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Chapter 42: ADVANCED BREAST ULTRASOUND

David O. Cosgrove; William E. Svensson

INTRODUCTION

Definitions

  1. Elastography: in elastography, strain = the applied force, stress = the tissues deformation in response. Young's modulus of elasticity is stress/strain. Shear wave; a transverse pressure wave that travels away from the pushing force from an acoustic radiation force pulse.

  2. Tsukuba elastography score: a subjective scoring system from 1 to 5 of the amount and extent of the stiffness of a lesion.

  3. Fibroadenoma: a common benign tumor composed of glandular and fibrous tissue.

  4. Neovascularization: new vessels supplying a tumor that are derived from the tissues surrounding a cancer, stimulated by angiogenesis factors secreted by the tumor.

  5. Desmoplastic reaction: an intense fibrous response by the breast tissue due to a malignancy within it.

  6. Granuloma: a fibrous mass that forms as a reaction to chronic inflammation.

  7. Gynecomastia: enlargement of the male breast because of fatty or glandular tissue accumulation.

  8. Benign breast change: a group of poorly defined and ill-understood benign alterations in breast structure that may be cyclically painful.

  9. Phyllodes tumors: a rare breast tumor with a structure similar to a fibroadenoma but with a malignant potential.

  10. In situ carcinoma: a pre-invasive malignancy which has not infiltrated the basement membrane.

Ultrasound detects breast lesions by depicting their structural, dynamic, and vascular differences from the surrounding normal tissue.1,2,3,4,5, and 6 The structural features are depicted on gray scale; the dynamic, traditionally, by probe palpation and attempts to move the lesion with a free finger, or better, using elastography (see Figure 42-1B); and the vascular with Doppler, perhaps enhanced by contrast agents. Few lesions larger than 1 cm in diameter lack all of these distinctions (these are the undetectable "non-mass" lesions), but for small lesions (<0.5 cm), the changes are often too subtle to be detectable reliably or are completely absent so that the differential diagnostic features may disappear.7 These form the limits of sensitivity and specificity of ultrasound, which are being improved continuously as better scanners and radically new techniques become available.8,9

Figure 42-1.

Normal breast. A: In a section through the nipple, the cone shape of the fibroglandular layer is seen within the echo-poor subcutaneous and retromammary fat layers. Note the normal shadowing from the nipple region. The Cooper's ligaments are also seen (arrowheads). B: On elastography (right panel), the stiffer glandular layer is shown as a darker band with the less stiff fatty tissue forming superficial and deeper layers, depicted in lighter grays. This breast also contains a simple cyst; on the elastogram, it is surrounded by a stiffer rim (arrowheads) caused by compression of the surrounding tissue. Within the cyst, a 3-band pattern is seen: its origins are not fully established, at the time of writing, but it is probably some kind of artifact. The pattern has been termed the hamburger, target, or doughnut sign, depending on its shape. (C, cyst; F, fat; G, ...

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