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By Dr Attiya

Breast ultrasound uses high-frequency sound waves to map the internal structures of the breast.

Though ultrasound is successfully used to aid assessment of abnormalities detected by mammography, it should not be used as a sole modality for screening as ultrasound does not always detect cancers that are visualised mammographically. Conversely, used in conjunction with mammography, ultrasound can detect clinically and mammographically occult cancers particularly when there is a higher possibility of cancer.

With new high-frequency transducers, it is also possible to detect malignancy associated with mammographically detected clustered microcalcifications.
These lesions may be evident as irregular masses, abnormal dilated ducts or clustered foci of increased echogenicity with increased Doppler vascularity.

High-quality images of the normal and abnormal breast can be obtained with modern ultrasound equipment.

Initial examination Machine to patients right Image with right hand Operate machine with left hand.

Patient Position MEDIAL LESIONS patient is supine ipsilateral arm is placed over the patients head. LATERAL LESIONS patient is opposite. SUPERIOR LESIONS patient is SITTING

Equipment selection:

Transducer At the minimum, a 7.5 MHz linear array probe should be used.

Apply gentle uniform pressure with the ultrasound transducer

Increase transducer pressure for: greater penetration scanning the subareolar region.

Scanning is done in three directions.

1. Radial 2. Transverse 3. Longitudinal

Localization is by the clock face.



3 3

6 6

Ultrasound of the Breast

Recent studies show if strict criteria for lesion analysis are followed, specificity of ultrasound in determining benign or malignant reaches 70%.

Sonographic Breast Anatomy

All macroscopic breast structures can be easily imaged with adequate sonographic equipment.

The breast can be divided into four regions skin, nipple, subareolar tissues subcutaneous region parenchyma (between the subcutaneous and retromammary regions) retromammary region.

Ultrasound interpretation
The subcutaneous fat layer is demonstrated superficially as hypoechoic tissue compared to the glandular tissue from which it is separated by a welldefined scalloped margin. Normal ducts are often visible, particularly in the subareolar region, as anechoic tubular structures. Deep to the glandular tissue, a retromammary fat layer is usually visible and, behind this, the structures of the chest wall.

Sonographic Breast Anatomy

Skin Subcutaneous fat Coopers Ligaments Breast parenchyma Retromammary fat Pectoralis muscle Ribs Pleura Nipple


Cooper's ligament

fibroglandular tissue

Consists of both dense
connective tissue and connective tissue of the duct which can cause posterior acoustic shadowing

Ribs Easily identified bone

attenuates causing an acoustic shadow

Duct Tubular branching


Ultrasound showing dilated ducts (lactating) The duct appears as branching hypoechoic structure within echogenic glandular tissue.

Intramammary vessel running branching under the skin.

Lymph Node Solid nodule

Ovoid Echogenic fatty hilum

Symptomatic breast lumps in women aged less than 35 years. Breast lump developing during pregnancy or lactation. Assessment of mammographic abnormality ( further mammographic views) Assessment of MRI or scintimammography detected lesions. Clinical breast mass with negative mammograms. Breast inflammation. The augmented breast (together with MRI). Breast lump in a male (together with mammography). Guidance of needle biopsy or localisation. Follow-up of breast cancer treated with adjuvant chemotherapy.

The original role of breast sonography is in the differentiation of cystic and solid lesions. Ultrasound complements both clinical examination and mammography. It is also successfully used as a 'second-look' procedure where an abnormality has been identified using MRI or scintimammography.

Because it does not use ionising radiation, it is the examination of choice in young women and is valuable in the assessment of the mammographically `dense' breast.

Ultrasound plays an important role in the triple assessment of symptomatic lesions.

Being the only `real-time' imaging modality also means it can be used to accurately localise or biopsy breast lesions.

Breast Ultrasound and Mammographic Correlation

Dense breast

Fatty breast

The echotexture of any lesion is compared relative to the echotexture of the intramammary fat.

Cysts are typically well-defined rounded

anechoic lesions with posterior acoustic enhancement, though the presence of debris can increase the overall internal echogenicity. Wall thickening, irregularity or mural nodules should be treated with suspicion and aspiration should be performed.

Simple Cysts

smooth, thin margins posterior acoustic enhancement

In practice, needle biopsy should be performed as part of triple assessment in the presence of a discrete solid mass. Not all breast pathology presents as a discrete lesion. Inflammatory or lobular cancers may present as areas of scattered indeterminate attenuation. The use of colour and power Doppler can also aid in benign-malignant differentiation of solid masses. In general, malignant masses tend to show an increased number of vessels that penetrate deep into the tumour with a branching morphology.

Breast Ultrasound
Imaging Characteristics size shape border definition internal echogenicity posterior enhancement architectural changes

Analytic Criteria
Margins Retrotumoral acoustic phenomena Internal echo pattern Echogenicity Compression effect on SHAPE Compression effect on INTERNAL ECHOES

Benign Characteristics Ellipsoid shape Thin definable capsule Two or three lobulations Hyperechogenicity.

Solid Mass - Malignant


shape Irregular/ill-defined borders Almost anechoic Angular margin Taller than wide

Irregular shape Irregular/ill-defined borders Almost anechoic Thick echogenic rim Posterior shadowing

Shape Alignment
Wider than deep; aligned parallel to tissue planes Smooth/thin echogenic pseudocapsule with 2-3 gentle lobulations

Deeper than wide


Irregular or spiculated; echogenic 'halo'

Homogeneity of internal echoes

Variable to intense hyperechogenicity


Low-level Marked hypoechogenicity


Lateral shadowing Posterior effect

Present Minimum attenuation/posterior enhancement


Absent Attenuation with obscured posterior margin

Calcification Microlobulation Intraductal extension Infiltration across tissue planes and increased echogenicity of surrounding fat

Other signs

A typical fibroadenoma with homogeneous internal echoes with an ovoid shape and circumscribed margins -- benign. There is posterior acoustic enhancement..

A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.

An invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.

Inflammatory breast cancer with secondary signs.

increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.

A power Doppler image of an invasive grade 3 breast cancer. irregular tortuous and branching vessels penetrating into the centre of the lesion.

The sonographic pattern varies with age and individually, and depends on the amount and type of contents, i.e. fat, fibrous and glandular tissues.

The fibrous and glandular components are variably echogenic, while fat is hypoechoic.

Benign ?? Malignant ??

Benign vs. Malignant

Benign ?? Malignant??