Breast Ultrasound: Benign vs. Malignant Lesions

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  • Breast Ultrasound: Benign vs. Malignant Lesions

    Jill Jill SteinkelerSteinkeler, Tufts University , Tufts University School of Medicine IVSchool of Medicine IV

    Gillian Lieberman, MDGillian Lieberman, MD

    October 25-November 19, 2004Jill Steinkeler, IV

    Gillian Lieberman, MD

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Breast Anatomy

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Case Presentation-Patient 1

    62 year old woman with a normal mammogram in 2/04 who presents with a two week history of focal left breast pain and an associated palpable nodule just inferior to the nipple of the left breast.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    The patient underwent a unilateral digital The patient underwent a unilateral digital diagnostic mammogram for diagnostic mammogram for evaluationevaluation

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Unilateral Left Diagnostic Mammogram

    Left CC Left MLO

    PACS, BIDMC

    IllIll--defined density defined density in middle inferior in middle inferior

    left breastleft breast

    PACS, BIDMC

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    A closer look at the density on LCC view

    PACS, BIDMC

    Note Note spiculatedspiculated irregular marginsirregular margins

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Mammographic Findings

    Heterogeneously dense parenchymaHeterogeneously dense parenchyma

    1.2 cm focally prominent ill1.2 cm focally prominent ill--defined density defined density in the lower middle left breast that had in the lower middle left breast that had increased in size from the prior examination increased in size from the prior examination 2/042/04

    No architectural distortion or clustered No architectural distortion or clustered microcalcificationsmicrocalcifications

    BIRADS 4BIRADS 4--suspicioussuspicious

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Given these suspicious Given these suspicious mammographic findings, the mammographic findings, the patient was referred for further patient was referred for further evaluation with a unilateral breast evaluation with a unilateral breast ultrasoundultrasound

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Indications for Breast Ultrasound

    Differentiation of both palpable and Differentiation of both palpable and mammographic lesions as either cystic or solidmammographic lesions as either cystic or solid

    Subsequent characterization and classification of Subsequent characterization and classification of solid nodules according to certain solid nodules according to certain sonographicsonographic featuresfeatures

    Evaluation of palpable breast mass in patient Evaluation of palpable breast mass in patient younger than age 30younger than age 30

    Interventional procedures (FNA, CNB)Interventional procedures (FNA, CNB)Smith, DS. Radiologic clinics of North America 2001; 39:485-496.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Left Breast Ultrasound-Patient 1

    PACS, BIDMC

    SkinSkin--thin thin echogenicechogenic lineline

    FatFatMixed Mixed echogenicityechogenicity of breast of breast

    parenchymaparenchyma

    PectoralisPectoralis fasciafascia-- thin thin echogenicechogenic

    lineline

    HypoechogenicHypoechogenic lesionlesion

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Left Breast Ultrasound with Power Doppler-Patient 1

    Jill Steinkeler, IV

    Gillian Lieberman, MD

    Peripheral Peripheral vascularityvascularity

    PACS, BIDMC

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    A brief word on Power Doppler

    Measures amplitude of blood flow rather Measures amplitude of blood flow rather than direction or velocity as in color than direction or velocity as in color dopplerdoppler

    The pattern of The pattern of vascularityvascularity of a breast lesion of a breast lesion on ultrasound may help to predict the on ultrasound may help to predict the likelihood of malignancy when used with likelihood of malignancy when used with other other sonographicsonographic criteriacriteria

    RazaRaza S, Baum, JK. S, Baum, JK. RadiologyRadiology 1997; 203:1641997; 203:164--168. 168.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Power Doppler

    A study by A study by RazaRaza and Baum assigned patterns of and Baum assigned patterns of vascularityvascularity of power of power dopplerdoppler for a series of 86 breast for a series of 86 breast lesions on ultrasoundlesions on ultrasound

    Patterns included peripheral and penetrating Patterns included peripheral and penetrating vascularityvascularity, or , or no no vascularityvascularity

    These breast lesions were subsequently biopsiedThese breast lesions were subsequently biopsied

    They found that 68% of biopsyThey found that 68% of biopsy--proven breast cancers in proven breast cancers in this study showed penetrating pattern of this study showed penetrating pattern of vascularityvascularity on on breast ultrasound (sensitivity 68%, specificity 95%)breast ultrasound (sensitivity 68%, specificity 95%)

    They concluded that the pattern of They concluded that the pattern of vascularityvascularity of breast of breast lesions should be considered with other lesions should be considered with other sonographicsonographic characteristics to help predict the possibility of malignancycharacteristics to help predict the possibility of malignancy

    RazaRaza S, Baum, JK. S, Baum, JK. RadiologyRadiology 1997; 203:1641997; 203:164--168.168.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Patient 2-An Example of Penetrating vascularity on power doppler imaging in lesion later found to be invasive ductal carcinoma

    PACS, BIDMC

    Note Note penetrating penetrating vascularityvascularity

    within lesionwithin lesion

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Now back to Patient 1, Left Breast Ultrasound

    PACS, BIDMC

    SkinSkin

    FatFatMixed Mixed echogenicityechogenicity of breast of breast

    parenchymaparenchyma

    PectoralisPectoralis fasciafascia

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Left Breast Ultrasound Results

    HypoechoicHypoechoic lesion in the area of palpable lesion in the area of palpable abnormality, measures 1.1x1.1x0.9cmabnormality, measures 1.1x1.1x0.9cm

    MacrolobulatedMacrolobulated with some with some microlobulationmicrolobulation, , incompletely circumscribedincompletely circumscribed

    Increased through transmissionIncreased through transmission

    Increased peripheral Increased peripheral vascularityvascularity on power on power dopplerdoppler imagingimaging

    Angular marginsAngular margins

    Taller than wide in areasTaller than wide in areas

    BIRADS 4BIRADS 4--suspicioussuspicious

    Jill Steinkeler, IV

    Gillian Lieberman, MD

    PACS, BIDMC

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    How can we interpret these ultrasound findings?

    How will our interpretation help to guide further management?

    Two Key Questions

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    A differential diagnosis of A differential diagnosis of hypoechoichypoechoic breast lesions on breast lesions on ultrasound will be helpfulultrasound will be helpful

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Differential Diagnosis of Hypoechoic Breast Lesions on Ultrasound

    FibroadenomaFibroadenoma

    CarcinomaCarcinoma

    AbscessAbscess

    CystCyst

    Fibrocystic changesFibrocystic changes

    IntramammaryIntramammary lymph nodelymph node

    IntraductalIntraductal papillomapapilloma

    Sebaceous cystSebaceous cystReeder, MM. Gamuts in Radiology, 4th edition. 2003.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    What is the next step?

    Next we will need a method of classifying Next we will need a method of classifying lesions on breast ultrasound. Using this lesions on breast ultrasound. Using this classification it will be possible to make classification it will be possible to make further decisions about patient further decisions about patient managementmanagement

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Landmark study by Stavros, et al

    Benign Indeterminate Malignant

    Prospectively classified 750 breast nodules sonographically

    Stavros, et al. Stavros, et al. Radiology 1995; 196:123Radiology 1995; 196:123--134.134.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Purpose of the Stavros study

    Distinguish benign solid breast nodules Distinguish benign solid breast nodules from indeterminate or malignant nodulesfrom indeterminate or malignant nodules

    Use this classification as a model to either Use this classification as a model to either recommend followrecommend follow--up imaging for benign up imaging for benign appearing nodules or biopsy for both appearing nodules or biopsy for both indeterminate and malignant appearing indeterminate and malignant appearing nodulesnodules

    Stavros, et al. Stavros, et al. Radiology 1995; 196:123Radiology 1995; 196:123--134.134.

  • Jill Steinkeler, IV

    Gillian Lieberman, MD

    Methods: Identification of Malignant Features

    First, they identified lesions with any of the following First, they identified lesions with any of the following malignant features:malignant features:

    SpiculationSpiculation

    Angular marginsAngular margins

    HypoechogenicityHypoechogenicity

    ShadowingShadowing