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Breast ultrasound is an important modality in breast imaging. It is the usual initial breast imaging modality in those under 30 years of age in many countries ref.
In assessing for malignancy, it is important to remember that one must use the most suspicious feature of three modalities (pathology, ultrasound and mammography) to guide management.
breast ultrasound is targeted to a clinical problem
reasonable sensitivity but poor specificity
may have a place in screening women at high risk or with mammographically-dense breasts
patient positioning: support elbow, flat, supine
probe: linear array 7-13 MHz
correct depth (skin to pectoral fascia) and correct focal zone (up to '2' is acceptable)
dynamic range: some settings can make a cystic lesion look solid and vice versa
clock face with distance from nipple
only caliper things that are real
compression and angulation of probe from heel to toe to sharpen up the edges of a lesion
compound imaging and resolution
cleans up speckles
gives between edge definition
transmits at one frequency
receives only multiples of this single frequency
most noise is generated near the transducer due to reverberation
traps for beginners
edge refraction: from vessels, Cooper's ligaments, edge of cysts
focal fat locules
Use of breast ultrasound
evaluate young (usually under 30 years of age) or pregnant patients who are symptomatic
evaluate a palpable lump with negative or equivocal mammographic findings
detect lesions in lower contrast field
help to distinguish between benign vs malignant characteristics
evaluate breast implants for rupture
See main article on breast cysts:
edge is the most important feature
well-defined all the way around
is it compressible?
can you move the inside?
is there a solid edge: sometimes color Doppler will help
Power Doppler and vocal fremitus
to help distinguish malignant from benign tumors
get patient to say "ahhh" or "99" very loud and observe the center of the lesion:
cancer - vibrations conducted along tumor infiltration into center, hence color pixels run into center of tumor and fill it in
benign lesions (e.g. fat lobules) - cannot get power Doppler into center of lesion
not a useful test in superficial lesions or large breasts
Features that are found not to be useful in differentiating malignant from benign lesions
heterogeneity/homogeneity of texture
normal/enhanced through transmission, e.g. mucinous cancers
being iso-mildly hypoechoic
Classification of nodules
benign: no malignant features, combinations of benign findings
indeterminate: no malignant findings; no combination of benign findings (needs biopsy)
malignant: one malignant feature (needs biopsy)
Potential pitfalls in breast ultrasound in practice
Always correlate the mammogram images before the ultrasound is done. The operator must know where the lesion is located in the breast and the nature of the lesion. What are you looking for and where is it located?
If you work with ultrasound technologists, review by the radiologist in real time is almost always required unless for the simplest of overtly benign breast pathology. In everyday practice, do not be tempted to review static images of breast pathology without looking in real time. This is a very significant potential pitfall for the misdiagnosis of breast pathology.
With the high resolution of the newest apparatus, consider doing ultrasound even if you are working up microcalcifications. In cases where you find them on ultrasound, you may be able to supply a tissue diagnosis and save the inconvenience of mammotome biopsy for the patient.
With greater emphasis now being placed on characterizing breast density, more authors feel there is a place for screening ultrasound in the dense (>75%) breast. In Connecticut, ultrasound of the dense breast is now mandated and paid for by the state. There is good evidence that in this group of patients the yield of ultrasound in picking up cancers is almost as high as mammography itself in the range of an additional 3-4/1000 cancers found (Berg, ECR, 2013). In the context of screening for breast cancer, ultrasound in capable hands will find low grade DCIS that may not be visible on mammography. "Second look" ultrasound after breast MRI will yield a positive finding in about 56% of cases.
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