Current uses of ultrasound in the evaluation of the breast
Section snippets
Technique
Breast ultrasound should be performed using a high-frequency transducer of 7.5 MHz or higher. A linear array transducer is preferred. A standoff pad may be used to evaluate superficial lesions. The patient should be placed in a supine or oblique position, with ipsilateral arm above the head. The breast is scanned in either the transverse and sagittal planes or the radial and antiradial planes. The retroareolar area is evaluated by angling the transducer in multiple planes to avoid shadowing
Normal breast anatomy
The skin is seen as an echogenic layer that measures up to 3 mm in thickness. Deep to the skin is breast tissue, which has different appearances depending on the overall density of the breast and the distribution of fatty and fibroglandular tissue. Unlike other areas of the body, fat within the breast is hypoechoic. The dense breast tissue is echogenic on ultrasound (Fig. 1). Solid masses are usually hypoechoic, and caution should be made not to mistake an island of fat surrounded by dense
Cystic lesions
Ultrasound is 96% to 100% accurate in the diagnosis of cysts [12], [13], [14], [15]. In the 1970s, ultrasound decreased the number of biopsies for benign masses 25% to 35% by reliably identifying simple cysts [15], [16]. A simple cyst is defined as a thin-walled anechoic lesion with sharp anterior and posterior borders and posterior acoustic enhancement (Fig. 2). Reverberation artifact can result in linear internal echoes at the anterior part of a cyst [15]. A proposed breast ultrasound lexicon
Non–contrast-enhanced Doppler ultrasound
Although gray-scale sonographic features are useful in distinguishing benign from malignant solid breast lesions, a significant number of breast masses do not present with the typical expected sonographic appearance [39], [40], [41]. Angiogenesis is defined as the formation of new blood vessels through the sprouting of capillaries from preexisting microvessels [42]. The formation of these new, abnormal vessels is associated with an increased risk of malignancy [43]. These concepts of
Tumor size and grade
Ultrasound cannot assess the size of a tumor accurately and usually underestimates the true size [64]. Ultrasound also cannot assess tumor grade accurately [33], [47], [59], [65]. One study found that high-grade invasive ductal carcinomas were significantly larger at time of diagnosis, however, and were more likely to have better-defined margins and acoustic enhancement compared with low- and intermediate-grade tumors [66]. Some researchers believe that the enhancement is caused by increased
Fine needle aspiration biopsy and core needle biopsy
Assuming a lesion can be seen, there are certain advantages to performing aspiration, biopsy, or localization with ultrasound guidance. The lesion can be visualized at all times during sampling, which ensures accurate needle placement. The procedure is easier for the patient, who can be supine to slightly oblique versus upright or prone for mammographic or stereotactic procedures. There is no radiation, which is particularly important to pregnant patients.
Fine needle aspiration biopsy in breast
Microcalcifications on ultrasound
Thirty-five percent to 45% of nonpalpable breast cancers detected at screening present as clusters of microcalcifications on mammography [105]. With higher frequency transducers, we are more able to detect mammographically isolated microcalcifications with ultrasound (Figs. 16A, B). One study examined 76 patients with 7.5 MHz and 10 MHz transducers and found increased visibility of microcalcifications from 45% to 74% in benign breast lesions and 91% to 97% in malignant lesions [106]. The
Screening for breast cancer
Mammography is the only widely accepted imaging modality used to screen for early, otherwise occult breast cancers. Many lesions are indistinguishable by mammography. Three older studies reported a cumulative total of 236 incidental sonographically detected lesions and found none to be malignant based on either biopsy or long-term follow-up [13], [111], [112]. More recent studies have shown that incidental cancers are detected with sonography performed in asymptomatic patients and in patients
Breast implants
MR imaging currently is more sensitive and accurate than ultrasound at evaluating silicone implants for rupture [115]. When MR imaging is not readily available or if it cannot be performed (because of claustrophobia, internal metallic clips, or other causes), ultrasound is an alternative. An intact implant, without rupture, appears anechoic with echogenic wall anteriorly on ultrasound [116]. Implant ruptures can be classified as “intracapsular” or “extracapsular,” the former having an intact
The male breast
Breast cancer in men is rare. It represents 1% of all breast cancers and only 1% of all malignancies in men [121]. Ultrasound has been used to evaluate the male breast [122], [123]. There is an overlap in appearance of benign and malignant diseases using mammography and ultrasound individually; however, the combination of these modalities is believed to improve accuracy. A common benign breast condition in men is gynecomastia. Men with this condition usually present with symptoms of a lump or
Summary
Ultrasound is an important imaging modality in evaluating the breast. One of the most common uses of ultrasound is to help distinguish benign from malignant breast disease, primarily with gray-scale ultrasound but also with Doppler ultrasound. Another common use is to provide guidance for interventional procedures. Less common uses include assisting in staging of breast cancer and evaluating patients with implants. Recently there has been an interest in using ultrasound to screen asymptomatic
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