US-visible Ca⁺⁺: More likely malignant, more likely invasive carcinoma; specimen x-ray needed on biopsy
Benefit to obtaining more material: Possible indication for vacuum-assisted US biopsy
Targeted US after MR: Highly variable performance
Average 58% success (range: 23-71%)
Average 81% (range: 58-100%) of invasive cancers seen
Average 50% (range: 20-100%) of DCIS identified
Average 52% (range: 16-71%) of benign lesions found
66% of all masses and 33% of nonmass enhancement (NME) seen: 50% of masses ≤ 5 mm, 56% if 6-10 mm, 73% if 11-15 mm, 86% if > 15 mm
Average 12% (range: 6-28%) malignancy rate among lesions not seen on targeted US: Need for MR-guided biopsy
Pathologic nipple discharge
93% sensitivity to cause of discharge vs. 68% for galactography (2 series)
Central papilloma is most common cause; 56-80% sensitivity for US vs. 15-32% for mammography
Guide aspiration
Aspirate cysts only if painful to patient and requested (BI-RADS 2) or if diagnostic uncertainty (BI-RADS 4)
Round, tense cysts most likely to be symptomatic
Aspirate/drain breast abscess: Drain can be placed
Guide localization for surgery
Provide depth ± wire or seed localization; mark overlying skin (optional)
US Appropriate
Supplemental screening in dense breasts: Handheld or automated
After mammography, average CDR 2.8 per 1,000
CDR 1-2/1,000 after tomosynthesis (studies ongoing)
CDR 4.8-13 cancers per 1,000 high-risk women screened
Same incremental CDR for prevalence and incidence screens
88% of cancers seen only on screening US are invasive; median size 10 mm; 85% are node (-); ↑ detection of ILC
Average 3.3% risk of US-induced biopsy
Average 10% of biopsies prompted only by US prove malignant (range: 5-31%)
Performed by physician or technologist
Extent of disease in breast
Of breasts suspected to have unifocal cancer on mammography and clinically, ~ 48% have additional tumor foci at histopathology
Combined mammogram + US depicts ~ 90% of all tumor foci
May underestimate tumor size, especially if > 2-3 cm
Axillary nodal staging
Node can be identified and sampled using FNAB or CNB: Sensitivity 71% for metastasis, specificity 100%
Axillary nodal US and biopsy is indicated when mastectomy or neoadjuvant chemotherapy is planned or if palpable suspicious node(s) are present
For lumpectomy, no palpable nodes, surgeons may plan only sentinel lymph node excision
Preoperative node biopsy is not indicated
Intraoperative US: May help achieve clear margins
Distinguishing recurrence from scar
Lumpectomy scar should ↓ over time, extend to skin incision
Recurrence tends to be convex, focal mass near scar
May be hypervascular on Doppler
Focal breast pain
0.3% of women with focal pain found to have malignancy; not indicated for work-up of nonfocal/diffuse breast pain
US Not Appropriate
Not a substitute for mammographic screening unless patient unable to cooperate (e.g., some disability patients)
Assessing chest wall invasion
Posterior shadowing obscures evaluation
Saline breast implant integrity: Clinical diagnosis
Silicone breast implant integrity better assessed by MR
US low sensitivity for uncollapsed rupture
Folds can mimic rupture
Particularly poor for double-lumen implants
Pathognomonic appearance of siliconoma on US ("snowstorm") can be helpful in documenting extracapsular silicone
IMAGING
Anatomy-Based Imaging Issues
Selected References
Barr RG et al: Diagnostic performance and accuracy of the 3 interpreting methods of breast strain elastography: a systematic review and meta-analysis. J Ultrasound Med. ePub, 2018
Chen Y et al: Value of mammography for women 30-39 years old presenting with breast symptoms. AJR Am J Roentgenol. 211(6):1416-24, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Breast Imaging of Pregnant and Lactating Women. J Am Coll Radiol. 15(11S):S263-S275, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Breast Pain. J Am Coll Radiol. 15(11S):S276-S282, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Evaluation of the Symptomatic Male Breast. J Am Coll Radiol. 15(11S):S313-S320, 2018
Jung I et al: Ultrasonography-guided 14-gauge core biopsy of breast: results of 7 yrs of experience. Ultrasonography. 37(1):55-62, 2018
Kushwaha AC et al: Overutilization of healthcare resources for breast pain. AJR Am J Roentgenol. 211(1):217-23, 2018
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
Vourtsis A and Berg WA: Breast density implications and supplemental screening. Eur Radiol. ePub, 2018
Moy L et al: ACR Appropriateness Criteria® Palpable Breast Masses. J Am Coll Radiol. 14(5S):S203-S224, 2017
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J Am Coll Radiol. 14(11S):S462-S475, 2017
Knabben L et al: Breast cancer and pregnancy. Horm Mol Biol Clin Investig. 32(1), 2017
Parker S et al: Spectrum of pregnancy- and lactation-related benign breast findings. Curr Probl Diagn Radiol. 46(6):432-40, 2017
Xue Y et al: Value of shear wave elastography in discriminating malignant and benign breast lesions: A meta-analysis. Medicine (Baltimore). 96(42):e7412, 2017
Berg WA: Current status of supplemental screening in dense breasts. J Clin Oncol. ePub, 2016
Berg WA et al: Ultrasound as the primary screening test for breast cancer: analysis from ACRIN 6666. J Natl Cancer Inst. 108(4), 2016
Monticciolo DL et al: Six-Month Short-Interval Imaging Follow-Up for Benign Concordant Core Needle Biopsy of the Breast: Outcomes in 1444 Cases With Long-Term Follow-Up. AJR Am J Roentgenol. 1-6, 2016
Moon HJ et al: Short-term follow-up in 6 months is unnecessary for asymptomatic breast lesions with benign concordant results obtained at ultrasonography-guided 14-gauge core needle biopsy. Am J Surg. 211(1):152-8, 2016
Bahl M et al: Diagnostic value of ultrasound in female patients with nipple discharge. AJR Am J Roentgenol. 205(1):203-8, 2015
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
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
Lehman CD et al: Imaging management of palpable breast abnormalities. AJR Am J Roentgenol. 203(5):1142-53, 2014
Spick C et al: Diagnostic utility of second-look ultrasound for breast lesions identified at MR imaging: systematic review and metaanalysis. Radiology. 273(2):401-9, 2014
Hooley RJ et al: Breast ultrasonography: state of the art. Radiology. 268(3):642-59, 2013
Mendelson EB et al: Breast Imaging Reporting and Data System, BI-RADS: Ultrasound. 2nd ed. Reston: American College of Radiology, 2013
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
Cho N et al: Distinguishing benign from malignant masses at breast US: combined US elastography and color doppler US--influence on radiologist accuracy. Radiology. 262(1):80-90, 2012
Giess CS et al: Risk of malignancy in palpable solid breast masses considered probably benign or low suspicion: implications for management. J Ultrasound Med. 31(12):1943-9, 2012
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
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
Abe H et al: MR-directed ("Second-Look") ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR Am J Roentgenol. 194(2):370-7, 2010
Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
Loving VA et al: Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 195(6):1472-7, 2010
Demartini WB et al: Utility of targeted sonography for breast lesions that were suspicious on MRI. AJR Am J Roentgenol. 192(4):1128-34, 2009
Meissnitzer M et al: Targeted ultrasound of the breast in women with abnormal MRI findings for whom biopsy has been recommended. AJR Am J Roentgenol. 193(4):1025-9, 2009
Alvarez S et al: Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. AJR Am J Roentgenol. 186(5):1342-8, 2006
Berg WA et al: Operator dependence of physician-performed whole-breast US: lesion detection and characterization. Radiology. 241(2):355-65, 2006
Dillon MF et al: The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases. Ann Surg. 242(5):701-7, 2005
Berg WA et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 233(3):830-49, 2004
Berg WA: Supplemental screening sonography in dense breasts. Radiol Clin North Am. 42(5):845-51, vi, 2004
Berg WA: Rationale for a trial of screening breast ultrasound: American College of Radiology Imaging Network (ACRIN) 6666. AJR Am J Roentgenol. 180(5):1225-8, 2003
Soo MS et al: Sonographic detection and sonographically guided biopsy of breast microcalcifications. AJR Am J Roentgenol. 180(4):941-8, 2003
Dennis MA et al: Breast biopsy avoidance: the value of normal mammograms and normal sonograms in the setting of a palpable lump. Radiology. 219(1):186-91, 2001
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
Loading...
Related Differential Diagnoses
Loading...
References
Tables
Tables
KEY FACTS
Imaging
Clinical Issues
TERMINOLOGY
Synonyms
Sonography
Definitions
Targeted US: Directed to area of clinical, mammographic, MR, or other imaging abnormality
MR-directed US: Directed to abnormality on MR
Automated breast US: Typically 3D acquisition obtained in axial plane and reconstructed in coronal plane
Spatial compounding: Averaging of signal from multiple (usually off-angle) beams to reduce noise
Loss of posterior features
Harmonic imaging: Insonates tissue at 1 frequency; receives at multiples of that frequency (usually 2x, e.g., 12 → 24 MHz)
Preserves posterior features; reduces noise
Elastography: Method to measure stiffness of lesion and surrounding tissue
Downgrade soft BI-RADS 4A masses to surveillance and upgrade hard BI-RADS 3 masses to biopsy to ↑ specificity of breast US
General Performance Statistics
Not limited by breast density
↓ performance in very large breasts (> 4-cm thick) and deep lesions
Invasive ductal carcinoma (IDC)
96% sensitivity across series (range: 95-97%) vs. 84% for mammography (range: 81-89%)
Invasive lobular carcinoma (ILC)
88% sensitivity across series (range: 68-98%) vs. 71% for mammography (range: 34-92%)
DCIS: Wide range of sensitivities, depending on gold standard: ~ 50% in most scenarios
Indications
Palpable abnormality
In combination with mammography: 97.3% sensitivity; 99.4% negative predictive value (NPV) across 9 series
Opportunity for direct real-time correlation of imaging and clinical findings
Normal fatty lobulation is common source of palpable concern
US-visible Ca⁺⁺: More likely malignant, more likely invasive carcinoma; specimen x-ray needed on biopsy
Benefit to obtaining more material: Possible indication for vacuum-assisted US biopsy
Targeted US after MR: Highly variable performance
Average 58% success (range: 23-71%)
Average 81% (range: 58-100%) of invasive cancers seen
Average 50% (range: 20-100%) of DCIS identified
Average 52% (range: 16-71%) of benign lesions found
66% of all masses and 33% of nonmass enhancement (NME) seen: 50% of masses ≤ 5 mm, 56% if 6-10 mm, 73% if 11-15 mm, 86% if > 15 mm
Average 12% (range: 6-28%) malignancy rate among lesions not seen on targeted US: Need for MR-guided biopsy
Pathologic nipple discharge
93% sensitivity to cause of discharge vs. 68% for galactography (2 series)
Central papilloma is most common cause; 56-80% sensitivity for US vs. 15-32% for mammography
Guide aspiration
Aspirate cysts only if painful to patient and requested (BI-RADS 2) or if diagnostic uncertainty (BI-RADS 4)
Round, tense cysts most likely to be symptomatic
Aspirate/drain breast abscess: Drain can be placed
Guide localization for surgery
Provide depth ± wire or seed localization; mark overlying skin (optional)
US Appropriate
Supplemental screening in dense breasts: Handheld or automated
After mammography, average CDR 2.8 per 1,000
CDR 1-2/1,000 after tomosynthesis (studies ongoing)
CDR 4.8-13 cancers per 1,000 high-risk women screened
Same incremental CDR for prevalence and incidence screens
88% of cancers seen only on screening US are invasive; median size 10 mm; 85% are node (-); ↑ detection of ILC
Average 3.3% risk of US-induced biopsy
Average 10% of biopsies prompted only by US prove malignant (range: 5-31%)
Performed by physician or technologist
Extent of disease in breast
Of breasts suspected to have unifocal cancer on mammography and clinically, ~ 48% have additional tumor foci at histopathology
Combined mammogram + US depicts ~ 90% of all tumor foci
May underestimate tumor size, especially if > 2-3 cm
Axillary nodal staging
Node can be identified and sampled using FNAB or CNB: Sensitivity 71% for metastasis, specificity 100%
Axillary nodal US and biopsy is indicated when mastectomy or neoadjuvant chemotherapy is planned or if palpable suspicious node(s) are present
For lumpectomy, no palpable nodes, surgeons may plan only sentinel lymph node excision
Preoperative node biopsy is not indicated
Intraoperative US: May help achieve clear margins
Distinguishing recurrence from scar
Lumpectomy scar should ↓ over time, extend to skin incision
Recurrence tends to be convex, focal mass near scar
May be hypervascular on Doppler
Focal breast pain
0.3% of women with focal pain found to have malignancy; not indicated for work-up of nonfocal/diffuse breast pain
US Not Appropriate
Not a substitute for mammographic screening unless patient unable to cooperate (e.g., some disability patients)
Assessing chest wall invasion
Posterior shadowing obscures evaluation
Saline breast implant integrity: Clinical diagnosis
Silicone breast implant integrity better assessed by MR
US low sensitivity for uncollapsed rupture
Folds can mimic rupture
Particularly poor for double-lumen implants
Pathognomonic appearance of siliconoma on US ("snowstorm") can be helpful in documenting extracapsular silicone
IMAGING
Anatomy-Based Imaging Issues
Selected References
Barr RG et al: Diagnostic performance and accuracy of the 3 interpreting methods of breast strain elastography: a systematic review and meta-analysis. J Ultrasound Med. ePub, 2018
Chen Y et al: Value of mammography for women 30-39 years old presenting with breast symptoms. AJR Am J Roentgenol. 211(6):1416-24, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Breast Imaging of Pregnant and Lactating Women. J Am Coll Radiol. 15(11S):S263-S275, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Breast Pain. J Am Coll Radiol. 15(11S):S276-S282, 2018
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Evaluation of the Symptomatic Male Breast. J Am Coll Radiol. 15(11S):S313-S320, 2018
Jung I et al: Ultrasonography-guided 14-gauge core biopsy of breast: results of 7 yrs of experience. Ultrasonography. 37(1):55-62, 2018
Kushwaha AC et al: Overutilization of healthcare resources for breast pain. AJR Am J Roentgenol. 211(1):217-23, 2018
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
Vourtsis A and Berg WA: Breast density implications and supplemental screening. Eur Radiol. ePub, 2018
Moy L et al: ACR Appropriateness Criteria® Palpable Breast Masses. J Am Coll Radiol. 14(5S):S203-S224, 2017
Expert Panel on Breast Imaging et al: ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J Am Coll Radiol. 14(11S):S462-S475, 2017
Knabben L et al: Breast cancer and pregnancy. Horm Mol Biol Clin Investig. 32(1), 2017
Parker S et al: Spectrum of pregnancy- and lactation-related benign breast findings. Curr Probl Diagn Radiol. 46(6):432-40, 2017
Xue Y et al: Value of shear wave elastography in discriminating malignant and benign breast lesions: A meta-analysis. Medicine (Baltimore). 96(42):e7412, 2017
Berg WA: Current status of supplemental screening in dense breasts. J Clin Oncol. ePub, 2016
Berg WA et al: Ultrasound as the primary screening test for breast cancer: analysis from ACRIN 6666. J Natl Cancer Inst. 108(4), 2016
Monticciolo DL et al: Six-Month Short-Interval Imaging Follow-Up for Benign Concordant Core Needle Biopsy of the Breast: Outcomes in 1444 Cases With Long-Term Follow-Up. AJR Am J Roentgenol. 1-6, 2016
Moon HJ et al: Short-term follow-up in 6 months is unnecessary for asymptomatic breast lesions with benign concordant results obtained at ultrasonography-guided 14-gauge core needle biopsy. Am J Surg. 211(1):152-8, 2016
Bahl M et al: Diagnostic value of ultrasound in female patients with nipple discharge. AJR Am J Roentgenol. 205(1):203-8, 2015
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
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
Lehman CD et al: Imaging management of palpable breast abnormalities. AJR Am J Roentgenol. 203(5):1142-53, 2014
Spick C et al: Diagnostic utility of second-look ultrasound for breast lesions identified at MR imaging: systematic review and metaanalysis. Radiology. 273(2):401-9, 2014
Hooley RJ et al: Breast ultrasonography: state of the art. Radiology. 268(3):642-59, 2013
Mendelson EB et al: Breast Imaging Reporting and Data System, BI-RADS: Ultrasound. 2nd ed. Reston: American College of Radiology, 2013
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
Cho N et al: Distinguishing benign from malignant masses at breast US: combined US elastography and color doppler US--influence on radiologist accuracy. Radiology. 262(1):80-90, 2012
Giess CS et al: Risk of malignancy in palpable solid breast masses considered probably benign or low suspicion: implications for management. J Ultrasound Med. 31(12):1943-9, 2012
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
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
Abe H et al: MR-directed ("Second-Look") ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR Am J Roentgenol. 194(2):370-7, 2010
Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
Loving VA et al: Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 195(6):1472-7, 2010
Demartini WB et al: Utility of targeted sonography for breast lesions that were suspicious on MRI. AJR Am J Roentgenol. 192(4):1128-34, 2009
Meissnitzer M et al: Targeted ultrasound of the breast in women with abnormal MRI findings for whom biopsy has been recommended. AJR Am J Roentgenol. 193(4):1025-9, 2009
Alvarez S et al: Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review. AJR Am J Roentgenol. 186(5):1342-8, 2006
Berg WA et al: Operator dependence of physician-performed whole-breast US: lesion detection and characterization. Radiology. 241(2):355-65, 2006
Dillon MF et al: The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases. Ann Surg. 242(5):701-7, 2005
Berg WA et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 233(3):830-49, 2004
Berg WA: Supplemental screening sonography in dense breasts. Radiol Clin North Am. 42(5):845-51, vi, 2004
Berg WA: Rationale for a trial of screening breast ultrasound: American College of Radiology Imaging Network (ACRIN) 6666. AJR Am J Roentgenol. 180(5):1225-8, 2003
Soo MS et al: Sonographic detection and sonographically guided biopsy of breast microcalcifications. AJR Am J Roentgenol. 180(4):941-8, 2003
Dennis MA et al: Breast biopsy avoidance: the value of normal mammograms and normal sonograms in the setting of a palpable lump. Radiology. 219(1):186-91, 2001
Stavros AT et al: Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 196(1):123-34, 1995
STATdx includes over 200,000 searchable images, including x-ray, CT, MR, and ultrasound images. To access all images, please log in or subscribe.