1. Kanjanaporn Mahatthanaphak
Ultrasound breast
Kanjanaporn Mahatthanaphak

2. Objectives Indication of breast ultrasound
Technique of breast ultrasound
Ultrasound interpretation

3. Diagnosis of breast diseases
History
Physical examination
Breast imaging
Biopsy

4. Breast Imaging Mammography Ultrasonography (US)
Magnetic resonance imaging (MRI)
Nuclear medicine
Sentinel node (Tc99m-sulfur colloid)
Breast specific gamma imaging (Tc99m-sestamibi)
PET (positron emission tomogram)

5. Ultrasonography Advantage Disadvantage Cheap No radiation Non invasive
Widely available
Need high resolution US for breast
Operator dependent

6. Indications for US Differentiate cyst from solid mass
Palpable mass in women < 30 yrs, pregnant and lactation
Evaluate dense breast with palpable mass
Evaluation for breast abscess
Evaluation problem with breast implants
Interventional procedure
Evaluation for multicentric or multifocal CA, bilateral CA, axillary lymph node involvement
Evaluate focal asymmetry seen on mammogram
Breast cancer screening

7. 1.Differentiate cyst from solid mass seen on mammogram
Fibroadenoma
Cyst

8. 2.Palpable mass in women <30 yrs, pregnant and lactation
Most common masses in women <35 yr are fibroadenoma and cyst

9. 3. Palpable mass in dense mammogram
41 yr, palpable mass RUOQ
Spiculated margin, irregular shaped, hypoechoic mass

10. 4.Evaluation for breast abscess

11. 5. Evaluation problems with breast implants
Questionable implants leak or rupture
MRI is the best imaging modality
US can be used in substituition

12. 6.Interventional procedure
Cyst aspiration
Drainage
Guided fine needle aspiration
Guided core biopsy
Mark skin for excisional biopsy

13. Drainage pus

14. US Guided fine needle aspiration

15. 7. Evaluation for multifocality, multicentricity

16. 8. Evaluation for focal asymmetrical density
Focal asymmetrical density could be from
Normal variation
Breast mass (benign, malignant)
Check if there is associated palpable mass

17. 9. Breast cancer screening
Decrease sensitivity of dense breast on screening mammogram
US can be used in addition to find underlying mass

18. Ultrasound technique lighting
patient positioning: support elbow, flat, supine
ergonomics
probe: linear array 7-13 MHz
scanning: radial/antiradial
clock face with distance from nipple
only caliper things that are REAL
correct depth (skin to pectoral fascia) and correct focal zone (up to 2 is OK)
dynamic range: some settings can make a cystic lesion look solid and vice versa

24. Ultrasound interpretation
Breast Composition
Mass
Calcifications
Associated features

25. Breast composition composition of breast tissue
Glandular tissue (soft tissue density)
Connective tissue (soft tissue density)
Fat (fat density)
Young women : glandular tissue > fat
Older women : fat > glandular tissue
More glandular tissue  dense breast on mammogram

26. Breast Composition: Homogeneous echotexture - fat
Homogeneous echotexture - fibroglandular
Heterogeneous echotexture

31. Mass
Shape
Margin
Orientation
Echo pattern
Posterior features

32. Breast mass
Shape

33. Breast mass
Margin

34. Orientation:
unique to US-imaging, and defined as parallel (benign) or not parallel (suspicious finding) to the skin.

35. Echo pattern Anechoic Hypoechoic, Complex cystic
Solid: isoechoic, hyperechoic, heterogeneous.

36. Posterior features:
Enhancement
Shadowing.

37. Calcifications:
On US poorly characterized compared with mammography, but can be recognized as echogenic foci, particularly when in a mass.

38. Associated features: Architectural distortion Duct changes
Skin changes
Edema
Vascularity
Elasticity assessment

39. Findings suggestive of malignancy
Duct extension or branch pattern
Acoustic shadowing
Microcalcifications
Hypoechogenicity
Spiculation or thick echogenic halo
Angular margin
Microlobulation
Shape taller than wide

40. Findings suggestive of benign
No suggestive findings of malignancy
Hyperechogenicity (compare to fat)
Wider than tall
Well circumscribed, less than 3 lobulations
Thin echogenic pseudocapsule

41. Ultrasound Features Suggestive of Benign and Malignant Nodules.
Shape
Round, wider than tall
Taller than wide
Margins
Smooth
Irregular, angular, spicular
Lobulations
None or up to 3
Multiple
Capsule
Encapsulated
No capsule
Halo
Absent
Echogenic halo
Fixity
None
Fixed to surrounding issue and/or underlying muscles
Shadowing or enhancement
Enhancement, edge shadowing
Shadowing behind lesion
Substance echogenicity
Anechoic (cystic), Hyperechoic
Hypoechoic, calcification

42. Special cases 
cases with a unique diagnosis or pathognomonic ultrasound appearance:
Simple cyst
Complicated cyst
Clustered microcysts
Mass in or on skin
Foreign body including implants
Lympnodes- intramammary
Lymph nodes- axillary
Vascular abnormalities
Postsurgical fluid collection
Fat necrosis

43. Simple cyst

44. Complicated cyst

45. Clustered microcysts

46. Breast abscess

47. Lymph nodes

48. Breast Imaging Reporting And Data System (BI-RADS)
BIRADS category
Conditions that fall into the category
Management 1
Normal tissue, focal thickening causing “lump”
Routine screening 2
Simple cysts, ductal ectasia, intramammary nodes, lipomas
Early follow-up to document stability unless clinical indications suggest a more aggressive evaluation 3
Complex cysts, small intraductal papillomas, fibroadenomas
Short interval follow-up or biopsy 4
One feature of malignancy
Biopsy 5
More than one feature of malignancy

49. Breast Imaging Reporting And Data System (BI-RADS) Mammography
Help clinicians for management
Category 0 ...incomplete assessment  additional imaging is needed
Category I ...negative  routine follow up (1 year)
Category II … benign finding  routine follow up (1 year)
Category III … probably benign finding  follow up 6 months
Category IV … suspicious abnormality  biopsy
Category V… highly suggestive of malignancy  biopsy
Category VI …known biopsy proven malignancy appropriate treatment