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Screening Ultrasound
Wendie A. Berg, MD, PhD
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KEY FACTS

  • Terminology

    • Clinical Issues

      • Diagnostic Checklist

        TERMINOLOGY

        • Definitions

          • Bilateral whole-breast US in asymptomatic women as supplement to mammography: Handheld (HHUS) or automated (AUS)
          • Dense breasts: Heterogeneously dense or extremely dense on mammography
          • Negative: BI-RADS 1 or 2 on routine images
          • Recall: BI-RADS 0, 3, 4, or 5 on screening = positive
            • BI-RADS 3, 4, 5 can be used directly on HHUS
          • Interval cancer: Cancer detected clinically in interval between recommended screenings 
            • Prior negative screening examination
            • Within 1 year in USA
          • Indications
            • ≥ 10-year life expectancy
            • Patient has dense breasts and does not meet criteria for supplemental MR screening
            • High-risk women unable to undergo MR screening
              • Pregnant
              • Pacemaker, aneurysm clip, or other ferrometallic implant near vital structure(s)
              • Severe claustrophobia not controlled by sedative
              • Lack access to MR
            • Not a replacement for screening mammography unless patient unable to cooperate (e.g., some disability patients)
          • Incremental cancer detection rate (ICDR) US: Added cancers detected by addition of screening US to mammography

        IMAGING

        • Mammographic Findings

          • Ultrasonographic Findings

            • Imaging Recommendations

              DIFFERENTIAL DIAGNOSIS

                CLINICAL ISSUES

                • Demographics

                  • Natural History & Prognosis

                    DIAGNOSTIC CHECKLIST

                    • Consider

                      • Image Interpretation Pearls

                        • Reporting Tips

                          Selected References

                          1. Buchberger W et al: Combined screening with mammography and ultrasound in a population-based screening program. Eur J Radiol. 101:24-29, 2018
                          2. 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):1045-1050, 2018
                          3. Tagliafico AS et al: A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2). Eur J Cancer. 104:39-46, 2018
                          4. Vourtsis A and Berg WA: Breast density implications and supplemental screening. Eur Radiol. ePub, 2018
                          5. Destounis S et al: New York State breast density mandate: follow-up data with screening sonography. J Ultrasound Med. 36(12):2511-2517, 2017
                          6. Destounis S et al: Qualitative versus quantitative mammographic breast density assessment: applications for the US and abroad. Diagnostics (Basel). 7(2), 2017
                          7. Grubstein A et al: Analysis of false-negative readings of automated breast ultrasound studies. J Clin Ultrasound. 45(5):245-251, 2017
                          8. Weigert JM: The Connecticut Experiment; the third installment: 4 years of screening women with dense breasts with bilateral ultrasound. Breast J. 23(1):34-39, 2017
                          9. Berg WA et al: Ultrasound as the primary screening test for breast cancer: analysis from ACRIN 6666. J Natl Cancer Inst. 108(4), 2016
                          10. Kim SY et al: Application of the downgrade criteria to supplemental screening ultrasound for women with negative mammography but dense breasts. Medicine (Baltimore). 95(44):e5279, 2016
                          11. Ohuchi N et al: Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-Cancer Randomized Trial (J-START): a randomised controlled trial. Lancet. 387(10016):341-348, 2016
                          12. Rafferty EA et al: Breast cancer screening using tomosynthesis and digital mammography in dense and nondense breasts. JAMA. 315(16):1784-6, 2016
                          13. Wilczek B et al: Adding 3D automated breast ultrasound to mammography screening in women with heterogeneously and extremely dense breasts: report from a hospital-based, high-volume, single-center breast cancer screening program. Eur J Radiol. 85(9):1554-63, 2016
                          14. Brem RF et al: Assessing improvement in detection of breast cancer with three-dimensional automated breast US in women with dense breast tissue: the SomoInsight Study. Radiology. 274(3):663-73, 2015
                          15. Moon HJ et al: Comparison of cancer yields and diagnostic performance of screening mammography vs. supplemental screening ultrasound in 4394 women with average risk for breast cancer. Ultraschall Med. 36(3):255-63, 2015
                          16. Moon HJ et al: Characteristics of breast cancer detected by supplementary screening ultrasonography. Ultrasonography. 34(3):153-6, 2015
                          17. Song SE et al: Undiagnosed breast cancer: features at supplemental screening US. Radiology. 277(2):372-80, 2015
                          18. Berg WA et al: How should screening breast US be audited? The patient perspective. Radiology. 272(2):309-15, 2014
                          19. Berg WA et al: Technologist-performed handheld screening breast US imaging: how is it performed and what are the outcomes to date? Radiology. 272(1):12-27, 2014
                          20. Sprague BL et al: Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 106(10), 2014
                          21. American College of Radiology Imaging Network. http://www.acrin.org/Portals/0/Protocols/6666/Protocol-ACRIN%206666%20Admin%20Update%2011.30.07.pdf. Review July 27, 2013. Accessed July 27, 2013
                          22. 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
                          23. Berg WA et al: Multiple bilateral circumscribed masses at screening breast US: consider annual follow-up. Radiology. 268(3):673-83, 2013
                          24. Tohno E et al: Effect of adding screening ultrasonography to screening mammography on patient recall and cancer detection rates: a retrospective study in Japan. Eur J Radiol. 82(8):1227-30, 2013
                          25. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                          26. Hooley RJ et al: Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology. 265(1):59-69, 2012
                          27. Weigert J et al: The connecticut experiment: the role of ultrasound in the screening of women with dense breasts. Breast J. 18(6):517-22, 2012
                          28. Chang JM et al: Breast cancers initially detected by hand-held ultrasound: detection performance of radiologists using automated breast ultrasound data. Acta Radiol. 52(1):8-14, 2011
                          29. Corsetti V et al: Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer. 47(7):1021-6, 2011
                          30. Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
                          31. Kelly KM et al: Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts. Eur Radiol. 20(3):734-42, 2010
                          32. Smith RA et al: Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 60(2):99-119, 2010
                          33. Berg WA: Tailored supplemental screening for breast cancer: what now and what next? AJR Am J Roentgenol. 192(2):390-9, 2009
                          34. Corsetti V et al: Breast screening with ultrasound in women with mammography-negative dense breasts: evidence on incremental cancer detection and false positives, and associated cost. Eur J Cancer. 44(4):539-44, 2008
                          35. Crystal P et al: Using sonography to screen women with mammographically dense breasts. AJR Am J Roentgenol. 181(1):177-82, 2003
                          36. Leconte I et al: Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. AJR Am J Roentgenol. 180(6):1675-9, 2003
                          37. Kolb TM et al: Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology. 225(1):165-75, 2002
                          38. Kaplan SS: Clinical utility of bilateral whole-breast US in the evaluation of women with dense breast tissue. Radiology. 221(3):641-9, 2001
                          39. Buchberger W et al: Clinically and mammographically occult breast lesions: detection and classification with high-resolution sonography. Semin Ultrasound CT MR. 21(4):325-36, 2000
                          40. Gordon PB et al: Malignant breast masses detected only by ultrasound. A retrospective review. Cancer. 76(4):626-30, 1995
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Clinical Issues

                              • Diagnostic Checklist

                                TERMINOLOGY

                                • Definitions

                                  • Bilateral whole-breast US in asymptomatic women as supplement to mammography: Handheld (HHUS) or automated (AUS)
                                  • Dense breasts: Heterogeneously dense or extremely dense on mammography
                                  • Negative: BI-RADS 1 or 2 on routine images
                                  • Recall: BI-RADS 0, 3, 4, or 5 on screening = positive
                                    • BI-RADS 3, 4, 5 can be used directly on HHUS
                                  • Interval cancer: Cancer detected clinically in interval between recommended screenings 
                                    • Prior negative screening examination
                                    • Within 1 year in USA
                                  • Indications
                                    • ≥ 10-year life expectancy
                                    • Patient has dense breasts and does not meet criteria for supplemental MR screening
                                    • High-risk women unable to undergo MR screening
                                      • Pregnant
                                      • Pacemaker, aneurysm clip, or other ferrometallic implant near vital structure(s)
                                      • Severe claustrophobia not controlled by sedative
                                      • Lack access to MR
                                    • Not a replacement for screening mammography unless patient unable to cooperate (e.g., some disability patients)
                                  • Incremental cancer detection rate (ICDR) US: Added cancers detected by addition of screening US to mammography

                                IMAGING

                                • Mammographic Findings

                                  • Ultrasonographic Findings

                                    • Imaging Recommendations

                                      DIFFERENTIAL DIAGNOSIS

                                        CLINICAL ISSUES

                                        • Demographics

                                          • Natural History & Prognosis

                                            DIAGNOSTIC CHECKLIST

                                            • Consider

                                              • Image Interpretation Pearls

                                                • Reporting Tips

                                                  Selected References

                                                  1. Buchberger W et al: Combined screening with mammography and ultrasound in a population-based screening program. Eur J Radiol. 101:24-29, 2018
                                                  2. 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):1045-1050, 2018
                                                  3. Tagliafico AS et al: A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2). Eur J Cancer. 104:39-46, 2018
                                                  4. Vourtsis A and Berg WA: Breast density implications and supplemental screening. Eur Radiol. ePub, 2018
                                                  5. Destounis S et al: New York State breast density mandate: follow-up data with screening sonography. J Ultrasound Med. 36(12):2511-2517, 2017
                                                  6. Destounis S et al: Qualitative versus quantitative mammographic breast density assessment: applications for the US and abroad. Diagnostics (Basel). 7(2), 2017
                                                  7. Grubstein A et al: Analysis of false-negative readings of automated breast ultrasound studies. J Clin Ultrasound. 45(5):245-251, 2017
                                                  8. Weigert JM: The Connecticut Experiment; the third installment: 4 years of screening women with dense breasts with bilateral ultrasound. Breast J. 23(1):34-39, 2017
                                                  9. Berg WA et al: Ultrasound as the primary screening test for breast cancer: analysis from ACRIN 6666. J Natl Cancer Inst. 108(4), 2016
                                                  10. Kim SY et al: Application of the downgrade criteria to supplemental screening ultrasound for women with negative mammography but dense breasts. Medicine (Baltimore). 95(44):e5279, 2016
                                                  11. Ohuchi N et al: Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-Cancer Randomized Trial (J-START): a randomised controlled trial. Lancet. 387(10016):341-348, 2016
                                                  12. Rafferty EA et al: Breast cancer screening using tomosynthesis and digital mammography in dense and nondense breasts. JAMA. 315(16):1784-6, 2016
                                                  13. Wilczek B et al: Adding 3D automated breast ultrasound to mammography screening in women with heterogeneously and extremely dense breasts: report from a hospital-based, high-volume, single-center breast cancer screening program. Eur J Radiol. 85(9):1554-63, 2016
                                                  14. Brem RF et al: Assessing improvement in detection of breast cancer with three-dimensional automated breast US in women with dense breast tissue: the SomoInsight Study. Radiology. 274(3):663-73, 2015
                                                  15. Moon HJ et al: Comparison of cancer yields and diagnostic performance of screening mammography vs. supplemental screening ultrasound in 4394 women with average risk for breast cancer. Ultraschall Med. 36(3):255-63, 2015
                                                  16. Moon HJ et al: Characteristics of breast cancer detected by supplementary screening ultrasonography. Ultrasonography. 34(3):153-6, 2015
                                                  17. Song SE et al: Undiagnosed breast cancer: features at supplemental screening US. Radiology. 277(2):372-80, 2015
                                                  18. Berg WA et al: How should screening breast US be audited? The patient perspective. Radiology. 272(2):309-15, 2014
                                                  19. Berg WA et al: Technologist-performed handheld screening breast US imaging: how is it performed and what are the outcomes to date? Radiology. 272(1):12-27, 2014
                                                  20. Sprague BL et al: Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 106(10), 2014
                                                  21. American College of Radiology Imaging Network. http://www.acrin.org/Portals/0/Protocols/6666/Protocol-ACRIN%206666%20Admin%20Update%2011.30.07.pdf. Review July 27, 2013. Accessed July 27, 2013
                                                  22. 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
                                                  23. Berg WA et al: Multiple bilateral circumscribed masses at screening breast US: consider annual follow-up. Radiology. 268(3):673-83, 2013
                                                  24. Tohno E et al: Effect of adding screening ultrasonography to screening mammography on patient recall and cancer detection rates: a retrospective study in Japan. Eur J Radiol. 82(8):1227-30, 2013
                                                  25. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                                  26. Hooley RJ et al: Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology. 265(1):59-69, 2012
                                                  27. Weigert J et al: The connecticut experiment: the role of ultrasound in the screening of women with dense breasts. Breast J. 18(6):517-22, 2012
                                                  28. Chang JM et al: Breast cancers initially detected by hand-held ultrasound: detection performance of radiologists using automated breast ultrasound data. Acta Radiol. 52(1):8-14, 2011
                                                  29. Corsetti V et al: Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer. 47(7):1021-6, 2011
                                                  30. Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
                                                  31. Kelly KM et al: Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts. Eur Radiol. 20(3):734-42, 2010
                                                  32. Smith RA et al: Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 60(2):99-119, 2010
                                                  33. Berg WA: Tailored supplemental screening for breast cancer: what now and what next? AJR Am J Roentgenol. 192(2):390-9, 2009
                                                  34. Corsetti V et al: Breast screening with ultrasound in women with mammography-negative dense breasts: evidence on incremental cancer detection and false positives, and associated cost. Eur J Cancer. 44(4):539-44, 2008
                                                  35. Crystal P et al: Using sonography to screen women with mammographically dense breasts. AJR Am J Roentgenol. 181(1):177-82, 2003
                                                  36. Leconte I et al: Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. AJR Am J Roentgenol. 180(6):1675-9, 2003
                                                  37. Kolb TM et al: Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology. 225(1):165-75, 2002
                                                  38. Kaplan SS: Clinical utility of bilateral whole-breast US in the evaluation of women with dense breast tissue. Radiology. 221(3):641-9, 2001
                                                  39. Buchberger W et al: Clinically and mammographically occult breast lesions: detection and classification with high-resolution sonography. Semin Ultrasound CT MR. 21(4):325-36, 2000
                                                  40. Gordon PB et al: Malignant breast masses detected only by ultrasound. A retrospective review. Cancer. 76(4):626-30, 1995