pathologic results sonography of solid breast nodules type...
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Solid Nodules
Cindy Rapp BS, RDMS, FAIUM, FSDMS
National Sales ManagerCanon Medical
Disclosure
Employee – Canon Medical
Pathologic Results Type of CA
IDC (81.6%)
first, seek malignant findings– if present, classify as malignant– if absent.....
then look for benign findings– if present, classify as benign– if absent.....
then classify as indeterminate
Sonography of Solid Breast Nodulesmethods (old 750 nodules)
Sonography of Solid Breast Nodulesurface characteristics
scan entire surface of nodule in 2 planes ..…surface characteristics heterogeneous
if mixture of benign and malignant surface findings……exclude nodule from benign classification.
Breast Cancer is Heterogeneous
from nodule to nodule often within a single nodule
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Circumscribed• cellular• high grade• inflammatory hr• enhanced transmission• Doppler +• elastography -
Spiculated• paucicellular• low grade• desmoplastic• shadowing• Doppler -• elastography +
Breast Cancer is Heterogeneous
...and mixed circumscribed& spiculated between ...
solid breast nodulescomplex spectrum of gross morphology for both benign and
malignant nodules that overlap extensively
single criterion -- high true negatives, high false negativesa single finding cannot identify a group of benign nodules
with an acceptable false negative rate
= bx’s prevented
= false negatives
need to havefalse negative rate of < 2%
When enough findings have been added to the algorithm to achieve a false negative rate of 2% or less, follow-up option can be offered.
=
Carlsbad Caverns
spiculation angular margins acoustic shadowing microlobulation taller-than-wide hypoechogenicity duct extension branch pattern calcifications
BUS algorithm for evaluation of solid breast nodules – step 1 –
search for suspicious findings
“hard” findingsinvasive
“soft” findingsDCIS
“nonspecific” findingsinvasive &/or DCIS
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Malignant Findingspiculation
“hard finding”
Spiculation“hard finding”
Breast Cancer can be heterogeneous within nodule
only part of surface may be spiculated
Spiculation
alternating hypoechoic and hyperechoic spiculesTabar
magnification helps evaluate surface characteristics
variant of spiculations = thick, echogenic halo
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thick, echogenic halohalo thicker on edges ,
Variant of Spiculations
less apparent ant. and post.
thick, echogenic halo = unresolved spiculationssame lesion, same examination
Malignant Findingangular margins
“hard finding”
Angular Margins
long trans
CA can be heterogeneous within a single nodule-- even circumscribed carcinomas have some --
angular and/or microlobulated margins.
1) cannot simply look at 2 “random slices” through nodule
2) must scan entire surface and volume of nodule in 2 planes (radial and anti-radial)
3) if mixture of benign and malignant findings, ignore benign findings
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radial
anti- radial
angular margins – heterogeneous within one nodule
A
AB
B
Angular Margins
Angular Margins
paths oflow resistance to
invasion
in bases of
Cooper’s ligaments
Malignant Findingmicrolobulation
“invasive or DCIS”
fingers of invasive tumor intraductal components cancerized lobules
Microlobulationmicrolobulation margins
invasive fingers of tumor
1) angular 2) associated with thick haloTabar
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* *
microlobulation marginsDCIS components of tumor
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*
*
85% of ductal CA is mixed invasive and DCIS1) invasive cords central (I) 2) DCIS peripheral (*)
(I)
microlobulation marginscancerized lobules
Microlobulation Sizerelated to tumor grade
LNG DCISsmall microlobulations
HNG DCISlarge lobulations
Malignant Finding“taller-than-wide”
James Bond Island – Phuket Thailand
Malignant Finding“taller-than-wide”
FAFA CACA
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Wider-than-tall Taller-than-wide
Benign Malignant
theories about why malignant nodules are taller-than-wide
growth across tissue planes lack of rotation of fixed malignant nodules only measuring central nidus incompressibility of malignant nodules reflection of axis of orientation of the TDLU in
which a small CA arose
Spread of Cancer
1 2
= cancerization of lobules= Pagetoid spread
typical small carcinomas of breast arising from…
Posterior TDLU - 2 Anterior TDLU - 1 Terminal TDLU - 3
taller-than-widea feature of small malignant nodules,
not of large malignant nodules
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Malignant Findingduct extension
Duct Extensionextensive intraductal components
important not just for dx, but staging and rx
Malignant Findingbranch pattern
branch pattern – “soft” finding
isolated duct extension or branch pattern indicates benign IDP 87% of time…
…but 6% are DCIS and another 7% ADH……therefore, cannot qualify for BIRADS 3 !
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Malignant Findingacoustic shadowing
“hard finding”
Acoustic Shadowing hard finding
proportional to degree of desmoplasia
complete shadowing partial shadowing
IDC histologic gradevs. sound transmission
BRS grade 3 (I) BRS grade 9 (III)
sound transmission in 409 solid malignant nodules
acoustic shadowing (complete or partial) 35%
normal through transmission 32%
enhanced through transmission 28%
mixed sound transmission 5%
TOTAL 100%
enhanced through transmission
HNG DCIS
= poor man’s CDIindicates cellular,
metabolically active lesions
acoustic shadowing & enhanced transmission are features of special type tumors as well as indicators
of histologic grade
shadowing (diff dx)– low grade IDC– invasive lobular CA– tubular CA (> 1.5 cm)
enhanced (diff dx)– high grade IDC– colloid CA (>1.5 cm)– medullary CA– invasive papillary CA
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Malignant Findingcalcification“soft finding”
Malignant Findingcalcification
mixed IDC and DCIS
Malignant Findingmarkedly hypoehoic*
* vs.fat
Malignant Findingmarkedly hypoechoic
hypoechogenicity intermediate finding
compared to fat
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hypoechogenicitydependent upon dynamic range
isoechoic at 90 dB
hypoechoic at 69 dB
Malignant Findingssensitivity
in order of sensitivity
individual findings have low to moderately good sensitivity
98.4 % of cancers detected because ....... the average malignant nodules cancer had 5.3 malignant findings.
benign grouped findingssought only if no suspicious findings1 of 3 must be present for BIRADS 3
Benign Findings
Benign Findings
marked hyperechogenicity ellipsoid shape 2 or 3 gentle lobulations thin echogenic capsule
* Must combine complete thin capsule with shapes to avoid missing pure DCIS & circumscribed invasive CA
Benign Findinghyperechogenicity
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hyperechogenicity must be purely hyperechoic
no isoechoic areas larger than ducts
purely hyperechoic not purely hyperechoic
Benign Findinghyperechogenicity
hyperechogenicity must be purely hyperechoic
can be no isoechoic areas larger than ducts
palpable lumpnot purely hyperechoic
4 months later
13 mm mammographic nodule
not purely hyperechoic – tangential image thru halo
Benign Findingelliptical shape
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Benign Findingelliptical shape Benign Finding
2 or 3 gentle lobulations
Benign Finding2 or 3 gentle lobulations
Benign Findingstear-drop shape
Benign Findingthin, echogenic pseudocapsule
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Benign Findingthin, echogenic pseudocapsule
use lighter scan pressure to show capsule
normal scan pressure light pressure
lighter scan pressure to show capsule bettermay lead to artifactual shadowing
need a combination of light and heavy scan pressure
“heeling and toeing” thetransducer to show the capsule on the ends of
lesions
circumscribed cancers can have thin, echogenic capsules…but capsule is either incomplete or shape is not elliptical
or gently lobulated, wider-than-tall…
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in order of NPV
we have never seen a purely hyperechoic CA !!!
Benign Findingsnegative predictive value
left palpable lump – pure fibrous tissue?lesion too superficial need standoff
Not pure fibrous tissueVolume averaging
normal sonographic lymph node appearancereniform appearance – but thinner cortex
long axis short axis
range of normal sonographic LN appearances
late
abnormal LN’shandle FB’s differently from tumor/infection
FB’s accumulate from medullary sinusoids outwardly
early
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metastasisfrom cortical sinusoids in
siliconefrom medullary sinusoids out
abnormal lymph nodesforeign bodies vs. tumor
range of abnormal sonographic LN appearances
malignant LN’sgrossly abnormal LN right next to morphology WNL LN
LN distributionright to left asymmetry favors mets
WNL or benign LNa single feeding artery
color Doppler of LN metastasestranscapsular feeding vessels
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Sonography of Solid Breast Nodules
patient chooses follow-up in 3 of every 5 cases
radiologist does not make decision about whether a solid, benign breast nodule is biopsied.
patient is told that we cannot be 100% sure the lesion is benign, but that we are more than 98% sure it is benign.
She is told she has 3 choices…
1. follow-up ultrasound in 6 months*
2. large core needle or vacuum assisted biopsy3. excisional biopsy