Ultrasound of the Breast BASICS FOR THE ORDERING CLINICIAN

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1 Ultrasound of the Breast BASICS FOR THE ORDERING CLINICIAN

2 Breast Ultrasound Anatomy Skin Breast Parenchyma Pectoralis Fascia Pectoralis

3 Breast Ultrasound Anatomy

4 Indications for Breast Ultrasound Palpable lesion of any age. Evaluation of a breast mass/lump in a patient younger than 30 skip straight to US. Differentiation of mammographic breast mass or nodule as solid or cystic. Interventional procedures.

5 Indications for Breast Ultrasound Interventional procedures. US guided core bx s FNA Cyst aspirations Needle localization Magnetic or radioactive seed placement

6 Breast Ultrasound Advantages No radiation Evaluation of the breast during pregnancy Real-time imaging Assessment of vascularity Dense breast evaluation No compression Good for ductal evaluation Comfort during procedures

7 Breast Ultrasound Weaknesses Operator dependent Experience Speed Lesion appearance Poor at evaluating microcalcifications Deep lesions Post-op breast Scar tissue

8 Malignant Breast Masses

9 Characteristics of Malignancy Hypoechoic Taller than wide Shadowing Spiculation or Angular Borders Microlobulation Ductal Extension Calcification Penetrating vascularity

10 Hypoechoic Breast Mass Differential Diagnosis Breast cancer Complex cyst Fibroadenoma Traumatic hematoma Abscess Post-op collection Fibrocystic changes Intraductal papilloma Sebaceous cyst Intramammary lymph node Benign breast lesions of pregnancy

11 Malignant Breast Masses Spiculations Posterior acoustic shadowing Angular margins

12 Malignant Breast Masses Duct Mass Ductal extension

13 Malignant Breast Masses Ductal extension

14 Malignant Breast Masses

15 Malignant Breast Masses Microlobulations Microlobulations

16 Malignant Breast Masses

17 Malignant Breast Masses

18 Malignant Breast Masses Indistinct margins

19 Benign Breast Masses

20 Benign Breast Masses Smoothly marginated Wider than tall Anechoic or Uniformly Hyperechoic Posterior acoustic enhancement (through transmission) Thin echogenic capsule 2-3 gentle lobulations or macrolobulations

21 Benign Breast Masses Posterior acoustic enhancement

22 Benign Breast Masses

23 Benign Breast Masses

24 Benign Breast Masses Gentle lobulations

25 Benign Breast Masses Thin echogenic pseudocapsule

26 Benign Breast Masses

27 Benign Breast Masses

28 Benign Breast Masses

29 Breast Lesions of Pregnancy

30 Breast Lesions of Pregnancy Mastitis with Abscess Lactating Adenoma Galactocele Fibroadenoma Can enlarge during pregnancy Breast cancer

31 Breast Abscess

32 Breast Abscess

33 Fibroadenoma

34 Galactocele Benign fat-containing breast mass Presentation may be delayed up to 6-10 months after cessation of breast feeding Aspiration is diagnostic and curative

35 Galactocele

36 Galactocele

37 Lactating Adenoma Can occur in any pregnant woman (not just breast feeding women) Can enlarge rapidly during 1 st and 2 nd trimester Usually regress after cessation of breast feeding

38 Lactating Adenoma

39 Lactating Adenoma

40 Problematic Lesions

41 Intraductal Papilloma Can mimic inspissated secretions or ductal debri Benign Surgically removed due to risk of upgraded pathology on excision 10% atypical or high risk lesion 6.5% carcinoma

42 Intraductal Papilloma

43 Intraductal Papilloma

44 Intraductal Papilloma

45 Phyllodes Tumor Often have characteristics similar to a fibroadenoma Gently lobulated borders Hypoechoic Well-circumscribed Through transmission Rapidly growing tumor usually in middle-aged women Consider PT if >20% increase in diameter in 6 months 75% Benign, 16% borderline, and 9% malignant Pathology may vary throughout the same tumor Tx: Surgical excision

46 Phyllodes Tumor

47 Phyllodes Tumor

48 Phyllodes Tumor

49 Papillary Carcinoma Uncommon (<2% of breast cancers) Good prognosis. Axillary node mets are very rare. Often well-circumscribed Often at least partially cystic with through transmission

50 Papillary Carcinoma

51 Papillary Carcinoma

52 Papillary Carcinoma

53 Papillary Carcinoma

54 Mucinous Carcinoma Rare (1-4% of breast cancers) Often well-circumscribed with through transmission Iso or slightly hypoechoic

55 Mucinous Carcinoma

56 Mucinous Carcinoma

57 Benign vs Malignant

58 Benign or Malignant?

59 Benign or Malignant?

60 Benign or Malignant?

61 Benign or Malignant?

62 Benign or Malignant?

63 Benign or Malignant?

64 References Smith, DS. Radiographic Clinics of North America 2001; 39: Stravos, et al. Radiology 1995; 196: Hooley R J, et al. Radiology 2013; 268: Raza S, Baum. Radiology 1997; 203: Reeder, MM. Gamuts in Radiology, 4 th edition Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rid: Case courtesy of Radswiki, Radiopaedia.org, rid: Egan, Breast Imaging, 3 rd Ed ultrasoundcases.info

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