Breast Ultrasound: Benign vs. Malignant Lesions

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1 October 25-November 19, 2004 Breast Ultrasound: Benign vs. Malignant Lesions Jill Steinkeler,, Tufts University School of Medicine IV

2 Breast Anatomy

3 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.

4 The patient underwent a unilateral digital diagnostic mammogram for evaluation

5 Unilateral Left Diagnostic Mammogram Left CC Left MLO Ill-defined density in middle inferior left breast PACS, BIDMC PACS, BIDMC

6 A closer look at the density on LCC view Note spiculated irregular margins PACS, BIDMC

7 Mammographic Findings Heterogeneously dense parenchyma 1.2 cm focally prominent ill-defined density in the lower middle left breast that had increased in size from the prior examination 2/04 No architectural distortion or clustered microcalcifications BIRADS 4-suspicious4

8 Given these suspicious mammographic findings, the patient was referred for further evaluation with a unilateral breast ultrasound

9 Indications for Breast Ultrasound Differentiation of both palpable and mammographic lesions as either cystic or solid Subsequent characterization and classification of solid nodules according to certain sonographic features Evaluation of palpable breast mass in patient younger than age 30 Interventional procedures (FNA, CNB) Smith, DS. Radiologic clinics of North America 2001; 39:

10 Left Breast Ultrasound-Patient 1 Hypoechogenic lesion Skin-thin echogenic line Mixed echogenicity of breast parenchyma Fat Pectoralis fascia- thin echogenic line PACS, BIDMC

11 Left Breast Ultrasound with Power Doppler-Patient 1 Peripheral vascularity PACS, BIDMC

12 A brief word on Power Doppler Measures amplitude of blood flow rather than direction or velocity as in color doppler The pattern of vascularity of a breast lesion on ultrasound may help to predict the likelihood of malignancy when used with other sonographic criteria Raza S, Baum, JK. Radiology 1997; 203:

13 Power Doppler A study by Raza and Baum assigned patterns of vascularity of power doppler for a series of 86 breast lesions on ultrasound Patterns included peripheral and penetrating vascularity,, or no vascularity These breast lesions were subsequently biopsied They found that 68% of biopsy-proven proven breast cancers in this study showed penetrating pattern of vascularity on breast ultrasound (sensitivity 68%, specificity 95%) They concluded that the pattern of vascularity of breast lesions should be considered with other sonographic characteristics to help predict the possibility of malignancy Raza S, Baum, JK. Radiology 1997; 203:

14 Patient 2-An Example of Penetrating vascularity on power doppler imaging in lesion later found to be invasive ductal carcinoma Note penetrating vascularity within lesion PACS, BIDMC

15 Now back to Patient 1, Left Breast Ultrasound Skin Mixed echogenicity of breast parenchyma Fat Pectoralis fascia PACS, BIDMC

16 Left Breast Ultrasound Results Hypoechoic lesion in the area of palpable abnormality, measures 1.1x1.1x0.9cm Macrolobulated with some microlobulation, incompletely circumscribed Increased through transmission Increased peripheral vascularity on power doppler imaging Angular margins Taller than wide in areas BIRADS 4-suspicious4 PACS, BIDMC

17 Two Key Questions How can we interpret these ultrasound findings? How will our interpretation help to guide further management?

18 A differential diagnosis of hypoechoic breast lesions on ultrasound will be helpful

19 Differential Diagnosis of Hypoechoic Breast Lesions on Ultrasound Fibroadenoma Carcinoma Abscess Cyst Fibrocystic changes Intramammary lymph node Intraductal papilloma Sebaceous cyst Reeder, MM. Gamuts in Radiology, 4 th edition

20 What is the next step? Next we will need a method of classifying lesions on breast ultrasound. Using this classification it will be possible to make further decisions about patient management

21 Landmark study by Stavros, et al Prospectively classified 750 breast nodules sonographically Benign Indeterminate Malignant Stavros, et al. Radiology 1995; 196:

22 Purpose of the Stavros study Distinguish benign solid breast nodules from indeterminate or malignant nodules Use this classification as a model to either recommend follow-up imaging for benign appearing nodules or biopsy for both indeterminate and malignant appearing nodules Stavros, et al. Radiology 1995; 196:

23 Methods: Identification of Malignant Features First, they identified lesions with any of the following malignant features: Spiculation Angular margins Hypoechogenicity Shadowing Calcification Duct extension Branch pattern Microlobulation Stavros, et al. Radiology 1995; 196:

24 Methods: If a single malignant feature was present on breast ultrasound, the nodule was excluded from the benign classification Stavros, et al. Radiology 1995; 196:

25 Patient 3-Example of two breast nodules with malignant features on ultrasound Angular margins Microlobulations Hypoechoic Spiculations PACS, BIDMC

26 Patient 4-Example of breast nodule with malignant features on ultrasound Internal Calcification Posterior acoustic shadowing PACS, BIDMC

27 Methods: Next they classified lesions as benign if they fit into any of 3 classifications Classification of Lesions as Benign in the Stavros study Benign lesions Intense and uniform hyperechogenicity Ellipsoid shape and thin echogenic capsule 2 or 3 gentle lobulations thin echogenic capsule Stavros, et al. Radiology 1995; 196:

28 Thin echogenic capsule Jill Steinkeler, IV Patient 5-Example of benign fibroadenoma on ultrasound Most common benign solid mass of the breast Ellipsoid shape (wider than tall) Smith, DS. Radiologic clinics of North America May 2001; 39(3)

29 Patient 6-Example of simple cyst on breast ultrasound Anechoic PACS, BIDMC Smooth margins

30 Methods: A lesion was classified as indeterminate if it had no malignant features, yet it did not fit any of the benign combinations. Stavros, et al. Radiology 1995; 196:

31 Results of the Stavros study All of the breast nodules were subsequently biopsied. The sonographic classification for each nodule was then compared with the final biopsy results. Stavros, et al. Radiology 1995; 196:

32 Results of the Stavros study cont d 750 Breast nodules 426 benign on US 324 indeterminate or malignant on US 424 benign histology 2 malignant histology 123 malignant histology 201 benign histology Stavros, et al. Radiology 1995; 196:

33 Results of the Stavros study cont d Sensitivity of breast ultrasound 98.4% (123 out of 125 malignant lesions were correctly classified as indeterminate or malignant) Negative predictive value of 99.5% (2 lesions out of 426 classified as benign on US showed malignant histology Stavros, et al. Radiology 1995; 196:

34 Conclusions of study: Given the results of the Stavros study and both the high sensitivity and negative predictive value, sonography can be used to accurately classify some solid lesions as benign. This classification permits imaging follow-up rather than biopsy for benign lesions on ultrasound. Stavros, et al. Radiology 1995; 196:

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

36 Core Needle Biopsy revealed Infiltrating Ductal Carcinoma Biopsy needle traversing lesion PACS, BIDMC

37 Conclusions Breast ultrasound not only helps in differentiating cystic from solid lesions, but also plays an important role in characterizing solid nodules. Sonographic features suggestive of malignancy include spiculations, hypoechogenicity, microlobulations,, internal calcifications, shadowing, taller than wide, angular margins among others Sonographic features suggestive of benignity include smooth margins, thin echogenic capsule, ellipsoid shape, macrolobulations, hyperechogenicity The ability to characterize lesions on breast ultrasound helps to determine the next step in patient care

38 References Rahbar G, Sie AC, Hansen GC, Prince JS, Melany ML, Reynolds HE, Jackson VP, Sayre JW, Bassett LW. Benign versus malignant solid breast masses: US differentiation. Radiology 1999; 213: Raza,, S, Baum JK. Solid breast lesions: Evaluation with power doppler US. Radiology 1997; 203: Reeder, MM. Reeder and Felson s Gamuts in Radiology, 4 th edition Smith, DN. Breast ultrasound. Radiologic clinics of North America 2001; 39: Stavros TA, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid Breast Nodules: Use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196:

39 Acknowledgements A special thank you to Larry Barbaras,, Dr. Gillian Lieberman, Pamela Lepkowski, Dr. Carla Rothaus,, Dr. Phyllis Kornguth, Dr. Janet Baum, Dr. Tejas Mehta, and Dr. Ferris Hall.

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