breast ultrasound: benign vs. malignant lesions

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


Breast Anatomy

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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.

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

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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

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A closer look at the density on LCC view

PACS, BIDMC

Note Note spiculatedspiculated irregular marginsirregular margins

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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

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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……

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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.

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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

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Left Breast Ultrasound with Power Doppler-Patient 1

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Peripheral Peripheral vascularityvascularity

PACS, BIDMC

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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.

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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.

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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

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Now back to Patient 1, Left Breast Ultrasound

PACS, BIDMC

SkinSkin

FatFatMixed Mixed echogenicityechogenicity

of breast of breast parenchymaparenchyma

PectoralisPectoralis fasciafascia

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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

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PACS, BIDMC

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How can we interpret these ultrasound findings?

How will our interpretation help to guide further management?

Two Key Questions

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

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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.

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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……

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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.

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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


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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

CalcificationCalcification

Duct extensionDuct extension

Branch patternBranch pattern

MicrolobulationMicrolobulation


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If a single malignant feature was present on breast ultrasound, the nodule was excluded from the benign classification…


Methods:

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Patient 3-Example of two breast nodules with malignant features on ultrasound

Angular Angular marginsmargins

SpiculationsSpiculations

MicrolobulationsMicrolobulations

HypoechoicHypoechoic

PACS, BIDMC

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Patient 4-Example of breast nodule with malignant features on ultrasound

PACS, BIDMC

Posterior Posterior acoustic acoustic

shadowingshadowing

Internal Internal CalcificationCalcification

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Classification of Lesions as Benign in the Stavros study

Intense and uniformhyperechogenicity

Ellipsoid shape andthin echogenic capsule

2 or 3 gentle lobulationsthin echogenic capsule

Benign lesions


Methods: Next they classified lesions as benign if they fit into any of 3 classifications

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Patient 5-Example of benign fibroadenoma on ultrasound

Smith, DS. Smith, DS. Radiologic clinics of North AmericaRadiologic clinics of North America May 2001; 39(3)May 2001; 39(3)

Thin Thin echogenicechogenic

capsulecapsule

Ellipsoid Ellipsoid shapeshape

(wider than (wider than tall)tall)

Most common Most common benign solid benign solid mass of the mass of the breastbreast

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Patient 6-Example of simple cyst on breast ultrasound

PACS, BIDMC

AnechoicAnechoic

Smooth Smooth marginsmargins

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A lesion was classified as indeterminate if it had no malignant features, yet it did not fit any of the benign combinations.


Methods:

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Results of the Stavros studyAll of the breast nodules were subsequently All of the breast nodules were subsequently

biopsied.biopsied.The The sonographicsonographic classification for each classification for each

nodule was then compared with the final nodule was then compared with the final biopsy results.biopsy results.


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Results of the Stavros study cont’d

424 benign histology2 malignant histology

426 benign on US

123 malignant histology201 benign histology

324 indeterminateor malignant on US

750 Breast nodules


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Sensitivity of breast ultrasound 98.4% (123 Sensitivity of breast ultrasound 98.4% (123 out of 125 malignant lesions were correctly out of 125 malignant lesions were correctly classified as indeterminate or malignant)classified as indeterminate or malignant)

Negative predictive value of 99.5% (2 Negative predictive value of 99.5% (2 lesions out of 426 classified as benign on lesions out of 426 classified as benign on US showed malignant histologyUS showed malignant histology

Results of the Stavros study cont’d


Jill Steinkeler, IV


Conclusions of study:Given the results of the Stavros study and Given the results of the Stavros study and

both the high sensitivity and negative both the high sensitivity and negative predictive value, predictive value, sonographysonography can be used to can be used to accurately classify some solid lesions as accurately classify some solid lesions as benign. This classification permits imaging benign. This classification permits imaging followfollow--up rather than biopsy for benign up rather than biopsy for benign lesions on ultrasound.lesions on ultrasound.


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Given the suspicious findings on our patient’s ultrasound and multiple malignant features, she was referred for an ultrasound guided core needle biopsy…

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Core Needle Biopsy revealed Infiltrating Ductal Carcinoma

PACS, BIDMC

Biopsy Biopsy needle needle

traversing traversing lesionlesion

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Conclusions

Breast ultrasound not only helps in differentiating cystic Breast ultrasound not only helps in differentiating cystic from solid lesions, but also plays an important role in from solid lesions, but also plays an important role in characterizing solid nodules.characterizing solid nodules.

SonographicSonographic features suggestive of malignancy include features suggestive of malignancy include spiculationsspiculations, , hypoechogenicityhypoechogenicity, , microlobulationsmicrolobulations, internal , internal calcifications, shadowing, taller than wide, angular calcifications, shadowing, taller than wide, angular margins among othersmargins among others

SonographicSonographic features suggestive of benignity include features suggestive of benignity include smooth margins, thin smooth margins, thin echogenicechogenic capsule, ellipsoid shape, capsule, ellipsoid shape, macrolobulationsmacrolobulations, , hyperechogenicityhyperechogenicity

The ability to characterize lesions on breast ultrasound The ability to characterize lesions on breast ultrasound helps to determine the next step in patient carehelps to determine the next step in patient care

Jill Steinkeler, IV


References

RahbarRahbar G, G, SieSie AC, Hansen GC, Prince JS, AC, Hansen GC, Prince JS, MelanyMelany ML, Reynolds HE, ML, Reynolds HE, Jackson VP, Sayre JW, Bassett LW. Benign versus malignant solid Jackson VP, Sayre JW, Bassett LW. Benign versus malignant solid breast masses: US differentiation. breast masses: US differentiation. RadiologyRadiology 1999; 213:8891999; 213:889--894.894.

RazaRaza, S, Baum JK. Solid breast lesions: Evaluation with power , S, Baum JK. Solid breast lesions: Evaluation with power dopplerdoppler US. US. RadiologyRadiology 1997; 203:1641997; 203:164--168.168.

Reeder, MM. Reeder and Reeder, MM. Reeder and FelsonFelson’’ss GamutsGamuts in Radiology, 4in Radiology, 4thth edition. edition. 2003. 2003.

Smith, DN. Breast ultrasound. Smith, DN. Breast ultrasound. Radiologic clinics of North AmericaRadiologic clinics of North America 2001; 39:4852001; 39:485--496.496.

Stavros TA, Stavros TA, ThickmanThickman D, Rapp CL, Dennis MA, Parker SH, D, Rapp CL, Dennis MA, Parker SH, SisneySisney GA. Solid Breast Nodules: Use of GA. Solid Breast Nodules: Use of sonographysonography to distinguish between to distinguish between benign and malignant lesions. benign and malignant lesions. Radiology Radiology 1995; 196:1231995; 196:123--134.134.

Jill Steinkeler, IV


AcknowledgementsA special thank you to Larry A special thank you to Larry BarbarasBarbaras, Dr. , Dr.

Gillian Lieberman, Pamela Gillian Lieberman, Pamela LepkowskiLepkowski, , Dr. Carla Dr. Carla RothausRothaus, Dr. Phyllis , Dr. Phyllis KornguthKornguth, ,

Dr. Janet Baum, Dr. Dr. Janet Baum, Dr. TejasTejas Mehta, Mehta, and Dr. Ferris Hall.and Dr. Ferris Hall.

breast ultrasound: benign vs. malignant lesions

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