Breast Ultrasound Signs of Malignancy

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Key Sonographic Features Suggestive of Malignancy:
    • Based on contemporary radiology references:
      • Hypoechoic echotexture
      • Posterior acoustic shadowing
      • Irregular or spiculated margins
      • Angular or microlobulated margins
      • Taller-than-wide orientation:
        • Non-parallel to skin
      • Thick echogenic halo:
        • Suggests desmoplastic reaction
      • Ductal extension or branching pattern
      • Intra-lesional calcifications
      • Increased stiffness on elastography:
        • High shear-wave values
      • Low apparent diffusion doefficient (ADC) values on diffusion-weighted imaging (DWI)
    • These align with standard teaching but are now reinforced by quantitative imaging advances such as elastography and DWI
  • Caveats — Not Exclusively Malignant:
    • Well-defined smooth borders and posterior acoustic enhancement can appear in both benign and malignant lesions:
      • Interpretation must rely on the whole feature set
    • Layering or “teacup” micro-calcifications on mammography typically lean benign, despite ultrasound appearance; correlation remains essential
  • Integrated Imaging Approach:
    • A sonographic mass that appears benign on mammography should be evaluated primarily based on B-mode ultrasound features rather than mammographic impression
    • Use of color Doppler improves specificity for malignancy in non-mass-like lesions without reducing sensitivity
  • Quantitative Imaging Enhancements:
    • Diffusion-weighted imaging (DWI):
      • Apparent Diffusion Coefficient (ADC) values provide quantitative assessment:
        • Malignant lesions typically show mean ADC ≈ 1.03 ×10⁻³ mm²/s, benign ≈1.5 ×10⁻³ mm²/s; ADC <1.0 ×10⁻³ mm²/s strongly favors malignancy
        • Recent meta-analysis confirms ADC’s usefulness for distinguishing lesions, though exact thresholds vary:
          • Most protocols now use ≥ 1.5T MRI with b-values around 800 s/mm²
      • Shear-wave elastography (SWE):
        • Mean values for malignancies often exceed 133 to 153 kPa (e.g., ~167 kPa), aiding differentiation
  • Full References:
    • Malherbe K. Breast Ultrasound. StatPearls, updated 2024 – Highlights classic sonographic features: hypoechoic texture, shadowing, margins, etc Verywell Health, “Breast Cancer Ultrasound: How It Works and What Results Mean.” (2022) – Discusses overlap of benign/malignant features and interpretive context.
    • Tarigan VN et al. 2025 systematic review: DWI (ADC) helps distinguish benign vs malignant lesions; ADC measurement challenges remain.
      Kwon M et al. (2024) – Mean ADC ~0.982 ×10⁻³ mm²/s for cancers; SWE stiffness ~167.7 kPa.
      Surov A et al. (2019) – Pooled ADC values show malignant lesions average 1.03 ×10⁻³ mm²/s vs benign 1.5 ×10⁻³ mm²/s; benign rarely under 1.0 ×10⁻³ mm²/s.
    • Stavros AT. Breast Ultrasound, 2004 – Covers foundational ultrasound interpretation concepts. Cardenosa G. Clinical Breast Imaging: The Essentials, 2015 – Classic reference listing the ten ultrasound signs of malignancy.
    • Tarigan VN et al. (2024) Frontiers in Oncology – Color Doppler specificity enhancement in non-mass lesions.

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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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