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Echogenicity: Hypoechoic (US)
Wendie A. Berg, MD, PhD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Internal echogenicity of mass is assessed relative to subcutaneous fat
            • Hypoechoic: Darker gray than subcutaneous fat
              • Markedly hypoechoic: One of "malignant" US features with ≥ 50% positive predictive value for malignancy among biopsied masses
            • Distinguish from anechoic, isoechoic, hyperechoic
              • Anechoic: Absence of internal echoes
            • Isoechoic: Echogenicity equal to subcutaneous fat
              • May ↓ sensitivity of US, poor conspicuity when surrounded by fat
            • Hypo- and isoechoic patterns are common among benign and malignant lesions
              • Mildly hypo- to isoechoic solid: 527/625 (84.3%) benign and 38/125 (30.4%) malignant masses (Stavros)
              • Markedly hypoechoic solid: 62/625 (9.9%) benign and 86/125 (69%) malignant masses (Stavros)
              • Useful only in combination with other features
            • Echotexture (echo pattern) can be homogeneous or heterogeneous (mixed)
              • Mixed echogenicity typically implies both hypo- and hyperechoic areas within mass
              • Complex cystic and solid implies anechoic (cystic) component as well as (usually) hypoechoic solid component
            • Oval shape = ellipsoid, includes 2 or 3 gentle lobulations

          IMAGING

          • General Features

            • Mammographic Findings

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      CLINICAL ISSUES

                      • Presentation

                        • Treatment

                          DIAGNOSTIC CHECKLIST

                          • Consider

                            Selected References

                            1. Wu T et al: Identification of a correlation between the sonographic appearance and molecular subtype of invasive breast cancer: A review of 311 cases. Clin Imaging. 53:179-85, 2019
                            2. Pistolese CA et al: Probably benign breast nodular lesions (BI-RADS 3): correlation between ultrasound features and histologic findings. Ultrasound Med Biol. 45(1):78-84, 2019
                            3. Koh J et al: Role of elastography for downgrading BI-RADS category 4a breast lesions according to risk factors. Acta Radiol. epub, 2018.
                            4. Koh J et al: Intrinsic subtypes of breast cancers initially assessed as probably benign or of low suspicion on ultrasonography differ according to tumor size. J Ultrasound Med. 37(6):1503-9, 2018
                            5. Moon HJ et al: Follow-up interval for probably benign breast lesions on screening ultrasound in women at average risk for breast cancer with dense breasts. Acta Radiol. 59(9):1045-50, 2018
                            6. Jang JY et al: Clinical significance of interval changes in breast lesions initially categorized as probably benign on breast ultrasound. Medicine (Baltimore). 96(12):e6415, 2017
                            7. Knabben L et al: Breast cancer and pregnancy. Horm Mol Biol Clin Investig. 32(1), 2017
                            8. Stavros AT et al: Ultrasound positive predictive values by BI-RADS categories 3-5 for solid masses: an independent reader study. Eur Radiol. 27(10):4307-15, 2017
                            9. Berg WA et al: Quantitative maximum shear-wave stiffness of breast masses as a predictor of histopathologic severity. AJR Am J Roentgenol. 205(2):448-55, 2015
                            10. Elverici E et al: Nonpalpable BI-RADS 4 breast lesions: sonographic findings and pathology correlation. Diagn Interv Radiol. 21(3):189-94, 2015
                            11. Barr RG et al: Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial. Radiology. 269(3):701-12, 2013
                            12. Irshad A et al: Assessing the role of ultrasound in predicting the biological behavior of breast cancer. AJR Am J Roentgenol. 200(2):284-90, 2013
                            13. Mendelson EB et al: Breast Imaging Reporting and Data System: BI-RADS, Ultrasound. 2nd ed. Reston, VA: American College of Radiology, 2013
                            14. Lehman CD et al: Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women 30-39 years of age. AJR Am J Roentgenol. 199(5):1169-77, 2012
                            15. Harvey JA et al: Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women. AJR Am J Roentgenol. 193(6):1723-30, 2009
                            16. Graf O et al: Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted? Radiology. 233(3):850-6, 2004
                            17. Stavros AT: Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins, 2004
                            18. Szopinski KT et al: Tissue harmonic imaging: utility in breast sonography. J Ultrasound Med. 22(5):479-87; quiz 488- 9, 2003
                            19. Stavros AT et al: Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 196(1):123-34, 1995
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Imaging

                                • Top Differential Diagnoses

                                  • Clinical Issues

                                    TERMINOLOGY

                                    • Definitions

                                      • Internal echogenicity of mass is assessed relative to subcutaneous fat
                                      • Hypoechoic: Darker gray than subcutaneous fat
                                        • Markedly hypoechoic: One of "malignant" US features with ≥ 50% positive predictive value for malignancy among biopsied masses
                                      • Distinguish from anechoic, isoechoic, hyperechoic
                                        • Anechoic: Absence of internal echoes
                                      • Isoechoic: Echogenicity equal to subcutaneous fat
                                        • May ↓ sensitivity of US, poor conspicuity when surrounded by fat
                                      • Hypo- and isoechoic patterns are common among benign and malignant lesions
                                        • Mildly hypo- to isoechoic solid: 527/625 (84.3%) benign and 38/125 (30.4%) malignant masses (Stavros)
                                        • Markedly hypoechoic solid: 62/625 (9.9%) benign and 86/125 (69%) malignant masses (Stavros)
                                        • Useful only in combination with other features
                                      • Echotexture (echo pattern) can be homogeneous or heterogeneous (mixed)
                                        • Mixed echogenicity typically implies both hypo- and hyperechoic areas within mass
                                        • Complex cystic and solid implies anechoic (cystic) component as well as (usually) hypoechoic solid component
                                      • Oval shape = ellipsoid, includes 2 or 3 gentle lobulations

                                    IMAGING

                                    • General Features

                                      • Mammographic Findings

                                        • Ultrasonographic Findings

                                          • MR Findings

                                            • Imaging Recommendations

                                              DIFFERENTIAL DIAGNOSIS

                                                CLINICAL ISSUES

                                                • Presentation

                                                  • Treatment

                                                    DIAGNOSTIC CHECKLIST

                                                    • Consider

                                                      Selected References

                                                      1. Wu T et al: Identification of a correlation between the sonographic appearance and molecular subtype of invasive breast cancer: A review of 311 cases. Clin Imaging. 53:179-85, 2019
                                                      2. Pistolese CA et al: Probably benign breast nodular lesions (BI-RADS 3): correlation between ultrasound features and histologic findings. Ultrasound Med Biol. 45(1):78-84, 2019
                                                      3. Koh J et al: Role of elastography for downgrading BI-RADS category 4a breast lesions according to risk factors. Acta Radiol. epub, 2018.
                                                      4. Koh J et al: Intrinsic subtypes of breast cancers initially assessed as probably benign or of low suspicion on ultrasonography differ according to tumor size. J Ultrasound Med. 37(6):1503-9, 2018
                                                      5. Moon HJ et al: Follow-up interval for probably benign breast lesions on screening ultrasound in women at average risk for breast cancer with dense breasts. Acta Radiol. 59(9):1045-50, 2018
                                                      6. Jang JY et al: Clinical significance of interval changes in breast lesions initially categorized as probably benign on breast ultrasound. Medicine (Baltimore). 96(12):e6415, 2017
                                                      7. Knabben L et al: Breast cancer and pregnancy. Horm Mol Biol Clin Investig. 32(1), 2017
                                                      8. Stavros AT et al: Ultrasound positive predictive values by BI-RADS categories 3-5 for solid masses: an independent reader study. Eur Radiol. 27(10):4307-15, 2017
                                                      9. Berg WA et al: Quantitative maximum shear-wave stiffness of breast masses as a predictor of histopathologic severity. AJR Am J Roentgenol. 205(2):448-55, 2015
                                                      10. Elverici E et al: Nonpalpable BI-RADS 4 breast lesions: sonographic findings and pathology correlation. Diagn Interv Radiol. 21(3):189-94, 2015
                                                      11. Barr RG et al: Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial. Radiology. 269(3):701-12, 2013
                                                      12. Irshad A et al: Assessing the role of ultrasound in predicting the biological behavior of breast cancer. AJR Am J Roentgenol. 200(2):284-90, 2013
                                                      13. Mendelson EB et al: Breast Imaging Reporting and Data System: BI-RADS, Ultrasound. 2nd ed. Reston, VA: American College of Radiology, 2013
                                                      14. Lehman CD et al: Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women 30-39 years of age. AJR Am J Roentgenol. 199(5):1169-77, 2012
                                                      15. Harvey JA et al: Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women. AJR Am J Roentgenol. 193(6):1723-30, 2009
                                                      16. Graf O et al: Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted? Radiology. 233(3):850-6, 2004
                                                      17. Stavros AT: Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins, 2004
                                                      18. Szopinski KT et al: Tissue harmonic imaging: utility in breast sonography. J Ultrasound Med. 22(5):479-87; quiz 488- 9, 2003
                                                      19. Stavros AT et al: Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 196(1):123-34, 1995