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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5767_Библиотеки_им_академика_М_И_Перельмана.pdf
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A. N. Sencha et al.
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Fig. 14.2 Simple breast cyst. Breast CEUS images. (a) No contrast enhancement of the cyst in the arterial phase. (b)
Another typical cyst with no contrast enhancement. (c) TIC demonstrates no enhancement within the cyst (blue ROI)
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Fig. 14.2 (continued)
enhancement on the periphery of the cystic
lesion and guide the targeted biopsy (Fig.14.3,
Video 14.2).
Breast broadenoma and many other benign
breast tumors usually have a poor vascular network with color Doppler. The vessels are mainly
located on the periphery of the lesion with sporadic regular branching. In some cases, a feeding
or draining vessel directed to the lesion center
may be identied.
The characteristic CEUS feature of breast
broadenoma is peripheral enhancement. The
combination of peripheral contrast enhancement
and prolonged wash-out is observed in 80% of
histopathologically veried broadenomas
(Fig.14.4, Videos 14.3 and 14.4).
Breast broadenoma is characterized by a longer TTP enhancement (≥30 s) and slower washout rate (70–150 s) [9]. These quantitative
indicators have signicantly higher values in
broadenoma as compared to breast malignancies. In some cases, a broadenoma may exhibit
intense heterogeneous contrast enhancement
(Fig.14.5, Videos 14.5 and 14.6). These broadenomas with Doppler imaging also demonstrate
intranodular blood ow with wide centrally
directed vessels.
In men with nodular gynecomastia, 60% of
lesions demonstrate no contrast enhancement
with CEUS. The rest lesions exhibit peripheral
enhancement, which is in concordance with their
benign nature (Fig.14.6).
Breast malignancies are considered vascularized tumors. However, the capabilities of color
and power Doppler imaging to visualize the vascular network in the tumor are limited due to low
sensitivity to slow blood ow.
With CEUS, breast malignant lesions in both
women and men typically demonstrate heterogeneous intense contrast enhancement in the arterial phase [17–21] (Figs.14.7 and 14.8, Videos
14.7, 14.8, and 14.9). This pattern is observed in
2/3 of cases [1, 4, 16]. Irregular intense contrast
enhancement depicts the abnormal branching of
the vessels, randomly and atypically located arterioles and venules, and the arteriovenous shunts,
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A. N. Sencha et al.
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Fig. 14.3 Complex breast cystic lesions. (a) Patient
A. CEUS image demonstrates enhancing solid components along the wall. (b) TIC quantitatively veries
enhancement of the cystic lesion. (c) Patient B. CEUS
image demonstrates mild enhancement in the cyst. (d)
Quantitative analysis of the cyst in (c) demonstrates
enhancement in the cyst (yellow ROI) as compared with
other structures
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d
Fig. 14.3 (continued)
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A. N. Sencha et al.
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b
Fig. 14.4 Breast broadenoma. CEUS. (a) Patient
A.The arterial phase CEUS image demonstrates peripheral enhancement. (b) Patient B.Poor enhancement of the
lesion in the arterial phase. (c) Patient C.Poor enhance-
ment in the arterial phase. (d) Quantitative analysis of TIC
for (c) demonstrates mild enhancement and slow washout of the lesion (pink and yellow ROIs) as compared with
other structures
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d
Fig. 14.4 (continued)
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A. N. Sencha et al.
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b
Fig. 14.5 Breast broadenoma. (a) Patient A.The arte-
rial phase CEUS image demonstrates moderate peripheral
and central enhancement. (b) Patient B.The arterial phase
CEUS image demonstrates pronounced heterogeneous
contrast enhancement in the arterial phase
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Fig. 14.6 Gynecomastia. (a) PDI reveals no vascularity. (b) The early venous phase CEUS image demonstrates no
contrast enhancement of the lesion
which work for rapid wash-out of UCA from the
tumor.
Fifteen percent of breast carcinomas have a
marginal accumulation of UCA in a separate
peripheral area of the tumor. This may be due to
the hypoperfused areas within the tumor central
part, which is associated with brosis and degeneration. In any case, the area of contrast enhancement is suspicious of malignancy, and a targeted
biopsy of this area with ultrasound guidance is
highly efcient.
Most breast malignant tumors have vascular
features specic for rapidly growing neoplasms,
such as irregular vessel course and caliber with
spirals and dilatations, arteriovenous shunts,
abnormal branching, and the inconsistency of the
vascular wall (Figs.14.9 and 14.10). The correlation between vascular disorganization and the
anaplasia grade is very strong [7].
Abnormal vessels with the altered course,
structure, and caliber end up with a mosaic pattern with CEUS, the detection of which corre-
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b
Fig. 14.7 Breast carcinoma in a woman. CEUS. (a)
Patient A.Heterogeneous intense arterial phase enhancement. (b) Patient A.Rapid wash-out in the venous phase.
(c) Patient B. Heterogeneous intense arterial phase
enhancement. (d) Patient B.Very rapid wash-out, which
starts at the end of arterial phase. (e) Patient C.Poor central enhancement in all vascular phases
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d
Fig. 14.7 (continued)