Solid Masses - Thomas Jefferson University
Transcript of Solid Masses - Thomas Jefferson University
4/13/2021
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Sonographic Evaluation of Solid
Breast Masses
ANNINA N. WILKES MD
History
Solid Breast Nodules: Use of Sonography to Distinguish between Benign and Malignant lesions
A T Stavros, D Thickman, C L Rapp, M A Dennis, S H Parker, and G A Sisney Radiology 1995
Ultrasound as a Complement to Mammography and Breast Examination to Characterize Breast Masses
Kenneth J.W Taylor, Christopher Merritt ,Catherine Piccoli, Robert Schmidt,Glenn Rouse, Bruno Fornage, Eva Rubin, Dianne Georgian-Smith,Fred Winsberg,,Barry Goldberg ,Ellen Mendelson, Radiology 2002
Characterizing Breast Lesions Using Quantitative Parametric 3D Subharmonic Imaging: A Multicenter Study
Anush Sridharan 1, John R Eisenbrey 2, Maria Stanczak 2, Priscilla Machado 2, Daniel A Merton 2, Annina Wilkes 2, Alexander Sevrukov 2, Haydee Ojeda-Fournier 3, Robert F Mattrey 3, Kirk Wallace 4, Flemming Forsberg 5 AcadRadiol. 2020
A Prospective Study of Automated Breast Ultrasound Screening of Women with Dense Breasts in a Digital Breast Tomosynthesis-based Practice
Denise M Chough, MD, Wendie A Berg, MD, PhD, Andriy I Bandos, PhD, Grace Y Rathfon, MD, Christiane M Hakim, MD, Amy H Lu, MD, Terri-Ann Gizienski, MD, Marie A Ganott, MD, David Gur, ScD Journal of Breast Imaging, Volume 2, Issue 2, March/April 2020, Pages 125–133
Computer-aided Diagnosis System for Breast Ultrasound Images Using Deep Learning
Hiroki Tanaka1,4, Shih-Wei Chiu1, Takanori Watanabe2, Setsuko Kaoku3 and Takuhiro Yamaguchi1 5 December 2019 • © 2019 Institute of Physics and Engineering in MedicinePhysics in Medicine & Biology, Volume 64, Number 23
History
Sonography can accurately classify solid lesions as benign, allowing
imaging follow up rather than biopsy
NPV 99.5% ( when something has benign characteristics, it is)
Sensitivity of 98.4% ( when something has malignant characteristics,
it is)
BIRADS
1 Negative
2 Benign
3 Probably Benign <2%
4 Suspicious. 2-95%
4a low suspicion 2-10%
4b moderate suspicion 10-50%
4c high suspicion 50-95%
5 Highly Suggestive of Malignancy
Benign – BIRADS 2
intramammary lymph nodes
lipomas
fat necrosis
post surgical scar
trauma - bruise
fibroadenolipoma/hamartoma
probable fibroadenomas that have been stable for
at least 2 years or have characteristic calcifications
associated on mammo
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lymph nodes lipoma
trauma bruise/hemorrhage
fat necrosis Post surgical scar
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fibroadenolipoma/hamartoma
silicone
Probably benign BIRADS 3
Benign characteristics of solid masses
circumscribed margins
oval/elliptical shape
parallel orientation ( wider than tall)
less than 3 gentle lobulations
thin echogenic pseudo capsule
iso or hypoechoic to fat
Probably Benign- BIRADS 3
Combination of benign characteristics
ABSENCE OF MALIGNANT FEATURES
Periodic imaging surveillance/follow up
– 6 mos - 6 mos -1 yr
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Juvenile fibroadenoma-children and teenage girls (10-16yo)- 5 cm
Sonography of Solid Breast Nodulesurface characteristics
scan entire of nodule in 2 planes
cine loops
if mixture of benign and malignant surface
findings……exclude from benign classification.
cine
cinecine
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cine cine
Breast Cancer is Heterogeneous
from nodule to nodule
often within a single nodule
Suspicious- BIRADS 4,5
Spiculations – most specific
Angular margins-most common
Irregular shape
Marked hypoechogenicity
Non parallel orientation to skin
Posterior acoustic shadowing
Microcalcifications
Ductal extension
Branching Pattern
Malignant FindingSpiculations
Spiculation
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Breast Cancer can be heterogeneous within nodule
only part of surface may be spiculated
Magnification helps evaluate surface
characteristics
thick, echogenic halo
halo thicker on edges ,
Variant of Spiculations
less apparent ant. and post.
Irregular Shape – not round or oval
Malignant Findingangular margins radial
anti- radial
Angular margins – heterogeneous within one nodule
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Angular Margins
paths of
low resistance to
invasion
in bases of
Cooper’s ligaments
Malignant Findingmicrolobulation
“invasive or DCIS”
fingers of invasive tumor
intraductal components
cancerized lobules
Microlobulationmicrolobulation margins
invasive fingers of tumor
1) angular 2) associated with thick halo
Tabar
**
* *
microlobulation margins
DCIS components of tumor
*
*
*
*
1) invasive cords central (I)2) DCIS peripheral (*)
(I)
Malignant Findingnon parallel
FA CA
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Wider-than-tall Taller-than-wide
Benign Malignant
taller-than-wide
a feature of small malignant nodules,
not of large malignant nodules
0
10
20
30
40
50
60
70
80
% o
f ca
ses
< 10 mm 11-15 mm 16-20 mm > 20 mm
size groups
< 10 mm
11-15 mm
16-20 mm
> 20 mm
Malignant Findingduct extension
Duct Extension
extensive intraductal components
important not just for dx, but staging and rx
Malignant Findingbranch pattern
Malignant Findingcalcification
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Malignant Findingmarkedly hypoechoic- relative to fat
vs.fat
Intraductal Masses
Papilloma
DCIS
IDC
Duct ectasia
Fibroadenoma
ADH
Duct ectasia/debris
Intraductal Masses suspicious characteristics
Intraductal Mass on Breast Ultrasound: Final Outcomes and Predictors of Malignancy. Won Hwa Kim, Jung Min Chang et al ALR 2013
• Large size>15 mm
• Irregular shape
• Peripheral duct- > 15 mm from nipple
• Causes duct expansion
• Spread into branch duct
atypical papilloma
Tools Color Doppler
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thick walled cyst?
cyst with debris?
Metastatic Melanoma
Tools -Posterior Acoustic Shadowing
• Cancers• Fibroadenomas• Scars
• Fat necrosis• Calcification• Free silicone – dirty shadowing
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Tools - Posterior Acoustic Enhancement
Indicates cellular, metabolically active cancers
High grade IDC
Colloid CA
Medullary CA
Invasive papillary CA
Cysts, Hematomas, Abscess
enhancing fibroadenoma shadowing fibroadenomamammographically stable
Elastography – based on tissue stiffness, resistance Contrast Enhanced Subharmonic Breast Ultrasound
BIRADS Positive Predictive Value (PPV) ACR
benchmarks
1 Negative 0%
2 Benign 0%
3 Probably Benign <2% chance of malignancy
4 Suspicious 2-95%
4a low suspicion 2-10%
4b moderate suspicion 0-50%
4c high suspicion 50-95%
5 Highly Suggestive of Malignancy
TI-RADS
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Proposed guidelines for BI-RADS 4 sub-categorization
BIRADS 3: No suspicious findings, one of two benign patterns: 1)oval shape, parallel orientation, circumscribed, abrupt interface with complete thin hyperechoic capsule 2)three or fewer lobulations, parallel orientation, circumscribed, abrupt interface with complete thin hyperechoic
capsule
BIRADS 4a: Three or fewer suspicious findings, all ‘weak’ non-mass findings… OR presence of a single angle… OR four total findings, none ‘strong’, with one or two nonspecific findings… OR two total findings, both nonspecific findings
BIRADS 4b: Four total suspicious findings with one ‘strong’ mass finding… Or three total suspicious
findings with two ‘strong’ mass findings
BIRADS 4c: Either five or six total suspicious findings… OR 4 total findings with two ‘strong’ mass
findings
BIRADS 5: Six or more findings… OR three or more ‘strong’ mass findings
Proposed guidelines did not improve overall reader performanceUltrasound positive predictive values by BI -RADS categories 3–5 for solid masses: An independent reader study A. Thomas Stavros1 & Andrea G. Freitas 2 & Giselle G. N. deMello2 & Lora Barke 3 &
Dennis McDonald4,5 & Terese Kaske 3,6 & Ducly Wolverton3,7 & Arnold Honick4,8 & Daniela Stanzani2 & Adriana H. Padovan2 & Ana Paula C. Moura2 10 April 2017 # European
Society of Radiology 2017
BIRADS 4 a,b,c
4a
Partially circumscribed mass suggestive of fibroadenoma
Complex cyst
4b
Calcifications -moderate suspicion for malignancy, some benign
characteristics
4c
.Highly suspicious but not classic
US of Breast Masses Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing Clinical Management, Sughra Raza, MD, Allison L. Goldkamp, MD, Sona A. Chikarmane, MD, and Robyn L. Birdwell, MD Radiographics 2010
Ultrasound
Technology-continuing study
Elastography
3D/4D= volumetric imaging
Whole Breast Imaging
Improved Lesion Detection/Characterization – vascularity-contrast, calcifications
Computer Aided Detection - AI
Guidance for tumor ablation -cryotherapy