- At first glance, the rounded, almost anechoic sonographic mass could be mistaken for a simple cyst:
- However, closer inspection shows some small spiculations, angular margins, and a suggestion of an echogenic halo
- These findings alone make it a BIRADS 4 lesion
- Even if they were not present:
- The lesion is rounded and, therefore, does not meet any of the 3 benign definitions:
- That would allow it to be classified BIRADS 3
- The lesion is rounded and, therefore, does not meet any of the 3 benign definitions:
- Although the lesion is small, homogeneous, and does not cause worrisome posterior acoustical artifacts:
- Cancers this small frequently have no shadowing or enhancement
- It could be benign:
- But it has the appearance that a high-grade carcinoma would have when it is less than a centimeter in diameter
- However, closer inspection shows some small spiculations, angular margins, and a suggestion of an echogenic halo
- When a nodule seen on mammogram and ultrasound are in the same location, have the same size and shape, and the same surrounding tissue:
- They can be confidently assumed to be the same
- If it were going to be followed, mammograms would expose this young woman to ionizing radiation and thus a small but real risk of developing a radiation-induced malignancy:
- So a 6-month follow-up ultrasound would be the modality of choice
- Because the lesion cannot be confidently considered to be less than BIRADS 4a:
- Evaluation with a needle is required:
- It is possible aspiration would collapse a small cyst:
- If not, percutaneous biopsy should be done with a spring-loaded, vacuum-assisted, or intact-removal device, depending on the experience and expertise of the surgeon
- It is possible aspiration would collapse a small cyst:
- Evaluation with a needle is required:
- Steps in the evaluation of breast nodules by ultrasound:
- You first evaluate the lesion for any of the 10 malignant signs:
- Shadowing
- Hypoechoic echotexture
- Spiculation
- Angular margins
- Thick echogenic halo
- Microlobulation
- Taller than wide
- Duct extension
- Branching pattern
- Calcifications)
- Finding none:
- You move on to the second step in the evaluation process and specifically look for one of the three strictly defined benign signs:
- If any of them are found:
- The lesion can be considered BIRADS 3:
- The three benign findings defined by Stavros are:
- A purely hyperechoic lesion with no hypoechoic area larger than a normal duct or lobule
- Elliptical, wider than tall, well-circumscribed and thin echogenic capsule
- Gently lobulated, wider than tall, well-circumscribed and thin echogenic capsule
- The three benign findings defined by Stavros are:
- Combining the elliptical or gently lobulated shapes with the presence of a complete, thin echogenic capsule:
- Is necessary because many circumscribed carcinomas and most ductal carcinoma in situ are encompassed in a thin, echogenic capsule:
- However, the shape of circumscribed invasive carcinoma or pure ductal carcinoma in situ:
- Is rarely elliptical or gently lobulated
- Is necessary because many circumscribed carcinomas and most ductal carcinoma in situ are encompassed in a thin, echogenic capsule:
- The lesion can be considered BIRADS 3:
- If any of them are found:
- Because this lesion is elliptical, wider-than-tall, well-circumscribed, and has a thin, echogenic capsule:
- It is BIRADS 3:
- A 6-month follow-up ultrasound would be appropriate unless the anxiety of the patient makes core biopsy a better option
- It is BIRADS 3:
- You move on to the second step in the evaluation process and specifically look for one of the three strictly defined benign signs:
- You first evaluate the lesion for any of the 10 malignant signs:
- References
- D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System, 5th ed. Reston, VA, American College of Radiology, 2013.
- Madjar H, Mendelson EB. The Practice of Breast Ultrasound. 2nd ed. Thieme; 2008;141-144.
- Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 