INTRODUCTION TO INTRODUCTION TO BREAST SonographyBREAST Sonography

DR : AYYAZ MAHMOOD RADIOLOGY SPECIALIST

KFH

ROLE OF SONOGRAPHYROLE OF SONOGRAPHYPRIMARY SCREENING

SECONDARY SCREENING

DIAGNOSIS

PRIMARY SCREENINGPRIMARY SCREENING

SECONDARY SCREENING

KOLB et al ( 2-

STUDIES )BUCHBERGE

R et alKAPLAN et al

Usg Detected 3 Usg Detected 3 CARCINOMAS missed by CARCINOMAS missed by

mamo /1000mamo /1000

NO CALCIFICATIONOBSURED BY SURROUNDING OR

SUPERIMPOSED DENSE TISSUE ON MAMMO

VALUE OF USG AS SECONDARY SCREENING

DIAGNOSIS….proven & DIAGNOSIS….proven & approved roleapproved role

SPECIFIC GOALS PREVENT BIOPSIES &SHORT INTERVAL

FOLLOW UP GUIDE INTERVENTIONS GIVE FEED BACK THAT IMPROVE

CLINICAL & MAMOGRAPHIC SKILLS DETECT MALIGNANCIES MISSED BY

MAMMO

EQUIPMENT EQUIPMENT

HIGH FREQUENCY TRANSDUCERSOptimised for near field imaging

ACS , ACR , AIUM

Minimum FREQUENCY 7 MHZ

DOCUMENTATIONDOCUMENTATION

Side

Clock face position

Distance from nipple

Transducer orientation

2 orthogonal planes

SURFACE

INTERNAL ARCHITECTURE

MAXIMUM DIAMETER

BIRADS BIRADS ….(Breast imaging reporting & data system.)….(Breast imaging reporting & data system.)

Standardizing reporting and data1 1 , 2 , 3 , 4a , 4b , 51 : sonographic normal tissue , mammographic or

clinical abnormalities2: benign entities ( intramammery lymph

nodes ,ectatic ducts , simple cysts , definitely benign solid nodules as LIPOMA

3: probably benign ….2 % or less chances as complex cysts ,small intraductal papillomas , subset of fibroadenoma .

BIRADS BIRADS ….(Breast imaging reporting & data ….(Breast imaging reporting & data system.)system.)

4: suspicious , two categories 4a…….mildly suspicious 3- 49 % 4b…….modera suspicious 50- 89 %

5: malignant ….. 90 % or greater

MANAGEMENT RULESMANAGEMENT RULES

1 – 2 ……ROUTINE SCREENING & FOLLOW UP

3 ……….SURGICAL BIOPSY , IMAGE GUIDED NEEDLE BIOPSY , SHORT INTERVAL FOLLOW UP

4a – 4b – 5 ……….BIOPSY

MAIN INDICATIONSMAIN INDICATIONS

PALPABLE LUMPS dense tissue area of palpable

lumpNO CALCIFICATION /

SURROUNDING TISSUE

GOAL…..FIND SOMETHING BENIGN TO AVOID BIOPSY

SONOGRAPHY PREVENTS SONOGRAPHY PREVENTS BIOPSYBIOPSY

NORMAL OR DEFINATEVELY BENIGN FINDING .

HIGH NEGATIVE PREDICTIVE VALUE FOR NEGATIVE MAMMO & NORMAL OR BENIGN ULTRASOUND FINDING

OLD COMMON WISDOM …ALL PALPABLE LUMPS NEEDS BIOPSY…NOT TRUE

NEGATIVE USG REPORTNEGATIVE USG REPORTPalpable lesion …… NOT ACCEPTABL DOCTOR …..NOT FULLY UNDERSTAND

THE PROBLEMALL SONOGRAM IN PALPABLE LUMPS BEING POSITIVE

NORMAL TISSUE , CLEARLY BENIGNFINDINGS…………………………CAUSE

MAMMOGRAPHIC DensitiesMAMMOGRAPHIC Densities

No calcification ….. Best for usgDiscrete masses ….. Focal asymmetrical densitiesUSG …….. ASYMMETRICAL NORMAL …………...DEFINITELY BENIGN

…………..MORE MALIGNANT THAN LOOKING BY MAMO

SONO MAMMO SONO MAMMO CORRELATIONCORRELATION

SIZESHAPELOCATIONSURROUNDING TISSUE DENSITY

SONO FINDINGSSONO FINDINGS

NORMAL TISSUE AND ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION ( ANDIs )

Ductal ectasia , fibrocystic changes , Benign proliferative disorder

Simple cystSimple cyst

Cyst…….. Solid Negative predictive

value 100% 99 % for sonographic

normal study

Simple Cyst Simple Cyst

anechoic well-marginated round, ovoid, or lobulated solitary or multiple well-defined posterior wall acoustic enhancement

Simple cystSimple cyst

Strict criteria for simple cyst………..No biopsy , aspiration or follow up..

MAIN INDICATIONSMAIN INDICATIONS

GOAL……Malignant lesion obscured by surrounding tissue

ABNORMALITY PALPATED WHILE SCANNING

AGGRASIVELY SCANNING DETECT CARCINOMAS MISSED BY MAMMO

Solid noduleSolid nodule

Automatic indication for biopsy ?…….

Solid noduleSolid nodule

SOLID NODULE

COMPLEX COMPLICATED COMPLEX COMPLICATED CYSTSCYSTS

THICK WALL , THICK SEPTATIONS ,MURAL NODULES

Debri …………….complicated

COMPLEX COMPLICATED COMPLEX COMPLICATED CYSTSCYSTS

MOST COMPLEX CYSTS FALL WITH IN BROAD SPECTRUM OF FIBROCYSTIC CHANGES ….

MALIGNANT CYSTS ….. RARECOMPLEX / COMPLICATED

CYSTS……..NO FLUID CYTOLOGY / US GUIDED BIOPSY

Breast Cancer EvaluationBreast Cancer Evaluation

PRIMARY SIGNSDOMINANT MASSDENSITYMICROCALCIFICATIONARCHITACTURE DISTORTIONINTERVAL CHANGES

Breast Cancer EvaluationBreast Cancer Evaluation

SECONDARY SIGNSASYMMETRIC THICKENINGASYMMETRIC DUCTSSKIN CHANGESNIPPLE / AREOLAR ABNORMALITIESABNORMAL VEINSAXILLARY NODES

INFECTION / ABSCESSINFECTION / ABSCESS

MASTITES ……. ABSCESS ABSCESS………… ASPIRATE//DRAINAPPEARANCE …….. VARYFEVER , PAIN ,TENDERNESS ,

INCREASE WHITE CELL COUNT

Duct EctasiaDuct Ectasia. .

VARIABLE APPERANCEELONGATED FILLED WITH FLUIDTUBULAR APPERANCE

                       

FibroadenomaFibroadenoma. .

ESTROGEN INDUCED TUMOUR .3 rd most common breast lesion .Most common benign lesion of child

bearing age .Firm ,smooth , oval , well marginated and

freely mobileRarely tender or painfulCan calcify

FibroadenomaFibroadenoma. .

                       

Fibrocystic ChangesFibrocystic Changes..

72 % of screening population over 55Round to ovoid cysts with smooth

margins , lobulated or multilocular

                       

CONCLUSIONCONCLUSION

USG HAS DEFINATE ROLE PROVIDING ADDITIONAL INFORMATION WITH OR AS AN ALTERNATIVE TO BIOPSY AS A SECONDARY SCREENING MODALITY

THANK YOUTHANK YOU