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BENIGN VS MALIGNANT MASSES IN BREAST

ULTRASOUND

Dr. Mona RozinDirector 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 findingsalone.

• 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. ShapeII. MarginIII. OrientationIV. Lesion boundaryV. Echogenic patternVI. Posterior acoustic featuresVII. Effect on surrounding

parenchymaVIII.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

IDC

IDC

radial scar

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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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ant.post. terminal

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Wider than tall !!

ant. lobule

terminal lobulesdistended 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

echogenic capsule

FA CA

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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

siliconefat necrosis

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hyper with iso 4 mo later

hyper?

NOT

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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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hematoma

phylloides

Intracystic papillary 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;

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

CA

cyst

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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 GRADE2) Mucinous CA3) Medullary CA4) Metaplastic CA5) Papillary CA

6) FA7) Cysts

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DD of Shadowing

1) IDC – low GRADE2) ILC3) Tubular CA

4) Scar5) Fat necrosis6) Radial scar7) Calcified FA8) 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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Inflammatory CA

Skin thickening

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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

1st lumpectomy with + margin

2nd lumpectomy with + margin

Duct extension

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VIII. Calcifications

• Macrocalcifications • Microcalcifications outside a

mass• Microcalcifications inside a mass

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FAOil 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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IDC-Grade I

Feeding vessel

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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 !!!!

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