Automated Breast Volume Scanner: 3D-Ultrasound of breast lesions

Transcription

1 Automated Breast Volume Scanner: 3D-Ultrasound of breast lesions Poster No.: C-2167 Congress: ECR 2011 Type: Educational Exhibit Authors: T. Fassaert, I. Dubelaar, M. D. F. de Jong, M. Rutten ; 's Hertogenbosch/NL, 's Hertogenbosch/NL, 'S-Hertogenbosch/NL Keywords: Neoplasia, Cysts, Diagnostic procedure, Ultrasound, Image manipulation / Reconstruction, Experimental, Oncology, Breast DOI: /ecr2011/C-2167 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 35

2 Learning objectives A pictorial essay of benign and malignant findings in 3-dimensional (3D) breast ultrasound. Background Automated Breast Volume Scanning (ABVS) is a promising new technique providing high-resolution ultrasound (US) data. The breast is automatically scanned in caudocranial direction using a high frequency (5-14 MHz) broadband transducer. Consecutive axial sections of the breast are obtained in 60-70s per scan. The result is a 3D-US data volume, from which views can be reconstructed in any desired plane including a new coronal (i.e. surgical) view. Multiplanar correlation facilitates lesion assessment. Exact localisation of lesions with their distance to skin and nipple are automatically provided. Images for this section: Page 2 of 35

3 Fig. 1: An automated breast volume scanner (ABVS) comprises of an ultrasound system next to a tripod on which an arm with a automated breast scanning system is mounted. Fig. 2: Image acquisition. The 16cm wide broadband transducer is positioned on the breast and fixed, position and depth are selected on the touch screen. After confirmation of scan settings and direction, the probe autopmatically starts scanning the breast in caudocranial direction, essentially filming the breast composition as it moves over the breast. The result is a multitude of axial images which can be viewed as a 3D ultrasound data set. Page 3 of 35

4 Fig. 3: The 3D US dataset is send to PACS and/ or a dedicated workstation. Hangings can be selected to suit the reader, allowing to scroll through the data volume in various directions simoultaneously. It is possible to adjust window-level, zoom, pan, measure, invert and take snapshots of ROI's. Page 4 of 35

5 Imaging findings OR Procedure details From september to december 2010 we have correlated three-dimensional ultrasound (3D-US) findings with digital mammography, Handheld (2D) ultrasound (HH-US), MRmammography and/or histopathological findings in a study of 100 consecutive patients with an indication for MR-mammography. We demonstrate 3D-US findings in a selection of illustrative cases of benign and malignant breast lesions. Multiplanar correlation of lesions in a 3D-US volume is shown with emphasis on the new coronal plane. Illustrative imaging of mammography, HH-US and MR-mammography is added for optimal understanding of the cases. NOTE: Due to technical reasons movie files (Figures 4,8,18,21 and 28) are skipped when leafing through the case series in the enlarged image mode. It's best to close the enlarged mode and double click the movie-files manually. Images for this section: Page 5 of 35

6 Fig. 1: Case 1: 36 y/o woman with cystic mastopathy. 3D US imaging in a 36 y/o woman with cystic mastopathy. Axial (top), coronal (bottom left) and sagittal (bottom right) views show a number of cysts in varying size. Notice an artefact produced when a firm lesion -in this case a cyst- slips underneath the moving probe. As a result the lesion is a cutoff on the cranial side (skip artefact). Page 6 of 35

7 Fig. 2: Case 2: 23 y/o woman with a biopsy proven fibroadenoma 3D US in a 23 y/o woman with a biopsy proven fibroadenoma Axial (top), coronal (bottom left) and sagittal (bottom right) view of an echogenic lobulated well demarcated mass with acoustic enhancement consistent with the fibroadenoma. Page 7 of 35

8 Fig. 3: Case 3: 33y/o woman with nipple discharge Upper images: Handheld 2D Ultrasound (HH-US) depicts multiple ductectasias in lower lateral quadrant of left breast. Power Doppler detects flow in an intraductal mass. Bottom left: MRI axial T2 Stir shows the segmental radiating high intensity of intraductal fluid and debris. Bottom right: MRI axial subtraction after Gadolinium (Gd) shows intense uptake in the intra-ductal mass. Page 8 of 35

9 Fig. 4: Case 3: 33 y/o woman with nipple discharge of her left breast and biopsy proven intraductal papilloma. 3D US Volume, movie file. Consecutive coronal US views show branching, radiating ductectasias. The intraductal papilloma is visible as a small intraductal mass. Lesion identification is best appreciated in combination with axial and sagittal view. Page 9 of 35

10 Fig. 5: Case 3: 33 y/o woman with nipple discharge. 3D US Volume. Axial (top), Coronal (bottom left)and Sagittal (bottom right) view of the lower lateral quadrant of left breast show branching ductectasias with an lobulated intraductal mass. Biopsy confirmed a intraductal papilloma. Page 10 of 35

11 Page 11 of 35

12 Fig. 6: Case 4: Post-operative scar in a patient with sclerosing adenosis. 54 y/o woman with sclerosing adenosis and a history of excision biopsy of left breast, received MRMammography because of dense breast tissue. Axial T2 Stir (top), Coronal T2 (middle) and axial subtraction imaging after Gadolinium (bottom) show symmetrical gradual enhancement in a woman with sclerosing adenosis. On coronal images, skin retraction following prior excision biopsy is visible. Fig. 7: Case 4: Post-operative scar in a patient with sclerosing adenosis. 3D US imaging of left breast. Axial (top), coronal (bottom left) and sagittal view (bottom right) of left breast show architectural distortion consistent with post-operative changes. Page 12 of 35

13 Fig. 8: Case 4: Post-operative scar in patient with sclerosing adenosis. 3D US volume, movie file. Consecutive coronal US views. Scrolling though the coronal plane proves helpful for visualisation of the architectural distortion in lower outer quadrant of left breast. Notice the absence of mass effect. Page 13 of 35

14 Fig. 9: Case 5: Follow-up after RFA A 84 y/o woman with a history of ablation of the right breast in 1996 and a small invasive ductal carcinoma centrally in her left breast one year ago. For this she received Radiofrequency Ablation (RFA). Follow-up MRI was performed 1 year after RFA. Axial T2, axial T2 Stir (top left and right)± centrally there is a region with ring-like edema, surrounding a oval mixed hyper- and hypointense region. Axial and coronal subtraction images after Gadolinium (bottom left and right): there is gradual enhancement on late series surrounding a central oval region with little gradual enhancement. Compared to MRI post-rfa (not shown) there is no notable change. Page 14 of 35

15 Fig. 10: Case 5 Follow-up after RFA 3D US of left breast. Axial, coronal and sagittal view of show a sharply demarcated oval area with distorted inner structure and cystic centre. Histological biopsy showed fat necrosis and debris with blood pigments, no sign of residual tumour. Page 15 of 35

16 Fig. 11: Case 6: Breast Implants 45 y/o woman with breast implants for which she received MRI. Axial T2 Stir (top left). axial (bottom left) and sagittal silicone sequence (right) Sagittal oblique view of right breast. Linguine sign and water droplets inside the implant consistent with an intra-capsular implant rupture of right breast. Page 16 of 35

17 Fig. 12: Case 6: Breast implants. 3D US data of right breast, lateral view. Axial, coronal and sagittal view show stepladder sign in the silicone implant. In a 3D volume it is possible to scroll and appreciate this analogue of the Linguine sign. Page 17 of 35

18 Fig. 13: Case 7: a 31 y/o woman with BRCA1 mutation and a solitary enhancing lesion on MR-Mammography. Axial T2 Stir (top) and maximum Intension Projection (MIP) after Gadolinium (bottom). The smooth, oval, 6mm sharply marginated nodule with fast and persistent enhancement (type 2 SI-curve) and high signal on T2Stir at 10 o'clock in right breast was interpreted as probably a small fibroadenoma. During target ultrasound and revision of imaging it was concluded to be a intramammary lymph node. Biopsy confirmed this. Page 18 of 35

19 Fig. 14: Case 7: 31 y/o woman with BRCA1 mutation and an enhancing nodule on MRI. 3D US data. Consistent with MRI enhancing lesion at 10 o'clock in right breast an oval sharp marginated hypoechoic mass with hyperechoic centre is identified. Combination of lesion characteristics and the location just medially from the lateral superficial thoracic vascular bundle confirm this to be an intra-mammary lymph node. In this example 3D US downstages MRI findings to BIRADS-2. Page 19 of 35

20 Fig. 15: 3D US of lupectomy specimen with an histological proven IDC Single coronal view of the tumor shows an advantage of the coronal reconstruction. Now the spiculated growth pattern can also be appreciated with ultrasound. Page 20 of 35

21 Page 21 of 35

22 Fig. 16: Case 8: A palpable mass 47 y/o woman with a palpable mass in her left breast. Top left and right: CC and left OBL mammogram clearly show a mass with retraction centrally in left breast. Bottom: subtraction MRI after Gadolinium: an irregular, fast and intense enhancing mass is visible centrally in left breast. Fig. 17: Case 8: A palpable mass 3D US. On axial (top) and sagittal (bottom right) images the hypoechoic, vertically orientated irregular mass with acoustic shadowing is visible. In the coronal perspective (bottom left) the spiculated growth pattern can be appreciated. Page 22 of 35

23 Fig. 18: Case 8: A palpable mass 3D US data, coronal consecutive images in movie file. The spiculated mass is easily identifiable at 12 o clock position. Biopsy revealed invasive ductal carcinoma (IDC). Page 23 of 35

24 Page 24 of 35

25 Fig. 19: Case 9: spiculated lesion on screening mammography 51 y/o woman without complaints was send from the breast screening program with a small spiculated mass. Top: CC and OBL views of left breast. A small dense spiculated mass is visible in the left upper lateral quadrant. Bottom: MRI shows an profound enhancement of an irregular mass, situated medially prepectoral. Fig. 20: Case 9: spiculated lesion on screening mammography. 3D US data. The lesion is visible as an hypo-echoic irregular lesion with acoustic shadowing on axial and sagittal views. On coronal view the speculated appearance is visible. Page 25 of 35

26 Fig. 21: Case 9: A spiculated lesion on screening mammography. 3D US data, coronal consecutive images in movie file. The spiculated lesion is seen prepectoral. Notice how the eye is drawn towards the spiculated mass. Biopsy proven IDC. Page 26 of 35

27 Fig. 22: Case 10: IDC with satellite metastasis 68 y/o woman presented with a large palpable mass in her right breast. Top left: an irregular mass with multiple calcifications is seen on mammography. Top right: he mass is readily found 2D HH-US. Flow is detectable within the lesion; micropure technique highlights the calcifications. Bottom left: on axial MRI subtraction after contrast, early phase. Enhancement of both the primary mass and 3 satellite metastases -of which 1 is shown here prepectoral - is reported. Biopsy showed IDC. Page 27 of 35

28 Fig. 23: Case 10: IDC with satellite metastases. 3D US data. Axial, coronal and sagittal views on 4 different levels. Both the primary mass and 3 additional satellite metastases can be depicted on various high-resolution images. The semi-automated lesion localisation points towards the lesions. Page 28 of 35

29 Fig. 24: Case 11: IDC with peau d'orange. 59 y/o woman presented with hardening of the lateral aspect of left breast. On clinical examination peau d'orange was found. Top left Mammography (CC and detail) shows skin thickening and asymmetry with pleomorphic calcifications. 2D HH-US (top right) shows a hypoechoic region with acoustic shadowing. bottom right: on MRI regional branching enhancement is visible reaching towards the skin. Page 29 of 35

30 Fig. 25: Case 11: IDC with peau d'orange. 3D US data. Axial (top), coronal (bottom left) and sagittal (bottom right) view of the affected region. Consistent with mammographythere is skin thickening and induration of fatty tissue as signs of mastitis carcinomatosa. In the centre a linear hypoechoic region is extends from the skin in accordance with MRI. Page 30 of 35

31 Fig. 26: Case 12: Shrinking breast 63 y/o woman presents with a gradual hardening of her left breast in 7 months. Top left: mammography of both breasts. Left breast is smaller and denser, there are no calcifications, mass or architectural distortion. On mammography 2 years before (not shown) size was symmetrical. Bottom left: 2D HH-US shows subtle hyperechoic fatty tissue and persistent acoustic shadows in the glandular tissue in all quadrants. MRI, axial T2 Stir (top right) and coronal subtraction after contrast (bottom right): Left breast is smaller and shows diffuse edema. There is marked enhancement in the entire left breast. PA revealed invasive lobular carcinoma. Page 31 of 35

32 Fig. 27: Case 12: A shrinking breast 3D US data. On axial (top) and sagittal (bottom right) views multiple acoustic shadows are discernable in glandular tissue. Surrounding fat is slight hyperechoic. The coronal reconstruction (bottom left) appears norma at first view. Page 32 of 35

33 Fig. 28: Case 12: A shrinking breast 3D US volume, movie file. Coronal view. At first sight it appears normal. Only when both breast are compared some branching acoustic shadows from Cooper's ligaments are slightly pronounced compared to the (normal) right breast. This is very subtle and likely will be missed when only the coronal view is attended. Page 33 of 35

34 Conclusion ABVS provides high-resolution 3D-Ultrasound images of breast lesions. The new coronal view and multiplanar correlation facilitate sonographic lesion assessment. Personal Information Mr. Fassaert, Thomas A., MD, radiology resident, Jeroen Bosch Hospital, 'shertogenbosch, The Netherlands. Mr. Dubelaar, Ivo. J.M., MD, radiology resident, Jeroen Bosch Hospital, 'shertogenbosch, The Netherlands. Mr de Jong, Mathijn, D.F., MD, radiology resident, Jeroen Bosch Hospital, 'shertogenbosch, The Netherlands. Mr Rutten, Matthieu J.C.M., MD, PhD. radiologist, Jeroen Bosch Hospital, 'shertogenbosch, The Netherlands. T. A. Fassaert M.D. Jeroen Bosch Ziekenhuis Postbus ME 's-hertogenbosch phone: , pager 319 Fax : t.fassaert@jbz.nl References None Page 34 of 35

35 Page 35 of 35