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.
Prevent unnecessary biopsies.
Find cancers missed by
mammography.

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.

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

BIRADS for U/S

BIRAD 1 normal
BIRAD 2 benign finding
BIRAD 3 probably benign

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

Spectrum of masses

Circumscribed vs Spiculated
malignant masses a
spectrum of ultrasound
features

I.

Desmoplastic vs. inflammatory

reaction

II.

Cellularity

III. Vascularity

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

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.

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.

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.

BIRADS for Ultrasound

Masses
I. Shape
II. Margin
III. Orientation
IV. Lesion boundary
V. Echogenic pattern
VI. Posterior acoustic features
VII. Effect on surrounding parenchyma
VIII. Calcifications
IX. Vascularity

Background Breast Pattern

Homogenous Fatty
Heterogeneous focally or
diffusely variable
Homogenous Fibroglandular

Fatty

Heterogeneous

Fibroglandular

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

Oval

fibroadeno
ma
DCIS

Round

cyst

DCIS

Irregular

radial
scar

IDC
IDC

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

Circumscribed

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

Microlobulated

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

Indistinct

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 Coopers ligaments
Spiculated sharp projecting lines; use U/S
MAG views to see surface
characteristics
This is a spectrum of findings

Angular

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 Coopers ligaments
Spiculated sharp projecting lines; use
U/S
MAG views to see surface
characteristics
This is a spectrum of findings

Spiculated

Mixed

III. Orientation
Parallel wider than tall long axis
parallel to skin
NOT parallel taller than wide
long
axis perpendicular
to skin
includes ROUND masses

TDLU

CA

FA

post.

ant.

termin
al

Wider than tall !!

ant.
lobule

distended duct
with invasion

terminal
lobules

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

Abrupt Interface

FA

CA

echogenic
capsule

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

Echogenic Rim

Echogenic Rim

Same mass with

& without Sono-CT

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.

normal fibrotic
tisssue

fat necrosis
silicone

hyper
?

hyper with iso

later

NO
T

4 mo

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.

Mucinous
CA

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.

IDC

seroma
FA

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.

Intracystic papillary
CA
phylloide
s

hematom
a

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;
cysts mets, IDC- high grade.

cyst
s

VI. Posterior Acoustic

Features
None
Enhancement highly cellular lesions
Shadowing seen in desmoplasia
Combined
Can use this finding to try and predict
GRADE; very small lesions (< 5 mm)
may have no transmission because
havent had time to develop
desmoplasia or inflammatory reaction

Shadowing

enhancement

norma
l

cys
t
CA

DO NOT FORGET May see artifactual shadowing from

steep Coopers ligaments can be
removed with compression !

artifac
t

compressi
on

DD of Enhancement
1)
2)
3)
4)
5)

IDC high GRADE

Mucinous CA
Medullary CA
Metaplastic CA
Papillary CA

6) FA
7) Cysts

DD of Shadowing
1) IDC low GRADE
2) ILC
3) Tubular CA
4)
5)
6)
7)
8)

Scar
Fat necrosis
Radial scar
Calcified FA
Calcified oil cysts

VII. Effect on Surrounding

Tissue
Straightening of Coopers
ligaments
Architectural distortion
Skin thickening normal 2 mm
Skin retraction
Edema mastitis, radiation Tx,
inflammatory CA, CHF
Ducts abnormal size, branching

Architectural
distortion

Thickening &
straightening of
coopers ligaments

VII. Effect on Surrounding

Tissue
Straightening of Coopers ligaments
Architectural distortion
Skin thickening normal 2 mm
Skin retraction
Edema mastitis, radiation Tx,
inflammatory CA, CHF
Ducts abnormal size, branching

Skin thickening

Inflammatory
CA

Skin retraction
in scar with
seroma

VII. Effect on Surrounding

Tissue
Straightening of Coopers ligaments
Architectural distortion
Skin thickening normal 2 mm
Skin retraction
Edema mastitis, radiation Tx,
inflammatory CA, CHF
Ducts abnormal size, branching

focal edema

Edema with
dilated
lymphatics

VII. Effect on Surrounding

Tissue
Straightening of Coopers ligaments
Architectural distortion
Skin thickening normal 2 mm
Skin retraction
Edema mastitis, radiation Tx,
inflammatory CA, CHF
Ducts abnormal size, branching

Duct
extension

Branch
pattern

IDC
Duct
extension

2nd lumpectomy with +

margin

1st lumpectomy with +

margin

VIII. Calcifications
Macrocalcifications
Microcalcifications outside a mass
Microcalcifications inside a mass

FA
Oil cyst

IDC
DCI
S

IX. Vascularity

Absent
Present
Adjacent to lesion
In surrounding tissue

Feeding
vessel

IDC-Grade
I

IDCGradeII

FA

FA

Cyst

Suspicious for Malignancy

I.

II.

Hard
spiculations, thick rim
angular margins
(shadowing)
Intermediate
hypoechoic
microlobulation
taller than wide
Stavaro
s

III. Soft
duct extension
branching pattern
calcifications

Stavaro
s

Most likely benign

Oval
Circumscribed echogenic
capsule
Parallel
Abrupt interface
Hyperechogenic

Algorithm for Sonographic

Evaluation
1) Look for malignant findings and if there
are any give BIRADS 4-5 and biopsy
2) If there are NO malignant findings look
for benign findings and if there are any
give BIRADS 2-3 and suggest follow-up
3) If NO benign findings found give
BIRADS 4A and biopsy

Sine Qua Non

(without which there is nothing)
technique, technique, technique
Must always base management
on the worst feature present !!!!