benign vs malignant masses in breast ultrasound

8/10/2019 Benign vs Malignant Masses in Breast Ultrasound

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BENIGN VS MALIGNANTMASSES IN BREASTULTRASOUND

Dr. Mona Rozin

Director of Breast ImagingAssuta Medical Centers


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Goal of Breast Ultrasound

SOLID VS CS!IC


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Goal of Breast Ultrasound

" Ma#e a more s$eci%c diagnosist&anclinical and mammogra$&ic %ndings

alone." 're(ent unnecessar) *io$sies.

" +ind cancers missed*)

mammogra$&).


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Breast cancer is e,tremel)

&eterogeneous t&erefore -eCAO!distinguis& *enign frommalignant on t&e *asis of onl) asingle sonogra$&ic %nding.

Breast cancer (aries greatl) not onl)from one mass to anot&er *ut e(en/I!0Ian indi(idual mass.


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Ultrasound s&o-s mor$&olog)andnot &istolog) 1 *iolog)

ONEsus$icious %nding re2uiresfurt&er e(aluation 333334 t&at is*io$s) and s&ould *e gi(en BIRAD

5Au$ to6


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BIRADS for U1S

BIRAD 78 normal

BIRAD 98 *enign %nding

BIRAD :8 $ro*a*l) *enign


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BIRADS for U1S

BIRAD 5A8 a*normal %nding 8 lo-sus$icion

BIRAD 5B8 a*normal %nding 8

intermediate sus$icionBIRAD 5C8 a*normal %nding 8 $ro*a*l)

malignant

BIRAD 68 &ig&l) sus$icious formalignanc)

BIRAD ;8 #no-n malignanc)


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S$ectrum of masses

t


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rcumscr e (s $ cu atemalignant masses 8 a

s$ectrum of ultrasoundfeatures

I. Desmo$lastic (s. in


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Desmo$lastic Reaction

"0ost res$onse to tumor 8 attem$t to-all o= t&e tumor -it& %*rosis andelastosis to #ee$ it from s$reading.

" De(elo$s slo-l)

"!&erefore s$iculatedlesions are usuall)slo- gro-ing GRAD> 7 8 9 tumors


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In


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Cellularit)

" Circumscri*edmasses are muc&more cellular t&an s$iculated masses.

"!&e) &a(e lots of tumor cells? l)m$&

cells and $lasma cells 8 t&is causes$osterior en&ancement.

" S$iculatedmasses &a(e muc& fe-er

cells and (er) &)$ocellulardesmo$lasia 8 t&is causes $osteriors&ado-ing.


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Vascularit)

" Circumscri*edmasses are usuall) (er)(ascular 8 lots of cells and di(isionsre2uire more *lood 8 moreangiogenetic factors@ in


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BIRADS f Ult d


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BIRADS for UltrasoundMasses

I. S&a$e

II. Margin

III. Orientation

IV. Lesion *oundar)

V. >c&ogenic $attern

VI. 'osterior acoustic features

VII. >=ect on surrounding $arenc&)ma

VIII.Calci%cations

I. Vascularit)


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Bac#ground Breast 'attern

" Homogenous Fatt

" Heterogeneous 8 focall) ordi=usel) (aria*le

" Homogenous F!"roglandular

+


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+att)


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0eterogeneous


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+i*roglandular


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I. S&a$e

" O(al8 includes tear dro$ s&a$e 93: macrolo*ulations ma) *e -it& t&in ec&ogenic

ca$sule

" Round8 c)sts? mets? IDC &ig& grade

" Irregular8 O! round or o(al

O l


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O(al

%*roadeno

maDCIS

R d


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Round

c)st

DCIS

I l


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Irregular

IDC

IDC

radial

scar


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II. Margin

" #!r$ums$r!"ed8 smoot&? distinct margin

" Microlo*ulated 8 ma) *e t&e e,$ression of

e,tended lo*ules %lled -it& DCIS@ EF ofall IDC &a(e a com$onent of DCIS

" Indistinct 8 O a*ru$t interface -it&surrounding tissue

Ci i* d


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Circumscri*ed


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II. Margin

" Circumscri*ed 8 smoot&? distinct margin

" M!$rolo"ulated8 ma) *e t&e

e,$ression of e,tended lo*ules %lled -it&DCIS@ EF of all IDC &a(e a com$onentof DCIS

" Indistinct 8 O a*ru$t interface -it&surrounding tissue

Mi l * l t d


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Microlo*ulated


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II. Margin

" Circumscri*ed 8 smoot&? distinct margin

" Microlo*ulated 8 ma) *e t&e e,$ression

of e,tended lo*ules %lled -it& DCIS@ EFof all IDC &a(e a com$onent of DCIS

" Ind!st!n$t8 O a*ru$t interface -it&surrounding tissue

Indistinct


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Indistinct


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Margin 8 cont." Angular8 $art of margin &as s&ar$ corners@

most accurate of all signs of malignanc)@in(asion follo-s $at& of least resistance 8 infat man) angles@ in %*rosis &orizontal andt&en along Coo$erHs ligaments

" S$iculated 8 s&ar$ $roecting lines@ use U1SMAG (ie-s to see surface

c&aracteristics

!&is is a s$ectrum of %ndings

Angular


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Angular


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Margin 8 cont." Angular 8 $art of margin &as s&ar$ corners@

most accurate of all signs of malignanc)@in(asion follo-s $at& of least resistance 8in fat man) angles@ in %*rosis &orizontaland t&en along Coo$erHs ligaments

" S%!$ulated8 s&ar$ $roecting lines@ useU1S MAG (ie-s to see surface

c&aracteristics

!&is is a s$ectrumof %ndings

S$iculated


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S$iculated

Mi d


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Mi,ed


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III. Orientation

" 'arallel8 -ider t&an tall 8 long a,is$arallel to s#in

" O! $arallel8 taller t&an -ide 8long a,is $er$endicularto s#in

includes ROUD masses

!DLU


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!DLU


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CA

+A


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ant.$ost. terminal


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/ider t&an tall JJ


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/ider t&an tall JJ

ant.lo*ule

terminallo*ulesdistended duct

-it& in(asion

IV L i B d


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IV. Lesion Boundar)" A"ru%t !nterfa$e8 no transition zone

*et-een mass and surroundingtissue

" >c&ogenic rim 8 (ariant of s$icules toosmall to resol(e on U1S@some masses &a(e a (er) t&ic# ec&ogenicrim -it& a tin) &)$oec&ogenic nidus 8 must

e,amine carefull)@ $eritumoral edema usuall) occurs *t-.

mass and s#in

A*ru$t Interface


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A*ru$t Interface

ec&ogenicca$sule

+A CA

IV L i B d


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IV. Lesion Boundar)" A*ru$t interface 8 no transition zone

*et-een mass and surroundingtissue

"E$&ogen!$ r!m8 (ariant of s$icules toosmall to resol(e on U1S@some masses &a(e a (er) t&ic# ec&ogenicrim -it& a tin) &)$oec&ogenic nidus 8 must

e,amine carefull)@ $eritumoral edema usuall) occurs *t-.

mass and s#in

>c&ogenic Rim


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>c&ogenic Rim

>c&ogenic Rim


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>c&ogenic Rim

Same mass 8 -it&K -it&out Sono3C!

V >c&ogenic 'attern


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V. >c&ogenic 'attern

" 0)$erec&oic8 more t&an fat@ (er)rarel) can *e angiosarcoma? ILC?l)m$&oma

" Isoec&oic 8 e2ual to fat" 0)$oec&oic 8 less t&an fat

" Mi,ed 8 &)$er and &)$o@ can *e

%*rosis? fat necrosis? +A? IDC" Anec&oic 8 a*sence of internal ec&oes@

mets? IDC3 &ig& grade.


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normal %*rotictisssue

siliconefat necrosis


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&)$er -it& iso 5 molater

&)$er

O!

V >c&ogenic 'attern


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" 0)$erec&oic 8 more t&an fat@ (er)rarel) can *e angiosarcoma? ILC?l)m$&oma

"Isoec&oic8 e2ual to fat" 0)$oec&oic 8 less t&an fat





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MucinousCA

V >c&ogenic 'attern


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"Isoec&oic 8 e2ual to fat" 0)$oec&oic8 less t&an fat





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IDC

seroma

+A

V >c&ogenic 'attern


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"Isoec&oic 8 e2ual to fat" 0)$oec&oic 8 less t&an fat





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&ematoma

$&)lloides

Intrac)stic $a$illar)

CA

V >c&ogenic 'attern


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"Isoec&oic 8 e2ual to fat" 0)$oec&oic 8 less t&an fat


%*rosis? fat necrosis? +A? IDC" Anec&oic8 a*sence of internal ec&oes@

c)sts mets? IDC3 &ig& grade.


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$st

s

. os er or cous c


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. os er or cous c+eatures

" None" En&an$ement8 &ig&l) cellular lesions

" S&ado'!ng8 seen in desmo$lasia

" #om"!nedCan use t&is %nding to tr) and $redictGRAD>@ (er) small lesions 6 mm

ma) &a(e no transmission *ecause&a(enHt &ad time to de(elo$desmo$lasia or in


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S&ado-ing


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en&ancement

normal

CA

c)st

DO O! +ORG>! 3


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DO O! +ORG>!

Ma) see artifactual s&ado-ing fromstee$ Coo$erHs ligaments 8 can *e

remo(ed -it& com$ression J


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artifact

com$ression

DD of >n&ancement


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DD of >n&ancement

7 IDC8 &ig& GRAD>

9 MucinousCA

: Medullar)CA

5 Meta$lasticCA6 'a$illar)CA

; +AN C)sts

DD of S&ado-ing


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DD of S&ado-ing

7 IDC8 lo- GRAD>

9 ILC

: !u*ularCA

5 Scar

6 +at necrosis

; Radial scarN Calci%ed +A

Calci%ed oil c)sts

VII. >=ect on Surrounding


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VII. >=ect on Surrounding!issue

" Stra!g&ten!ngof Coo$erHsligaments

" Arc&itectural d!stort!on

" S#in t&ic#ening 8 normal 9 mm

" S#in retraction

" >dema 8 mastitis? radiation !,?in


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Arc&itecturaldistortion

!&ic#ening Kstraig&tening ofcoo$erHs ligaments



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VII. >=ect on Surrounding!issue

" Straig&tening of Coo$erHs ligaments

" Arc&itectural distortion

" S(!n t&!$(en!ng8 normal 9 mm" S(!n retra$t!on

" >dema 8 mastitis? radiation !,?

in


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In


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S#in retractionin scar -it&seroma



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ec o Su ou d g!issue

" Straig&tening of Coo$erHs ligaments

" Arc&itectural distortion

" S#in t&ic#ening 8 normal 9 mm" S#in retraction

" Edema8 mastitis? radiation !,?

in


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focal edema

>dema -it&dilatedl)m$&atics


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Ducte,tension

Branc&$attern


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VIII. Calci%cations


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VIII. Calci%cations

" Macrocalci%cations

" Microcalci%cations outside a mass

" Microcalci%cations inside a mass


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+A

Oil c)st


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IDCDCIS

I. Vascularit)


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)

" A*sent

" 'resent

" Adacent to lesion

" In surrounding tissue


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IDC3GradeI

+eeding(essel


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+A C)st


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Sus$icious for Malignanc)


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I. 0ards$iculations? t&ic# rimangular marginss&ado-ing

II. Intermediate&)$oec&oicmicrolo*ulation

taller t&an -ide

Sta(aros


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III. Soft

duct e,tension *ranc&ing $attern calci%cations

Sta(aros

Most li#el) *enign


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) g

" O(al

" Circumscri*ed 8 ec&ogenicca$sule

" 'arallel

" A*ru$t interface

" 0)$erec&ogenic


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Sine Pua on

-it&out -&ic& t&ere is not&ingtechnique? technique? technique

Must al-a)s*ase managementon t&e -orstfeature $resent JJJJ


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benign vs malignant masses in breast ultrasound

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