern
• Hyperechoic – more than fat; very rarely
  can be angiosarcoma, ILC, lymphoma
• Isoechoic – equal to fat
• Hypoechoic – less than fat
• Mixed – hyper and hypo; can be fibrosis, fat
  necrosis, FA, IDC
• Anechoic – absence of internal echoes;
  mets, IDC- high grade.


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Intracystic papillary CA


                   phylloides   hematoma




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        V. Echogenic Pattern
• Hyperechoic – more than fat; very rarely can
  be angiosarcoma, ILC, lymphoma
• Isoechoic – equal to fat
• Hypoechoic – less than fat
• Mixed – hyper and hypo; can be fibrosis, fat
  necrosis, FA, IDC
• Anechoic – absence of internal echoes; cysts
  mets, IDC- high grade.


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cysts




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    VI. Posterior Acoustic Features
•   None
•   Enhancement – highly cellular lesions
•   Shadowing – seen in desmoplasia
•   Combined
    Can use this finding to try and predict
    GRADE; very small lesions (< 5 mm) may
    have no transmission because haven’t had
    time to develop desmoplasia or
    inflammatory reaction
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Shadowing




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enhancement




              normal




                            cyst


                       CA




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       DO NOT FORGET -
May see artifactual shadowing from
 steep Cooper’s ligaments – can be
    removed with compression !




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artifact




compression




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DD of Enhancement
1)   IDC – high GRADE
2)   Mucinous CA
3)   Medullary CA
4)   Metaplastic CA
5)   Papillary CA

6) FA
7) Cysts

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DD of Shadowing
1) IDC – low GRADE
2) ILC
3) Tubular CA

4)   Scar
5)   Fat necrosis
6)   Radial scar
7)   Calcified FA
8)   Calcified oil cysts
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    VII. Effect on Surrounding
               Tissue
• Straightening of Cooper’s ligaments
• Architectural distortion
• Skin thickening – normal 2 mm
• Skin retraction
• Edema – mastitis, radiation Tx,
  inflammatory CA, CHF
• Ducts – abnormal size, branching

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Architectural distortion




                           Thickening & straightening
                           of cooper’s ligaments

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    VII. Effect on Surrounding
               Tissue
• Straightening of Cooper’s ligaments
• Architectural distortion
• Skin thickening – normal 2 mm
• Skin retraction
• Edema – mastitis, radiation Tx,
  inflammatory CA, CHF
• Ducts – abnormal size, branching

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Skin thickening




                  Inflammatory CA

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Skin retraction in
scar with seroma


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    VII. Effect on Surrounding
               Tissue
• Straightening of Cooper’s ligaments
• Architectural distortion
• Skin thickening – normal 2 mm
• Skin retraction
• Edema – mastitis, radiation Tx,
  inflammatory CA, CHF
• Ducts – abnormal size, branching

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focal edema




              Edema with
              dilated lymphatics

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    VII. Effect on Surrounding
               Tissue
• Straightening of Cooper’s ligaments
• Architectural distortion
• Skin thickening – normal 2 mm
• Skin retraction
• Edema – mastitis, radiation Tx,
  inflammatory CA, CHF
• Ducts – abnormal size, branching

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Duct extension




                 Branch pattern




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                                           IDC
        Duct extension




2nd lumpectomy with + margin
                               1st lumpectomy with + margin




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      VIII. Calcifications

•   Macrocalcifications
•   Microcalcifications outside a mass
•   Microcalcifications inside a mass




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FA
     Oil cyst




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IDC
      DCIS




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     IX. Vascularity

•   Absent
•   Present
•   Adjacent to lesion
•   In surrounding tissue




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              Feeding vessel




IDC-Grade I




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IDC-GradeII




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FA




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FA   Cyst




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Suspicious for Malignancy
I.  Hard
     spiculations, thick rim
     angular margins
     (shadowing)
II. Intermediate
     hypoechoic
     microlobulation
     taller than wide
                               Stavaros

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III. Soft
     duct extension
     branching pattern
     calcifications



                         Stavaros




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      Most likely benign

•   Oval
•   Circumscribed – echogenic capsule
•   Parallel
•   Abrupt interface
•   Hyperechogenic




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      Algorithm for Sonographic
              Evaluation

1) Look for malignant findings and if there are
   any – give BIRADS 4-5 and biopsy
2) If there are NO malignant findings look for
   benign findings and if there are any give
   BIRADS 2-3 and suggest follow-up
3) If NO benign findings found – give BIRADS
   4A and biopsy

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Sine Qua Non
(without which there is nothing)
 technique, technique, technique

Must always base management
 on the worst feature present !!!!

                               mrozin,md
mrozin,md

				
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