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Practice guideline for the performance of breast ultrasound elastography. Su Hyun Lee1, Jung Min Chang1, Nariya Cho1, Hye Ryoung Koo2. Ultrasound imaging of the breast uses sound waves to produce pictures of the internal structures of the breast. It is primarily used to help diagnose breast lumps . PDF | Frequent advances in transducer design, electronics, computers, and signal Ease of use and real-time imaging capability make breast ultrasound a.

Breast Ultrasound Pdf

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scenario, the interventional and diagnostic breast ultrasound has played a significant role. and description of breast ultrasound images has resulted in reports. scanning (ABVS) in comparison to hand-held breast ultrasound in women going Key Words: Whole breast ultrasound; automated breast volumetric scanning;. for palpable or nonpalpable breast masses, but isoechoic lesions sur- rounded by fat can .. and pitfalls of ultrasound-guided core-needle biopsy of the breast.

Malignant lesions. Transverse scan A shows a typical malignant nodule that is taller than wide, with hypoechoic echotexture. Arrowheads indicate irregular spiculated margins.


Some of the nodules may reveal a branching pattern arrows in B. Sagittal view C shows a nodule with multilobulated margins; the presence of more than 3—4 lobulations is suspicious for malignancy. Sagittal D and transverse E scans show duct extension arrows. Duct extension appears smooth in outline in cross-section arrowheads in E.

Transverse scan F shows a typical malignant lesion with irregular spiky margins, microcalcifications and a branching pattern. Malignant lesion. Transverse scan A shows smooth margins, suggesting a category 3 lesion.

A 3Dimage in the coronal plane B however reveals spiky margins with a sunray appearance, suggestive of a category 4 lesion. A smooth margin and homogenous echotexture suggest a category 3 lesion. Color Doppler reveals irregularly branching neovascularity. In a landmark study in , Stavros et al.

Although it may be impossible to distinguish all benign from all malignant solid breast nodules using USG criteria, a reasonable goal for breast USG is to identify a subgroup of solid nodules that has such a low risk of being malignant that the option of short-interval follow-up can be offered as a viable alternative to biopsy. Source of Support: Conflict of Interest: None declared.

National Center for Biotechnology Information , U. Indian J Radiol Imaging. Sudheer Gokhale. Author information Copyright and License information Disclaimer. Dr Gokhale's Sonography clinic, Indore, India. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC.

Abstract A lump in the breast is a cause of great concern. Introduction Breast cancer is among the most common causes of cancer deaths today, coming fifth after lung, stomach, liver and colon cancers.

High-density probes provide better lateral resolution Harmonic imaging leads to improved resolution and reduced reverberation and near-field artifacts Real-time compound scanning results in increased tissue contrast resolution Extended or panoramic views provide a better perspective of the lesion in relation to the rest of the breast Harmonic imaging and real-time compounding has been shown to improve image resolution and lesion characterization. Normal breast parenchymal patterns In the young non-lactating breast, the parenchyma is primarily composed of fibroglandular tissue, with little or no subcutaneous fat.

Open in a separate window. Figure 1. Abnormal appearances Breast cysts Breast cysts are the commonest cause of breast lumps in women between 35 and 50 years of age.

Figure 2 A—D. Chronic abscess of the breast Patients may present with fever, pain, tenderness to touch and increased white cell count. Fibrocystic breast condition This condition is referred to by many different names: Figure 3 A-C. Duct ectasia This lesion has a variable appearance.

Figure 4 A, B. Fibroadenoma Fibroadenoma is an estrogen-induced tumor that forms in adolescence. Figure 5.

Cystosarcoma phyllodes This is a large lesion that presents in older women. Figure 6. Lipoma Lipoma is a slow-growing, well-defined tumor. Figure 7. Breast ultrasound: Characteristics of malignant lesions Malignant lesions are commonly hypoechoic lesions with ill-defined borders. Figure 8 A—F. Figure 9 A,B. Figure Table 1 USG suspicious for malignancy. Solid nodule Positive predictive value Spiculation Discussion Although it may be impossible to distinguish all benign from all malignant solid breast nodules using USG criteria, a reasonable goal for breast USG is to identify a subgroup of solid nodules that has such a low risk of being malignant that the option of short-interval follow-up can be offered as a viable alternative to biopsy.

Footnotes Source of Support: Nil Conflict of Interest: References 1. When a suspicious lesion is identifiable on US, US is the preferred image guidance technique for percutaneous needle biopsy [ 55 , 56 ].

In fact, the procedure is fast, has low costs, allows for the use of smaller needles, is only minimally uncomfortable for the patient and does not expose the patient to radiation.

US-guided breast biopsies offer great advantages over mammography or MRI guidance methods for needle biopsy. US-guided interventions can be requested not only by radiologists but also by referring physicians to established histopathologic diagnosis and allow treatment planning.

Independent of whether a mass is palpable or not, US guidance allows the operator to follow the procedure in real time and to verify the needle position for improving the overall accuracy. The patient position during biopsy is quite similar to the US examination. Breast compression is not required. The skin is disinfected and local anaesthesia is injected. A small incision of the skin is sometimes made at the entry site for an easier needle passage. The current good practice is the use of a gauge or larger needle which means using needles identified with smaller gauge numbers to obtain three to six samples [ 50 , 51 ].

Markers visible at various imaging modalities may be positioned at the biopsy site under US guidance, especially when there is a chance of masking or the disappearance of the biopsied lesion due to bleeding or very small size. This final step allows the evaluation of the concordance of the biopsy position as compared with other imaging modalities and, in case of neo-adjuvant therapy i.

US-guided needle biopsy is a minimally invasive and safe technique for obtaining histologic diagnosis of a breast mass. The risk of complications such as infections and large haematomas sometimes with pseudoaneurysms is very low, approximately one every procedures [ 50 , 51 ]. Further, pre-surgical localisation of non-palpable lesions can be similarly easily performed under US guidance in order to indicate the site or the disease extent to the surgeon. Mammography- and MRI-guided procedures both biopsies and localisations are reserved for those lesions not visible on US, as those procedures are more uncomfortable and more time consuming than under US guidance.

During US-guided interventions, usually a nurse or a technologist assists the radiologist.

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More detailed information will be provided in a specific article dedicated to image-guided breast interventions. Loco-regional staging In women with a suspected breast cancer, detected with US or with other modalities, the whole breast harbouring the suspicious lesion, the ipsilateral axilla, and the contralateral breast can be examined with US.

In fact, US has proven to be very valuable for assessing the size of invasive cancers, detecting other cancer foci in the affected breast, and identifying cancers in the contralateral breast [ 57 , 58 , 59 ]. However, the most accurate method for detecting additional ipsilateral and contralateral cancers in women with a newly diagnosed breast cancer is breast MRI, even though its routine preoperative use is still controversial [ 3 ].

At any rate, the additional findings of MRI can be considered for changing therapy planning only if they are pathologically verified to be malignant through a percutaneous biopsy.

If an additional lesion seen on MRI is also visible on targeted so-called second look, as mentioned above US, the biopsy should be performed under US guidance [ 52 ].

If an additional lesion cannot be identified at targeted second-look US, the radiologist, together with a multidisciplinary team, will decide the next step, such as an MRI-guided biopsy or follow-up [ 3 ]. When an invasive cancer is newly diagnosed, the status of axillary lymph nodes is important for treatment planning, in particular for decision making about axillary treatment i. Lymph nodes suspected of harbouring metastases can be revealed by US also in the absence of palpable axillary findings.

In that case, US-guided percutaneous sampling concludes the diagnostic work-up, using fine needle aspiration or larger core needles [ 60 ]. These tumours are often treated with systemic treatment using different drugs before surgery, an approach referred as neo-adjuvant therapy.

The aim is to reduce the tumour bulk, allowing for conservative surgery and preventing the spread to distant organs. Of note, the tumour in the breast and axillary involvement may respond differently.

Breast US has been shown to be a useful tool for early prediction of pathologic response to this kind of treatment [ 63 ] and may potentially aid the optimisation of therapy in case the of poor response, allowing for a prompt regimen change. However, it has to be noted that in this setting breast MRI has been shown to offer the best performance [ 64 , 65 , 66 , 67 ]. Patients with breast implants Breast US is usually the first line examination performed in women with implants to investigate breast implant complications that may present with pain, lumps, or asymmetries.

It can be used to detect alterations of the implant structure, typically subdivided into intracapsular ruptures when the implant envelope is broken but the silicon remains inside the capsule and extracapsular ruptures when the silicone leaks out of the broken capsule [ 68 ].

Of note, the fibrotic capsule around the implant develops through a natural foreign body reaction of the breast tissues to the implant. Considering breast implant integrity, US is a very specific, although not very sensitive, method: if an implant rupture is suspected on US, the probability of a true rupture is high; conversely, if no rupture is visible on US, a rupture mostly intra-capsular is still possible.

In addition, US is useful in diagnosing other implant complication such as infection, seroma, or granuloma. MRI is the usual second step after US in this setting, especially for detecting intracapsular ruptures unnoticed with US [ 33 , 69 ].

There are no contraindications to performing US-guided interventions biopsy, preoperative localisation in women with breast implants [ 17 ]. This way, a measure of noise based on the difference in contrast could be established.

The image contrast and the overall brightness have to lie within a certain range in order to allow best possible image analysis, both for clinical diagnosis, as well as for automated analysis lesion detection and classification. It might be useful to calculate a contrast value only in the foreground region of an image after a breast segmentation has discarded the background. As for the brightness, an AQUA tool could focus on the absolute intensities of the image maximum intensities, intensity range or try to analyze the distribution of intensities.

In the latter case, one possibility would be to use shape measures such as skewness or kurtosis. According to the classification re- sult table 1 , contrast and brightness are acceptable or good in most of the cases.

Depending on the position and angle of the transducer frame, there might be sub- stantial black areas at the edges of the images because the breast was compressed in such a way that there was no more tissue to be imaged. These shadow regions in the borders of the image do not convey useful information and might indicate that not the whole of the breast is visible see figure 3. In order to detect them, an edge shadow will be characterized as a set of rows columns adjacent to an image extreme holding that all their pixels are black except for a small threshold to account for noise.

The algorithm to measure these shadows, consequently, begins scanning at an image edge and proceeds row by row column by column until a non-black pixel is detected. The width height of the edge shadow is then determined as the number of rows columns times the dimen- sions of the pixel.

Typical ABUS image artifacts. Another common artifact in ultrasound imaging are shadows air artifacts caused by a lack of contact gel.

Ultrasound characterization of breast masses

If there is no good contact between the transducer and the skin via a contact fluid, the sound waves are reflected by the air between transducer membrane and skin. In this way, a characteristic pattern of some bright and dark stripes on the image near the surface is produced which quickly ends up in a shadow column in longitudinal direction see figure 1. These air artifacts can be detected by blob detection, i.

As the volumetric image data set is reconstructed from several 2D ultrasound im- age slices which are collected one after another by the transducer scanning over the breast, it is crucial that the transducer moves smoothly at constant velocity through its frame.

If, however, the pressure of the transducer on the skin is too high or if there are hard tissue structures in the breast, the transducer motion may be hampered. In conse- quence there will be discontinuities between the lines in the reconstructed images see figure 1. Some kind of gradient image filter could detect the transducer bump- ing.

Eventually, the success of the imaging process also depends on the cooperation of the patient. If the woman is breathing strongly, talking or coughing during the exami- nation, the volumetric image will show some kind of sinusoidal pattern in the recon- structed image plane see figure 1.

This may also be detected by customized gradient image filters. Groundwork in this area has already been performed by Boehler and Peitgen [12]. In order to allow further automatic image analysis, i. A chest wall detection algorithm developed by Tan et al.

In order to decide whether or not a sufficient number of ribs is clearly visible, a first version of a rib detection algorithm was implemented see sec- tion 2. In figure 2, some single steps and the result of the proposed algorithm are presented. In this case, the upper three ribs are segmented correctly while the bottom rib is detected in two separate parts. The correct counting in this case is still a pending challenge. The different stages in automated rib detection from left to right: 1 typical ultrasound slice in coronal view where ribs are visible, 2 binary map of this slice, 3 sum projection of all slice-wise binary maps result in the probability map, and 4 the segmented ribs.

Many times, a major concern in ultrasound breast images are the nipple and the ducts. On the one hand, the nipple is an important landmark which helps, e. On the other hand, the nipple can cause severe shadows in the ultrasound images due to entrapped air and lack of contact between transducer and skin see figure 1.

The ducts are also filled with air and, thus, can produce elongated shadow regions along their axes.

Mammography & Breast Procedures

These shadows may cover important structures in the breast image and hinder a solid diagnosis. Furthermore, the position of the nipple relative to the rest of the breast in the image is a quality aspect that should be considered. The nipple being too close to the edge of the laterally compressed breast might constrain the view of the radiologist on im- portant areas and induce uncertainty about the true edge of the breast.

Figure 3 presents an exemplary output of the pro- posed nipple detection algorithm see section 2 , which allows computing the distance to the edge. In order to translate the above described subjective human image quality criteria into an objective criterion, the single software tools will have to be trained by a ma- chine learning algorithm on the classified image data set.

As some artifacts only ap- pear very rarely, it might be necessary to expand the image data base and to get the images classified by more than one radiologist. As soon as the single AQUA tools are in a stable version, they might be integrated to clinical practice as add-on.

Depending on the false positive rate, the examination time might be increased needlessly for some woman.

However, saving the effort of recalling women some days later for a repeated examination should outweigh this effect. Of course, the possible increase in workload and costs will have to be investi- gated thoroughly. Coronal views of the breast.

Middle: position of the nipple is very close to the edge of the breast.

Right: example output image of the automatic nipple detection algorithm. The proposed nipple position is marked by a red star and coincides well with the true position.

In the end, it should be practical to rely on AQUA findings alone for repeating a scan.

However, it remains to be seen during the course of this study whether the com- promise of additional visual conformation might be necessary.D Elastosonography shows blue and green mosaic. Focal fibrocystic changes may appear as solid masses or thin-walled cysts. To the best of our knowledge, there are no reported harms related to the delivery of US to the adult human body at the level of energy applied in diagnostic medical use [ 4 , 76 ]. J Ultrasound Med.

In crosssection B , the intraductal debris may appear as a focal lesion arrowheads. Breast cancer is characterized by increasing stiffness of breast tissue; at physical examination, it has long been recognized that malignant tumors tend to feel hard compared with benign tumors.

This condition is referred to by many different names: Assessment of lesions detected by MRI Breast MRI is the most sensitive tool for diagnosing breast cancer [ 33 ], in particular when mammographic calcifications are absent [ 47 , 48 ].

Well-designed large studies with sufficient follow-up are needed. The stromal microenvironment of tumor cells is different from that of normal cells.

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