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Fig. 4.2 (continued)
614.1 Grayscale Imaging
62
Fig. 4.2 (continued)
4 Ultrasound Diagnosis of Breast Cancer
observed in 18 % of women, and synchronous
affection of the second breast is detected in 43 %
of cases. The number of local metastases (“daughter tumors”) of multicentric carcinoma may vary.
They are most often located near the primary
tumor and, in rare cases, affect other breast quadrants. According to Sinyukova et al. ( 2007 ) , the
sensitivity of grayscale US in revealing multicentric breast carcinoma is 83.6 % with speci fi city
of 86.9 % and diagnostic accuracy of 79.9 %.
In fi ltrative type of breast carcinoma in gray-
scale regimen is often characterized by thickening of the skin with the increase in echodensity of
subcutaneous adipose layer and the parenchyma,
disorganization of its structure, dilation of lactiferous ducts and lymph vessels, and enlargement
of regional lymph nodes (Fig. 4.2 ). It often exhib-
its expressed local disorders, such as breast swelling, hyperemia, and hyperthermia. Primary
in fi ltrative type of breast carcinoma does not
634.4 Color and Power Doppler Imaging
exhibit any lesion against local swelling of the
breast. Secondary in fi ltrative type is characterized by a combination of swelling and lesion. US
diagnosis of primary in fi ltrative breast carcinoma
is dif fi cult. Skin thickening, local swelling of
breast tissue, dilation of lymph vessels, and
abnormal regional lymph nodes may serve as US
signs.
Breast US has certain disadvantages in the
detection of lesions against adipose involution and
in assessment of ductal extension of the tumor.
The tumors that are located in retromammary
space in large breasts and small lesions (smaller
than 0.5 cm in size) may be left undetected. One
signi fi cant disadvantage of US is operator dependency ( Zabolotskaya and Zabolotsky 2005 ) . The
sensitivity of grayscale US in differential diagnosis of breast carcinoma is 98.4 % with speci fi city
of 59–100 %.
4.2 Tissue Harmonic Imaging
Tissue harmonic imaging bases on the algorithm
of detection of harmonic component of US waves
induced in tissues with basic US impulse. The
option is usually incorporated into ordinary scanners and utilizes conventional US probes.
It permits more exact detection of US signs of
breast carcinoma (the quality of imaging subjectively improves in 30 % of cases) mainly at the
expense of accurate de fi nition of the contours and
heterogeneity of the lesion with speci fi cation of
presence and location of calci fi cations (Fig. 4.3 ).
The option is especially effective in the assessment of large (more than 30 mm in size) or small
(below 5 mm) lesions; however, its value in differential diagnosis of breast carcinoma is not very
signi fi cant.
4.3 Adaptive Coloring
The technology of adaptive coloring utilizes color
scale to substitute gray scale of conventional US.
The intensity of color depends on the power of
obtained US signal (Fig.
of image is possible. It is applied as a software
4.4 ). Inversion of color
option for color US systems and does demand
any hardware modi fi cation.
The option is effective in combination with
grayscale mode for detection of breast abnormalities (often isoechoic), characterization of its contours, and effects of posterior artifacts, especially
in small-sized lesions (smaller than 0.5–0.7 cm).
To improve the imaging of microcalci fi cations,
the technology “MicroPure” may be applicable.
The modality is based on grayscale image, displayed in dark blue color (Blue Layer method)
with allocation of small hyperechoic structures
displayed as white incorporations. The speci fi city
of the technology in detection of microcalci fi cations
within breast lesions is reported 61 % with sensitivity of 85 % and diagnostic accuracy of 70 %.
4.4 Color and Power Doppler
Imaging
Color Doppler imaging (CDI) is an US technol-
ogy of blood fl ow imaging based on registration
of velocities of blood fl ow in the area of interest
with further coding with different colors and
superimposing on 2D grayscale image (Fig. 4.5 ).
The modality is available on all modern scanners
and utilizes the same probes as conventional
grayscale US.
Modern US equipment with Doppler permits
imaging of blood fl ow in arteries and veins of the
caliber above 2 mm on the depths up to 25 cm.
The majority of researchers and practitioners
agree about the great value of CDI for diagnosis
of malignant breast lesions.
CDI normally detects poor vascular pattern in
breast tissue. Color pattern, as a rule, is presented
by individual color points, which are distributed
in a relatively regular way among all quadrants of
the breast ( Harchenko et al. 1993a, b ; Sandrikov
and Fisenko 1998 ) . There were suggested several
methods to make PDI more objective, such as
calculation of color pixel density. According to
Folkman ( 1995 ) , one signi fi cant feature of the
breast carcinoma is vascular asymmetry.
Tumor growth is often accompanied with neovascularization and development of own pathological vascular rete. Neoangiogenesis of a
64
Fig. 4.3 Breast carcinoma.
Tissue harmonic imaging
4 Ultrasound Diagnosis of Breast Cancer
malignant tumor results in vascular architectonics, which differs from the same of a benign
lesion and physiological breast changes. According to Holcombe et al. ( 1995 ) , large number of
vessels within a malignant breast lesion suggests
its higher stage and possible metastases in axillary lymph nodes.
Madjar et al. ( 1995 ) suggested counting all
vessels detected within the nodule for quantitative assessment of the vascularity of breast
lesions. According to their data, benign lesions
demonstrated 2 arteries on the average, while
malignant demonstrated up to 11. Sohn et al.
( 1997 ) report correlation between vascularization
and size of the tumor. Fiedler et al. ( 1996 ) consider that CDI is effective only in tumors larger
than 1–2 cm in size (blood fl ow was identi fi ed in
90 % of cases, whereas in tumors smaller than
1 cm, in 41.7 %). According to Сhao ( 1999 ), the
average size of avascular breast neoplasms was
654.4 Color and Power Doppler Imaging
1.9 ± 0.1 cm, and vascularized tumors had the
size of 2.7 ± 0.1 cm. Sohn et al. ( 1997 ) consider
that the mentioned methods of scoring are too
labor-consuming and are not reliable in practice
due to high operator and scanner dependency.
According to Madjar et al. ( 1995 ) , the vessels
in a malignant breast neoplasm can be detected in
43–100 % of instances with 5–14 arteries (8–11
on the average) identi fi ed within the tumor.
Madjar et al. ( 1995 ) report that the presence of
two and more vessels within a tumor is a typical
sign of cancer. According to Ivanova et al. ( 2006 ),
only in fi ltrative cancer is vascularized in 100 %
of cases. It has speci fi c characteristics with
pulsed-wave Doppler, such as absence of diastolic component and arteriovenous shunts.
Trufanov et al. ( 2009 ) report that the majority of
malignant breast tumors are well vascularized
and exhibit intranodular (72.6 %) or mixed
(13.8 %) type of vascular pattern.
Fig. 4.4 Breast cancer.
Adaptive coloring
66
Fig. 4.4 (continued)
4 Ultrasound Diagnosis of Breast Cancer
Cosgrove et al. ( 1993 ) differentiate three types
of blood fl ow within a lesion: perinodular, intranodular, and mixed. Lesions are often divided into
hypervascular (with multiple arterial and venous
vessels), hypovascular (with 2–3 color pixels),
and avascular (without color pixels within)
(Harchenko et al. 1999 ) . Sinyukova et al. ( 2007 )
defi ne three patterns of blood fl ow within breast
masses, as follows: with an individual vessel,
with local increase in blood fl ow, and with diffuse vascularization.
Nadareishvili et al. ( 2002 ) suggested to divide
Doppler signals in lesion structure into four types
according to their shape: individual, linear, chaotic, and branching. Depending on localization,
the intratumoral blood fl ow is divided into three
groups: central (up to 6.4 %), peripheral (25.9 %),
and mixed (67.7 %).
674.4 Color and Power Doppler Imaging
The vessels within malignant breast lesions
are often located chaotically with multiple anastomoses and arteriovenous shunts. They often
have irregular caliber (narrow and wide parts)
and looped or spiral shape (Madjar et al. 1995 ) .
Dilation of vessels within breast carcinoma
results from several factors, such as local
increase in the temperature and the in fl uence of
an oxide of nitrogen due to malignant process.
These aspects explain the increase in local
vascularity of breast carcinoma with CDI and
PDI (Fisenko 1999 ) .
According to Madjar et al. ( 1995 ) , breast carcinoma is often surrounded with hypervascular
area. Lee et al. ( 1995 ) and Fisenko and Sandrikov
( 1998 ) report that the presence of vascular structures within the nodule or around it is suspicious
for breast carcinoma.
Tro fi mova ( 2000a, b ) reports that vascularization can be detected in 90.5 % of malignant
Fig. 4.5 Breast carcinoma.
CDI. ( a ) Avascular lesion.
( b ) Well-vascularized tumor
a1
a2
68
Fig. 4.5 (continued)
4 Ultrasound Diagnosis of Breast Cancer
a3
a4
Fig. 4.5 (continued)
694.4 Color and Power Doppler Imaging
b1
b2
70
Fig. 4.5 (continued)
4 Ultrasound Diagnosis of Breast Cancer
b3
b4