Evaluation of breast lesions with ultrasonography and colour doppler

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1 ORIGINAL ARTICLE Evaluation of breast lesions with USG and colour Doppler Evaluation of breast lesions with ultrasonography and colour doppler Falguni Shah 1, Hemangi Patel 2*, Nila Gandhi 3, Sudhir Singh 4, Sunil Charpot 4. 1 Professor and Head, Department of Radiology, GMERS Sola medical college and hospital, Sola Ahmedabad 2 Associate professor, Department of Radiology, GMERS Sola medical college and hospital, Sola Ahmedabad 3 Assistant professor, Department of Radiology, GMERS Sola medical college and hospital, Sola Ahmedabad 4 Senior resident, Department of Radiology, GMERS Sola medical college and hospital, Sola Ahmedabad ABSTRACT BACKGROUND: cancer is leading causes of death in women around the world. Aim of the study was to evaluate breast lesions and early diagnosis of breast malignant mass with help of ultrasonography (USG) and colour doppler. The objective of our study was to study the various sonographic and color Doppler features of breast lesions irrespective of breast symptom. MATERIALS AND METHODS: A prospective study of 75 patients with breast pathology was carried. The study group consists of patients with positive USG and color doppler findings of breast pathology. The sonographic characterization of the breast lesions along with doppler characteristics of the lesion was done. RESULTS: The study age group varied from 11 years 80 years of age. The most frequent lesion encountered was fibroadenoma follow by breast Abscess. Fibroadenoma was common in young age group, breast abscess is commonly seen in breast feeders mothers while breast carcinoma was more common in older age group. CONCLUSION: USG of breast lesion is the basic imaging modality in evaluation of breast lesion with almost 98 % accuracy to differentiate between benign and malignant lesion, over and above very helpful in interventional procedure like FNAC for confirmation of diagnosis and further management. Key words: lesions, Ultrasonography, benign, breast carcinoma. INTRODUCTION cancer remains 2 nd most common causes of death due to malignancy after cervix in developing country like India while 1 st common cause of death in few urban countries. Early detection of malignancy is one of the most rewarding areas especially for breast malignancy. The goal is to differentiate between benign and malignant lesions at earliest possible stage and yet keep unnecessary biopsies to a bare minimum. Ultrasound is inexpensive, easily available and can be repeated. Comparison with opposite side is very easy. Ultrasound is the only modality with technologic advances and availability of extra high frequency linear transducers up to 18 megahertz (MHz) for evaluation of thin superficial structures like breast become easy. These high-frequency transducers allow visualization with high spatial and temporal resolution and relation with skin and subcutaneous fat plane as well as underlying chest wall and muscle evaluation is very crucial. Ultrasound is very sensitive and very specific for detection of cysts. Ultrasonography of breast can * Corresponding Author: Hemangi Patel Associate professor, Department of Radiology block B,.GMERS Sola medical college and hospital, Sola, Ahmedabad Hemangi_63@yahoo.com play a very important role in disease of the breast in young, pregnant and lactating women, as it avoids harmful radiation. Differentiation of inflammatory and benign lesions from early carcinoma becomes very important, especially in women with family history of carcinoma of breast. The emphasis is on early detection of nonplapable in situ lesion. For a palpable lesion, ultrasonography is the primary modality of choice for characterization of lesion and its further management. Color doppler also play important role in differentiating inflammatory verses metastatic lymph nodes. By demonstrating internal vascularity in hypoechoic solid nodules, color doppler can differentiate it from breast cyst. 1 X-ray Mammography is an essential part of approach to investigation of breast disease. However, it has not yet become widely available, time consuming and costly along with low acceptability due to pain due to breast compression and risk of radiation hazards. MATERIALS AND METHODS In our study, 75 patients with positive or abnormal sonographic findings were selected irrespective of clinical signs and symptoms of breast pathology. Study was done during July 2013 to December Detailed history and presenting symptoms along with clinical examination findings were evaluated. Patients 32 Int J Int Med Res. 2015; 2(3):32-36 e ISSN: p ISSN:

2 with clinically suspected breast pathologies that turned out normal on sonography and patients who could not be followed up to the final diagnosis as well as male patient with breast pathologies were excluded in our study. Patients were scanned with linear high frequency probe ( 7-12 MHz) on the ultrasound machine Esaote My Lab series. Ultrasound was performed on the patient in the supine position. A direct contact scanning technique with the use of the acoustic coupling gel was used and scanning was done in the sagittal, transverse, coronal and oblique sections. Diagnosis was confirmed with clinico pathological correlation and/ or surgery with histopathology. Color and power doppler sonography was performed with color box adjusted to include the lesion and a small margin of normal breast tissue. The color sensitivity was adjusted so that only the background color was suppressed and small vessels could be detected. Care was taken to avoid pressure by probe to prevent vessels from collapsing. The exploration with power doppler sonography was considered positive if at least one vessel was depicted within the lesion and it showed an arterial flow pattern when pulsed doppler imaging was used. In Intra lesional vascularisation was detected then pulsed doppler sonography was performed to obtain spectral wave forms. The resistive index (RI) and pulsatility index (PI) were calculated from all these waveforms. The RI value is calculated as (maximum systolic velocity minimum systolic velocity / maximum systolic velocity). The PI values was calculated as (maximum diastolic velocityminimum diastolic velocity) / mean velocity. The calculations were done automatically using the equipments inbuilt software. RESULTS Table 1: Age wise distribution of pathologies Age group 11 to to to to to to to 80 Age of the patients involved in this study, ranged from 11 to 80 years old patients. lesions were commonest in the 31 to 40 years followed by 21 to 30 years of age group. Table 2: Clinical presentation No. abscess Symptoms and clinical presentations cyst Fibroadenoma No. of patients % 1 swelling (n-75) lump(n-75) Mastalgia (n-75) Nipple discharge(n-75) Nipple Retraction(n-75) Redness(n-75) Pu d orange (n-75) Trauma(n-75) fever(n-75) Asymptomatic with only positive family history(n- 75) Lipoma In present study, most common clinical presentation was breast lump noted in 51 patients, followed by Mastalgia. Few Patients had more than one presenting complains. In present study, out of 75 patients, most common pathology was fibroadenoma followed by breast abscess. 33 Int J Int Med Res. 2015; 2(3):32-36 e ISSN: p ISSN: Mastitis Fibroadenosis Galactocele Duct- ectasia Carcinoma Total Total

3 Table 3: Ultrasonographic Diagnosis of lesions. No No Diagnosis of % cases 1 Infection abscess Inflammation Mastitis 3 4 cyst 9 12 Fibroadenoma Benign Lipoma 3 4 Fibroadenosis 6 8 Galactocele Duct ectasia Malignant carcinoma Total Table 4: Length / Anteroposterior(AP) ratio Length / AP ratio Fibroadenoma Malignancy < Malignant mass had AP distance is more than length while in Fibroadenoma length is more than AP distance. Table 5: Resistive Index (RI) and pulsatility index (PI) in vascular lesion Sr. RI PI Lesion No. 1 <1 4 <4 1 Benign Malignant X 2 = 6.16, P< out of 11 malignant lesions shows abnormal increase in vascularity, among them 4 out of 7 cases show RI 1 and PI 4. While 3 Out of 3 all benign lesions show vascular pattern of benign type (RI <1 and PI<4). DISCUSSION Detection and evaluation of breast lesions were made easy with use of high resolution sonography machine. Most common presenting features in the present study were palpable lump which was present in 51 cases (68 %). Mastalgia is the second commonest presenting feature in our study 28 cases (45%). According to study of Adesunkanni et at 2, symptoms of breast lesions in 225 patients shows 17.3% of patients had mastalgia. In the present study, fibroadenoma accounted for maximum number of cases 19 (25.3%). According to the study by Haagensen et al 3 in 1973, fibroadenoma is the most common tumour. Stavros AT et al 4 studied 750 breast lesions and fibroadenoma accounted for 338 (48%) of all lesions. Evaluation of breast lesions with USG and colour Doppler Figure 1: Case of fibroadenoma, sonography show hypoechoic lesion with well defined smooth margin with posterior enhancement, lesion appears wider than taller Figure 2: Case of breast abscess, sonography show irregular shape collection with internal echos Freely mobile mass (mouse in breast) is its classical presentation. According to the study of Haagensen et al 3 in 1973, fibroadenoma is the most common tumour below 30 of age. Present study had similar observations, 11 out of 19 cases were below 30 years of age. It represent most common benign tumour of young age group. In the present study, out of 19 fibroadenoma, 12 cases were Hypoechoic and 7 cases showed heterogeneous echogenicity. In the same study, 10 cases had Smooth margins; 3cases had lobulated margins, whereas 6cases had irregular well defined margins. cysts are the leading causes of breast lump in women between years. In our study these are the 4 th most common lesion accounted for 9 (12%) patients. Stavors AT 4 has reported 20% incidence in his study of Int J Int Med Res. 2015; 2(3):32-36 e ISSN: p ISSN:

4 breast lesions, whereas Hilton et al 5 in study of 300 palpable breast masses, 25% of all lesions as breast cyst. In the present study, maximum number of cases was between years, 4 (50%). FNAC was done and contents were aspirated and all patients and all patients were followed up to 6 months. No features suspicious of malignancy in these lesions developed over a period of 6 months. Figure 3: Case of breast carcinoma, sonography shows irregular shape hypoechoic lesion with speculated margin and posterior acoustic shadowing, lesion appears taller than wider Bland KL 6 reported that breast abscess most frequently occurs in lactating mothers. The present study had similar findings as 14 cases (18%) of breast abscess. Out of them, 12cases were lactating mothers and 1 was post-traumatic and another was 16 years old girl with no such specific etiology. In 1986, Hilton et al 5 had studied 500 cases sonographically and found that breast abscess were hypoechoic, ill defined masses with some internal echoes with air trapping, thick wall and internal septation and according to Verconica et al 7, in 1989, in a study 626 patients between the ages of 13 and 34 years found that breast abscess were predominantly Hypoechoic, ill defined masses with some internal echoes, thick wall and internal septation. In the present study breast abscess had similar findings, as all 5 cases were Hypoechoic, with irregular and ill defined margins, internal echoes and showed posterior acoustic enhancement. Ultrasound guided aspiration of breast abscess were done in 4 cases. In 6 cases abscess was drained surgically and findings were confirmed. The present study had one case of lipoma was studied. It was diffuse homogeneous mass lesion with echogenicity higher than normal breast. In our study, we came across 2 cases of duct ectasia. One patient presented with nipple discharge and nipple retraction while other patient presented only with nipple discharge. Mc Sweeney et al 8 has studied 14 cases of duct ectasia, 7 presented with nipple retraction. In their study mean age was between years. In present study mean age is between years. In present study both lesions was tubular hypoechoic. One of the lesions had ill defined margins while other had lobulated margins. In our study, we have 11 cases (14.6%) of breast carcinoma. all of which were infiltrating ductal carcinoma between years of age group. Infiltrating ductal carcinoma is the most common and lethal form of breast cancer accounting for 65-85% of invasive cancer. Stavros AT et al 4 in a study of 750 breast lesion, reported incidence of malignant lesion was 17%, out of these malignant mass, 81.5% were infiltrating ductal carcinoma. In present study, 7 out of 11 cases had abnormal increase vascularity within lesion, 8 patients had associated lymphadenopathy, and 3 patients had distal metastasis, 2 patients had lobulated margin, 5 patients had irregular margin and 4 patients had speculated margin. Out of 11 cases of breast malignancy, 3 showed loss of retro mammary fat and involvement of underlying pectoralis muscle. Most of malignant mass had AP distance is more than length while in fibroadenoma length is more than AP distance. On ultrasonic feature that has shown promise in helping to distinguish benign from malignant masses is L/AP ratio. In 1989 Fornage et al 9 studied 100 pathological proven nodules, 86% of fibroadenoma showed L/AP ratio 1.4 and Harper et al 10 had similar results with 86% fibroadenoma had L/AP ratio 1.4, while all carcinomas showed L/AP ratio<1.4. In present study, L/AP ratio<1.4 was seen in 9 out of 11 cases of malignancy (81.8%). In present study, RI values 1 and PI values 4 were considered suspicious for malignancy in accordance with a study done by Jose L Del curaet al 11 on 826 breast lesions. Jose L del Curaet at 11 investigated the difference in doppler sonography features between benign and malignant breast lesion in a total of 826 breast lesions. Color flow was more frequently seen in 35 Int J Int Med Res. 2015; 2(3):32-36 e ISSN: p ISSN:

5 malignant (237/148 lesions, 68%) than in benign (171/478, 36%) lesions. The RI and PI value were significantly higher in cancers. In present study, 7 out of 11 malignant lesions (63.6%) shows abnormal increase in vascularity, among them 4 out of 7 cases (57.1%) show RI 1 and PI 4. While 3 Out of 3, all benign lesions show vascular pattern of benign type (RI <1 and PI<4). In present study, 5 patients of benign and/ or inflammatory cases had associated lymphadenopathy while 8 patients of malignant cases had lymphadenopathy in axilla. Metastatic nodes were more hypoechoic with loss of central fat and shows abnormal increase in vascularity in centre as well as in entire node while benign node shows preservation of central fat with only central vascularity. Spectral waveforms show high peak systolic waveforms with high RI in metastatic nodes while benign or inflammatory nodes show low peak systolic velocity with low RI as compare with metastatic nodes. 1 CONCLUSION Ultrasound is a safe and effective method for evaluation of breast lesion. In maximum number of cases the synchronized evaluation and characterization of breast lesion by ultrasound will help in overall assessment of breast lesions. Taking into consideration the physical findings and the breast cancer risk profile (age, personal history, and family history of breast cancer) along with sonographic features of breast lesion will help to arrive a probable diagnosis of the lesion and play a vital role in management of the patient. Depends on its Ultrasonographic findings we can decide further management of a solid breast lesion whether to go for mammography or FNAC or biopsy. cysts had features like round or oval shape, thin walled, anechoic with posterior enhancement without internal echoes and septation. Benign lesion including wider than taller, hypoechoic echotexture with regular margins and showed posterior acoustic enhancement. Malignant lesions were taller than wider, predominantly hypoechoic with irregular margins and posterior acoustic shadowing with or without local deep invasion to retro mammary space and pectoralis muscle as well as regional lymphadenopathy was confirmed on ultrasound. Intra lesional vascularity on doppler study was seen more frequently in malignant solid lesions when compared with benign lesions. All lesions with RI value 1 and PI value 4 were found to be malignant. The identification of common lesion like breast cyst by ultrasound, which has a diagnostic accuracy of 100%, obviated the need for any further intervention. REFERENCES 1. Carol M. Rumack. Diagnostic ultrasound, The breast. Vol-1 and 2, 4 th edition; (20): 825, 832, Adesunkanmi A R. Benign breast diseases. West Afr J Med 2001; 20: Haagensen CD. Diseases of the breast 3 rd ed. Philadelphia: Saunders,1986; Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196: Saskia Hilton, George Leopoid, Olson LK, Wilson SA. Real time breast sonography: Application in 300 consecutive patients. AJR 1986; 147: Bland KI. Inflammatory, infections and metabolic disorders of : Bland KI, Copeland E Meds. The breast: Comprehensive Management of benign and Malignant Disease. Philadelphia; WB Saunders Co; 1991: Veronica J Harris, Valerie P Jackson. Indication for breast imaging in women under age of 35years. Radiology 1989; 172: Mc Sweeney MB, Murphy CH. Whole breast sonography. Radio Cin North Am 1985; 147: Fornage BD, Lorian JB, Andry E. Fibroadenoma of the breast: Sonographic appearance. Radiology 1989; 172; Patricia Harper A, Elizabeth Kelly-Fry, Noe JS, John R Bies, Valerie P Jackson. Ultrasound in the evaluation of solid breast masses. Radiology 1983; 146: Jose L del Cura, Elena Elizagaray, Rosa Zabala, Ana Legorburu, Domingo Grande. The use of unenhanced doppler Sonography in the evaluations of solid breast lesions. AJR 2005; 184: Int J Int Med Res. 2015; 2(3):32-36 e ISSN: p ISSN: