SON 2147 Sonography of the Breast Part ONE: Introduction Lecture TWO Breast Screening Sonographic Evaluation Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, LRT(AS)

Breast Screening The primary purpose of breast screening is the detection and diagnosis of breast cancer in its earliest and most curable stage. Breast cancer screening is recommended in women without clinical signs of breast cancer. According to the American Cancer Society, breast cancer screening involves a monthly breast self-examination (BSE), regular clinical breast examinations (CBE) by a physician or another health care provider, and an annual screening mammography.

Mammography, Sonography, and MRI are the primary imaging tools used for diagnostic breast evaluation. Mammography provides a sensitive method of screening for breast cancer, whereas ultrasound and MRI are used to provide additional characterization and further interrogation of breast lesions that are not well visualized by mammography. Ultrasound may be used for screening purposes in young, dense breasts, which are difficult to penetrate by mammography. Ultrasound is able to evaluate palpable masses that are not visible on a mammogram and to image the deep juxtathoracic tissue not normally visible by mammography.

Ultrasound is also useful in differentiating solid, round masses from fluid-filled cysts.

MRI is also a useful tool in breast imaging, but is prohibitively expensive for screening purposes.

Sonographic Evaluation of the Breast The Sonographer must have basic clinical information regarding any patient who is referred for breast ultrasound. Pertinent clinical information includes: The patient’s age Risk factors Symptoms Location of the lump Clinical impression of any breast lump

Sonography is normally used as an adjunct to mammography, but may be the initial method of imaging for the following patients: In a patient with a palpable breast lump In a young patient with dense breasts In a pregnant or lactating patient In a patient with breast augmentation In a patient with a difficult or compromised mammogram

That breast cancer is rare under age 20 The three main reasons mammography is rarely indicated for patients under age 20 are: That breast cancer is rare under age 20 That breast tissue is generally dense Young breast tissue is more sensitive to damage from radiation

Most breast masses that arise during the teen years are fibroadenomas.

Malignant breast lesions in patients under 20 years of age are extremely rare. Although Sonography is an invaluable aid to breast imaging, it should not be used as a substitute for a mammogram.

Moderate compression applied with the transducer during scanning will improve detail and decrease the depth of tissue the ultrasound beam must traverse.

Positioning: The patient is positioned with her arm behind her head on the side of the breast to be examined.

Scanning Technique: When examining for a palpable mass or for a correlation with an abnormal mammogram, some centers scan only the area of interest.

The mass is then thoroughly scanning in orthogonal planes (90 degrees apart) to evaluate the lesion in three dimensions.

This can be recorded using sagittal and transverse images or using radial/anti-radial transducer positions.

radial and anti-radial transducer positions.

Most imaging centers scan the breast not unlike a clock

Clock method-left breast

Distance from the nipple method-Lateral distance

Distance from the nipple-Depth

All dominant solid masses are generally recorded with three-dimensional measurements: Length Width Height

The distinction between a cyst and a solid mass is extremely important for management purposes.

A mass that meets the criteria of a simple cyst on ultrasound is universally considered benign - but solid masses have a malignant potential.

If a cyst has features not associated with a simple cyst, aspiration and/or biopsy should be considered.

The demonstration of increased vascular flow could accelerate the need for biopsy of this mass.

High-quality sonographic imaging of a solid breast mass is quite accurate at characterizing a lesion as probably benign or probably malignant in a majority of cases.

Benign lesions usually have smooth, rounded margins.

Malignant tumors are aggressive and tend to grow through tissue via finger-like extensions called spiculations.

Benign tumors are usually slow growing and do not invade surrounding tissue. They tend to grow horizontally within the tissue planes, parallel to the chest wall. Malignant lesions, on the other hand, tend to grow right through the normal breast tissue. Rule of thumb: Non cancerous mass - wider than tall, rubbery and compressible. Cancerous mass - taller than wide, hard and non-compressible.

Benign breast tumor/Mammography

Malignant breast tumor/Mammography

As malignant masses enlarge, they may cause retraction of the nipple or dimpling of the skin as the spiculations pull the Cooper’s ligaments.

Shape: A rounded or oval shape is usually associated with benign lesions, while sharp, angular margins are associated with malignancy.

Sharp, angular margins

Orientation: Benign lesions tend to grow within the normal tissue planes and their long axis lies parallel to the chest wall.

Orientation: Malignant lesions are able to grow through the connective tissue and may have a vertical orientation when imaging the breast from anterior to posterior.

Internal Echo Pattern: Lesions that appear isoechoic with the breast parenchyma are most often benign. BUT… Mucinous adenocarcinoma with an isoechoic mass causes architectural distortion

A solid lesion that is hypoechoic relative to the normal breast parenchyma is more suspicious for malignancy.

While calcifications are not frequently visualized by Sonography, their detection in a hypoechoic mass is suspicious for malignancy.

Attenuation Effects: Enhancement behind a lesion is a characteristic associated with benign lesions.

Shadowing behind a solid breast mass is another suspicious sonographic sign for malignancy.

Mobility: Benign lesions will normally demonstrate a limited degree of mobility, whereas malignant lesions are normally very fixed or rigid in their position.

Compressibility: If pressure applied by the transducer causes the lesion to compress or change shape, the lesion is probably benign and most likely represents a fat lobule.

Malignant lesions are normally very hard and non-compressible.

Vascularity: Doppler interrogation of a breast lesion is an essential element of the study.

Malignant masses will often demonstrate increased vascularity Malignant masses will often demonstrate increased vascularity. Adenocarcinoma

Pathology: Benign lesions are the most common breast lesions, occurring in 70% of proved lesions in biopsies or removed.

Several parameters must be considered when a dominant mass has been palpated, including the patient’s age, physical characteristics of the mass, and previous medical history.

Older or postmenopausal women are more likely to have Lesions that are more common to younger women include: Fibrocystic diseases Fibroadenomas Older or postmenopausal women are more likely to have Intraductal papillomas Ductal Ectasia Cancer

Symptoms of a breast mass include: Pain A palpable mass Spontaneous or induced nipple discharge Skin dimpling Ulceration Nipple retraction

Skin dimpling or ulceration and nipple retraction nearly always result from cancer.

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