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Posterior Features (US)
Uzma Waheed, MD; Wendie A. Berg, MD, PhD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Synonyms

                • Posterior enhancement: Increased through transmission
                • Posterior shadowing: Posterior attenuation, acoustic shadowing
              • Definitions

                • Posterior (acoustic) enhancement
                  • Sound travels better through lesion than surrounding tissue → ↑ echoes (brighter) in tissues posterior to lesion relative to adjacent tissues at comparable depth
                • No posterior features: No shadowing or enhancement
                  • Echogenicity of tissue immediately behind mass is not different from that of adjacent tissue at same depth
                • Posterior (acoustic) shadowing
                  • Attenuation of US beam → ↓ echoes in tissue posterior to lesion relative to adjacent tissue at comparable depth
                  • Calcifications > 1-2 mm can cause shadowing
                • Does not include refractive edge shadowing
                  • Refraction of sound waves occurs at edges of curved mass or ligaments perpendicular to US beam → ↓ echoes in tissue directly deep to curved surface
                  • Thin (1-2 mm) stripe of shadowing tangential to surface of mass, perpendicular to beam
                    • Essentially eliminated with spatial compounding (multiple off-angle beams)
                • Mixed pattern: Some portions of lesion cause posterior enhancement, and others cause posterior shadowing
                • Spatial compounding: Use of multiple off-angle US beams
                  • Improves margin assessment on sides of mass
                  • Posterior features less apparent

              IMAGING

              • General Features

                • Mammographic Findings

                  • Ultrasonographic Findings

                    • MR Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              CLINICAL ISSUES

                              • Presentation

                                DIAGNOSTIC CHECKLIST

                                • Consider

                                  • Image Interpretation Pearls

                                    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. 53:179-185, 2019
                                    2. Wen X et al: Correlations between ultrasonographic findings of invasive lobular carcinoma of the breast and intrinsic subtypes. Ultraschall Med. ePub, 2018
                                    3. Au FW et al: Histological grade and immunohistochemical biomarkers of breast cancer: correlation to ultrasound features. J Ultrasound Med. 36(9):1883-1894, 2017
                                    4. Elverici E et al: Nonpalpable BI-RADS 4 breast lesions: sonographic findings and pathology correlation. Diagn Interv Radiol. 21(3):189-94, 2015
                                    5. Zhang L et al: Identifying ultrasound and clinical features of breast cancer molecular subtypes by ensemble decision. Sci Rep. 5:11085, 2015
                                    6. Çelebi F et al: The role of ultrasonographic findings to predict molecular subtype, histologic grade, and hormone receptor status of breast cancer. Diagn Interv Radiol. 21(6):448-53, 2015
                                    7. Aho M et al: Correlation of sonographic features of invasive ductal mammary carcinoma with age, tumor grade, and hormone-receptor status. J Clin Ultrasound. 41(1):10-7, 2013
                                    8. 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
                                    9. Mendelson EB et al: Breast Imaging Reporting and Data System: BI-RADS, Ultrasound. 2nd ed. Reston: American College of Radiology. 2013
                                    10. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                                    11. Blaichman J et al: Sonographic appearance of invasive ductal carcinoma of the breast according to histologic grade. AJR Am J Roentgenol. 199(3):W402-8, 2012
                                    12. Linda A et al: Nonsurgical management of high-risk lesions diagnosed at core needle biopsy: can malignancy be ruled out safely with breast MRI? AJR Am J Roentgenol. 198(2):272-80, 2012
                                    13. Barr RG and Lackey AE: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 27:151-5, 2011
                                    14. Hsu HH et al: Complex cystic lesions of the breast on ultrasonography: feature analysis and BI-RADS assessment. Eur J Radiol. 79(1):73-9, 2011
                                    15. Berg WA et al: Cystic breast lesions and the ACRIN 6666 experience. Radiol Clin North Am. 48:931-87, 2010
                                    16. Lopez JK et al: Invasive lobular carcinoma of the breast: spectrum of mammographic, US, and MR imaging findings. Radiographics. 29(1):165-76, 2009
                                    17. Kim SH et al: Correlation of ultrasound findings with histology, tumor grade, and biological markers in breast cancer. Acta Oncol. 47(8):1531-8, 2008
                                    18. Berg WA et al: Operator dependence of physician-performed whole-breast US: lesion detection and characterization. Radiology. 241:355-65, 2006
                                    19. Costantini M et al: Characterization of solid breast masses: use of the sonographic breast imaging reporting and data system lexicon. J Ultrasound Med. 25(5):649-59; quiz 661, 2006
                                    20. Cawson JN: Can sonography be used to help differentiate between radial scars and breast cancers? Breast. 14(5):352-9, 2005
                                    21. Hong AS et al: BI-RADS for sonography: positive and negative predictive values of sonographic features. AJR Am J Roentgenol. 184(4):1260-5, 2005
                                    22. Paulinelli RR et al: Risk of malignancy in solid breast nodules according to their sonographic features. J Ultrasound Med. 24(5):635-41, 2005
                                    23. Watermann DO et al: Ultrasound morphology of invasive lobular breast cancer is different compared with other types of breast cancer. Ultrasound Med Biol. 31(2):167-74, 2005
                                    24. Selinko VL et al: Role of sonography in diagnosing and staging invasive lobular carcinoma. J Clin Ultrasound. 32(7):323-32, 2004
                                    25. Stavros AT: Breast Ultrasound. Philadelphia: Lippincott Williams & Wilkins. 641-8, 2004
                                    26. Weinstein SP et al: Posterior acoustic shadowing in benign breast lesions: sonographic-pathologic correlation. J Ultrasound Med. 23(1):73-83, 2004
                                    27. Ahn BY et al: Pregnancy- and lactation-associated breast cancer: mammographic and sonographic findings. J Ultrasound Med. 22(5):491-7; quiz 498-9, 2003
                                    28. Berg WA et al: Cystic lesions of the breast: sonographic-pathologic correlation. Radiology 227:183-191, 2003
                                    29. Memis A et al: Granulomatous mastitis: imaging findings with histopathologic correlation. Clin Radiol. 57(11):1001-6, 2002
                                    30. Samardar P et al: Focal asymmetric densities seen at mammography: US and pathologic correlation. Radiographics. 22(1):19-33, 2002
                                    31. Seo BK et al: Sonographic evaluation of breast nodules: comparison of conventional, real-time compound, and pulse-inversion harmonic images. Korean J Radiol. 3(1):38-44, 2002
                                    32. Wong KT et al: Ultrasound and MR imaging of diabetic mastopathy. Clin Radiol. 57(8):730-5, 2002
                                    33. Woo KM et al: US of ductal carcinoma in situ. Radiographics. 22:269-81, 2002
                                    34. Lamb PM et al: Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast. Clin Radiol. 55(1):40-4, 2000
                                    35. Revelon G et al: Focal fibrosis of the breast: imaging characteristics and histopathologic correlation. Radiology. 216(1):255-9, 2000
                                    36. Butler RS et al: Sonographic evaluation of infiltrating lobular carcinoma. AJR Am J Roentgenol. 172(2):325-30, 1999
                                    37. Georgian-Smith D et al: From the RSNA refresher courses. Freehand interventional sonography in the breast: basic principles and clinical applications. Radiographics. 16(1):149-61, 1996
                                    38. Paramagul CP et al: Invasive lobular carcinoma: sonographic appearance and role of sonography in improving diagnostic sensitivity. Radiology. 195(1):231-4, 1995
                                    39. Stavros AT et al: Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 196(1):123-34, 1995
                                    40. Hilton SV et al: Real-time breast sonography: application in 300 consecutive patients. AJR Am J Roentgenol. 147(3):479-86, 1986
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Imaging

                                        • Top Differential Diagnoses

                                          • Pathology

                                            • Clinical Issues

                                              • Diagnostic Checklist

                                                TERMINOLOGY

                                                • Synonyms

                                                  • Posterior enhancement: Increased through transmission
                                                  • Posterior shadowing: Posterior attenuation, acoustic shadowing
                                                • Definitions

                                                  • Posterior (acoustic) enhancement
                                                    • Sound travels better through lesion than surrounding tissue → ↑ echoes (brighter) in tissues posterior to lesion relative to adjacent tissues at comparable depth
                                                  • No posterior features: No shadowing or enhancement
                                                    • Echogenicity of tissue immediately behind mass is not different from that of adjacent tissue at same depth
                                                  • Posterior (acoustic) shadowing
                                                    • Attenuation of US beam → ↓ echoes in tissue posterior to lesion relative to adjacent tissue at comparable depth
                                                    • Calcifications > 1-2 mm can cause shadowing
                                                  • Does not include refractive edge shadowing
                                                    • Refraction of sound waves occurs at edges of curved mass or ligaments perpendicular to US beam → ↓ echoes in tissue directly deep to curved surface
                                                    • Thin (1-2 mm) stripe of shadowing tangential to surface of mass, perpendicular to beam
                                                      • Essentially eliminated with spatial compounding (multiple off-angle beams)
                                                  • Mixed pattern: Some portions of lesion cause posterior enhancement, and others cause posterior shadowing
                                                  • Spatial compounding: Use of multiple off-angle US beams
                                                    • Improves margin assessment on sides of mass
                                                    • Posterior features less apparent

                                                IMAGING

                                                • General Features

                                                  • Mammographic Findings

                                                    • Ultrasonographic Findings

                                                      • MR Findings

                                                        • Imaging Recommendations

                                                          DIFFERENTIAL DIAGNOSIS

                                                            PATHOLOGY

                                                            • General Features

                                                              • Staging, Grading, & Classification

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  DIAGNOSTIC CHECKLIST

                                                                  • Consider

                                                                    • Image Interpretation Pearls

                                                                      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. 53:179-185, 2019
                                                                      2. Wen X et al: Correlations between ultrasonographic findings of invasive lobular carcinoma of the breast and intrinsic subtypes. Ultraschall Med. ePub, 2018
                                                                      3. Au FW et al: Histological grade and immunohistochemical biomarkers of breast cancer: correlation to ultrasound features. J Ultrasound Med. 36(9):1883-1894, 2017
                                                                      4. Elverici E et al: Nonpalpable BI-RADS 4 breast lesions: sonographic findings and pathology correlation. Diagn Interv Radiol. 21(3):189-94, 2015
                                                                      5. Zhang L et al: Identifying ultrasound and clinical features of breast cancer molecular subtypes by ensemble decision. Sci Rep. 5:11085, 2015
                                                                      6. Çelebi F et al: The role of ultrasonographic findings to predict molecular subtype, histologic grade, and hormone receptor status of breast cancer. Diagn Interv Radiol. 21(6):448-53, 2015
                                                                      7. Aho M et al: Correlation of sonographic features of invasive ductal mammary carcinoma with age, tumor grade, and hormone-receptor status. J Clin Ultrasound. 41(1):10-7, 2013
                                                                      8. 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
                                                                      9. Mendelson EB et al: Breast Imaging Reporting and Data System: BI-RADS, Ultrasound. 2nd ed. Reston: American College of Radiology. 2013
                                                                      10. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                                                                      11. Blaichman J et al: Sonographic appearance of invasive ductal carcinoma of the breast according to histologic grade. AJR Am J Roentgenol. 199(3):W402-8, 2012
                                                                      12. Linda A et al: Nonsurgical management of high-risk lesions diagnosed at core needle biopsy: can malignancy be ruled out safely with breast MRI? AJR Am J Roentgenol. 198(2):272-80, 2012
                                                                      13. Barr RG and Lackey AE: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 27:151-5, 2011
                                                                      14. Hsu HH et al: Complex cystic lesions of the breast on ultrasonography: feature analysis and BI-RADS assessment. Eur J Radiol. 79(1):73-9, 2011
                                                                      15. Berg WA et al: Cystic breast lesions and the ACRIN 6666 experience. Radiol Clin North Am. 48:931-87, 2010
                                                                      16. Lopez JK et al: Invasive lobular carcinoma of the breast: spectrum of mammographic, US, and MR imaging findings. Radiographics. 29(1):165-76, 2009
                                                                      17. Kim SH et al: Correlation of ultrasound findings with histology, tumor grade, and biological markers in breast cancer. Acta Oncol. 47(8):1531-8, 2008
                                                                      18. Berg WA et al: Operator dependence of physician-performed whole-breast US: lesion detection and characterization. Radiology. 241:355-65, 2006
                                                                      19. Costantini M et al: Characterization of solid breast masses: use of the sonographic breast imaging reporting and data system lexicon. J Ultrasound Med. 25(5):649-59; quiz 661, 2006
                                                                      20. Cawson JN: Can sonography be used to help differentiate between radial scars and breast cancers? Breast. 14(5):352-9, 2005
                                                                      21. Hong AS et al: BI-RADS for sonography: positive and negative predictive values of sonographic features. AJR Am J Roentgenol. 184(4):1260-5, 2005
                                                                      22. Paulinelli RR et al: Risk of malignancy in solid breast nodules according to their sonographic features. J Ultrasound Med. 24(5):635-41, 2005
                                                                      23. Watermann DO et al: Ultrasound morphology of invasive lobular breast cancer is different compared with other types of breast cancer. Ultrasound Med Biol. 31(2):167-74, 2005
                                                                      24. Selinko VL et al: Role of sonography in diagnosing and staging invasive lobular carcinoma. J Clin Ultrasound. 32(7):323-32, 2004
                                                                      25. Stavros AT: Breast Ultrasound. Philadelphia: Lippincott Williams & Wilkins. 641-8, 2004
                                                                      26. Weinstein SP et al: Posterior acoustic shadowing in benign breast lesions: sonographic-pathologic correlation. J Ultrasound Med. 23(1):73-83, 2004
                                                                      27. Ahn BY et al: Pregnancy- and lactation-associated breast cancer: mammographic and sonographic findings. J Ultrasound Med. 22(5):491-7; quiz 498-9, 2003
                                                                      28. Berg WA et al: Cystic lesions of the breast: sonographic-pathologic correlation. Radiology 227:183-191, 2003
                                                                      29. Memis A et al: Granulomatous mastitis: imaging findings with histopathologic correlation. Clin Radiol. 57(11):1001-6, 2002
                                                                      30. Samardar P et al: Focal asymmetric densities seen at mammography: US and pathologic correlation. Radiographics. 22(1):19-33, 2002
                                                                      31. Seo BK et al: Sonographic evaluation of breast nodules: comparison of conventional, real-time compound, and pulse-inversion harmonic images. Korean J Radiol. 3(1):38-44, 2002
                                                                      32. Wong KT et al: Ultrasound and MR imaging of diabetic mastopathy. Clin Radiol. 57(8):730-5, 2002
                                                                      33. Woo KM et al: US of ductal carcinoma in situ. Radiographics. 22:269-81, 2002
                                                                      34. Lamb PM et al: Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast. Clin Radiol. 55(1):40-4, 2000
                                                                      35. Revelon G et al: Focal fibrosis of the breast: imaging characteristics and histopathologic correlation. Radiology. 216(1):255-9, 2000
                                                                      36. Butler RS et al: Sonographic evaluation of infiltrating lobular carcinoma. AJR Am J Roentgenol. 172(2):325-30, 1999
                                                                      37. Georgian-Smith D et al: From the RSNA refresher courses. Freehand interventional sonography in the breast: basic principles and clinical applications. Radiographics. 16(1):149-61, 1996
                                                                      38. Paramagul CP et al: Invasive lobular carcinoma: sonographic appearance and role of sonography in improving diagnostic sensitivity. Radiology. 195(1):231-4, 1995
                                                                      39. Stavros AT et al: Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 196(1):123-34, 1995
                                                                      40. Hilton SV et al: Real-time breast sonography: application in 300 consecutive patients. AJR Am J Roentgenol. 147(3):479-86, 1986