Breast Ultrasound PDF
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13401cFM.PGS 11/11/03 12:25 PM Page i BREAST ULTRASOUND 13401cFM.PGS 11/11/03 12:25 PM Page ii 13401cFM.PGS 11/11/03 12:25 PM Page iii BREAST ULTRASOUND A. THOMAS STAVROS, MD, FACR Radiology Imaging Associates / Invision–Sally Jobe Breast Centers Englewood, Colorado With contributions by Cynthia L. Rapp, BS, RDMS, FAIUM, FSDMS Invision / Radiology Imaging Associates Greenwood Village, Colorado Steve H. Parker, MD, FACR Sally Jobe Breast Center Greenwood Village, Colorado 13401cFM.PGS 11/11/03 12:25 PM Page iv Acquisitions Editor: Lisa McAllister Developmental Editor: Keith Donnellan Production Editor: Steven P. Martin Production Editor: Richard Rothschild, Print Matters, Inc. Manufacturing Manager: Benjamin Rivera Cover Designer: David Levy Compositor: Compset, Inc. Printer: Edwards Brothers © 2004 by LIPPINCOTT WILLIAMS & WILKINS 530 Walnut Street Philadelphia, PA 19106 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in the USA Library of Congress Cataloging-in-Publication Data Stavros, A. Thomas. Breast ultrasound / A. Thomas Stavros. p. ; cm. Includes bibliographical references and index. ISBN 0-397-51624-X 1. Breast—Ultrasonic imaging. 2. Breast—Diseases—Diagnosis. 3. Breast—Cancer—Ultrasonic imaging. I. Title. [DNLM: 1. Ultrasonography, Mammary. WP 815 S798b 2003] RG493.5.U47S73 2003 618.1(cid:2)907543—dc22 2003060296 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. 10 9 8 7 6 5 4 3 2 1 13401cFM.PGS 11/11/03 12:25 PM Page v CONTENTS Preface vii 1 Introduction to Breast Ultrasound 1 2 Breast Ultrasound Equipment Requirements 16 3 Breast Ultrasound Technique 42 4 Breast Anatomy: The Basis for Understanding Sonography 56 5 Targeted Indication: Palpable Abnormality 109 6 Targeted Indication: Mammographic Abnormality 124 7 Nontargeted Indications 147 8 Nontargeted Indications: Breast Secretions, Nipple Discharge, and Intraductal Papillary Lesions of the Breast 157 9 Nontargeted Indications: Mammary Implants 199 A. Thomas Stavros and Cynthia L. Rapp 10 Sonographic Evaluation of Breast Cysts 276 11 Nonmalignant Breast Disorders that have Complex Cystic Phases 351 12 Ultrasound of Solid Breast Nodules: Distinguishing Benign from Malignant 445 13 Benign Solid Nodules: Specific Pathological Diagnoses 528 14 Malignant Solid Breast Nodules: Specific Types 597 15 Atypical, High-Risk, Premalignant, and Locally Aggressive Lesions 689 16 Evaluation of the Male Breast 712 17 Ultrasound-Guided Needle Procedures in the Breast 742 Steve H. Parker 18 Sonographic Evaluation of the Iatrogenically Altered Breast 778 19 Evaluation of Regional Lymph Nodes in Breast Cancer Patients 834 20 Doppler Evaluation of the Breast 877 21 False-Negative and False-Positive Breast Sonographic Examinations 947 Appendix 979 Index 981 v 13401cFM.PGS 11/11/03 12:25 PM Page vi 13401cFM.PGS 11/11/03 12:25 PM Page vii PREFACE I have written Breast Ultrasound for radiologists, breast Dr. Tabar has pioneered the teaching of mammography surgeons, breast pathologists, sonographers, and mammog- based upon subgross histologic alterations of anatomy. Dr. raphy technologists who perform diagnostic breast sonog- Teboul has pioneered the anatomic approach to breast raphy. While this book is officially the first edition, it imaging. The anatomic and pathologic bases for sono- unofficially represents the third edition. During the nearly graphic evaluation of the breast should be of interest to all 10 years that I have been writing this book, ultrasound subgroups of the targeted audience. technology and our ability to demonstrate breast anatomy The algorithms that we employ to assess breast lesions and pathology has changed so dramatically and rapidly sonographically were designed to comfort mammographers that it has continually altered our ideas of possibilities and who might otherwise feel uncomfortable with sonographic limitations. Each of the first two times I neared completion characterization. To the greatest extent possible, we have of the book, new developments made earlier writings seem tried to avoid reinventing the wheel. We have used as much obsolete, requiring significant rewriting and replacement of the information gleaned from mammography over the of older images. Ultrasound transducer frequencies have years as possible. We use mammographic ACR BIRADS climbed, bandwidths expanded, and dynamic ranges in- categories to classify sonographic lesions. The risk of ma- creased. Coded harmonics and real-time spatial com- lignancy for a sonographic lesion in any given BIRADS pounding have suppressed speckle artifact and improved category is the same as the risk of malignancy for a mam- contrast resolution. Far more is possible today than was mographic finding of the same category. Thus, manage- possible 10 years ago. ment rules used every day by a mammographer for any Sonographic resolution has increased beyond the abil- given mammographic BIRADS category can be used to ity to identify zones of the breast and tissue types to being manage a sonographic finding in the same BIRADS cate- able to identify several orders of mammary ducts and the gory. The sonographic algorithm, like the mammographic functional unit of the breast, the terminal ducto-lobular algorithm, requires multiple suspicious findings in order to unit (TDLU). Most benign and malignant breast pathol- take into account the heterogeneity of breast cancer. We ogy arises within the TDLU. Breast cancer enlarges and also use as many mammographic findings as possible in distorts the lobules from which it arises and the ducts our sonographic algorithms. Six of the nine suspicious through which it spreads. We now have the potential to sonographic findings that we use to characterize solid recognize these changes at earlier stages, increasing sono- breast nodules are simply suspicious mammographic find- graphic sensitivity for early breast carcinoma and improv- ings applied directly to sonography. Similarly, about half ing our ability to determine extent of malignant disease. the benign findings that we use for sonographic assessment Many benign processes also arise in the TDLU, some caus- of complex cysts are mammographic findings applied di- ing characteristically benign sonographic findings, improv- rectly to sonography. Finally, the algorithm that we use for ing our negative predictive ability. sonographically evaluating solid nodules and complex cysts This book has been written with a strong emphasis on is very similar to the mammographic algorithm. Both the how the gross histopathologic morphology of both benign mammographic and sonographic algorithms involve look- malignant processes alters sonographic anatomy and how ing for suspicious findings first, and if any suspicious find- to use this information to improve our ability to character- ings are found, an action is required. The sonographic ize cystic and solid lesions of the breast. It is influenced algorithm goes one step further, requiring specific identifi- greatly by the teachings of Laszlo Tabar and Michel Teboul. cation of benign findings before a nodule can be character- vii 13401cFM.PGS 11/11/03 12:25 PM Page viii viii Preface ized as probably benign. Because the sonographic algo- ment of familiar mammographic findings, algorithms, and rithms are based so heavily upon the algorithms with management rules helps readers achieve a comfort zone which all US mammographers are familiar, the mam- with diagnostic breast ultrasound that they may not have mographer should be comfortable with the sonographic al- had before reading the book. gorithm that we present. The mammographer should I would like to offer thanks for all those who have in- conclude after reading this book that sonographic charac- spired, encouraged, and helped me to finally complete this terization beyond cyst vs. solid is not at all a wild and crazy task. I have been inspired by my partner and mentor Bill scheme—it is merely the mammographic algorithm with Jobe (Jobee-wan-Kanobe) and my partner and co-conspir- extra steps of conservatism built into it. ator Steve Parker, who has written the chapter on ultra- This text was designed to be a reference text. Thus, sound-guided intervention and who has encouraged me to each chapter was designed to stand alone. Some informa- speak and to write about breast ultrasound. I would like to tion has been presented more than once, and therefore, ap- thank Dr. Hanne Jensen and Dr. Laszlo Tabar for granting pears in several different chapters. me permission to use some of their magnificent subgross This book emphasizes the diagnostic role of sonogra- 3D pathology images in this book. I would also like to phy in characterizing and managing palpable and mammo- thank: Maureen Biffinger, who made sure that I received graphic abnormalities rather than its role as a screening copies all the breast biopsy reports over a period of about modality. However, other roles—such as evaluating nipple 15 years; Mary Mucilli and Charlie Winger, who helped discharge and mammary implants—have also been pre- manage the database of tens of thousands of sonography sented in detail. The important roles of sonography in as- and breast biopsy reports and sonographic-pathologic sessing extent of malignant disease and regional lymph correlations; and Jon McGrath, who helped manage and nodes and in assessing the breast after breast cancer treat- catalogue the database of thousands of sonographic, mam- ment have also been presented. mographic, and pathologic images. I would like to thank Diagnostic imagers are visual learners. Seeing lots Cindy Rapp, RDMS, and Dr. David Harshfield for help- of images facilitates visual learning. Thus, this book has ing to edit multiple versions the book and Dr. Terry been extensively illustrated. The images included should Giezinski, who helped proofread the galley proofs. Finally, be useful as frames of reference within the readers’ own I thank my wife, Margaret, and my children, Becca, Sarah, departments. Charles, and Anne, for putting up with me and my ab- We sincerely hope that the emphasis on how breast pa- sences during the long and winding journey to completion. thology affects the underlying anatomy and the employ- 13401c01.PGS 11/5/03 10:54 AM Page 1 1 INTRODUCTION TO BREAST ULTRASOUND GOALS AND INDICATIONS The early failure of BUS as a replacement for mam- mography in breast cancer screening does not diminish its Ultrasound (US) evaluation of the breast can be catego- value as a diagnostic tool. Its use in selected patients as a di- rized as either diagnostic or screening. Breast imaging agnostic adjunct to clinical and mammographic evaluation requires detection and characterization of breast abnormal- can be invaluable. The remainder of this book addresses ities. The relative importance of detection and characteri- the use and interpretation of BUS in a diagnostic role. zation is different for screening and diagnosis. The primary goal of screening is to detect breast cancer in large popula- General Goal of Diagnostic tions of asymptomatic patients. On the other hand, the Breast Ultrasound primary goal of diagnostic breast ultrasound is to charac- terize either abnormalities that have already been detected The general goal of diagnostic BUS is to make a more spe- by screening mammography or palpable abnormalities. cific noninvasive diagnosis in patients who have clinical or Breast ultrasound (BUS) was evaluated as a breast mammographic abnormalities than could be achieved with cancer–screening tool early in its development. It was an mammography and clinical findings alone. The use of BUS attractive alternative to mammography because it did not in appropriately selected patients (those who have clinical use ionizing radiation. Furthermore, because the mecha- or mammographic findings that are not clearly malignant) nism by which ultrasound showed anatomy and pathology should increase the certainty of a benign diagnosis in a was different from that of mammography, it enabled one large number of patients and should increase the suspicion to “see through” mammographically featureless dense tis- of carcinoma in a small number of patients. Sonographic sue and to show breast anatomy and pathology that mam- demonstration of suspicious findings appropriately leads mography could not demonstrate. To capitalize on these to biopsy, even when mammographic findings are nega- advantages, automated whole breast ultrasound scanning tive.On the other hand, sonographic demonstration of de- devices were built and evaluated. Unfortunately, breast finitively benign findings obviates biopsy. Consequently, cancer–screening studies performed with these dedicated appropriately used BUS should lead to biopsy in some pa- whole breast ultrasound scanners showed US to be less ef- tients but should prevent unnecessary biopsy in most. fective than mammography. Because of this, BUS is not Ultrasound has a greater ability than mammography to recommend or widely used for primary breast cancer differentiate among types of normal tissues and to charac- screening in the United States. Instead, it is used for diag- terize complex cysts and solid nodules. Mammography is nosis, after mammography has been performed in most capable only of showing four different densities (air, fat, cases. In our practice, 90% of all patients who undergo water, and metal or calcium) and can further distinguish be- BUS have had mammography first. Of the 10% who do tween different water-density tissues only by differences in not undergo mammography before sonography, almost all thickness and compressibility and by whether the tissues are younger than 30 years of age, pregnant, or undergoing contain some fatty or calcium density. Ultrasound, on the short-interval sonographic follow-up for lesions that are other hand, can distinguish among many different types visible only by sonography. A few others have developed a of normal breast tissue. Like mammography, ultrasound new palpable mass with last screening mammogram less can identify air, fat, and metallic or calcium densities. How- than 6 months earlier. ever, unlike mammography, ultrasound can also distinguish 1 13401c01.PGS 11/5/03 10:54 AM Page 2 2 Breast Ultrasound among different types of normal water-density tissues by Classification of mammographic findings into BI- echogenicity as well as thickness and compressibility. Sono- RADS categories was instituted to force radiologists to stan- graphic breast anatomy is discussed in detail in Chapter 4. dardize terminology, commit themselves in the official Furthermore, the method of image acquisition differs report, prevent unclear reports, and reduce variability be- between mammography and ultrasound. The mammo- tween radiologists in reporting of mammographic findings. graphic image is a three-dimensional summation of anatomy Additionally, it was hoped that this would enable easy entry and pathology resulting in superimposition of water-density of data into databases for analysis of efficacy. Finally, assign- tissues that tends to obscure anatomy and pathology. The ul- ment of an ACR BIRADS category was intended to stan- trasound image, on the other hand, is essentially a tomo- dardize management decisions based on mammographic graphic slice through the breast. The mammographic findings. In our opinion, although not perfect, the ACR BI- density of breast tissues elsewhere within the breast, outside RADS categorization has generally been successfully used in the slice of tissue within the ultrasound beam, is thus irrele- mammography. Table 1–1 shows the mammographic ACR vant to ultrasound. Because ultrasound can identify different BIRADS categories, the descriptive term and risk for malig- echogenicities of various normal water-density tissues, and nancy, and management suggestions for each category. because superimposition of densities is not the problem that In the United States, characterization of mammo- it is for mammography, ultrasound is more capable of show- graphic findings into ACR BIRADS categories is manda- ing the breast ductal and lobular anatomy and pathology tory to achieve Mammography Quality Standards Act than is mammography. Additionally, ultrasound can distin- (MQSA) accreditation. It is unwise to expect any less from guish cystic from solid pathology of the breast. Mammogra- sonography. All complex cystic, indeterminate cystic versus phy cannot. Unfortunately, many mammographers in the solid, and solid nodules shown on sonography should un- United States have advocated limiting ultrasound’s role to dergo level 2 characterization into ACR BIRADS cate- distinguishing cystic from solid masses, a serious mistake. gories. Such lesions may be characterized as BIRADS Properly used, ultrasound is clearly capable of much more category 2 through category 5. Normal anatomy can be and should be used at least as aggressively in patient manage- characterized as BIRADS category 1, and simple cysts may ment as is diagnostic mammography. all be characterized as BIRADS category 2. Only by rigor- ously classifying all ultrasound examinations with BIRADS codes and performing long-term follow-up on hundreds or Mammographic Experience and thousands of cases can the true value of showing normal American College of Radiology Lexicon anatomy for palpable lumps or the real risk for malignancy and Categories of various types of complex cysts be established. Those of It is useful to think of sonographic characterization of us who have performed breast ultrasound for years feel we breast lesions as occurring on two different levels. Level 1 have a good subjective feeling for the value of ultrasound in characterization includes what even the least enthusiastic predicting these things, but our subjective feelings to date mammographers will credit ultrasound with being good at: have been verified only in very small groups of patients. distinguishing cystic from solid. However, level 1 charac- Categorization of every sonographic finding into a BI- terization goes further than just assessment of cystic versus RADS category, entry of the finding and its BIRADS cate- solid masses. There are really five separate categories that gory into a database, and either biopsy or long-term palpable lumps and mammographic densities can be placed sonographic or mammographic follow-up (3 years or into by level 1 characterization: more) will be necessary to prove the negative predictive value of sonographically normal findings in large groups of 1. Normal tissue patients. 2. Simple cystic lesion There is every reason to expect that sonographic BI- 3. Complex or complicated cystic lesion RADS categorization will be as successful as it has been 4. Indeterminate cystic or solid lesion mammographically. In fact, we have been prospectively as- 5. Solid lesion signing BIRADS risk categories to sonographic findings Level 2 characterization goes further, placing each for several years, accumulating the findings in a database, sonographic finding into a risk category for malignancy. and correlating with the data histologic findings, and we These categories were developed for mammography rather are now managing patients based on these correlations. For than sonography by the American College of Radiology ultrasound, we have adopted a slight variation of the ACR (ACR) to help standardize and improve the quality of BIRADS categories. We have broken the BIRADS 4 cate- mammographic reporting and data analysis within the gory into two groups: 4a and 4b. We have done this be- United States and are referred to as Breast Imaging Report- cause we feel that the concept of “probable” is important ing and Data System (BIRADS) categories. Although the medicolegally. The term probable implies a risk of 50% or BIRADS categories were developed for mammography, greater and is useful to patients and referring physicians in not ultrasound, we believe that they can and should be ap- making management decisions as well as being a common plied directly to ultrasound with only minor modifications. legal concept. Thus, our category 4a includes risks from at
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