BREAST SONOGRAPHY FINANCIAL ... of Clinical Radiology Vanderbilt University Medical Center Chief, Section of Breast Imaging Vanderbilt Diagnostic SonographySonography Symposium Symposium

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BREAST BREAST SONOGRAPHYSONOGRAPHY

John Huff, M.D.John Huff, M.D.Professor of Clinical RadiologyProfessor of Clinical RadiologyVanderbilt University Medical CenterVanderbilt University Medical CenterChief, Section of Breast ImagingChief, Section of Breast Imaging

Vanderbilt Diagnostic Vanderbilt Diagnostic SonographySonography SymposiumSymposiumJuly 24, 2011July 24, 2011

DR. JOHN HUFF HAS NO DR. JOHN HUFF HAS NO FINANCIAL RELATIONSHIPSFINANCIAL RELATIONSHIPSFINANCIAL RELATIONSHIPS FINANCIAL RELATIONSHIPS

TO DISCLOSETO DISCLOSE

InstrumentationInstrumentation Logistical and Technical ConsiderationsLogistical and Technical Considerations Sonographic Breast AnatomySonographic Breast Anatomy

Fib ti ChFib ti Ch

BREAST SONOGRAPHYBREAST SONOGRAPHY

Fibrocystic ChangeFibrocystic Change Characterization of Cystic MassesCharacterization of Cystic Masses Characterization of Solid MassesCharacterization of Solid Masses ReportingReporting SummarySummary

INSTRUMENTATIONINSTRUMENTATION

TransducerTransducer LinearLinear

FrequencyFrequency >10 mHz>10 mHz

Dynamic RangeDynamic Range >50 db>50 db

Spatial Compounding and Spatial Compounding and Tissue HarmonicsTissue Harmonics

Especially at higher dynamic Especially at higher dynamic rangerange

LOGISTICAL AND TECHNICAL LOGISTICAL AND TECHNICAL CONSIDERATIONSCONSIDERATIONS

Screening vs Diagnostic Screening vs Diagnostic –– ACRIN 6666ACRIN 6666 Technical Technical

•• TargetingTargeting•• CorrelationCorrelation•• DocumentationDocumentation•• Scan planesScan planes•• Patient positionPatient position•• Gain / TGCGain / TGC•• Transducer manipulationTransducer manipulation•• Doppler Doppler •• Special CircumstancesSpecial Circumstances

ArtifactsArtifacts•• Spatial Compounding and Tissue HarmonicsSpatial Compounding and Tissue Harmonics

Emerging TechnologyEmerging Technology

SCREENING VS DIAGNOSTICSCREENING VS DIAGNOSTIC

DIAGNOSTICDIAGNOSTIC•• Most breast sonography is performed as Most breast sonography is performed as

a targeted evaluation to further explain a targeted evaluation to further explain a focal mammographic or clinical a focal mammographic or clinical a oca a og ap c o c caa oca a og ap c o c caabnormalityabnormality

SCREENINGSCREENING•• Remains controversial primarily because Remains controversial primarily because

of operator dependency and logistics… of operator dependency and logistics… ACRIN 6666ACRIN 6666

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ACRIN 6666ACRIN 6666

JAMA, 5JAMA, 5--1414--08 08 –– Vol 299, No.18Vol 299, No.18•• 2809 women with heterogeneously or extremely 2809 women with heterogeneously or extremely

dense tissuedense tissue in at least one quadrantin at least one quadrant•• Participants classified as Participants classified as high riskhigh risk based on based on

various parametersvarious parametersvarious parametersvarious parameters•• Examination performed directly by Examination performed directly by experienced experienced

breast imagers breast imagers with with additional special additional special trainingtraining for exam criteriafor exam criteria

•• Median time of exam: 19 minutesMedian time of exam: 19 minutes•• Compared Screening mammography alone to Compared Screening mammography alone to

screening mammography plus screening breast screening mammography plus screening breast sonography; later addition of MRI sonography; later addition of MRI

ACRIN 6666 RESULTS & UPDATEACRIN 6666 RESULTS & UPDATE

Addition of screening US to screening Addition of screening US to screening mammography (M+US) increased mammography (M+US) increased the diagnostic yield with an average the diagnostic yield with an average the diagnostic yield with an average the diagnostic yield with an average of about 4.3 additional cancers per of about 4.3 additional cancers per 1000 women screened1000 women screened

This increased yield remains constant This increased yield remains constant at year 3 of the studyat year 3 of the study


Initial PPV for biopsy Initial PPV for biopsy recommendation based on US alone recommendation based on US alone was 8.9% (compared to 22.6% for was 8.9% (compared to 22.6% for

h l )h l )mammography alone)mammography alone) PPV for US increased in year 3 but PPV for US increased in year 3 but

remained about half of that for remained about half of that for mammography alonemammography alone


After 3 years’ screening with M+US, After 3 years’ screening with M+US, adding MRI increased the cancer adding MRI increased the cancer detection rate among women at detection rate among women at ggelevated risk of breast cancerelevated risk of breast cancer

This suggests that M+US screening This suggests that M+US screening in the high risk population may be in the high risk population may be less effective than M+MRI screening less effective than M+MRI screening in this populationin this population

ACRIN 6666 CONCLUSIONSACRIN 6666 CONCLUSIONS

Adding screening US to mammography Adding screening US to mammography in high risk women with dense breast in high risk women with dense breast tissue: tissue: •• Yields an additional average of 4.3 cancers Yields an additional average of 4.3 cancers

per 1000 women screenedper 1000 women screened•• Substantially increases the number of false Substantially increases the number of false

positive biopsy recommendationspositive biopsy recommendations

UNRESOLVED ISSUESUNRESOLVED ISSUES

Physician time / Reimbursement Physician time / Reimbursement •• Can results be duplicated with technologist performed Can results be duplicated with technologist performed

exams and shorter time for examsexams and shorter time for exams•• Whole breast USWhole breast US

PPV PPV C PPV’ ld b d d bl l C PPV’ ld b d d bl l •• Current PPV’s would be regarded as unacceptably low Current PPV’s would be regarded as unacceptably low for mammography; attendant cost of false positive for mammography; attendant cost of false positive biopsy recommendationsbiopsy recommendations

Probably benign criteria Probably benign criteria •• Determination of, and logistics for followDetermination of, and logistics for follow--upup

Frequency of screeningFrequency of screening Role of US screening vs MRM screeningRole of US screening vs MRM screening

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ACR / SBI STATEMENTACR / SBI STATEMENT

“The American College of Radiology (ACR) and “The American College of Radiology (ACR) and the Society of Breast Imaging (SBI) feel that the the Society of Breast Imaging (SBI) feel that the results of ACRIN 6666 increase the evidence base results of ACRIN 6666 increase the evidence base for the utility and limitations of screening for the utility and limitations of screening ultrasound. ACRIN 6666 established standardized ultrasound. ACRIN 6666 established standardized technique and interpretive criteria as well as technique and interpretive criteria as well as

i i t f h i i i i t f h i i experience requirements for physicians experience requirements for physicians performing these examinations. At centers which performing these examinations. At centers which follow similar practice, US may improve detection follow similar practice, US may improve detection of early breast cancer in women at increased risk of early breast cancer in women at increased risk of breast cancer who are not currently of breast cancer who are not currently recommended for MRI. These results do not recommended for MRI. These results do not justify the recommendation for screening justify the recommendation for screening ultrasound for the general public or in lieu of or in ultrasound for the general public or in lieu of or in addition to MRI for very highaddition to MRI for very high--risk women.”risk women.”

BOTTOM LINEBOTTOM LINE

Screening breast sonography should be used very Screening breast sonography should be used very judiciously judiciously •• Limit to centers that adopt the rigorous ACRIN 6666 Limit to centers that adopt the rigorous ACRIN 6666

criteria for training and performance or have similar criteria for training and performance or have similar experienceexperience

•• Selected population (high risk / increased density)Selected population (high risk / increased density)•• Selected population (high risk / increased density)Selected population (high risk / increased density)•• Commitment to scan timeCommitment to scan time•• Understanding of poor reimbursement Understanding of poor reimbursement •• Acceptance of poor PPV for biopsyAcceptance of poor PPV for biopsy

Does not replace mammographyDoes not replace mammography For now, MRM may be more practical and For now, MRM may be more practical and

effective for this patient populationeffective for this patient population

TARGETING OF EXAMTARGETING OF EXAM

ClinicalClinical•• Palpate: If the exam is being performed for a palpable Palpate: If the exam is being performed for a palpable

abnormality, palpate the finding before placing the abnormality, palpate the finding before placing the transducer on the patienttransducer on the patient

•• Confirm that an US finding corresponds to the palpable Confirm that an US finding corresponds to the palpable findingfindinggg

MammographicMammographic•• Predict location based on mammographic positionPredict location based on mammographic position

MULDMULD Predict US coordinates before US performancePredict US coordinates before US performance

•• Predict US appearance based on size and relationship of Predict US appearance based on size and relationship of mammographic abnormality to anatomic landmarksmammographic abnormality to anatomic landmarks Is it in premammary or retromammary fat; is it in the Is it in premammary or retromammary fat; is it in the

glandular tissue; is it at the junction of identifiable glandular tissue; is it at the junction of identifiable anatomic structures?anatomic structures?

ULTRASOUND COORDINATESULTRASOUND COORDINATES

PositionPosition should be determined in 3 should be determined in 3 planes:planes:•• RadialRadial

This is almost universally done with clock face This is almost universally done with clock face positionposition

•• Distance from nippleDistance from nipple Can be done with distance from the nipple or with Can be done with distance from the nipple or with

concentric zones from nipple (e.g. RA, 1, 2, or 3)concentric zones from nipple (e.g. RA, 1, 2, or 3)

•• DepthDepth Superficial, mid or deep (e.g. A, B, C)Superficial, mid or deep (e.g. A, B, C)

DocumentDocument finding with images in 2 finding with images in 2 planes and measurements in 3 planesplanes and measurements in 3 planes

SCAN PLANESSCAN PLANES

•• Axial or TransverseAxial or Transverse•• Longitudinal or SagittalLongitudinal or Sagittal•• Radial and antiradial Radial and antiradial

duct orientationduct orientation

•• Alter as neededAlter as needed Look at all of the lesion as well as its Look at all of the lesion as well as its

marginsmargins

PATIENT POSITIONPATIENT POSITION

To correlate with other modalities, begin To correlate with other modalities, begin supine with breast evenly falling on chest supine with breast evenly falling on chest wallwall•• Locate anticipated US coordinates from other Locate anticipated US coordinates from other

imaging studies in this positionimaging studies in this positionM dif i i i f i d M dif i i i f i d Modify patient position for improved Modify patient position for improved scanningscanning•• e. g. For lesions in the UOQ of the breast, role e. g. For lesions in the UOQ of the breast, role

patient away from you to thin out the tissue patient away from you to thin out the tissue overlying the area of interestoverlying the area of interest

For palpable lesions, modify position as For palpable lesions, modify position as needed to reproduce palpable findingneeded to reproduce palpable finding

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GAIN AND TGCGAIN AND TGC

The reference tissue in the breast is fatThe reference tissue in the breast is fat•• Overall gain should be adjusted with fat Overall gain should be adjusted with fat

medium graymedium gray

TGC is adjusted for uniform echogenicity TGC is adjusted for uniform echogenicity throughout the depth of tissuethroughout the depth of tissue•• Hyperechoic implies more echogenic than fatHyperechoic implies more echogenic than fat•• Hypoechoic implies less echogenic than fatHypoechoic implies less echogenic than fat

FOCAL ZONE AND FRAME RATEFOCAL ZONE AND FRAME RATE

Appropriately adjust focal zoneAppropriately adjust focal zone As frame rate is less important than As frame rate is less important than

i th li ti i th li ti in some other applications, one can in some other applications, one can use wider focal zones without use wider focal zones without significant compromisesignificant compromise

TRANSDUCER MANIPULATIONTRANSDUCER MANIPULATION Rocking Rocking

•• Reduce edge shadowingReduce edge shadowing•• Improve margin assessmentImprove margin assessment

AnglingAngling•• Project area of interest free of overlapping structures Project area of interest free of overlapping structures

(e.g. nipple)(e.g. nipple) RotatingRotatinggg

•• OrientationOrientation•• Relation to adjacent structuresRelation to adjacent structures•• Follow ductsFollow ducts

PressurePressure•• IncreaseIncrease

Enhance capsuleEnhance capsule Reduce artifactual shadowing (you can decrease real Reduce artifactual shadowing (you can decrease real

shadowing too)shadowing too)•• DecreaseDecrease

Enhance flowEnhance flow

DOPPLERDOPPLER

TechniqueTechnique•• PowerPower•• Transducer pressureTransducer pressure

Solid vs cysticSolid vs cystic•• Only useful if flow identifiedOnly useful if flow identified

Characterization of solid massesCharacterization of solid masses•• Poor predictive valuePoor predictive value

SPECIAL CIRCUMSTANCESSPECIAL CIRCUMSTANCES

•• SuperficialSuperficial Gel or standoffGel or standoff

•• DeepDeep Lower frequenciesLower frequencies ArtifactArtifact ArtifactArtifact

•• RetroareolarRetroareolar GelGel Angle from side and change orientationAngle from side and change orientation “Two hand” technique“Two hand” technique

•• FremitusFremitus ExperimentExperiment

ARTIFACTSARTIFACTS

Improved resolution and wider dynamic Improved resolution and wider dynamic range produce significant artifacts in range produce significant artifacts in breast sonographybreast sonography

Tissue harmonicsTissue harmonics Tissue harmonicsTissue harmonics•• Reduces artifactual echoes by detecting harmonic Reduces artifactual echoes by detecting harmonic

frequencies and separating them from the fundamental frequencies and separating them from the fundamental frequency and associated artifacts frequency and associated artifacts

Spatial compoundingSpatial compounding•• Reduces artifactual echoes by generating multiple sound Reduces artifactual echoes by generating multiple sound

beams across the transducer facebeams across the transducer face

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HARMONICSHARMONICS

STAVROS

HARMONICSHARMONICS

STAVROSSTAVROS

SPATIAL COMPOUNDINGSPATIAL COMPOUNDING

STAVROSSTAVROS

EMERGING TECHNOLOGYEMERGING TECHNOLOGY

ElastographyElastography•• Technique for mapping relative tissue stiffness in Technique for mapping relative tissue stiffness in

response to an applied forceresponse to an applied force•• Techniques for breast:Techniques for breast:

Vib i l h Vib i l h U f l U f l Vibration sonoelastography Vibration sonoelastography –– Use of external or Use of external or internal sources of vibration (respiration/heart) to internal sources of vibration (respiration/heart) to produce tissue deformationproduce tissue deformation

Compression sonoelastography Compression sonoelastography –– Use of mechanical Use of mechanical compression to produce deformationcompression to produce deformation

•• Criteria for assessment:Criteria for assessment: Size Size StiffnessStiffness

SIZESIZE

No change in size of benign fibroadenomaNo change in size of benign fibroadenoma

Image Courtesy PhilipsImage Courtesy Philips

SIZESIZE

Malignant mass showing larger on the elastogramMalignant mass showing larger on the elastogram


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STIFFNESSSTIFFNESS

Dark blue depicts the stiffest areas in this imageDark blue depicts the stiffest areas in this image A=Malignant mass; B=Benign massA=Malignant mass; B=Benign mass


UNRESOLVED ISSUESUNRESOLVED ISSUES

Lack of established standards for Lack of established standards for performance and assessmentperformance and assessment

Operator dependency and Operator dependency and Operator dependency and Operator dependency and Inter/IntraInter/Intra--observer variabilityobserver variability

Role in relation to standard Role in relation to standard sonographic assessment criteriasonographic assessment criteria

BOTTOM LINEBOTTOM LINE

Primary application remains Primary application remains investigationalinvestigationalR ti li i l li ti ill R ti li i l li ti ill Routine clinical application will Routine clinical application will require additional validation with require additional validation with prospective trialsprospective trials

Sonographic Breast AnatomySonographic Breast Anatomy

SkinSkin

DuctsDucts

Premammary FatPremammary Fat

Anterior Mammary FasciaAnterior Mammary Fascia

Glandular TissueGlandular Tissue Glandular TissueGlandular Tissue

Posterior Mammary FasciaPosterior Mammary Fascia

Cooper’s LigamentsCooper’s Ligaments

Retromammary FatRetromammary Fat

MuscleMuscle

RibsRibs

PleuraPleura

ANATOMYANATOMY

PREMAMMARY FATPREMAMMARY FASCIA

GLANDULAR TISSUE

RETROMAMMARY FASCIA

RETROMAMMARY FATMUSCLE

ANATOMYANATOMY

COOPER’S LIGAMENTS

FAT LOBULE

SKIN

GLANDULAR TISSUE

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LARGE DUCTSLARGE DUCTS SMALL DUCTS / TDLU’SSMALL DUCTS / TDLU’S

TDLUEXTRALOBULAR TERMINAL DUCT

FIBROCYSTIC CHANGEFIBROCYSTIC CHANGE

STAVROS / TABAR STAVROS / TABAR

FIBROCYSTIC CHANGEFIBROCYSTIC CHANGE

STAVROS / TABARSTAVROS / TABAR

CYSTIC MASSESCYSTIC MASSES

SimpleSimple ComplicatedComplicated ComplicatedComplicated ComplexComplex Clustered MicrocystsClustered Microcysts Dermal Dermal

SIMPLE CYSTSSIMPLE CYSTS

CircumscribedCircumscribed Posterior Acoustic Posterior Acoustic

EnhancementEnhancementEnhancementEnhancement AnechoicAnechoic Thin Avascular SeptationsThin Avascular Septations

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SIMPLE CYSTSIMPLE CYST

THIN SMOOTH WALL

ANECHOIC

SOUND TRANSMISSION

MANAGEMENT OF SIMPLE MANAGEMENT OF SIMPLE CYSTSCYSTS

No further diagnostic evaluationNo further diagnostic evaluation AspirateAspirate

ff•• If symptomaticIf symptomatic•• If interference with other If interference with other

evaluationevaluation•• Significant incidence of recurrenceSignificant incidence of recurrence

COMPLICATED CYSTSCOMPLICATED CYSTS

CircumscribedCircumscribed Posterior Acoustic Posterior Acoustic

EnhancementEnhancement Low Level Internal EchoesLow Level Internal Echoes

COMPLICATED CYSTCOMPLICATED CYST

THIN SMOOTH WALL

INTERNAL ECHOES

SOUND TRANSMISSION

INTERNAL ECHOES

GALACTOCELEGALACTOCELE

THIN SMOOTH WALL

SOUND TRANSMISSION

INTERNAL ECHOES

MOVING INTERNAL ECHOESMOVING INTERNAL ECHOES

STAVROSSTAVROS

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MANAGEMENT OF MANAGEMENT OF COMPLICATED CYSTSCOMPLICATED CYSTS

Correlation with other modalitiesCorrelation with other modalities•• Stable mammographic finding Stable mammographic finding -- dismissdismiss•• Benign cyst on MRM Benign cyst on MRM -- dismissdismissSi l diff f hSi l diff f h Single or different from othersSingle or different from others•• Aspirate vs followAspirate vs follow

Multiple; none dominant or differentMultiple; none dominant or different•• Depends on setting and riskDepends on setting and risk

SymptomaticSymptomatic•• AspirateAspirate

COMPLEX CYSTIC MASSCOMPLEX CYSTIC MASS

Any mass with both cystic and solid Any mass with both cystic and solid componentscomponents•• Mural noduleMural nodule•• Eccentric wall thickeningEccentric wall thickeninggg•• Indistinct margins or involvement of Indistinct margins or involvement of

surrounding structuressurrounding structures

Terminology often used for complicated Terminology often used for complicated cysts but implication very differentcysts but implication very different

Significant risk of neoplasiaSignificant risk of neoplasia


SOLID

CYSTIC


CYSTIC

SOLID

MANAGEMENT OF COMPLEX MANAGEMENT OF COMPLEX CYSTIC MASSESCYSTIC MASSES

BIOPSYBIOPSY

CLUSTERED MICROCYSTSCLUSTERED MICROCYSTS

Look for thinly walled hypoLook for thinly walled hypo-- to to anechoic microcystsanechoic microcysts

Minimal fibrotic componentMinimal fibrotic componenta b ot c co po e ta b ot c co po e t No malignant featuresNo malignant features No significant associated blood No significant associated blood

flow (especially no vascular flow (especially no vascular pedicle)pedicle)

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CLUSTERED MICROCYSTSCLUSTERED MICROCYSTS CLUSTERED MICROCYSTSCLUSTERED MICROCYSTS

CLUSTERED MICROCYSTSCLUSTERED MICROCYSTS PITFALLPITFALL

MICROPAPILLARY DCISMICROPAPILLARY DCIS MICROCYSTS VS DCISMICROCYSTS VS DCIS

STAVROSSTAVROS

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MICROCYSTS VS DCISMICROCYSTS VS DCIS

STAVROSSTAVROS

MICROCYSTS VS DCISMICROCYSTS VS DCIS

STAVROSSTAVROS

MANAGEMENT OF MANAGEMENT OF CLUSTERED MICROCYSTSCLUSTERED MICROCYSTS

Multiple vs solitary clustersMultiple vs solitary clusters Associated suspicious findingsAssociated suspicious findingsp gp g Correlation with other modalitiesCorrelation with other modalities ContextContext Micropapillary DCIS much less Micropapillary DCIS much less

common than clustered microcystscommon than clustered microcysts

DERMAL ORIGINDERMAL ORIGIN

STAVROSSTAVROS


STAVROSSTAVROS


STAVROSSTAVROS

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STAVROSSTAVROS

INFLAMMED SEBACEOUS CYSTINFLAMMED SEBACEOUS CYST

CLAW SIGN

MANAGEMENT OF DERMAL MANAGEMENT OF DERMAL LESIONSLESIONS

BASED ON CLINICAL SETTINGBASED ON CLINICAL SETTINGBASED ON CLINICAL SETTINGBASED ON CLINICAL SETTING

WHAT TO WORRY ABOUTWHAT TO WORRY ABOUT

Irregular or asymmetrically Irregular or asymmetrically thickened wallsthickened walls

Thick or enhancing Thick or enhancing septationsseptations Solitary or enlarging complicated Solitary or enlarging complicated Solitary or enlarging complicated Solitary or enlarging complicated

cystcyst Any complex cystic massAny complex cystic mass Clusters of Clusters of microcystsmicrocysts with with

significant solid components, flow or significant solid components, flow or suspicious featuressuspicious features

WHAT NOT TO WORRY ABOUTWHAT NOT TO WORRY ABOUT

Multiple benign appearing complicated Multiple benign appearing complicated cysts and clusters of cysts and clusters of microcystsmicrocysts•• Make sure they have no malignant Make sure they have no malignant

featuresfeaturesfeaturesfeatures•• Don’t try to follow (analogous to multiple Don’t try to follow (analogous to multiple

mammographic nodules or calcifications)mammographic nodules or calcifications)•• If high risk setting, consider MRMIf high risk setting, consider MRM

Dermal lesions in uncomplicated Dermal lesions in uncomplicated settingssettings

SOLID MASSESSOLID MASSES

Sonographic Features:Sonographic Features:••BenignBenign••IndeterminateIndeterminate••SuspiciousSuspicious

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BENIGN FEATURESBENIGN FEATURES Markedly and uniformly hyperechoic Markedly and uniformly hyperechoic

to fatto fat•• Don’t cheatDon’t cheat

Ellipsoid shape / parallel axisEllipsoid shape / parallel axis Gently lobulatedGently lobulated Thin continuous echogenic Thin continuous echogenic

pseudocapsulepseudocapsule•• Multiple planes; angleMultiple planes; angle

Dermal in uncomplicated settingDermal in uncomplicated setting Morphologically benign lymph nodeMorphologically benign lymph node

FIBROADENOMAFIBROADENOMA

THIN ECHOGENIC CAPSULE

PARALLEL ORIENTATION


FIBROADENOMAFIBROADENOMA


INTRAMAMMARY NODEINTRAMAMMARY NODE

HILUM

SYMMETRIC CORTEX

INTRAMAMMARY NODEINTRAMAMMARY NODE

HILUM

SYMMETRIC CORTEX

INDETERMINATE FEATURESINDETERMINATE FEATURES

SizeSize Echogenicity other than markedly Echogenicity other than markedly

hyperhyper-- or hypoechoicor hypoechoic EchotextureEchotexture Normal or enhanced sound Normal or enhanced sound

transmissiontransmission Pattern of blood flowPattern of blood flow

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MALIGNANT FEATURESMALIGNANT FEATURES

Sonographic spiculationSonographic spiculation Taller than wide (nonTaller than wide (non--parallel)parallel) Angular marginsAngular margins Markedly hypoechoic to fatMarkedly hypoechoic to faty ypy yp Acoustic shadowingAcoustic shadowing Punctate calcificationsPunctate calcifications Duct Extension Duct Extension –– towards the nippletowards the nipple Branch pattern Branch pattern –– away from the nippleaway from the nipple Microlobulation / Thick echogenic collarMicrolobulation / Thick echogenic collar

INFILTRATING DUCTAL CAINFILTRATING DUCTAL CA

SPICULATION

HYPOECHOIC

SHADOWING


NON-PARALLEL

ANGULAR MARGINS


ANGULAR MARGINS

DUCTAL CARCINOMA IN SITUDUCTAL CARCINOMA IN SITU

MICROCALCIFICATIONS

INFILTRATING AND IN SITU INFILTRATING AND IN SITU DUCTAL CARCINOMADUCTAL CARCINOMA

MICROCALCIFICATIONS

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DUCT EXTENSION BRANCH PATTERN


INDISTINCT / MICROLOBULATED MARGINS


INDISTINCT / MICROLOBULATED MARGINS


THICK ECHOGENIC COLLAR


THICK ECHOGENIC COLLAR

INTRADUCTAL PAPILLOMAINTRADUCTAL PAPILLOMA

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WHAT TO WORRY ABOUTWHAT TO WORRY ABOUT

Any new or enlarging solid nodule that is Any new or enlarging solid nodule that is not clearly an intramammary lymph not clearly an intramammary lymph nodenode

Any solid mass demonstrating any Any solid mass demonstrating any malignant featuremalignant featuremalignant featuremalignant feature

Any change in a solid nodule originally Any change in a solid nodule originally felt to be benign and placed into followfelt to be benign and placed into follow--upup

Intraductal massIntraductal mass

WHAT NOT TO WORRY ABOUTWHAT NOT TO WORRY ABOUT

Solid lesions with no malignant features and one Solid lesions with no malignant features and one of the following:of the following:

•• Intense and uniform hyperechogenicityIntense and uniform hyperechogenicity•• Parallel ellipsoid shape and thin continuous echogenic capsuleParallel ellipsoid shape and thin continuous echogenic capsule•• Gently lobulated and thin continuous echogenic capsuleGently lobulated and thin continuous echogenic capsule

This does not apply to new or enlarging massesThis does not apply to new or enlarging masses <2% risk of malignancy (Stavros); BI<2% risk of malignancy (Stavros); BI RADS 3 imaging RADS 3 imaging <2% risk of malignancy (Stavros); BI<2% risk of malignancy (Stavros); BI--RADS 3, imaging RADS 3, imaging

surveillancesurveillance

Single enlarging, but morphologically benign Single enlarging, but morphologically benign intramammary nodeintramammary node

Multiple similar solid nodules with no malignant Multiple similar solid nodules with no malignant featuresfeatures

Follow?Follow? Biopsy something dominant and follow others?Biopsy something dominant and follow others? Consider MRM?Consider MRM?

REPORTINGREPORTING

Integration with other modalitiesIntegration with other modalities Answer the questionAnswer the question

I f llI f ll i t i t Is followIs follow--up appropriate or up appropriate or practicalpractical

BIBI--RADSRADS

SUMMARYSUMMARY

Targeted examTargeted exam Correlation with mammographic or clinical Correlation with mammographic or clinical

findingsfindings Optimize technical parametersOptimize technical parameters Optimize technical parametersOptimize technical parameters Meticulous scanningMeticulous scanning Thorough documentationThorough documentation Integrated reporting, including BIIntegrated reporting, including BI--RADSRADS Concise, practical recommendationsConcise, practical recommendations

Documents

BREAST SONOGRAPHY FINANCIAL ... of Clinical Radiology Vanderbilt University Medical Center Chief, Section of Breast Imaging Vanderbilt Diagnostic SonographySonography Symposium Symposium