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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 3.13 Normal breast.
The back leaf of the fascia.
Grayscale US and CDI
413.2 Types of Ultrasound Picture of the Normal Breast
4. Presence of lesions or fi elds (areas) with
abnormal structure, their location, and precise
description in different US regimens
5. The analysis of the status of regional lymph
nodes
The example of US report in normal breast:
First name, middle initial, last name:
Age:
Date:
The fi rst day of last menses:
The breasts are of reproductive type, mainly
presented with adipose tissue. The thickness
of glandular tissue up to 20 mm. Fibrous tissue
is moderately expressed in all regions.
Lactiferous ducts are not dilated; the caliber
up to 2 mm. Cystic and solid lesions are not
detected.
Axillary, supraclavicular, and subclavian
lymph nodes are not enlarged.
CONCLUSION: Normal breast US
42
Fig. 3.14 Normal breast.
Retromammary space
( arrow ). Grayscale US
3 Ultrasound of the Normal Breast
3.3 Dif fi culties and Pitfalls
in Breast Ultrasound
The causes of mistakes at breast US can be
divided into the following groups:
1. Objective
Anatomic, physiological, constitutional •
features of the patient that decrease the
quality of breast imaging
Limitations of the equipment (class of US •
scanner, characteristics of probes, etc.)
2. Subjective
Lack of experience of personnel •
Inadequate or incomplete technique of the •
examination
Low reproducibility of breast US is often a
consequence of the differences in the class of
equipment and quali fi cation of the doctor. Rare
Fig. 3.15 Normal breast.
The nipple ( arrow ). Grayscale
U S
433.3 Difficulties and Pitfalls in Breast Ultrasound
breast pathology can be misinterpreted because
of the insuf fi cient experience of US specialist
that results in diagnostic errors. Psychological
predilection to bring the detected abnormalities
under standards also affects the quality of
diagnosis.
The development of high-resolution US equipment permitted to recognize the number of breast
abnormalities, which used to be regarded as the
norm.
At the same time, there are cases of hyperdiagnostics of pathology in the normal breast,
when normal breast structures are interpreted as
lesions. This especially concerns the structures
located on the periphery of the breast, in the retromammary space, and subareolar area.
Differentiation of malignant and benign
tumors, tumorlike, and non-tumoral processes of
breast requires special attention. Correct diagnosis of local tumors, such as breast carcinoma with
44
3 Ultrasound of the Normal Breast
expansive growth, requires certain experience and
efforts. Breast carcinoma without nodular structure and prominent diffuse or local in fi ltration is
also dif fi cult for differential diagnosis. The minimum changes in a kind of local clump of ducts
(dilated or not dilated), in association with their
chaotic distribution, especially in peripheral parts
of the breast, can be a sign of ductal breast carcinoma. Differentiation of sclerosing adenosis from
breast carcinoma is extremely important, since
this borderline breast disease is associated with
a
high incidence of malignancy. Sclerosing adenosis can hide early signs of breast carcinoma due
to the number of identical US features (excessive
fi brosis, calci fi cations, heterogeneity of breast
structure). Hence, only the examination targeted
to the search of characteristic features for malignant neoplasm results in the correct diagnosis.
Lymph nodes, which are adjacent to the
breast, often cause dif fi culties in correct diagnosis. It is necessary to use the highest possible
frequency of US probe to achieve detailed image,
Fig. 3.16 Normal breast US.
( a ) CDI. ( b ) PDI. ( c ) 3D.
( d ) Multislice
Fig. 3.16 (continued)
453.3 Difficulties and Pitfalls in Breast Ultrasound
b
46
3 Ultrasound of the Normal Breast
c
Fig. 3.16 (continued)
473.3 Difficulties and Pitfalls in Breast Ultrasound
d
Fig. 3.16 (continued)
48
3 Ultrasound of the Normal Breast
to pay attention to speci fi c features of lymph
nodes, such as the shape, echostructure with
differentiation of cortex and hilum, and typical
pattern of blood fl ow in the hilum. Alternatively,
there are mistakes, when breast lesions are interpreted for lymph nodes. The conclusion of breast
lesion is only permitted in the case of its clear
demonstration at least in two perpendicular projections. Correct diagnosis sometimes requires
long follow-up or application of other diagnostic
methods.
Auxiliary methods, such as lifting of patient’s
arms, turns of the body to one or another side,
and change of body position, are important for
differential diagnosis.
Following the methodology of the examination is extremely valuable. Breast structure can
be assessed only with linear probes with the frequency of 7.5 MHz or higher. Convex probes for
abdominal examinations can be used additionally
for the measurement of large breast lesions. The
use of a convex probe alone for breast examination results in multiple severe errors and discredits the fi eld of sonography.
Color Doppler mapping also requires special
regimens (packages), optimum choice of technologies for improving the color image quality,
small region of interest, correct Doppler angles,
minimization of noises, high-quality preprocessing and averaging, and minimum values of color
Doppler scale to improve the obtained data.
The recommended terms for breast US are the •
following:
Normal breast for preventive purposes – once •
in 2 years
Benign diffuse and nodular changes for assess-•
ment of the disease development – 1–2 times a
year
Postoperative breast – once in 6 months •
Due to the safety and availability of US, the
monitoring of breast pathology can be performed
with shorter intervals if relevant indications arise.
Ultrasound Diagnosis of Breast Cancer
4
The fi rst publications devoted to differential
diagnosis of breast pathology with US technologies in A-mode belong to J.J. Wild and D. Neil
( 1951 ) and in B-mode to J.J. Wild and J.M. Reid
( 1952 ) . Before the middle of the 1970s of the
twentieth century, breast lesion larger than 1 cm
could be successfully detected only in 8 % of
cases. In the 1980s, the echography was considered an additional diagnostic procedure to clinical
survey and mammography. US today is a highly
effective (Chap. 1 , Table 1.1 ) and obligatory
method of examination, which is utilized along
with mammography, clinical survey, and palpation in diagnosis of breast pathology, including
early and differential diagnosis of malignancies
( Zabolotskaya and Zabolotsky 1997 ; Tro fi mova
2000a ; Korzhenkova 2004 ; Komarova 2006 ) .
US is based on the ability of tissues with different acoustic resistance to re fl ect US (cyclic sound
pressure waves with a frequency greater than
20,000 Hz). Modern US scanners work in real time
that gives the opportunity to observe the locomotion of organs in natural time course. The development of new diagnostic equipment, introduction of
digital US scanners, modern high-frequency probes
of 7.5–15 MHz, complex utilization of modern
options, and technologies signi fi cantly increased
the diagnostic possibilities of sonography.
The complex of modern US technologies for
diagnosis of breast diagnostics confers the following options:
1. Grayscale regimen
2. Tissue harmonics
3. Adaptive coloring
4. Color Doppler imaging
5. Power Doppler mapping
6. Three-dimensional reconstruction of grayscale images, real-time 3D
7. Three-dimensional reconstruction of the
image in vascular regimen
8. Panoramic scan
9. Spectral pulse Doppler
10. US elastography (compression and shear
wave)
11. Other options (multislice view, volume CT
view, contrast US, etc.)
Wide range of frequencies and options of US
scanning facilitates daily work of US specialists
providing detailed image of breast and surrounding tissue for a short time period. Modern algorithms of automatic optimization based on signal
preprocessing optimize the in fl uence of tissue
irregularity and minimize noises and artifacts.
Our own experience is based on the data of
more than 50,500 mammographies and 20,000
US breast examinations on scanners of high and
expert class that were performed in 2007–2012.
Among them, 9,000 patients were indicated for US
with benign breast changes and 1,500 with suspicion for malignant neoplasms. Sonoelastography
and ARFI were utilized in complex examination
in 88 patients with breast carcinoma. More than
10,000 women with normal breast were diagnosed that corresponded to clinical examinations
and the results of other imaging methods.
Totally, 1,144 patients with suspected breast
carcinoma underwent core biopsy with histology,
which proved the diagnosis in 89 % of cases.
A.N. Sencha et al., Breast Ultrasound,
DOI 10.1007/978-3-642-36502-7_4, © Springer-Verlag Berlin Heidelberg 2013
49
50
4 Ultrasound Diagnosis of Breast Cancer
US screening detected 307 cases of breast carcinoma and 26.8 % of them were impalpable.
The average age of patients with breast cancer
was 57.6 years. Seventy- fi ve percent of patients
were of 41–70 years of age. Invasive ductal cancer (59 %) prevailed among veri fi ed histological
types of breast carcinoma in our study. Also invasive lobular (8 %), tubular (7 %), carcinoma in a
cyst (5 %), mucous (4 %), medullary (4 %), and
other types (13 %) of breast malignancies were
observed.
The patients were distributed in accordance
with TNM classi fi cation in the following way: T
in situ, 80 (7 %); T1N0M0, 229 (20 %); T1N1M0,
80 (7 %); T1N2M0, 23 (2 %); T1N3M0, 11 (1 %);
T2N0M0, 343 (30 %); T2N1M0, 126 (11 %);
T2N2M0, 34 (3 %); T3N1M0, 11 (1 %); T3N1M1,
11 (1 %); and T4NM, 114 (10 %). In 7 % (80
instances), the stage of breast carcinoma remained
unspeci fi ed.
The dimensions of malignant lesions according to US were as follows: 0.5–1.0 cm, 286 cases
(25 %); 1.1–3.0 cm, 790 (69 %); and larger than
3.1 cm, 68 (6 %).
Some US signs suspicious for breast malignancy according to our data are listed below:
1. Irregular shape of the breast lesion (98.8 %).
2. Rough borders (67.0 %).
3. Indistinct contours (86.7 %).
4. Decreased echodensity (88.4 %).
5. Heterogeneous structure (96 %).
6. Hyperechoic incorporations and microcalci-
fi cations (24 %).
7. Posterior acoustic shadow (77.9 %).
8. Absence of halo (73.9 %).
9. CDI, PDI, and 3DPD reveal the following
features: lesions that are smaller than 2 cm in
size demonstrate avascular structure (94.4 %),
and larger lesions (more than 2 cm in size)
are hypovascular in 56 % and hypervascular
in 32 %.
10. In 3DPD mode, irregular distribution of ves-
sels, disorganized vascular pattern, and pathological transformation of vessels (32 %) are
characteristic.
11. Compression elastography demonstrates
hard (blue color) structure of the lesion in
76.1 %. In 12.5 % of cases, the lesion exhibits
mixed-type (blue-green-red) color pattern.
81.8 % of lesions are characterized with irregular stiffness with ultrasound elastography.
12. Strain elastography reveals that strain ratio in
76 % of breast carcinoma is above 5.1
(22.9 ± 2.14 on the average) and ranges from
5.1 to 28.9 depending on histological structure of the lesion. Strain ratio in noninvasive
cancer was lower (8.42 ± 3.41) than in
in fi ltrating types (22.64 ± 2.61). In the regimen of Virtual Touch Tissue Quanti fi cation
(ARFI technology), the average velocity of
shear wave within malignant breast lesions
was 4.1 m/s, while in the surrounding normal
breast tissue, 2.9 m/s.
13. Enlargement of regional lymph nodes (37.5 %).
4.1 Grayscale Imaging
Grayscale (2D, B-mode) US is the principal
ultrasound imaging modality to diagnose breast
diseases and breast cancer in particular (Figs. 4.1
and 4.2 ).
Grayscale imaging supplies basic information
on the character of pathological process, thus
decreasing the number of unspeci fi ed diagnoses.
Wide range of histological types of tumoral
growth invoke the interest to the search of correlations between morphological and ultrasound
structures.
Breast carcinoma exhibits nodular or diffuse
(in fi ltrative) types of growth.
Nodular type of breast cancer (up to 80 % of
breast carcinoma) is fi rst of all characterized by
the presence of a lesion within breast structure
that can be revealed in grayscale mode or
other US regimens (Fig.
Zabolotskaya ( 2006 ) , up to 50 % of all cancers
originate from the upper-outer quadrant of the
breast, 15 % are located in the upper-inner quadrant, 10 % in the lower outer, 5 % in the lower
inner, and up to 17 % in the central area. The
lesion can demonstrate in fi ltrating or expansive
growth. Nodular type of breast carcinoma can be
accompanied with the change in breast shape,
nipple inversion, pain and discomfort in the
breast independent of the phase of menstrual
4.1 ). According to