Solid Breast Nodules: Benign vs. Malignant

[Music] hi I&#39;m Cindy Rath I am from the University of Colorado Hospital in Denver Colorado today I&#39;ll be talking about solid nodules how to differentiate the nine vs. malignant lesions solid breast nodules benign versus malignant if we look at the type of cancers that we see with ultrasound the number one cancer that will diagnosed is invasive ductal carcinoma you can see the second most common is invasive lobular we also have medullary mucinous DCIS and other types and metastasis das is much more common in the mammographic role but with ultrasound we typically will find invasive ductal cancer most often now just the opposite of our judicial system with breast filmography what we want to do when we find a solid lesion is think of it as being something worrisome so the first thing we&#39;re going to do is seek malignant findings once you have looked for malignant findings and you haven&#39;t seen any then what you want to do is make sure you can classify the lesion as being benign if you cannot classify it as being benign then we have to classify it as indeterminate and if it&#39;s indeterminate it&#39;s recommended for a biopsy breast cancer is extremely heterogeneous it&#39;s very important to make sure that you scan the entire nodule in two planes looking for any subtle changes that you might see if you happen to find a mixture of benign and malignant findings it will exclude the lesion from being benign and classify it as being something worrisome for malignancy and I already mentioned the heterogeneity of breast cancer not only from nodule to nodule but often within a single module we&#39;ll see very heterogeneous findings we look at this chart you can see the heterogeneity of breast cancer we&#39;ve got one in the spectrum where we&#39;ll have lesions that are very well circumscribed on those will see regions that are extremely cellular you may have high-grade lesions once with an inflammatory reaction enhance through transmission these are ones that are pop are positive on color Doppler on the opposite end of the spectrum we have our speculated lesions they tend to be more positive cellular their low-grade cancers they host a dismal plastic reaction will see shadowing behind those these are typically negative with color Doppler and because of the heterogeneity of breast cancer often we have a mixture between these two findings that we&#39;ll see within a single lesion looking at solid nodules the complex spectrum of the growth morphology we can see lesions that are fairly well circumscribed that are malignant and then we have lesions such as five Brad nomas that can be extremely worrisome looking especially you&#39;re scanning a young teenage patient more often in black females they can have what are called juvenile five Brad nomás those look very worrisome simha graphically and then we have things such as radial scars that present a speculated lesions that we really won&#39;t talk about much today now if people sometimes think that we should not use ultrasound to try and differentiate benign versus malignant lesions they say if you took a single finding you can see such as shadowing how many fibroadenomas that we could prevent a biopsy and the area of green but you can see how many false negatives that we would have in the area in red but with ultrasound we don&#39;t take this to single finding we take multiple findings we apply basically the same algorithm that we do with mammography and what we&#39;re able to do by doing this is get our false negative rate less than 2% which is pretty much the gold standard for mammography so with ultrasound and using these multiple features were able to get our false negative rate of less than 2% these are the different things that we will talk about features of breast cancer we can look at speculation angular margins and acoustic shadowing these are what I call hard findings they tend to go along with an invasive process more nonspecific findings in other words can go along with either invasion or DCIS or micro lab relation taller than wide and looking at the echo jinnah City of the lesion we compare all lesions in the breast to fat so if I say a lesion is hypoechoic that means it is darker than fat more soft findings that tend to go with DCIS or things such as duct extension branch pattern and calcifications so the first feature that we&#39;ll look at are speculations this is more of a hard finding now depending upon the background of the tissue surrounding the lesion we may see hypoechoic spicules if there is an echogenic more of a fiber glandular background we will notice hypoechoic spicules if the lesion is surrounded by fat the speculations that we&#39;ll see will tend to be more echogenic these are the ones that show up mammogram quickly because we&#39;ve got a fatty background so on mammogram we can see those type of speculations if we look at the image on the left here in this particular breast cancer we have an area duct extension this cancer is also taller than it is wide through this portion and here you can see these high poco spicules radiating out because there is an echogenic background you also notice that there&#39;s a smaller cancer sitting right here a multifocal lesion if we notice the image on the right these are more eco genic speculations that we can see radiating out because there is a fatty background so since we have a fatty background we can see echogenic speculations versus the hypoechoic ones when we have the bright background because of the heterogeneity of breast cancer sometimes only a certain surface of the lesion may have speculations and here we can see speculations on the anterior surface and appears a little bit more like thick halo around the lateral side of it why is it sometimes that we see echogenic versus hypoechoic speculations actually we have both of them present and typically the background tissue will alternate or will eliminate one of those so if you notice here is the actual spicule which is more hypoechoic which is we&#39;re seeing here on this pathology specimen the speculation the interface between one spicule and the other is more of the echogenic background so this is a nice example of being able to demonstrate both hypo and hyper acute speculations and typically we&#39;ll only see one of those when we do our imaging one thing that&#39;s very important when you are looking at a lesion make sure that you optimize the image completely when you first start scanning you want to make sure you take a picture that you can see all the way from skin surface down to the chest wall but once you&#39;re ready to look at that look at the surface characteristics of this lesion make sure that you do MUP and here you can see these speculations much better on a zoomed image so optimize your image completely when you&#39;re looking at it a variation of speculations are what we refer to as the thick echogenic halo that you can see surrounding this lesion now one thing that we&#39;ll notice is the thick echogenic halo a lot of times will appear to be thicker on the edges than it is on the anterior post to your surface so usually it&#39;s sticking around the anterior-posterior I&#39;m sorry thicker on the edges and it is anterior and posterior Li this is the same lesion that was scanned the same day the only difference is that we can see this image on the left was done on a mid-range ultrasound equipment versus scanning it on a high-end equipment so what appears to be a sick echogenic a low seen here are actually individual spicules that we can see radiating out once we used our high-end equipment I think both of the systems will show that this is a lesion that needs to have a biopsy exist if you&#39;re using high-end equipment you can make your diagnosis with a lot more confidence I think using high-end equipment now the next finding we&#39;re going to talk about our angular margins angular margins are a hard finding so if we see this we typically are dealing with an invasive carcinoma you can see this lesion here all the multiple angular margins that were able to demonstrate also notice that this lesion is markedly high poco compared to the fat there&#39;s some areas of calcification with it there&#39;s enhanced through transmission behind it so most malignant lesions have multiple features that we will be able to see in evaluating them because of the heterogeneity of breast cancer it&#39;s very important to make sure that you scan a lesion all the way through and two planes don&#39;t just take one random cut transverse through here and another one longitudinal through this plane or you will miss the angular margin seen here or the Micro ovulation seen in this area so very important to make sure you scan all the way through and look for these subtle little changes that we might see on ultrasound looking at this cancer that we can see I&#39;m going to show you a dotted line and a dashed line right through the cancer that&#39;s just about a centimeter apart from each other notice on this image on the right right through this area how well circumscribed this lesion can appear where is it cut just about a centimeter away there are obviously malignant features angular margins and shadowing that we can see that&#39;s just showing you or demonstrating the amount of heterogeneity that we can see within a single module now in looking at breast cancer cancer likes to take the path of least resistance so as the cancer becomes invasive and starts to spread a lot of times what they&#39;ll do is when it hits up against this and too a premium a fascial layer the anterior pre memory facial layer comes along wherever there&#39;s a Cooper&#39;s ligament it goes up attaches at the skin and comes back down so if cancer starts and hits up against that pre memory facial layer a lot of times it will start invading up through Cooper&#39;s ligaments and one thing we learned is if we&#39;re looking for subtle changes on cancers that are fairly well circumscribed it&#39;s looking to the area of a Cooper&#39;s ligament and that is where we&#39;ll be able to find these little angular margins right in that area they tend to invade Cooper&#39;s ligaments so looking at this cancer one thing you&#39;ll notice is wherever we have a Cooper&#39;s ligaments in the base of it we can see an angular margin so angular margins is everywhere there&#39;s a Cooper&#39;s ligament attached the cancer cancer likes to take the path of least resistance when it starts to invade our next feature that we&#39;re going to look for is micro lab ulation that can go along with either invasion or DCIS different ways that it can present you can have fingers of invasive tumor we can have intraductal components or actual cancer ization of the lobules if we look at the invasive fingers of tumor sort of an angular or also associated with the thick echogenic halo you can see right through here we&#39;ve got those areas and very similar to what we would call sort of speculation within that that those are the fingers of invasive tumor that will see with micro ovulation looking at my sole ovulation the DCIS components of the tumor are in this area here that are highlighted 85% of ductal cancer is in mixed invasion and DCIS the invasive cords tend to be more centrally located the DCIS tend to be more peripherally this is why it&#39;s very important when a lesion is biopsied that different areas of the lesions are biopsied and not all of them right through the same area if you&#39;ve got a sample back of just DCIS treatment for the patient is much different than they know that it is an invasive carcinoma so very important to take different samples through a lesion where the biopsy is performed the last part of micro ovulation is cancer ization of the lobules you can see here that we have actual the PDL you cancer within the lobby itself now depending upon the nuclear grade of the cancer your low nuclear grade lesions tend to have small micro ovulation your high grade lesions tend to have much larger micro lobule Asians also notice with your high grade lesion that you have enhanced through transmission that we can see behind the lesion very important to make sure once again that when you&#39;re looking at lesions this lesion may appear to be fairly well circumscribed but once we zoom up notice how you can see these little areas of micro lobulated so be sure to Mai&#39;s your image completely every time that you&#39;re looking at it the next feature worrisome for malignant so we&#39;re going to talk about is if a lesion is taller than wide so when it&#39;s taller in the anterior and posterior dimension versus the transverse dimension so finding that tends to be more with benign lesions or when the lesion is wider than tall seeing the fiber adenoma small cancers sometimes we will see growing in a taller than wide parent so here we&#39;ve got the wider than tall versus taller than wide tends to be more of a benign finding this tends to go along more with malignant findings now there are several theories as to why we see malignant nodules taller than white I can remember doing breast lectures about ten years ago and saying oh it&#39;s the growth of tissue planes cancer grows against a tissue plane the nine regions tend to grow with tissue planes some will say it&#39;s the lack of rotation within a fixed malignant nodule or they may say that it&#39;s only because we&#39;re measuring the central - it may be because being compressibility of malignant nodules but the real reason of why we see cancers taller than wide it reflects the axis of the orientation of a tdiu terminal ductal lobular unit in which a small cancer arose now you&#39;re saying okay Cindy what what did you just say that&#39;s sort of confusing I&#39;ll show you a diagram of what we&#39;re talking about so if we look at the ductal system and what we&#39;re going to do is take a cut right through this portion and now look at the short axis of that duct if you notice here is an anterior lobule this is a PDL you this is the extra log of a terminal duct coming into the main ductal system so if we&#39;re looking at anterior lobule so they have fairly long extra little ducks if you look at posterior lobules they have fairly short term el ducks so if we look at the patent wide spread of cancer where the yellow dot is is where cancer will start cancer takes to take the path of least resistance so if cancer starts to spread you can see that if it arises in an anterior lobby oh it&#39;s got a pretty good distance that it can grow before it hits the main ductal system and starts branching out and spreading if you have a cancer there rises in a posterior law bill there&#39;s a fairly short extra lobular terminal duct so when the cancer starts to invade or spread out it&#39;s going to hit the main deck toe fairly soon if you have a cancer that arises in a terminal law bill those cancers will never be taller than why they start out more in a transverse orientation to begin with so here are examples of small cancers all which arose in a PDL you here&#39;s a cancer that arose in a posterior lobby you can see it looks like a tennis racket with a handle up here&#39;s a small cancer that arose in an anterior lobby &#39;el and here&#39;s one that arose in a terminal lobule so these are all examples of small cancers that are taller than white if you notice they keep seeing small cancer one reason is this is a feature that we tend to see in smaller nodules we don&#39;t see it as often in large malignant nodules if a cancer is less than 10 millimeters we see this feature about 70% of the time once the cancer gets up to 2 centimeters we probably only see it about 12 to 15% of the time so it is something that tends to go along with smaller nodules the entire nodule does not have to be taller than wide but if any portion of the nodule is taller than white we will use that as one of the malignant findings the next feature we&#39;re going to talk about is duct extension this is when the cancer starts to grow back towards the nipple so you can see this cancer here and we&#39;ve got a fairly long segment of duct extending down it and this is very important as to why we want to make sure we scan in a radial plane Radio scanning is scanning the same way like spokes of a bicycle run is scanning in the ductal system if you lurk in a fairly large Breast Center and you have never seen decked extension like this it may be because you&#39;re imaging more in a transfer some longitudinal scan plane but very important to make sure that you do see direct extension if you&#39;ve ever been into the operating room one thing that you&#39;ll notice is when they go in and do a lumpectomy on a patient like this what they&#39;ll do is make sure that when they remove the tissue that they have at least a one centimeter clear margin all the way around the lesion now why the patient is still on the table they&#39;ll send the specimen either for a radiograph or send it to pathology and then they&#39;ll go ahead and start doing a sitting or mode procedure while the patient still on the table if they send it to pathology and the pathologist is on the ball what he&#39;ll do is say you don&#39;t have a free margin let the physician know what area tell the surgeon he&#39;ll go back in and take another cut of tissue if the pathologist notices is it still has got a margin that is not clear the surgeon goes back in and takes another sample of tissue and a patient who went under the knife thinking they&#39;re going to have a lumpectomy has now had so much breast tissue removed but they need to convert it to a mastectomies but what&#39;s even worse than that is that the physician or surgeon does the first initial cut and it&#39;s never detected that there was not a free margin and say five years later this patient may represent with quotes recurrent breast cancer the majority of recurrent breast cancer is breast cancer that was missed the first time now the next finding we&#39;re going to talk about is branch pattern branch pattern is just the opposite of duct extension so as soon as the cancer growing back towards the nipple it branches out away from it this is more of a soft finding we tend to see this more with DCIS but here you can see all these branches radiating out away from the nipple of cancer that has invaded and the main lesion is sitting in this area here depending upon the nuclear grade of the cancer if you have high nuclear grades you may see large juicy branches medium branches tend to go along with your intermediate grade and small branches tend to go along more with your low grade DCIS now if you find an isolated duct extension or branch pattern this indicates a benign intraductal papillary seven percent of the time but six the time RDI yes and another 7% can be in typical ductal hyperplasia so you cannot classify this as being a buyer has three we want to make sure that it were ninety-eight percent sure that it&#39;s going to be to call something a buyer reg 3 so having an isolated finding of duct extension or branch pattern tends to be benign majority of the time but still it&#39;s not enough to call it a buyer adds 3 B should be given at least a buyer adds for a and should be biopsied the next finding where I talk about is acoustic shadowing this is a hard finding when we see a crew stick shadowing typically we&#39;re dealing with an invasive carcinoma now depending upon the degree of desmo plays a is how much shadowing lee will see behind a lesion we may have a breast cancer that shadows entirely behind it or we may have a lesion that only has partial shadowing baha&#39;i it and it just once again depends upon the dismal plastic reaction that we&#39;ll see posterior to that lesion if we look at the histology grade versus sound transmission your low-grade ductal cancers invasive ductal carcinoma tend to have shadowing seen behind it high-grade invasive ductal cancers tend to have enhanced through transmission seen behind them we did a study looking at 409 solid malignant nodules and we could see acoustic shadowing either partial or complete 35 percent of the time normal sound transmission behind the lesion 32 percent of the time and enhanced through transmission about 28 percent of time and mixed findings 5 percent of the time so if you&#39;re looking for the presence of shadowing to call something a cancer you&#39;ll only be right about a third of the time cancer can present itself in any way that it wants either with normal sound transmission enhance sound transmission or shadowing dr. Stavros always called our high-grade lesions poor man&#39;s color Doppler so that if you did not have color you can just imagine the flow but the cancers that have the enhanced through transmission behind them are the ones are going to light up with color Doppler so we will see quite a bit of flow one other thing to note is anytime you&#39;re looking for the presence of blood flow in a lesion you want to make sure that you scan with very light pressure scanning with light pressure is when we will see flow if you&#39;re scanning with heavy pressure you can temporarily oblate all the flow so anytime you&#39;re looking for the presence of blood so make sure you scan with very light pressure now if we look at acoustic shadowing and enhance through transmission differential diagnosis that we&#39;ll see with those with our low-grade shadowing we&#39;re going to see low-grade invasive ductal cancer invasive lobular carcinoma also cause shadowing and tubular carcinomas once they&#39;re over one and a half centimeters inside enhanced through transmission we&#39;ll see with our high-grade invasive vessel cancers colloid carcinomas once they&#39;re over one and a half centimeters medullary and invasive papillary also have enhanced through transmission the next finding we&#39;re going to talk about our calcifications that tends to be more of a soft finding which will see with DCIS if you notice we can see these tiny little calcifications inside the solid nodule now a lot of times the calcifications that we see Mela graphically are within a duct you&#39;re saying your doctor may say to you I want you to go ahead and scan this patient and you&#39;re going but there&#39;s only calcifications ultrasound is not real good at we&#39;re picking up calcifications but what your doctor wants to do is see if there is any math associated with those calcifications if there&#39;s a mass associated with the calcifications it&#39;s going to be much easier to biopsy those with ultrasound guidance than it is stereotactic method but typically the calcification seen inside the depth we do not see with ultrasound the depth is echogenic the calcifications or echogenic we typically will only see ones when they are associated with a mass the next malignant finding where I talk about is markedly hypoechoic now we used to be in the old days we would see cancers that look just like this this is markedly hypo quote compared to the surrounding fat nowadays we don&#39;t tend to see cancers that are those dark and one reason is we&#39;re running with equipment that so much better than we had in the old days here&#39;s some more examples this is a cancer that is markedly hypo quo compared to the fat and one with intense shadowing that we can see is also markedly high poco compared to fat now looking why is it we don&#39;t see this feature as often as we used to we&#39;ll show you the same region scan the same day the only differences I changed the dynamic range here we have a dynamic range of 68 DB and then what I&#39;m going to do is actually increase my dynamic range to 90 dB notice here where we have a lesion that is markedly hypoechoic compared to the fat now this lesion is almost ISO Clos compared to that and the only thing I change with dynamic range are machines that we&#39;re using nowadays run with much wider dynamic range with broadband technology compound imaging things like this that help improve our image that we&#39;re just not seeing cancer as dark as we did before also if you notice we can see this area of central necrosis much better in the lesion running at 90 90 DB compared to the one at 69 dB I&#39;m not saying that we need to all drop our dynamic range way back and start scanning so that we&#39;ve got more contrast in the image but just be aware that we typically see lesions a lot more asically than we used to you may see some new what happens if I have a really bad day and I happen to miss one of those malignant findings the average breast cancer has 5.3 malignant features to it so even if you&#39;re having a bad day hopefully you&#39;ll be able to pick up at least one of those findings so once you search that solid lesion you&#39;ve looked for all those different malignant findings you&#39;ve not found any of them now what we have to do is prove that the lesion is benign what we have to do is find one of the three to be able to classify it as a bio rad 3 either markedly hypercolor tissue we want to see in elliptical shape and we will allow up to two to three gentle modulations now we need to make sure that that lesion is completely surrounded by a thin echogenic pseudo capsule so we&#39;ll talk about these purely hyper coat we can have a rigid normal fiber glandular tissue or an area just sort of fibrosis or normal tissue this showed up as a mammographic nodule so we knew it wasn&#39;t a lipoma sometimes like comas can appear to be echogenic like this in the subcutaneous fat but since it showed up on the mammogram this is just an area of fibrosis this is something we would consider purely hyper coat and nothing else needs to be done now looking at this lesion here this is not purely hyper Cooke there is a small lesion in the center of it that is isochoric so we would not classify that as being purely hyper colored tissue here&#39;s another finding this is one we would consider to be purely hyper a co ik and this is a patient that had just a palpable rigid normal fibre glandular tissue we would not be concerned with that if a patient presents with the palpable abnormality and this person came in in feeling that abnormality we could see that it was just this Ridge of normal fiber glandular tissue anytime we&#39;re going to tell a patient that something is normal tissue what we recommend is that they check that area once a month we told her to go back and have a clinician recheck this area in six months if anything was to change to have it reevaluated well the patient came back to our department four months later and we can see kind of within this gray area here which nobody could really make out a mass at the time this high-grade invasive ductal carcinoma kind of exploded that she had not felt previously so these high-grade lesions are very rapidly growing very important that if somebody&#39;s going to follow up what you think is normal tissue that they check that area at least once a month now when we look at ultrasound and we&#39;re comparing it to things on the mammogram we want to make sure that the size shape location and surrounding tissue all match up this lesion here was a 13 millimeter mammographic module we expect maybe a little bit of measurement error when we&#39;re comparing them on a fetus phonography but they should be pretty much the same you can see we have almost a 50% difference in that so our size was not matching up going back in and rechecking this particular patient what had happened was the technologist had dentist Canmore through this area the tissue creating this area of echogenicity and actually had missed these two small cancer sitting on top of each other and just sort of mistook this thick echogenic halo as being the mammographic nodule but your size shape location surrounding tissue should all match up if you have something that&#39;s 13 millimeters on the mammogram it should be pretty much the same size when you do the ultrasound looking at elliptical shape for our benign finding it be wonderful while fiber I do almost look like this but we know that they don&#39;t they tend to be more wider than tall or elliptical shape and almost looks like a little almond sitting in there but this is a classic fiber adenoma we will allow up to two to three gentle ovulations of fibroadenomas one other thing we want to make sure is that there is a nice thin capsule completely surrounding it so these are gently lobulated fibroadenomas and that is okay for calling it a by registry that means probably been mine one other feature that will allow for is what&#39;s called a teardrop shape where you&#39;ve got one edge of the fiber adenoma that comes to just a little point we don&#39;t consider this to be an angular margin but more of a tear drop shape fiber adenoma and that is something that we will allow for in calling fiber adenoma as already mentioned we want to make sure that either elliptical or gently lobulated structure also has a sin echogenic pseudo capsule surrounding it if you have compound imaging it makes it much easier to be able to see these two neckla genic capsules if the capsule surrounded by echogenic fiber glandular tissue it&#39;s a little bit more difficult to see the thin capsule surrounding that so much easier to see it if we are scanning against a fatty background just the normal scan pressure of your hand resting on the breast tissue sometimes is enough to compress that fiber glandular tissue up against the capsule so what I&#39;ll do real time is lighten up my pressure and you can see by scanning with lighter pressure we&#39;re able to actually see the capsule a lot better than we could with our normal scan pressure here so in looking at that another thing to be aware of once you lighten up your pressure to see the capsule better you may cause some artefactual shadowing and remember shadowing is a feature worrisome for malignancy so in real-time is just one thing you want to do is scan with normal pressure and lighten your pressure to be able to see the capsule a little bit better so you will need a combination of both heavy and light scanning plane the other thing is making sure that the capsule is complete all the way around the ends of a lesion you can see on this fiber adenoma here we can see the capsule very well on the anterior and posterior surface but we don&#39;t see it very well on the ends of the lesion so coming in and healing from this end you can see the capsule extending all the way around toeing from the other ends we can see the capsule come around that way is this something I take pictures of no it&#39;s just something that I&#39;ll make sure I do with skinning lesions real time any solid nodule that we have in our department our radiologist comes back in the room and talks to the patient so either all scan and show them this during real-time or something that if they&#39;re scanning they&#39;ll make sure that they can see the capsule extend all the way around the lesion now in a lecture once at the RSA and I heard this physician get up and present a paper and say well according to stavros&#39;s criteria this is a benign lesion because there&#39;s a thin echogenic pseudo capsule there is a thin capsule but this is obviously not a benign lesion there&#39;s micro lobule Asian&#39;s is very heterogeneous that we put on color Doppler you would see all kinds of flow within this this is a high-grade lesion high-grade lesions are very rapidly growing and we would expect to see a thin echogenic capsule if you look here on the specimen you can see how soon the capsule would be because those high-grade lesions grow very rapidly they are pushing their way through the tissue so anytime you see it&#39;s an echogenic capsule don&#39;t always assume the lesion is benign a lot of things you want to make sure there are no other features we&#39;ll reach them for malignancy that we&#39;ll see such in this particular lesion looking at our negative predictive value we have never seen a purely hyper occult cancer I&#39;d say about once a year we get a case it would come in something like this would be sent in by dr. Stavros and they would say look this is a purely hyper code cancer but is it look in the center there is a two millimeter hypoechoic central portion that we can see and then what we&#39;re noticing is just this thick epigenetic halo surrounding the lesion now one thing that might happen is you have a patient that presents something like this is a palpable lump you might think that this is just normal fiber glandular tissue right here but this is one centimeter across here we want to get this closer to the elevation plane focus where our transducer is focused so when we do that we want to use a standoff pad you can notice that once we use a standoff pad you can see these two small hyper coil cancers in this area of the thick echogenic halo that we got some volume averaging through here so be sure that you optimize your image completely if anything was within that first centimeter of the transducer use a standoff pad or a big glop of gel to make sure that you get the lesion closer to the elevation plane focus that you don&#39;t get volume averaging calling something purely hyper collect tissue now once I&#39;ve seen a suspicious lesion in the breast what I want to do is check the axilla I want to look at lymph nodes and see if there&#39;s anything suspicious in the axilla a normal lymph node looks just like a kidney here we can see in a long access view and a short access view these were zoomed up pretty large but looks just like a kidney this would be our prank amore the cortex and our fatty central hilum this is a transverse view that we can see that coming around one question I get is we know that the center of a lymph node is fat why is the fat on the lymph node more eco jannat compared to normal fat now what it is is the lymphatic channels running through that cause the fatty hilum to be more eco genic now there&#39;s a variation of normal that we can see within lymph nodes we can have the perfectly normal lymph node we can start to get thinning of the cortex just like what will see with kidneys and at times we may actually get fatty infiltration into a lymph node so here you can see this is the cortex this is the lymphatic portion of the fat that is more echogenic and this is fatty infiltration that we see within this lymph node this is perfectly normal the only time we get more concerned about lymph nodes is when the cortex itself is thick we&#39;re going to talk about lymphatic flow this is not the blood flow but this is how the lymph lymphatic system will flow it&#39;s from the subscapular sinusoidal cortical sinusoids and into the metal reso lymphatic flow is going to start from the outside of the lymph node and move in centrally and if we look at a foreign body it affects a lymph node differently foreign bodies are going to be from the medullary sinusoids out so if you have a patient that had a silicone implant that ruptured these are silicone granulomas within a lymph node here you can see the cortex right there is that tiny little hyper cook line where as is when we have a tumor metastasis to a lymph node that affects from the outside of the lymph node going in so the cortex is what will be thickened so the opposite for a foreign body versus metastasis foreign bodies or from medullary sinusoids out the caster&#39;s are from the kardec cortical sinusoids coming in now there&#39;s a range of abnormal sonographic appearances that we&#39;ll see with a lymph node in the center we have a perfectly normal lymph node then what we will notice is that sometimes you might see a lymph node we&#39;re just the cortex is thickened all the way around you may have it where you see dis portions of the cortex being thickened or abnormal you may have a lymph node that looks like there was a rat bite taken out of it new you may have ones where the cortex gets so sick that it compresses the fatty hilum centrally you may have it where it compresses the fatty hilum to the outside of the lymph node sometimes you may have a lymph node that just looks grossly abnormal almost like a round ball and at time some lymph nodes may even become very ragged and jagged and actually look just like a metastatic lesion itself now beware any of these types of appearances either this lymph node this lymph node or this one can go along with either metastasis or it could be an inflammatory process but if you&#39;re scanning the patient doing a breast ultrasound you see a suspicious lesion in the breast then you go scan the axilla most likely you&#39;re dealing with a metastatic lymph node sometimes we are asked to scan a patient because they present with a palpable abnormality in the axilla if that&#39;s the case and you see the appearance of any of these types of lymph nodes the patient definitely needs to have a breast workup to make sure that there is not a breast lesion causing it but if you see multiple abnormal lymph nodes it possibly could be an inflammatory process and not a metastatic if you start looking in the axilla to begin with now one thing that we have found is anytime we see a grossly abnormal lymph node sitting next to normal lymph node that&#39;s pretty much a malignant lymph node here&#39;s another example here&#39;s a grossly abnormal lymph node sitting right next to a normal lymph node and another one grossly abnormal lymph node sitting next to one that&#39;s probably a little bit too thick within that cortex so this is also an abnormal no but if you have metastases you may find this type of pattern if you have an inflammatory condition or inflammation typically that&#39;s going to affect the whole range or the whole region of lymph nodes in that and not just one so if you see one abnormal next to normal that will typically be a metastatic lymph node what we&#39;ll do on the case if we do see these lymph nodes we will go ahead and biopsy them if it&#39;s proven to be a metastatic lymph node then the patient does not need to go for a sentinel node procedure they can go straight to an axillary dissection so seeing these types of abnormal lymph nodes can be very helpful but once you guys all understand breast sonography you&#39;ll love it and watch out for those speed humps thank you

[Music] hi I&amp;#39;m Cindy Rath I am from the University of Colorado Hospital in Denver Colorado today I&amp;#39;ll be talking about solid nodules how to differentiate the nine vs. malignant lesions solid breast nodules benign versus malignant if we look at the type of cancers that we see with ultrasound the number one cancer that will diagnosed is invasive ductal carcinoma you can see the second most common is invasive lobular we also have medullary mucinous DCIS and other types and metastasis das is much more common in the mammographic role but with ultrasound we typically will find invasive ductal cancer most often now just the opposite of our judicial system with breast filmography what we want to do when we find a solid lesion is think of it as being something worrisome so the first thing we&amp;#39;re going to do is seek malignant findings once you have looked for malignant findings and you haven&amp;#39;t seen any then what you want to do is make sure you can classify the lesion as being benign if you cannot classify it as being benign then we have to classify it as indeterminate and if it&amp;#39;s indeterminate it&amp;#39;s recommended for a biopsy breast cancer is extremely heterogeneous it&amp;#39;s very important to make sure that you scan the entire nodule in two planes looking for any subtle changes that you might see if you happen to find a mixture of benign and malignant findings it will exclude the lesion from being benign and classify it as being something worrisome for malignancy and I already mentioned the heterogeneity of breast cancer not only from nodule to nodule but often within a single module we&amp;#39;ll see very heterogeneous findings we look at this chart you can see the heterogeneity of breast cancer we&amp;#39;ve got one in the spectrum where we&amp;#39;ll have lesions that are very well circumscribed on those will see regions that are extremely cellular you may have high-grade lesions once with an inflammatory reaction enhance through transmission these are ones that are pop are positive on color Doppler on the opposite end of the spectrum we have our speculated lesions they tend to be more positive cellular their low-grade cancers they host a dismal plastic reaction will see shadowing behind those these are typically negative with color Doppler and because of the heterogeneity of breast cancer often we have a mixture between these two findings that we&amp;#39;ll see within a single lesion looking at solid nodules the complex spectrum of the growth morphology we can see lesions that are fairly well circumscribed that are malignant and then we have lesions such as five Brad nomas that can be extremely worrisome looking especially you&amp;#39;re scanning a young teenage patient more often in black females they can have what are called juvenile five Brad nomás those look very worrisome simha graphically and then we have things such as radial scars that present a speculated lesions that we really won&amp;#39;t talk about much today now if people sometimes think that we should not use ultrasound to try and differentiate benign versus malignant lesions they say if you took a single finding you can see such as shadowing how many fibroadenomas that we could prevent a biopsy and the area of green but you can see how many false negatives that we would have in the area in red but with ultrasound we don&amp;#39;t take this to single finding we take multiple findings we apply basically the same algorithm that we do with mammography and what we&amp;#39;re able to do by doing this is get our false negative rate less than 2% which is pretty much the gold standard for mammography so with ultrasound and using these multiple features were able to get our false negative rate of less than 2% these are the different things that we will talk about features of breast cancer we can look at speculation angular margins and acoustic shadowing these are what I call hard findings they tend to go along with an invasive process more nonspecific findings in other words can go along with either invasion or DCIS or micro lab relation taller than wide and looking at the echo jinnah City of the lesion we compare all lesions in the breast to fat so if I say a lesion is hypoechoic that means it is darker than fat more soft findings that tend to go with DCIS or things such as duct extension branch pattern and calcifications so the first feature that we&amp;#39;ll look at are speculations this is more of a hard finding now depending upon the background of the tissue surrounding the lesion we may see hypoechoic spicules if there is an echogenic more of a fiber glandular background we will notice hypoechoic spicules if the lesion is surrounded by fat the speculations that we&amp;#39;ll see will tend to be more echogenic these are the ones that show up mammogram quickly because we&amp;#39;ve got a fatty background so on mammogram we can see those type of speculations if we look at the image on the left here in this particular breast cancer we have an area duct extension this cancer is also taller than it is wide through this portion and here you can see these high poco spicules radiating out because there is an echogenic background you also notice that there&amp;#39;s a smaller cancer sitting right here a multifocal lesion if we notice the image on the right these are more eco genic speculations that we can see radiating out because there is a fatty background so since we have a fatty background we can see echogenic speculations versus the hypoechoic ones when we have the bright background because of the heterogeneity of breast cancer sometimes only a certain surface of the lesion may have speculations and here we can see speculations on the anterior surface and appears a little bit more like thick halo around the lateral side of it why is it sometimes that we see echogenic versus hypoechoic speculations actually we have both of them present and typically the background tissue will alternate or will eliminate one of those so if you notice here is the actual spicule which is more hypoechoic which is we&amp;#39;re seeing here on this pathology specimen the speculation the interface between one spicule and the other is more of the echogenic background so this is a nice example of being able to demonstrate both hypo and hyper acute speculations and typically we&amp;#39;ll only see one of those when we do our imaging one thing that&amp;#39;s very important when you are looking at a lesion make sure that you optimize the image completely when you first start scanning you want to make sure you take a picture that you can see all the way from skin surface down to the chest wall but once you&amp;#39;re ready to look at that look at the surface characteristics of this lesion make sure that you do MUP and here you can see these speculations much better on a zoomed image so optimize your image completely when you&amp;#39;re looking at it a variation of speculations are what we refer to as the thick echogenic halo that you can see surrounding this lesion now one thing that we&amp;#39;ll notice is the thick echogenic halo a lot of times will appear to be thicker on the edges than it is on the anterior post to your surface so usually it&amp;#39;s sticking around the anterior-posterior I&amp;#39;m sorry thicker on the edges and it is anterior and posterior Li this is the same lesion that was scanned the same day the only difference is that we can see this image on the left was done on a mid-range ultrasound equipment versus scanning it on a high-end equipment so what appears to be a sick echogenic a low seen here are actually individual spicules that we can see radiating out once we used our high-end equipment I think both of the systems will show that this is a lesion that needs to have a biopsy exist if you&amp;#39;re using high-end equipment you can make your diagnosis with a lot more confidence I think using high-end equipment now the next finding we&amp;#39;re going to talk about our angular margins angular margins are a hard finding so if we see this we typically are dealing with an invasive carcinoma you can see this lesion here all the multiple angular margins that were able to demonstrate also notice that this lesion is markedly high poco compared to the fat there&amp;#39;s some areas of calcification with it there&amp;#39;s enhanced through transmission behind it so most malignant lesions have multiple features that we will be able to see in evaluating them because of the heterogeneity of breast cancer it&amp;#39;s very important to make sure that you scan a lesion all the way through and two planes don&amp;#39;t just take one random cut transverse through here and another one longitudinal through this plane or you will miss the angular margin seen here or the Micro ovulation seen in this area so very important to make sure you scan all the way through and look for these subtle little changes that we might see on ultrasound looking at this cancer that we can see I&amp;#39;m going to show you a dotted line and a dashed line right through the cancer that&amp;#39;s just about a centimeter apart from each other notice on this image on the right right through this area how well circumscribed this lesion can appear where is it cut just about a centimeter away there are obviously malignant features angular margins and shadowing that we can see that&amp;#39;s just showing you or demonstrating the amount of heterogeneity that we can see within a single module now in looking at breast cancer cancer likes to take the path of least resistance so as the cancer becomes invasive and starts to spread a lot of times what they&amp;#39;ll do is when it hits up against this and too a premium a fascial layer the anterior pre memory facial layer comes along wherever there&amp;#39;s a Cooper&amp;#39;s ligament it goes up attaches at the skin and comes back down so if cancer starts and hits up against that pre memory facial layer a lot of times it will start invading up through Cooper&amp;#39;s ligaments and one thing we learned is if we&amp;#39;re looking for subtle changes on cancers that are fairly well circumscribed it&amp;#39;s looking to the area of a Cooper&amp;#39;s ligament and that is where we&amp;#39;ll be able to find these little angular margins right in that area they tend to invade Cooper&amp;#39;s ligaments so looking at this cancer one thing you&amp;#39;ll notice is wherever we have a Cooper&amp;#39;s ligaments in the base of it we can see an angular margin so angular margins is everywhere there&amp;#39;s a Cooper&amp;#39;s ligament attached the cancer cancer likes to take the path of least resistance when it starts to invade our next feature that we&amp;#39;re going to look for is micro lab ulation that can go along with either invasion or DCIS different ways that it can present you can have fingers of invasive tumor we can have intraductal components or actual cancer ization of the lobules if we look at the invasive fingers of tumor sort of an angular or also associated with the thick echogenic halo you can see right through here we&amp;#39;ve got those areas and very similar to what we would call sort of speculation within that that those are the fingers of invasive tumor that will see with micro ovulation looking at my sole ovulation the DCIS components of the tumor are in this area here that are highlighted 85% of ductal cancer is in mixed invasion and DCIS the invasive cords tend to be more centrally located the DCIS tend to be more peripherally this is why it&amp;#39;s very important when a lesion is biopsied that different areas of the lesions are biopsied and not all of them right through the same area if you&amp;#39;ve got a sample back of just DCIS treatment for the patient is much different than they know that it is an invasive carcinoma so very important to take different samples through a lesion where the biopsy is performed the last part of micro ovulation is cancer ization of the lobules you can see here that we have actual the PDL you cancer within the lobby itself now depending upon the nuclear grade of the cancer your low nuclear grade lesions tend to have small micro ovulation your high grade lesions tend to have much larger micro lobule Asians also notice with your high grade lesion that you have enhanced through transmission that we can see behind the lesion very important to make sure once again that when you&amp;#39;re looking at lesions this lesion may appear to be fairly well circumscribed but once we zoom up notice how you can see these little areas of micro lobulated so be sure to Mai&amp;#39;s your image completely every time that you&amp;#39;re looking at it the next feature worrisome for malignant so we&amp;#39;re going to talk about is if a lesion is taller than wide so when it&amp;#39;s taller in the anterior and posterior dimension versus the transverse dimension so finding that tends to be more with benign lesions or when the lesion is wider than tall seeing the fiber adenoma small cancers sometimes we will see growing in a taller than wide parent so here we&amp;#39;ve got the wider than tall versus taller than wide tends to be more of a benign finding this tends to go along more with malignant findings now there are several theories as to why we see malignant nodules taller than white I can remember doing breast lectures about ten years ago and saying oh it&amp;#39;s the growth of tissue planes cancer grows against a tissue plane the nine regions tend to grow with tissue planes some will say it&amp;#39;s the lack of rotation within a fixed malignant nodule or they may say that it&amp;#39;s only because we&amp;#39;re measuring the central - it may be because being compressibility of malignant nodules but the real reason of why we see cancers taller than wide it reflects the axis of the orientation of a tdiu terminal ductal lobular unit in which a small cancer arose now you&amp;#39;re saying okay Cindy what what did you just say that&amp;#39;s sort of confusing I&amp;#39;ll show you a diagram of what we&amp;#39;re talking about so if we look at the ductal system and what we&amp;#39;re going to do is take a cut right through this portion and now look at the short axis of that duct if you notice here is an anterior lobule this is a PDL you this is the extra log of a terminal duct coming into the main ductal system so if we&amp;#39;re looking at anterior lobule so they have fairly long extra little ducks if you look at posterior lobules they have fairly short term el ducks so if we look at the patent wide spread of cancer where the yellow dot is is where cancer will start cancer takes to take the path of least resistance so if cancer starts to spread you can see that if it arises in an anterior lobby oh it&amp;#39;s got a pretty good distance that it can grow before it hits the main ductal system and starts branching out and spreading if you have a cancer there rises in a posterior law bill there&amp;#39;s a fairly short extra lobular terminal duct so when the cancer starts to invade or spread out it&amp;#39;s going to hit the main deck toe fairly soon if you have a cancer that arises in a terminal law bill those cancers will never be taller than why they start out more in a transverse orientation to begin with so here are examples of small cancers all which arose in a PDL you here&amp;#39;s a cancer that arose in a posterior lobby you can see it looks like a tennis racket with a handle up here&amp;#39;s a small cancer that arose in an anterior lobby &amp;#39;el and here&amp;#39;s one that arose in a terminal lobule so these are all examples of small cancers that are taller than white if you notice they keep seeing small cancer one reason is this is a feature that we tend to see in smaller nodules we don&amp;#39;t see it as often in large malignant nodules if a cancer is less than 10 millimeters we see this feature about 70% of the time once the cancer gets up to 2 centimeters we probably only see it about 12 to 15% of the time so it is something that tends to go along with smaller nodules the entire nodule does not have to be taller than wide but if any portion of the nodule is taller than white we will use that as one of the malignant findings the next feature we&amp;#39;re going to talk about is duct extension this is when the cancer starts to grow back towards the nipple so you can see this cancer here and we&amp;#39;ve got a fairly long segment of duct extending down it and this is very important as to why we want to make sure we scan in a radial plane Radio scanning is scanning the same way like spokes of a bicycle run is scanning in the ductal system if you lurk in a fairly large Breast Center and you have never seen decked extension like this it may be because you&amp;#39;re imaging more in a transfer some longitudinal scan plane but very important to make sure that you do see direct extension if you&amp;#39;ve ever been into the operating room one thing that you&amp;#39;ll notice is when they go in and do a lumpectomy on a patient like this what they&amp;#39;ll do is make sure that when they remove the tissue that they have at least a one centimeter clear margin all the way around the lesion now why the patient is still on the table they&amp;#39;ll send the specimen either for a radiograph or send it to pathology and then they&amp;#39;ll go ahead and start doing a sitting or mode procedure while the patient still on the table if they send it to pathology and the pathologist is on the ball what he&amp;#39;ll do is say you don&amp;#39;t have a free margin let the physician know what area tell the surgeon he&amp;#39;ll go back in and take another cut of tissue if the pathologist notices is it still has got a margin that is not clear the surgeon goes back in and takes another sample of tissue and a patient who went under the knife thinking they&amp;#39;re going to have a lumpectomy has now had so much breast tissue removed but they need to convert it to a mastectomies but what&amp;#39;s even worse than that is that the physician or surgeon does the first initial cut and it&amp;#39;s never detected that there was not a free margin and say five years later this patient may represent with quotes recurrent breast cancer the majority of recurrent breast cancer is breast cancer that was missed the first time now the next finding we&amp;#39;re going to talk about is branch pattern branch pattern is just the opposite of duct extension so as soon as the cancer growing back towards the nipple it branches out away from it this is more of a soft finding we tend to see this more with DCIS but here you can see all these branches radiating out away from the nipple of cancer that has invaded and the main lesion is sitting in this area here depending upon the nuclear grade of the cancer if you have high nuclear grades you may see large juicy branches medium branches tend to go along with your intermediate grade and small branches tend to go along more with your low grade DCIS now if you find an isolated duct extension or branch pattern this indicates a benign intraductal papillary seven percent of the time but six the time RDI yes and another 7% can be in typical ductal hyperplasia so you cannot classify this as being a buyer has three we want to make sure that it were ninety-eight percent sure that it&amp;#39;s going to be to call something a buyer reg 3 so having an isolated finding of duct extension or branch pattern tends to be benign majority of the time but still it&amp;#39;s not enough to call it a buyer adds 3 B should be given at least a buyer adds for a and should be biopsied the next finding where I talk about is acoustic shadowing this is a hard finding when we see a crew stick shadowing typically we&amp;#39;re dealing with an invasive carcinoma now depending upon the degree of desmo plays a is how much shadowing lee will see behind a lesion we may have a breast cancer that shadows entirely behind it or we may have a lesion that only has partial shadowing baha&amp;#39;i it and it just once again depends upon the dismal plastic reaction that we&amp;#39;ll see posterior to that lesion if we look at the histology grade versus sound transmission your low-grade ductal cancers invasive ductal carcinoma tend to have shadowing seen behind it high-grade invasive ductal cancers tend to have enhanced through transmission seen behind them we did a study looking at 409 solid malignant nodules and we could see acoustic shadowing either partial or complete 35 percent of the time normal sound transmission behind the lesion 32 percent of the time and enhanced through transmission about 28 percent of time and mixed findings 5 percent of the time so if you&amp;#39;re looking for the presence of shadowing to call something a cancer you&amp;#39;ll only be right about a third of the time cancer can present itself in any way that it wants either with normal sound transmission enhance sound transmission or shadowing dr. Stavros always called our high-grade lesions poor man&amp;#39;s color Doppler so that if you did not have color you can just imagine the flow but the cancers that have the enhanced through transmission behind them are the ones are going to light up with color Doppler so we will see quite a bit of flow one other thing to note is anytime you&amp;#39;re looking for the presence of blood flow in a lesion you want to make sure that you scan with very light pressure scanning with light pressure is when we will see flow if you&amp;#39;re scanning with heavy pressure you can temporarily oblate all the flow so anytime you&amp;#39;re looking for the presence of blood so make sure you scan with very light pressure now if we look at acoustic shadowing and enhance through transmission differential diagnosis that we&amp;#39;ll see with those with our low-grade shadowing we&amp;#39;re going to see low-grade invasive ductal cancer invasive lobular carcinoma also cause shadowing and tubular carcinomas once they&amp;#39;re over one and a half centimeters inside enhanced through transmission we&amp;#39;ll see with our high-grade invasive vessel cancers colloid carcinomas once they&amp;#39;re over one and a half centimeters medullary and invasive papillary also have enhanced through transmission the next finding we&amp;#39;re going to talk about our calcifications that tends to be more of a soft finding which will see with DCIS if you notice we can see these tiny little calcifications inside the solid nodule now a lot of times the calcifications that we see Mela graphically are within a duct you&amp;#39;re saying your doctor may say to you I want you to go ahead and scan this patient and you&amp;#39;re going but there&amp;#39;s only calcifications ultrasound is not real good at we&amp;#39;re picking up calcifications but what your doctor wants to do is see if there is any math associated with those calcifications if there&amp;#39;s a mass associated with the calcifications it&amp;#39;s going to be much easier to biopsy those with ultrasound guidance than it is stereotactic method but typically the calcification seen inside the depth we do not see with ultrasound the depth is echogenic the calcifications or echogenic we typically will only see ones when they are associated with a mass the next malignant finding where I talk about is markedly hypoechoic now we used to be in the old days we would see cancers that look just like this this is markedly hypo quote compared to the surrounding fat nowadays we don&amp;#39;t tend to see cancers that are those dark and one reason is we&amp;#39;re running with equipment that so much better than we had in the old days here&amp;#39;s some more examples this is a cancer that is markedly hypo quo compared to the fat and one with intense shadowing that we can see is also markedly high poco compared to fat now looking why is it we don&amp;#39;t see this feature as often as we used to we&amp;#39;ll show you the same region scan the same day the only differences I changed the dynamic range here we have a dynamic range of 68 DB and then what I&amp;#39;m going to do is actually increase my dynamic range to 90 dB notice here where we have a lesion that is markedly hypoechoic compared to the fat now this lesion is almost ISO Clos compared to that and the only thing I change with dynamic range are machines that we&amp;#39;re using nowadays run with much wider dynamic range with broadband technology compound imaging things like this that help improve our image that we&amp;#39;re just not seeing cancer as dark as we did before also if you notice we can see this area of central necrosis much better in the lesion running at 90 90 DB compared to the one at 69 dB I&amp;#39;m not saying that we need to all drop our dynamic range way back and start scanning so that we&amp;#39;ve got more contrast in the image but just be aware that we typically see lesions a lot more asically than we used to you may see some new what happens if I have a really bad day and I happen to miss one of those malignant findings the average breast cancer has 5.3 malignant features to it so even if you&amp;#39;re having a bad day hopefully you&amp;#39;ll be able to pick up at least one of those findings so once you search that solid lesion you&amp;#39;ve looked for all those different malignant findings you&amp;#39;ve not found any of them now what we have to do is prove that the lesion is benign what we have to do is find one of the three to be able to classify it as a bio rad 3 either markedly hypercolor tissue we want to see in elliptical shape and we will allow up to two to three gentle modulations now we need to make sure that that lesion is completely surrounded by a thin echogenic pseudo capsule so we&amp;#39;ll talk about these purely hyper coat we can have a rigid normal fiber glandular tissue or an area just sort of fibrosis or normal tissue this showed up as a mammographic nodule so we knew it wasn&amp;#39;t a lipoma sometimes like comas can appear to be echogenic like this in the subcutaneous fat but since it showed up on the mammogram this is just an area of fibrosis this is something we would consider purely hyper coat and nothing else needs to be done now looking at this lesion here this is not purely hyper Cooke there is a small lesion in the center of it that is isochoric so we would not classify that as being purely hyper colored tissue here&amp;#39;s another finding this is one we would consider to be purely hyper a co ik and this is a patient that had just a palpable rigid normal fibre glandular tissue we would not be concerned with that if a patient presents with the palpable abnormality and this person came in in feeling that abnormality we could see that it was just this Ridge of normal fiber glandular tissue anytime we&amp;#39;re going to tell a patient that something is normal tissue what we recommend is that they check that area once a month we told her to go back and have a clinician recheck this area in six months if anything was to change to have it reevaluated well the patient came back to our department four months later and we can see kind of within this gray area here which nobody could really make out a mass at the time this high-grade invasive ductal carcinoma kind of exploded that she had not felt previously so these high-grade lesions are very rapidly growing very important that if somebody&amp;#39;s going to follow up what you think is normal tissue that they check that area at least once a month now when we look at ultrasound and we&amp;#39;re comparing it to things on the mammogram we want to make sure that the size shape location and surrounding tissue all match up this lesion here was a 13 millimeter mammographic module we expect maybe a little bit of measurement error when we&amp;#39;re comparing them on a fetus phonography but they should be pretty much the same you can see we have almost a 50% difference in that so our size was not matching up going back in and rechecking this particular patient what had happened was the technologist had dentist Canmore through this area the tissue creating this area of echogenicity and actually had missed these two small cancer sitting on top of each other and just sort of mistook this thick echogenic halo as being the mammographic nodule but your size shape location surrounding tissue should all match up if you have something that&amp;#39;s 13 millimeters on the mammogram it should be pretty much the same size when you do the ultrasound looking at elliptical shape for our benign finding it be wonderful while fiber I do almost look like this but we know that they don&amp;#39;t they tend to be more wider than tall or elliptical shape and almost looks like a little almond sitting in there but this is a classic fiber adenoma we will allow up to two to three gentle ovulations of fibroadenomas one other thing we want to make sure is that there is a nice thin capsule completely surrounding it so these are gently lobulated fibroadenomas and that is okay for calling it a by registry that means probably been mine one other feature that will allow for is what&amp;#39;s called a teardrop shape where you&amp;#39;ve got one edge of the fiber adenoma that comes to just a little point we don&amp;#39;t consider this to be an angular margin but more of a tear drop shape fiber adenoma and that is something that we will allow for in calling fiber adenoma as already mentioned we want to make sure that either elliptical or gently lobulated structure also has a sin echogenic pseudo capsule surrounding it if you have compound imaging it makes it much easier to be able to see these two neckla genic capsules if the capsule surrounded by echogenic fiber glandular tissue it&amp;#39;s a little bit more difficult to see the thin capsule surrounding that so much easier to see it if we are scanning against a fatty background just the normal scan pressure of your hand resting on the breast tissue sometimes is enough to compress that fiber glandular tissue up against the capsule so what I&amp;#39;ll do real time is lighten up my pressure and you can see by scanning with lighter pressure we&amp;#39;re able to actually see the capsule a lot better than we could with our normal scan pressure here so in looking at that another thing to be aware of once you lighten up your pressure to see the capsule better you may cause some artefactual shadowing and remember shadowing is a feature worrisome for malignancy so in real-time is just one thing you want to do is scan with normal pressure and lighten your pressure to be able to see the capsule a little bit better so you will need a combination of both heavy and light scanning plane the other thing is making sure that the capsule is complete all the way around the ends of a lesion you can see on this fiber adenoma here we can see the capsule very well on the anterior and posterior surface but we don&amp;#39;t see it very well on the ends of the lesion so coming in and healing from this end you can see the capsule extending all the way around toeing from the other ends we can see the capsule come around that way is this something I take pictures of no it&amp;#39;s just something that I&amp;#39;ll make sure I do with skinning lesions real time any solid nodule that we have in our department our radiologist comes back in the room and talks to the patient so either all scan and show them this during real-time or something that if they&amp;#39;re scanning they&amp;#39;ll make sure that they can see the capsule extend all the way around the lesion now in a lecture once at the RSA and I heard this physician get up and present a paper and say well according to stavros&amp;#39;s criteria this is a benign lesion because there&amp;#39;s a thin echogenic pseudo capsule there is a thin capsule but this is obviously not a benign lesion there&amp;#39;s micro lobule Asian&amp;#39;s is very heterogeneous that we put on color Doppler you would see all kinds of flow within this this is a high-grade lesion high-grade lesions are very rapidly growing and we would expect to see a thin echogenic capsule if you look here on the specimen you can see how soon the capsule would be because those high-grade lesions grow very rapidly they are pushing their way through the tissue so anytime you see it&amp;#39;s an echogenic capsule don&amp;#39;t always assume the lesion is benign a lot of things you want to make sure there are no other features we&amp;#39;ll reach them for malignancy that we&amp;#39;ll see such in this particular lesion looking at our negative predictive value we have never seen a purely hyper occult cancer I&amp;#39;d say about once a year we get a case it would come in something like this would be sent in by dr. Stavros and they would say look this is a purely hyper code cancer but is it look in the center there is a two millimeter hypoechoic central portion that we can see and then what we&amp;#39;re noticing is just this thick epigenetic halo surrounding the lesion now one thing that might happen is you have a patient that presents something like this is a palpable lump you might think that this is just normal fiber glandular tissue right here but this is one centimeter across here we want to get this closer to the elevation plane focus where our transducer is focused so when we do that we want to use a standoff pad you can notice that once we use a standoff pad you can see these two small hyper coil cancers in this area of the thick echogenic halo that we got some volume averaging through here so be sure that you optimize your image completely if anything was within that first centimeter of the transducer use a standoff pad or a big glop of gel to make sure that you get the lesion closer to the elevation plane focus that you don&amp;#39;t get volume averaging calling something purely hyper collect tissue now once I&amp;#39;ve seen a suspicious lesion in the breast what I want to do is check the axilla I want to look at lymph nodes and see if there&amp;#39;s anything suspicious in the axilla a normal lymph node looks just like a kidney here we can see in a long access view and a short access view these were zoomed up pretty large but looks just like a kidney this would be our prank amore the cortex and our fatty central hilum this is a transverse view that we can see that coming around one question I get is we know that the center of a lymph node is fat why is the fat on the lymph node more eco jannat compared to normal fat now what it is is the lymphatic channels running through that cause the fatty hilum to be more eco genic now there&amp;#39;s a variation of normal that we can see within lymph nodes we can have the perfectly normal lymph node we can start to get thinning of the cortex just like what will see with kidneys and at times we may actually get fatty infiltration into a lymph node so here you can see this is the cortex this is the lymphatic portion of the fat that is more echogenic and this is fatty infiltration that we see within this lymph node this is perfectly normal the only time we get more concerned about lymph nodes is when the cortex itself is thick we&amp;#39;re going to talk about lymphatic flow this is not the blood flow but this is how the lymph lymphatic system will flow it&amp;#39;s from the subscapular sinusoidal cortical sinusoids and into the metal reso lymphatic flow is going to start from the outside of the lymph node and move in centrally and if we look at a foreign body it affects a lymph node differently foreign bodies are going to be from the medullary sinusoids out so if you have a patient that had a silicone implant that ruptured these are silicone granulomas within a lymph node here you can see the cortex right there is that tiny little hyper cook line where as is when we have a tumor metastasis to a lymph node that affects from the outside of the lymph node going in so the cortex is what will be thickened so the opposite for a foreign body versus metastasis foreign bodies or from medullary sinusoids out the caster&amp;#39;s are from the kardec cortical sinusoids coming in now there&amp;#39;s a range of abnormal sonographic appearances that we&amp;#39;ll see with a lymph node in the center we have a perfectly normal lymph node then what we will notice is that sometimes you might see a lymph node we&amp;#39;re just the cortex is thickened all the way around you may have it where you see dis portions of the cortex being thickened or abnormal you may have a lymph node that looks like there was a rat bite taken out of it new you may have ones where the cortex gets so sick that it compresses the fatty hilum centrally you may have it where it compresses the fatty hilum to the outside of the lymph node sometimes you may have a lymph node that just looks grossly abnormal almost like a round ball and at time some lymph nodes may even become very ragged and jagged and actually look just like a metastatic lesion itself now beware any of these types of appearances either this lymph node this lymph node or this one can go along with either metastasis or it could be an inflammatory process but if you&amp;#39;re scanning the patient doing a breast ultrasound you see a suspicious lesion in the breast then you go scan the axilla most likely you&amp;#39;re dealing with a metastatic lymph node sometimes we are asked to scan a patient because they present with a palpable abnormality in the axilla if that&amp;#39;s the case and you see the appearance of any of these types of lymph nodes the patient definitely needs to have a breast workup to make sure that there is not a breast lesion causing it but if you see multiple abnormal lymph nodes it possibly could be an inflammatory process and not a metastatic if you start looking in the axilla to begin with now one thing that we have found is anytime we see a grossly abnormal lymph node sitting next to normal lymph node that&amp;#39;s pretty much a malignant lymph node here&amp;#39;s another example here&amp;#39;s a grossly abnormal lymph node sitting right next to a normal lymph node and another one grossly abnormal lymph node sitting next to one that&amp;#39;s probably a little bit too thick within that cortex so this is also an abnormal no but if you have metastases you may find this type of pattern if you have an inflammatory condition or inflammation typically that&amp;#39;s going to affect the whole range or the whole region of lymph nodes in that and not just one so if you see one abnormal next to normal that will typically be a metastatic lymph node what we&amp;#39;ll do on the case if we do see these lymph nodes we will go ahead and biopsy them if it&amp;#39;s proven to be a metastatic lymph node then the patient does not need to go for a sentinel node procedure they can go straight to an axillary dissection so seeing these types of abnormal lymph nodes can be very helpful but once you guys all understand breast sonography you&amp;#39;ll love it and watch out for those speed humps thank you

Transcript for:Solid Breast Nodules: Benign vs. Malignant

Transcript for:
Solid Breast Nodules: Benign vs. Malignant