Breast Ultrasound Boot Camp
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1 Breast Ultrasound Boot Camp Dr. Adam Braithwaite Delaney Radiology? US Features of Malignancy Not Circumscibed - Irregular shape, Indistinct margins Hypoechoic relative to surrounding tissue Not Parallel Posterior shadowing 1
2 Breast Cancer Breast Cancer 1 in 8 women will be diagnosed with breast cancer in their lifetime 250,000 new cases in ,000 deaths in 2015 Death rates decreasing since 1990 due to treatment advances and earlier detection 2.8 million survivors Every 2 minutes a woman in US is diagnosed with breast cancer 100 million results on Google compared to 41 million for lung cancer and 27 million for prostate cancer #1 Lawsuit Against Radiologists 6-20 ducts that open on the nipple Each defines a lobe or segment of breast Beneath nipple, lactiferous sinuses Segmental subsegmental terminal duct Breast Anatomy Image Marking Helpful Hints Measure Transducer! 1 cm Equals a regular M & M. 2 cm mass like a Peanut M & M. 2
3 What is BI-RADS? BREAST IMAGING REPORTING AND DATA SYSTEM (BI- RADS) Common Language Consistent Care and Management BI-RADS - Masses Mass Shape Mass Margin Echo Pattern BI-RADS - Masses Mass Shape Mass Margin Echo Pattern Mass Shape Mass Shape - Oval Oval Round Irregular elliptical egg-shaped May have 2 or 3 lobulations 3
4 spherical circular globular Mass Shape - Round Round and Oval DDx: Cyst Fibroadenoma Papilloma Sebaceous Cyst Other Benign Cancer Mass Shape Mass Shape - Irregular shape cannot be characterized DDx: Radial scar Fat necrosis Phyllodes tumor FA, papilloma, etc Cancer until proven otherwise Parallel Not Parallel Mass Orientation Parallel In relation to skin line Wider than Tall Horizontal Taller than Wide Vertical Not Parallel 4
5 BI-RADS - Masses Mass Shape Mass Margin Echo Pattern Mass Margin Often most important feature of a mass It s All About That Margin! Mass Margin - Circumscribed abrupt transition between lesion and tissue 100 % sharply demarcated Likely benign No guarantee Not Circumscribed Indistinct Angular Microlobultaed Spiculated Mass Margin - Indistinct Mass Margin - Angular Margins poorly defined Possible Infiltration Includes Echogenic Rim 5
6 Mass Margin - Microlobulated Mass Margin - Spiculated lines radiating from margins of a mass DDX CANCER Radial scar Post-op scar Granular cell tumor Extra-abdominal desmoid Mass Margin - Spiculated lines radiating from margins of a mass Note: biopsy even if stable! (tubular CA?) BI-RADS - Masses Mass Shape Mass Margin Echo Pattern Echo Pattern Anechoic Hyperechoic Complex Cystic and Solid Hypoechoic Isoechoic Heterogeneous Anechoic Cyst 6
7 Hyperechoic Complex Cystic and Solid Complex Cyst Complex Mass Colloid Carcinoma NOT Lipoma Adenocarcinoma Special Case Complicated Cyst Careful - This Was A Cancer! Abscess Hypoechoic Invasive Ductal Carcinoma 7
8 Isoechoic Heterogeneous Tubular Adenoma Metaplastic Carcinoma Posterior Features Enhancement Shadowing Mixed Enhancement Sound Passes Through Mass Cyst or High Grade Cancer Triple Negative Cancer Cysts Shadowing Sound Impeded by Mass Associated with Fibrosis Calcification Cannot See Fine Microcalcifications Associated with DCIS, So Mammograms Still Necessary 8
9 Intraductal Calcification Associated Features Architectural Distortion Duct Changes Skin Changes Edema Vascularity Elasticity Architechtural Distortion Can Look like Indistinct Mass. Terminology should not matter though as both should be biopsied unless a known stable surgical scar. Duct Changes Duct Changes Lactation Solitary Dilated Duct Abnormal even without Mass or Debris and is associated with DCIS 9
10 Skin Changes Vascularity Lymphedema Inflammatory Cancer Skin should be less than 2 mm in thickness. Called a complex Cyst Vascularity Imaging Tricks Better flow? Less compression. Compression occludes vessels. But remember that flow is a supportive, NOT primary feature. Cancer can have no flow. IDC Elasticity Special Case - Cyst Circumscribed Round or Oval Anechoic Posterior Enhancement Measures the Stiffness of a lesion. Associated NOT Primary feature. This was called benign by elasticity, but look at margins 10
11 Simple Cyst Clustered Microcysts Cluster of Anechoic Masses 2-3 mm each Septations NO DISCRETE SOLID COMPONENT Margins Not Indistinct Clustered Microcysts Skin Mass Epidermoid Inclusion Cyst Keloid Mole Pimple Neurofibroma Accessory Nipple Sebaceous Cyst Accessory Nipple Physical Exam is the key to Diagnosing Skin Lesions. Sebaceous Cyst should have dark pore. Use stand off pad or extra gel to see pore. 11
12 Intramammary Node Circumscribed Margin Round or Oval Echogenic Hilum Hilar Vessel Morphology More Important than size! Normal up to 2 cm, Though Can Be Larger if Predominantly Fat Normal IMLN Abnormal LN Inflamed IMLN Special Case Vascular Abnormality Mondor Disease AVM 12
13 BREAST IMAGING REPORTING AND DATA SYSTEM (BI- RADS) BI-RADS 0 Incomplete; Needs further imaging BI-RADS 1 Negative; routine follow up BI-RADS 2 Benign; routine follow up BI-RADS 3 Probably Benign; Short interval follow up (usually 6 months) BI-RADS 4 Suspicious; Biopsy BI-RADS 5 Highly Suggestive of Malignancy; Biopsy BI-RADS 6 Known Malignancy Category 0 Needs Additional Imaging Evaluation Almost always used in a screening situation Role of Screening US Additional 3 cancers per 1000 patients Category 1 Negative There is nothing to comment on. symmetric no masses no calcs no distortion Category 2 Benign Finding Finding is present but DEFINITELY benign Continue w/ routine screening Category 3 Probably Benign Finding Short interval follow-up suggested 1 st Screening Mammogram Should get diagnostic workup Circumscribed mass Round or Oval Margins Complicated cyst (aspirate) Category 3 Probably Benign Finding Short interval follow-up suggested <2% risk of malignancy Biopsy if ANY change at follow up Note: NEVER off screening Most Incorrectly and Overused BIRADS Category 13
14 NOT Probably Benign Lesions Extremely dense but o/w negative Multiple bilateral masses Any lesion that has already changed or is palpable Angular Margins Category 4 Suspicious Abnormality Biopsy should be considered DCIS Possibility of cancer (2-94%) Almost always Biopsy Optional for self audit: 4A (low) Enlarging Circumscribed Mass 4B (intermed) Questionable margins 4C (moderate) Irregular Mass Category 5 Highly Suggestive of Malignancy Appropriate action should be taken Very high probability of cancer (~95%). Note: Excise if core biopsy is benign Category 6 Known Biopsy-Proven Malignancy Appropriate action should be taken Known cancer prior to therapy 2 nd opinions Monitor response 14
15 Diagnosis? CASES Fibroadenoma Diagnosis? 2002 Case 12 Hx: Baseline screening mammogram Invasive CA- Pt refused treatment B 15
16 Multiple Bilateral Circumscribed Masses Multiple bilateral partially circumscribed similarappearing masses BIRADS 2, benign Recommend routine screening in one year. 0.14% interval cancers in one year (vs. 0.24%) DDx: Cysts vs Fibroadenomas w/u: Don t ultrasound unless palpable 16
17 Metastatic Disease to the Breast Metastatic disease is very uncommon Most common met: from contralateral breast History of non-breast primary? Lymphoma, melanoma, lung, ovarian Simple?? Cyst Cyst 17
18 Breast Mass IDC IDC Invasive Ductal Carcinoma Margin!! Small Cancer Breast Mass IDC 18
19 Scar Radial Scar Clinical History and Stability is Key Focal Fibrosis 19
20 Unilateral Axillary?? Adenopathy 20
21 21
22 Diagnosis? Case 7 Hx: Palpable lump Malignant lymph node - ICA with cals UOQ Gynecomastia?? 22
23 Causes of Gynecomastia Idiopathic (newborn, adolescent, senile) Drugs Cimetidine, Digitalis, Spirinolactone, THC Other Cirrhosis, Testicular tumors Interesting Morticians (Estrogens in embalming fluid) Exposure to estrogens in manufacture of oral contraceptives Use of hair preparations containing estrogens Invasive Ductal Carcinoma?? - male DDX Spiculated Mass This is cancer Carcinoma Post surgical scar Fibromatosis Granular cell tumor Abscess mass Mixed fat/tissue: hamartoma (fibroadenolipoma) lymph node fat necrosis galactocele 23
24 breast within a breast slice of sausage pattern Fat Necrosis Hamartoma CC Milk Fistula Post Biopsy MLO Galactocele: Cyst with inspissated milk Mixed fat/tissue: lymph node hamartoma fat necrosis galactocele Galactocele 24
25 Galactocele Oil Cysts Steatocystoma?? Multiplex?? Intracystic Invasive Ductal Carcinoma 25
26 Intraductal Papilloma 63 year old woman - Presented with large palpable mass - Reports six month history of left breast swelling - Recent onset of nipple discharge 26
27 ?? Intracystic Papillary Carcinoma In Situ 27
28 Phyllodes Phyllodes Tumor Rare fibroepithelial tumor resembling fibroadenomas Occur in women ages 30-70, mean 52 On mammo are lobulated, round or oval masses usually noncalcified On US well defined solid masses with heterogeneous internal echoes and may have fluid filled clefts Phyllodes Classification is controversial Usually classified as benign, borderline or malignant (75-80% are benign) Fewer than 20% of the malignant lesions metastasize, usually to lungs, pleura or bone. Excisional biopsy recommended Juvenile FA Diagnosis? 27 y/o unilateral mammo, palpable mass Fibromatosis 28
29 Fibroadenosis Case 10 Hx: s/p lumpectomy; new palpable lump Post-op Seroma Findings: Lump at surgical site DDX: Cancer, seroma, hematoma, abscess 29
30 R CC R MLO 3/12/ /15/ /12/2007 3/15/
31 R CC Invasive Lobular Cancer 10-15% of breast cancers Common mammographic finding is architectural distortion. Others include normal exam, spiculated mass, poorly defined mass, asymmetric opacity, round or oval well defined mass, microcalcifications (uncommon) Case yo diabetic female with new palpable thickening 31
32 Diabetic Mastopathy Differential- Cancer, abscess, hematoma, diabetic mastopathy Mass Margin - Circumscribed DDx: circumscribed cancers Peanut M&Ms Papillary Carcinoma Medullary carcinoma Mucinous carcinoma Papillary Cancer 32
33 Colloid (Mucinous) Carcinoma Peanut M & Ms Better prognosis than NOS invasive ductal CA May be well defined on mammo, but remember if a well defined mass is cancer it is statistically more likely to be NOS invasive ductal CA? Epidermal Inclusion?? Cyst (Sebaceous Cyst)? Granular Cell?? Tumor 33
34 Granular Cell Tumor Diagnosis? Exact mimic of IDC Enlarging palpable, painless, fixed mass Spiculated mass Complete excision or recurs Fat necrosis Diagnosis? Diagnosis? Palpable mass-snowstorm Double lumen implant rupture Diagnosis? Bilateral Lobular Carcinoma 34
35 35
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