Solid Breast Nodules. Pathologic Results Type of CA. Benign vs. Malignant. Sonography of Solid Breast Nodules methods (old 750 nodules)

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1 Solid Breast Nodules Pathologic Results Type of CA Benign vs. Malignant Cindy Rapp BS, RDMS, FSDMS, FAIUM University of Colorado Hospital Denver, Colorado IDC (81.6%) ILC (4.8%) Medullary (4.0%) Mucinous (1.6%) DCIS (4.0%) Other (2.4%) Metastasis IDC (81.6%) Sonography of Solid Breast Nodules methods (old 750 nodules) 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 Nodule surface 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 Breast Cancer is Heterogeneous from nodule to nodule often within a single nodule Circumscribed...and mixed circumscribed cellular & spiculated between... high grade inflammatory hr enhanced transmission Doppler + elastography - Spiculated paucicellular low grade desmoplastic shadowing Doppler - elastography +

2 solid breast nodules complex spectrum of gross morphology for both benign and malignant nodules that overlap extensively single criterion -- high true negatives, high false negatives a single finding cannot identify a group of benign nodules with an acceptable false negative rate = bx s prevented = false negatives need to have false negative rate of < 2% = Carlsbad Caverns When enough findings have been added to the algorithm to achieve a false negative rate of 2% or less, followup option can be offered. BUS algorithm for evaluation of solid breast nodules step 1 search for suspicious findings Malignant Finding spiculation hard finding hard findings invasive nonspecific findings invasive &/or DCIS soft findings DCIS spiculation angular margins acoustic shadowing microlobulation taller-than-wide hypoechogenicity duct extension branch pattern calcifications

3 Spiculation hard finding Breast Cancer can be heterogeneous within nodule only part of surface may be spiculated Spiculation magnification helps evaluate surface characteristics Tabar alternating hypoechoic and hyperechoic spicules Variant of Spiculations thick, echogenic halo halo thicker on edges, less apparent ant. and post. thick, echogenic halo = unresolved spiculations same lesion, same examination

4 Malignant Finding angular margins hard finding Angular Margins CA can be heterogeneous within a single nodule -- even circumscribed carcinomas have some -- angular and/or microlobulated margins. angular margins heterogeneous within one nodule radial 1) cannot simply look at 2 random slices through nodule 2) must scan entire surface and volume of nodule in 2 planes (radial and antiradial) 3) if mixture of benign and malignant findings, ignore benign findings long trans anti- radial Angular Margins Angular Margins B in bases of Cooper s ligaments B A A paths of low resistance to invasion

5 Malignant Finding microlobulation invasive or DCIS microlobulation margins invasive fingers of tumor fingers of invasive tumor intraductal components cancerized lobules Tabar 1) angular 2) associated with thick halo microlobulation margins DCIS components of tumor microlobulation margins cancerized lobules * * * * * * * (I) * 85% of ductal CA is mixed invasive and DCIS 1) invasive cords central (I) 2) DCIS peripheral (*) Microlobulation Size related to tumor grade Microlobulation write magnification helps LNG DCIS small microlobulations HNG DCIS large lobulations write magnification

6 Malignant Finding taller-than-wide Malignant Finding taller-than-wide FA CA James Bond Island Phuket Thailand 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 Wider-than-tall Taller-than-wide Spread of Cancer = cancerization of lobules = Pagetoid spread 1 2

7 typical small carcinomas of breast arising from taller-than-wide a feature of small malignant nodules, not of large malignant nodules Posterior TDLU - 2 Anterior TDLU - 1 Terminal TDLU - 3 % of cases < 10 mm mm mm > 20 mm size groups < 10 mm mm mm > 20 mm Malignant Finding duct extension Duct Extension extensive intraductal components important not just for dx, but staging and rx Malignant Finding branch pattern Branch Pattern finding of DCIS components multiple ducts variable sized away from nipple large branches IDP or HNG DCIS components medium branches ING DCIS components small branches or spicules LNG DCIS components

8 Malignant Finding acoustic shadowing hard finding Acoustic Shadowing hard finding proportional to degree of desmoplasia complete shadowing partial shadowing IDC histologic grade vs. sound transmission 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% BRS grade 3 (I) BRS grade 9 (III) TOTAL 100% enhanced through transmission HNG DCIS = poor man s CDI indicates 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

9 Malignant Finding calcification soft finding Malignant Finding calcification mixed IDC and DCIS Malignant Finding markedly hypoehoic* Malignant Finding markedly hypoechoic* * vs. fat * vs. fat hypoechogenicity intermediate finding hypoechogenicity dependent upon dynamic range hypoechoic at 69 db compared to fat isoechoic at 90 db

10 Malignant Findings sensitivity 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 Findings benign grouped findings sought only if no suspicious findings 1 of 3 must be present for BIRADS 3 Benign Findings Benign Finding hyperechogenicity 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 hyperechogenicity must be purely hyperechoic no isoechoic areas larger than ducts Benign Finding hyperechogenicity purely hyperechoic not purely hyperechoic

11 hyperechogenicity must be purely hyperechoic can be no isoechoic areas larger than ducts not purely hyperechoic tangential image thru halo 13 mm mammographic nodule palpable lump not purely hyperechoic 4 months later Benign Finding elliptical shape Benign Finding elliptical shape Benign Finding 2 or 3 gentle lobulations Benign Finding 2 or 3 gentle lobulations

12 Benign Finding thin, echogenic pseudocapsule Benign Finding thin, echogenic pseudocapsule use lighter scan pressure to show capsule lighter scan pressure to show capsule better may lead to artifactual shadowing normal scan pressure light pressure need a combination of light and heavy scan pressure heeling and toeing the transducer to show the capsule on the ends of lesions

13 circumscribed cancers can have thin, echogenic capsules but capsule is either incomplete or shape is not elliptical or gently lobulated, wider-than-tall Benign Findings negative predictive value in order of NPV we have never seen a purely hyperechoic CA!!! normal sonographic lymph node appearance reniform appearance but thinner cortex range of normal sonographic LN appearances long axis short axis US of WNL LN s the hilum (mediastinum) fatty on mammography, echogenic on US lymph flow is from subcapsular sinusoids - to cortical sinusoids - to medullary sinusoids

14 abnormal LN s handle FB s differently from tumor/infection FB s accumulate from medullary sinusoids outwardly abnormal lymph nodes foreign bodies vs. tumor early late silicone from medullary sinusoids out metastasis from cortical sinusoids in range of abnormal sonographic LN appearances malignant LN s grossly abnormal LN right next to morphology WNL LN LN distribution right to left asymmetry favors mets WNL or benign LN a single feeding artery

15 color Doppler of LN metastases transcapsular feeding vessels Sonography of Solid Breast Nodules if B9 findings uncertain, classify indeterminate NO BX BX BENIGN INDETERMINATE MALIGNANT Sonography of Solid Breast Nodules 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 biopsy or Mammotomy 3. excisional biopsy patient chooses follow-up in 3 of every 5 cases Roles of Color Duplex Sonography in Breast Diagnosis Solid vs. cystic lesions Solid nodules benign from malignant Inflammation Fremitus Roles of Color Duplex Sonography in Breast Diagnosis Variable Compression Technique Fibroadenoma color duplex sonography of the breast indicates high metabolic state which may be present in benign and malignant conditions high cellularity epithelium stroma inflammatory response very sensitive to pressure

16 Variable Compression Technique Color Doppler Variable Compression Technique Power Doppler Variable Compression Technique Color Doppler Cystic lesions Breast Cysts Color Doppler Inflamed cyst

17 Intra-cystic papilloma Intra-cystic mural nodule papillary apocrine metaplasia Inflamed cyst VS ICP orientation of the vessels Intra-cystic papilloma with hemorrhage parallel to the inflamed cyst passing through the cyst wall Intra-ductal papilloma Benign VS Malignant intracystic lesion fed by single vessel fed by multiple vessels

18 cluster of cysts or solid? Other breast tumors pseudo-cystic lesions lymphoma metaplastic carcinoma some high grade IDCA metastatic lesions medullary carcinoma Metastatic IML Mammographic nodule complex cyst? Roles of Color Duplex Sonography in Breast Diagnosis helpful in distinguishing B9 from CA comparison of central to peripheral flow benign -- flow same centrally and peripherally Metastasis - uterine Leiomyosarcoma malignant -- flow centrally different from peripheral flow Roles of Color Duplex Sonography in Breast Diagnosis central malignant flow higher peak systolic velocity sharp systolic peak higher resistivity index Roles of Color Duplex Sonography in Breast Diagnosis peripheral malignant flow central and peripheral benign flow lower peak systolic velocity rounded systolic peak lower resistivity index

19 malignant flow pattern systolic velocity high centrally, low peripherally FA similar central and peripheral flow pattern low peak systolic and low RI Color Doppler lymph nodes Lymph Nodes metastatic VS inflamed metastatic flow similar to center of primary lesion high systolic velocities sharp systolic peaks relatively high resistance reactive or inflamed lower systolic velocities rounded systolic peaks lower impedance metastatic node reactive or inflamed node Lymph node reactive Lymph nodes metastatic h single vessel multiple vessel

20 Color Doppler Acute lactational mastitis inflammation Acute lactational mastitis Bloody nipple discharge acute periductal mastitis Inflamed duct VS papillary lesion

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