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• The sonographic appearance of a normal lymph node:
  • Is elliptical with a thin, hypoechoic cortex and an isoechoic to hyperechoic fatty hilum (Image).

• Metastatic carcinoma in a lymph node:
  • Would usually have an asymmetric thick cortex or have near-total or total obliteration of the hilum:
    • Resulting in a rounded, hypoechoic mass (Image)

• Axillary adenopathy can occur in association with rheumatoid arthritis:
  • But the sonographic findings would usually be a symmetrical, mild thickening of the cortex:
    • Usually with preservation of the hilum
• Silicone granulomas:
  • Classically create a snowstorm appearance:
    • Which allows a definitive diagnosis by ultrasound alone

• The mass in the image has a rounded anterior border and “dirty” incoherent shadowing that obscures the posterior border of the lesion:
  • Nothing other than silicone can cause this sonographic appearance:
    • But it is difficult to distinguish free silicone that has migrated to the axilla from a node that has been replaced with silicone
  • In different stages of development, silicone extravasation can also mimic complex cysts or fibrotic nodules:
    • Depending on the amount of silicone extravasated and the amount of time from extravasation
  • If a large amount of silicone is released into the tissue:
    • The ultrasound pattern is that of a complex cyst
  • Silicone’s presence in tissues can cause a local inflammatory reaction:
    • Which may cause tissue fibrosis and a fibrotic nodule:
      • This is a late finding seen following extravasation
• References
  • Berg WA, Caskey CI, Hamper UM, Anderson ND, Chang BW, Sheth S, et al. Diagnosing breast implant rupture with MR imaging, US, and mammography. Radiographics. 1993;13(6):1323-1336.
  • Juanpere S, Perez E, Huc O, Motos N, Pont J, Pedraza S. Imaging of breast implants‒a pictorial review. Insights Imaging. 2011;2(6):653-670.

• The mammogram shows a spiculated mass with extensive edema:
  • As evidenced by skin thickening and increased trabecular markings in the breast (Images)
• Ultrasound shows a heterogeneous, irregular, hypoechoic mass with some angular and spiculated margins (Image):
  • Internal vascularity is demonstrated on Doppler examination (Image)
• Gynecomastia:
  • Does not cause erythema, skin thickening, and breast edema:
    • The mammogram would usually show a triangular shaped density radiating from the nipple into the breast tissue (Image)

• The sides of the mammographic triangle in gynecomastia are:
  • Usually straight or concave (Image) as opposed to convex in breast cancer
• The sonographic appearance of gynecomastia depends on the phase of development:
  • It can appear quite hypoechoic and have angular margin
• Paget’s disease of the breast is rare, but it does occur in males:
  • It would present with a nipple rash and would not be expected to have secondary infection
  • There are usually no mammographic or sonographic features unless there is an underlying invasive carcinoma
• References
  • Abeywardhana DY, Nascimento VC, Dissanayake D, Taylor D, Metcalf C, Saunders C, et al. Review of ultrasound appearance in inflammatory breast cancer: a pictorial essay. J Med Imaging Radiat Oncol. 2016;60(1):83-87.
  • Stavros AT. Evaluation of the male breast. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:712-741.
  • Khalkhali I, Cho J. Male breast cancer imaging. Breast J. 2015;21(3):217-218.
  • Ottini L, Palli D, Rizzo S, Ferico M, Bazan V, Russo A. Male breast cancer. Crit Rev Oncol Hematol. 2010;73(2):141-155.

• Breast hamartomas:
  • Most likely result from an overgrowth of a portion of normal breast tissue, or from fibrous and glandular elements becoming incorporated into a lipomatous growth:
    • Thus, they are sometimes called a “breast within a breast”
  • They are also variously called:
    • Adenolipofibroma
    • Lipofibroadenoma
    • Adenolipofibroma
    • Fibroadenolipoma:
      • Because they contain fibrous, fatty, and epithelial tissues
  • They may present as palpable masses:
    • But are more commonly discovered on routine imaging
  • They are round, oval, or lobulated, and usually are well-circumscribed:
    • They have a mixture of water density and fatty elements and frequently have either a capsule or the appearance of a capsule resulting from surrounding compressed breast tissue
  • A mammographically classic hamartoma does not require further imaging:
    • Short interval follow-up, or biopsy
• The presence of a breast hamartoma should prompt further questioning of the patient to be sure there is nothing to suggest she has multiple hamartoma syndrome (Cowden syndrome):
  • A rare disorder caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene:
    • Patients with this disorder have an increased head circumference, multiple trichilemmoma skin lesions, intestinal hamartomas, and an increased risk of cancer of the breast, thyroid, endometrium, and kidney
    • Genetic testing should be done if there is a personal or family history suggestive of the disorder
• References
  • Crothers JG, Butler NF, Fortt RW, Gravelle IH. Fibroadenolipoma of the breast. Br J Radiol. 1985;58(687):191-202.
  • Daya D, Trus T, D’Souza TJ, Minuk T, Yemen B. Hamartoma of the breast, an underrecognized breast lesion. A clinicopathological and radiographic study of 25 cases. Am J Clin Pathol. 1995;103(6):685-689.
  • Murat, A, Ozdemir H, Yildirim H, Poyraz AK, Ozercan R. Hamartoma of the breast. Australas Radiol. 2007;51(Spec No.):B37-B39.
  • Schrager CA, Schneider D, Gruener AC, Tsou HC, Peacocke M. Clinical and pathological features of breast disease in Cowden’s syndrome: an underrecognized syndrome with an increased risk of breast cancer. Hum Pathol. 1998;29(1):47-53.

• The patient has a BIRADS 2 simple cyst:
  • To be regarded as a simple cyst, a mass must meet three criteria:
  • The margins must be circumscribed:
    • i.e., a margin “that is well defined or sharp, with an abrupt transition between the lesion and surrounding tissue”
  • It must be anechoic:
    • i.e., “without internal echoes”
  • It must show posterior acoustical enhancement:
    • i.e., “a column that is more echogenic deep to the mass”
• Simple cysts are almost never associated with cancer in the absence of other abnormalities seen on mammogram or ultrasound
• There are numerous reflectors in breast tissue:
  • All of the sound waves that are reflected do not make it back to the transducer:
    • Many of them bounce back and forth (reverberate) between reflectors in the tissue, and with each reverberation, part of the echoes return to the transducer, are recorded, and part undergo another excursion between the reflectors
  • Most of these echoes are obscured by all of the other echoes in the tissue, but when an otherwise anechoic window (a cyst) is present:
    • The reverberation echoes can be seen in the anterior part of the cyst:
      • In the image shown, a hyperechoic band can be seen within or just above the anterior wall of the cyst, especially on the left side of the image
    • The acoustic mismatches between this band and the less echogenic tissue superficial to it and the anechoic fluid deep to it, cause echoes that reverberate, creating the artifact in the near field of the cyst
• References
  • D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS^® Atlas: Breast Imaging Reporting and Data System, 5^th ed. Reston, VA: American College of Radiology; 2013.
  • Kremkau FW. Diagnostic Ultrasound: Principles and Instruments, 7^th ed. Elsevier; 2006:274-292.

• There are two main groups of diffuse breast cancers:
  • That present as large areas of architectural distortion on the mammogram:
    • One is neoductgenesis
    • The other is a diffusely infiltrating carcinoma:
      • Which makes up approximately

• When the tumor is e-cadherin negative:
  • It is usually called invasive “lobular” carcinoma
• When it is e-cadherin positive:
  • It is called infiltrating “ductal” carcinoma:
    • The designation based on e-cadherin staining is arbitrary:
      • Because the behavior of diffusely invasive carcinoma is the same regardless of the staining
• Lacking calcifications and a central tumor mass:
  • These cancers are notoriously difficult to perceive on mammogram:
    • Even when they are large and palpable or when they occur in fatty involuted breasts:
      • However, the associated connective tissue response:
        • Makes this type of cancer quite visible with ultrasound

• In contrast to diffusely infiltrating cancers:
  • Circular (Image) and spiculated (Image) tumors arising in the terminal ductal lobular units (TDLU):
    • Have bulging, convex contours protruding into the adipose tissue

• The solid variety of infiltrating lobular carcinoma:
  • Most probably arises within the TDLU and has a circular / oval shape on breast imaging
• There are two other variants of invasive lobular carcinoma that arise in the TDLUs:
  • The tubulolobular variant:
    • Is either a unifocal or multifocal spiculated lesion on the mammogram (Image 5a-b)
  • The alveolar type of invasive lobular carcinoma:
    • Is usually mammographically occult, or it can be seen as a subtle, asymmetric density (Image)

• The various forms of invasive lobular carcinoma that develop in the TDLUs and present as localized lesions:
  • Have a significantly better prognosis than the diffusely infiltrating type breast cancer
• Complex sclerosing lesions:
  • Present mammographically as nonpalpable architectural distortion with no central tumor mass and lucent radiating structures, the so called “black star”:
    • As opposed to cancers originating from the TDLU:
      • Which have a dense central tumor mass surrounded by radiopaque spiculation, giving the impression of looking at a “white star”
• Malignant phyllodes tumors:
  • Present as large, high density masses:
    • The borders may be circumscribed or ill defined
• Fat necrosis:
  • Also presents as a hypoechoic, high-density mass
• References:
  • Tot T. Diffuse invasive breast carcinoma of no special type. Virchows Arch. 2016;468(2):199-206.
  • Tabár L, Dean PB. Teaching Atlas of Mammography. New York, NY: Thieme; 2011.

• This axilla ultrasound shows a case of severe eccentric compression and displacement of the hilum to the edge of the node:
  • Favoring metastatic disease:
    • Biopsy of the node provides pathology staging:
      • Which may influence treatment options
• Typical lymph node ultrasound appearances include:
  • Uniformly mildly thickened cortex:
    • Typical of inflamed or reactive lymph node
  • Eccentric cortical thickening:
    • Favors metastatic disease

• Convex indentations of the hilum:
  • Favors metastatic diseased
• Severe compression of the hilum to slit-like configuration:
  • Can occur in metastatic or severely inflamed lymph node
• Severe eccentric compression and displacement of the hilum to the edge of the node:
  • Favors metastatic disease
• Complete obliteration of the hilum and rounding of the node:
  • Favors metastatic disease (can also occur in severe necrotizing lymphadenitis)
• Perinodal invasion by metastasis:
  • The outer thin echogenic capsule cannot be identified
  • Angular margins
• References
  • Stavros AT. Evaluation of regional lymph nodes in breast cancer patients. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:858-859.
  • AIUM curriculum for fundamentals of ultrasound physics and instrumentation. JUltrasound Med 2019;38(8):1933-1935. https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15088. Accessed July 16, 2020.

• Tissue harmonic imaging (THI):
  • Creates images derived solely from higher frequencies
• The ultrasound beam:
  • Is transmitted centered at 1 frequency, e.g., 6 MHz, and received centered at a multiple of the transmitted frequency, e.g., 12 MHz
• Different techniques can be used to process the received signals so that only the returning high-frequency harmonic signal is used to produce the image:
  • Whereas echoes from the fundamental / lower frequencies are rejected
• THI increases signal-to-noise ratio:
  • Resulting in better tissue contrast
• THI:
  • Reduces reverberation, clutter, and speckle artifacts:
    • Improving contrast resolution
  • It accentuates real echoes in addition to suppressing artifactual echoes
  • The suppression of speckle artifact by coded harmonics makes solid nodules more hypoechoic and conspicuous than they are with fundamental imaging (Images)
  • It makes the thin, echogenic capsule that surrounds most benign lesions appear to be thinner, more echogenic and more complete than with fundamental imaging
• THI cannot be combined with simultaneous color Doppler imaging because the resulting frame rate would be unacceptable:
  • When Doppler is required, the image that is interlaced with Doppler must be constructed at fundamental rather than harmonic frequencies
• THI is of limited value in differentiating benign from malignant lesions
• Another method of reducing artifactual echoes, improving contrast, and making the thin, echogenic capsule more conspicuous is real time spatial compounding of images
• In conventional imaging, each frame is created by a single sweep of the beam at a 90 degree angle to the long axis of the transducer:
  • In compound imaging, there are multiple sweeps of the beam from different angles, creating a spatially and temporally compounded image from multiple angles over time
  • Among other things, the lateral borders of lesions can be seen better with compound imaging

• References:
  • Mesurolle B, Helou T, El-Khoury M, Edwardes M, Sutton EJ, Kao E. Tissue harmonic imaging, frequency compound imaging, and conventional imaging use and benefit in breast sonography. J Ultrasound Med. 2007;26(8):1041-1051.
  • Cha JH, Moon WK, Cho N, Kim SM, Park SH, Han BK, et al. Characterization of benign and malignant solid breast masses: comparison of conventional US and tissue harmonic imaging. Radiology. 2007;242(1):63-69.
  • Stavros AT. Breast ultrasound equipment requirements. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:16-41.

• Screening mammography:
  • Is important in identifying breast cancer at an early stage
• Calcifications have many forms:
  • The characteristics of the calcifications:
    • Help identify whether they are associated with a benign or malignant process
  • Smooth, round, large and layering calcium:
    • Are generally associated with benign findings

• Fine, irregular, punctate, linear and branching, and pleomorphic calcifications:
  • Are characteristics generally associated with malignant findings

• Magnification views of the calcifications are essential in helping to evaluate the calcifications to determine the appearance and to be able to accurately interpret the findings
• References:
  • Brant W, Helms C. Fundamentals of Diagnostic Radiology, 5th Edition. Lippincott, Williams & Wilkins; 2019
  • Baldwin P. Breast calcification imaging. Radiol Technol. 2013;84(4):383M-404M.

• 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
  • 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
• 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
• 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
        • 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
    • 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
• References
  • D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System, 5^th 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.

• Marked hypoechogenicity with immobile echogenic foci:
  • Representing calcifications

• The 10 signs of malignancy in breast ultrasound include:
  • Shadowing
  • Hypoechoic echotexture
  • Spiculation
  • Angular margins
  • Thick echogenic halo
  • Microlobulation
  • Taller than wide dimensions
  • Duct extension
  • Branching pattern
  • Calcifications
• Well-defined smooth border and posterior acoustic enhancement:
  • Are found in both malignant and nonmalignant lesions
• Layering / teacup mammographic microcalcifications:
  • Are usually associated with benign disease
• Sonographic mass with a benign mammographic imaging:
  • Is managed based on ultrasound features
• References
  • Evaluation and imaging features of malignant breast masses. In: Cardenosa G. Clinical Breast Imaging: The Essentials. Philadelphia, PA: Wolters Kluwer; 2015:234-282.
  • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.