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BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND

BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND. Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers. Goal of Breast Ultrasound. SOLID VS CYSTIC. Goal of Breast Ultrasound. Make a more specific diagnosis than clinical and mammographic findings alone.

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BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND

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  1. BENIGN VS MALIGNANT MASSES IN BREAST ULTRASOUND Dr. Mona Rozin Director of Breast Imaging Assuta Medical Centers mrozin,md

  2. Goal of Breast Ultrasound SOLID VS CYSTIC mrozin,md

  3. Goal of Breast Ultrasound • Make a more specific diagnosis than clinical and mammographic findingsalone. • Prevent unnecessary biopsies. • Find cancers missed by mammography. mrozin,md

  4. Breast cancer is extremely heterogeneous therefore we CANNOT distinguish benign from malignant on the basis of only a single sonographic finding. Breast cancer varies greatly not only from one mass to another but even WITHIN an individual mass. mrozin,md

  5. Ultrasound shows morphology and not histology / biology ONE suspicious finding requires further evaluation -----> that is biopsy and should be given BIRAD 4A up to 5 mrozin,md

  6. BIRADS for U/S BIRAD 1 – normal BIRAD 2 – benign finding BIRAD 3 – probably benign mrozin,md

  7. BIRADS for U/S BIRAD 4A – abnormal finding – low suspicion BIRAD 4B – abnormal finding – intermediate suspicion BIRAD 4C – abnormal finding – probably malignant BIRAD 5 – highly suspicious for malignancy BIRAD 6 – known malignancy mrozin,md

  8. Spectrum of masses mrozin,md

  9. Circumscribed vs Spiculated malignant masses – a spectrum of ultrasound features • Desmoplastic vs. inflammatory reaction • Cellularity III. Vascularity mrozin,md

  10. Desmoplastic Reaction • Host response to tumor – attempt to wall off the tumor with fibrosis and elastosis to keep it from spreading. • Develops slowly • Therefore spiculated lesions are usually slow growing GRADE 1 – 2 tumors mrozin,md

  11. Inflammatory Response • GRADE 3 tumors may be circumscribed and grow so fast that desmoplasia has no time to develop. • These carcinomas incite an inflammatory response with lymphocytes and plasma cells. mrozin,md

  12. Cellularity • Circumscribed masses are much more cellular than spiculated masses. • They have lots of tumor cells, lymph cells and plasma cells – this causes posterior enhancement. • Spiculated masses have much fewer cells and very hypocellular desmoplasia – this causes posterior shadowing. mrozin,md

  13. Vascularity • Circumscribed masses are usually very vascular – lots of cells and divisions require more blood – more angiogenetic factors; inflammatory response also creates hypervascularity. • Spiculated masses may have same vascularity as normal tissue or benign masses because of the smaller amount of cells and angiogenetic factors. mrozin,md

  14. mrozin,md

  15. BIRADS for Ultrasound Masses • Shape • Margin • Orientation • Lesion boundary • Echogenic pattern • Posterior acoustic features • Effect on surrounding parenchyma • Calcifications • Vascularity mrozin,md

  16. Background Breast Pattern • Homogenous Fatty • Heterogeneous – focally or diffusely variable • Homogenous Fibroglandular mrozin,md

  17. Fatty mrozin,md

  18. Heterogeneous mrozin,md

  19. Fibroglandular mrozin,md

  20. I. Shape • Oval – includes tear drop shape 2-3 macrolobulations may be with thin echogenic capsule • Round – cysts, mets, IDC (high grade) • Irregular – NOT round or oval mrozin,md

  21. Oval fibroadenoma DCIS mrozin,md

  22. Round cyst DCIS mrozin,md

  23. Irregular radial scar IDC IDC mrozin,md

  24. II. Margin • Circumscribed – smooth, distinct margin • Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS • Indistinct – NO abrupt interface with surrounding tissue mrozin,md

  25. Circumscribed mrozin,md

  26. II. Margin • Circumscribed – smooth, distinct margin • Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS • Indistinct – NO abrupt interface with surrounding tissue mrozin,md

  27. Microlobulated mrozin,md

  28. mrozin,md

  29. II. Margin • Circumscribed – smooth, distinct margin • Microlobulated – may be the expression of extended lobules filled with DCIS; 80% of all IDC have a component of DCIS • Indistinct – NO abrupt interface with surrounding tissue mrozin,md

  30. Indistinct mrozin,md

  31. Margin – cont. • Angular – part of margin has sharp corners;most accurate of all signs of malignancy;invasion follows path of least resistance – in fat: many angles; in fibrosis: horizontal and then along Cooper’s ligaments • Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings mrozin,md

  32. Angular mrozin,md

  33. mrozin,md

  34. Margin – cont. • Angular – part of margin has sharp corners;most accurate of all signs of malignancy;invasion follows path of least resistance – in fat: many angles; in fibrosis: horizontal and then along Cooper’s ligaments • Spiculated – sharp projecting lines; use U/S MAG views to see surface characteristics This is a spectrum of findings mrozin,md

  35. Spiculated mrozin,md

  36. Mixed mrozin,md

  37. III. Orientation • Parallel – wider than tall – long axis parallel to skin • NOT parallel – taller than wide – long axis perpendicular to skin includes ROUND masses mrozin,md

  38. TDLU mrozin,md

  39. CA FA mrozin,md

  40. mrozin,md

  41. mrozin,md

  42. post. ant. terminal mrozin,md

  43. mrozin,md

  44. Wider than tall !! ant. lobule terminal lobules distended duct with invasion mrozin,md

  45. IV. Lesion Boundary • Abrupt interface – no transition zone between mass and surrounding tissue • Echogenic rim – variant of spicules too small to resolve on U/S; some masses have a very thick echogenic rim with a tiny hypoechogenic nidus – must examine carefully; peritumoral edema usually occurs btw. mass and skin mrozin,md

  46. Abrupt Interface FA CA echogenic capsule mrozin,md

  47. IV. Lesion Boundary • Abrupt interface – no transition zone between mass and surrounding tissue • Echogenic rim – variant of spicules too small to resolve on U/S; some masses have a very thick echogenic rim with a tiny hypoechogenic nidus – must examine carefully; peritumoral edema usually occurs btw. mass and skin mrozin,md

  48. Echogenic Rim mrozin,md

  49. Echogenic Rim Same mass – with & without Sono-CT mrozin,md

  50. V. Echogenic Pattern • Hyperechoic – more than fat; very rarely can be angiosarcoma, ILC, lymphoma • Isoechoic – equal to fat • Hypoechoic – less than fat • Mixed – hyper and hypo; can be fibrosis, fat necrosis, FA, IDC • Anechoic – absence of internal echoes; mets, IDC- high grade. mrozin,md

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