Non-Simple Cysts and Color Doppler in Breast Sonography - SD

Introduction

Hi, I am Cindy Rap from Denver, Colorado.

Today we're gonna be talking about sonography of non simple breast cyst and color doppler, non simple breast cyst and color doppler in breast sonography.

Understanding Non-Simple Breast Cysts

We have been taught that with our improved resolution cyst that appear to be simple on some of our older equipment actually appear to have internal echoes on the higher resolution equipment that we scan.

Now the problem is that we have been taught that any cyst with internal echoes should be classified as a complex cyst.

And we've also been taught that most complex cysts are something that are worrisome and scanning breast cyst.

Sometimes we'll see things that look like this where you have one cyst that is almost simple, but if you notice there's a little bit of internal debris sitting right next to it is a lesion that almost appears to be solid nice through transmission, similar to the other cyst.

No matter how we turn the transducer, it remains round.

So I know one trick that a lot of us wanna do, just take our gain, turn it down just to make sure that we clear out the echoes and make these cysts look more simple.

But one thing we wanna make sure when we are doing breast imaging is to always keep fat at medium gray.

If we have black fat, we can actually make solid lesions appear that they're cystic.

So we really need to retrain our brain in looking at these types of lesions.

Now, some cysts that we see in breast sonography have almost what looked like a solid and cystic component to 'em.

These we refer to as a acorn cyst and there are cysts that appear as solid as a fibroadenoma.

These we will call foam cyst.

They're also referred to as a gel cyst or an inspissated cyst.

We'll also see cysts that have internal echoes and if you do something that increases the intensity of the beam, such as turning up your output power or turning on color or pulse doppler, you can actually get these echoes to start moving in there.

Now, non simple breast cysts, they are so common.

We take this pathology specimen, invert the image of it.

They occur way too common for us to biopsy any of these or even aspirate them.

If we were doing that, we would be following up every CY aspirating, every cyst that comes through the department.

We need more of a rational approach on how to evaluate non simple breast cyst with sonography.

Now the percentage of cysts that are complicated is increasing.

One reason is we're using higher frequency transducers than we did in the past.

We have broadband technology and we're using a higher dynamic range than we used to.

So also what we're noticing is real echos produce internal structures and there's also some artifact that we'll see.

Terminal Ductal Lobular Unit (TDLU)

If we look at A-T-D-L-U, the terminal ductal lobular unit, these are where cyst and also solid nodules arise.

So you can see the different changes.

If you have a normal TDLU, you can go through some cystic degeneration.

The cysts start to enlarge, breakthrough the walls of the cyst and eventually will form one fairly large tension cyst.

If you rotate your transducer on the long axis where you can see the duct coming in, we have a better idea that these are actually cysts that we're dealing with or cystic change rather than true lesions.

So here we can see ultrasounds of a normal TDLU.

Here's one that we've gone through some cystic change or some microcyst of the TDLU.

You can see the cyst have gone to a little bit larger all the way up to attention cyst.

These are the same lesions but just rotating around and finding the normal extra lobular terminal duct that goes into the TDLU makes you much more confident that you're actually dealing with a cystic lesion or cystic change of the TDLU.

Strict Criteria for BI-RADS 2

So if we look at our strict criteria, if we're going to call something a birads two, it needs to be completely anti coic, well circumscribed thinly encapsulated with enhanced through transmission and a lot of times we'll see thin edge shadows.

Now things like compounding and harmonics will help with these if you look at the ones with the asterisk behind the, but compounding may actually decrease through transmission and thin edge shadows if you're using that.

However, these are features that can be turned on and off while you're scanning if you still like to be able to see the thin edge shadows and the enhanced through transmission.

So here's an example of what is a strict criteria for a birads two, a normal simple cyst and it would be wonderful if we would see simple cysts like this all the time.

But so many of the cysts we see with sonography do have internal echoes.

General Rules for Non-Simple Breast Cysts

General rules about nons, simple breast cysts.

The vast majority of nons simple breast cysts are within the spectrum of fibrocystic change.

Malignant cysts are something that are exceedingly rare and usually if there is a malignant cyst, it's gonna be obviously malignant.

There will be features that you're gonna notice that will say this is something that definitely needs to be biopsied.

In individual cases, general rules are not necessarily reassuring.

So we really need a systematic approach on how to evaluate cysts in the breast similar to what we do with solid nodules.

Systematic Approach to Non-Simple Breast Cysts

So we look at nons, simple breast cysts in lesion two, our systematic approach.

The first thing we wanna try and do, eliminate artifacts.

So we want to take what's complex and indeterminate, try to make it a simple, if we can't eliminate the artifact or what appears to be an artifact, what we're gonna do is search for the worrisome features.

So anything that would be considered a birads four or five are the findings that we're going to be looking for.

If we don't find any of the BIRADS four or five features, then what we wanna try and do is identify it as a birads two classification.

If we cannot do that, then what we do is try and move it into a birads three, which is a probably benign classification.

If we cannot classify it as BIRADS three, then we will consider it to be a birads four classification.

This is basically the same thing that we use when we look at solid nodules.

First thing you wanna do is start looking for the the most severe type things such as our fours and fives on birads and then try and prove that it is completely benign and if you can't classify it as something that is indeterminate.

Causes of Echoes in Cysts

If we look at the types of things that cause echoes within these cysts, we have protein globs, cholesterol crystals, fat globules, white and red cells, epithelial cells, foamy macrofasia, acan cells, papillary APR and metaplasia.

Solid structures that we can see within.

These are also papillomas and carcinomas.

Now if you aspirate breast cysts, the fluid that comes out isn't just a clear serous fluid.

These were all just examples of aspirations from different breast cysts.

If we video invert those, you can see the different echogenicity that we'll see within this fluid.

And now you kind of have an understanding is why we see the echoes that we do in the breast cyst when we're scanning.

Pathology Examples

Now each of these here what we have is a pathology.

Then we video inverted the pathology and have an ultrasound exam.

You can see this is a nice thin echogenic wall of a simple cyst.

This is where we sort of have a fatty buildup on the inside wall of a cyst.

This is a single layer of acan metaplasia that we'll see one layer within this cyst wall.

And when you have papillary arican metaplasia, you can also have what sort of a appears to be a solid nodule within it.

But this is papillary AP and metaplasia, which is just part of the spectrum of fibrocystic change.

Complicated Cysts and BI-RADS 3

Looking at our complicated cysts, our simplified rule for a birads three identify those for solid nodules.

So what we're looking for something round or oval, we're looking for thinly encapsulated and we use color doppler to check and see if there are any fibrovascular stock.

Once again, for seeing the thinly encapsulated using features such as harmonics and compound imaging can be very helpful in looking at that.

Artifactual Echoes

The artifactual echoes we'll notice with our increased frequency and increased bandwidth and dynamic range, we can have reverberations within cyst, we can get clutter ring down, we'll have volume averaging and actually some speckle that we'll see within them.

So the first thing we want to try and do, eliminate artifacts within these cyst.

As I mentioned earlier, coated harmonics and realtime compounding can be things that will help to eliminate these artifactual echoes.

So if we look at this ultrasound image, this is a cyst that was scanned just with normal fundamental imaging.

You can see all the internal echoes that we see within this.

We've got edge shadows coming off of it nice through transmission.

By turning on harmonics, we cleared out a lot of those artifactual echos.

You can still see the nice through transmission and the edge shadows.

So we were able to partially clear out some of the internal noise just by using harmonics on this particular cyst.

Here's another example of a breast cyst that we can see some internal noise on.

This one is slightly lobulated and you can just see that the TDLU can go through these lobulated changes by using compounding.

This is taking the beam and steering it in from the size you can see how much of the artifact has been eliminated.

Also notice that we can see the wall of the cyst, nice thin echogenic wall much better.

But the other thing to note, the enhanced through transmission that we see so well on the image on the left, you don't see quite as well with the image on the right and that is something that we are aware of when we use compound imaging.

Now if you have a cyst that has real internal echoes and when you use something such as harmonics, you'll see that the echoes actually increase when you have real echoes in there.

So the image on the left was done in fundamental imaging image on the right was using harmonics and now it appears that there are more echoes inside.

We still have the normal sound transmission and edge shadows that we'd expect to see from the cyst.

So first thing we try to do is eliminate artifactual echoes.

Worrisome Features for BI-RADS 4 or 5

Now we're gonna use a systematic approach.

So next we're going to look for any features that might be worrisome that you would classify as a birads four or five.

Anything that's given a birads four or five is typically recommended for a biopsy.

So the things that we're gonna look for are thick, iso, coac, acceptations, any type of a mural nodule.

We also use colored doppler to look for the presence of a fibrovascular stock and we're gonna look at clustered microcyst.

So the image on the left, this we would just consider to be simple cysts.

It's basically one simple cyst up against another one.

These are just sort of a cluster of cysts sitting together.

These we would not be concerned about, but when you have a thick iso coac acceptation in between cyst, it still could be fibrocystic change.

But this is something that we typically would classify at least as a Bio RADS four A And these we would recommend for a biopsy.

So the features that we look for, if we're going to classify something as bio rads four or five, we look for angular margins where the solid portion attaches to the wall.

We look for loss of the capsule.

Also at the attachment to the wall we sort of draw an imaginary circle around the lesion and if there's anything that protrudes beyond that circle that is going to be abnormal, we'll use colored output to see if there's presence of any type of a fibrovascular stock and we'll also roll the patient up to see if moving them will change the position of what appears to be the solid lesion.

Now most nodules that we see within these nons simple breast cysts are actually caused by papillary akin metaplasia.

When you look at this cyst, it looks just like a solid mural nodule.

If you use color doppler, you typically will not see any flow and this was aspirated in, it was just proven to be papillary arican metaplasia that you see quite often in a lot of these cyst, only a small percentage of mineral nodules are caused by papillomas or papillary carcinomas.

So if you notice this lesion, we can see that it's micro lobulated.

If we look at the attachment to the wall, there's a little bit of extension coming out through here.

So most likely this is going to be where the duct is coming in.

But as I mentioned, only a small percentage of what appear to be mineral nodules are caused by these sod solid nodules.

If we look at the growth of an intra cystic papilloma, they start within the ductal system.

As they start to grow and spread, you can see how they will obstruct the neck of this and then a cyst basically will form around that.

So if we actually draw our imaginary line, you'll see that there's extension coming down the area where the duct is at.

And here's just an example, this is growth of an inters papilloma that we can see the neural nodule.

This is the cyst that has formed around it.

Here is our papilloma and you can see that we actually see it coming down through the ductal system and branching out.

So growth of an intra cystic papilloma.

Now on these cys that appear to be half cystic and half solid, what we wanna do is look for any type of an angular margin or loss of a capsule where the attachment is of the solid looking portion.

So if you notice we have a nice thin echogenic line completely surrounding this particular lesion.

This is reassuring that we're not dealing with a solid lesion inside of here.

If we look at this lesion, you can see that there's extension beyond where the imaginary line should be.

This is something that is more suspicious and this turned out to be an intra cystic papillary carcinoma.

So once again looking for any type of protrusion beyond the wall of the cyst, you can see that it's very well confined With this, this is reassuring.

And here we have another lesion.

Not only that, but if we notice we don't have a thin echogenic wall, we do have some irregularity, some angular margins protrusion beyond where the wall should be.

This is something once again that is suspicious and this is recommended for a biopsy.

Fibrovascular Stalks and Color Doppler

The other thing we're going to check for our fibrovascular stocks.

So with papillary ap and metaplasia, rarely will you see any fibrovascular stock with your intra cystic pap palomas or carcinomas.

Typically we will see fibrovascular stocks.

Now one thing is anytime you're looking for the presence of blood flow in the breast, you need to make sure that you scan with very light pressure.

Just the weight of your hand compressing on the transducer is enough to temporarily ablate the flow.

So you do wanna make sure you scan with light pressure if you're looking for blood flow.

One problem with these intra intra cystic papillary lesions, they can infarct frequently.

So just because you do not see flow within the lesion does not necessarily mean that you're dealing with papillary ap and metaplasia.

Here we can see example of a complicated cyst or non simple cyst with what appears to be a solid lesion.

There is no fibrovascular flow.

This did turn out to be just papillary ap and metaplasia.

Here on this side you can see we definitely have a fibrovascular sock.

So we know that this is not papillary AP and metaplasia and this was an intra cystic papillo.

Now in using color doppler we find it more reassuring when we have a single vessel feeding into these lesions rather than multiple vessels.

One thing we found that with multiple vessels, these tend to be more worrisome and actually this is a intra cystic carcinoma.

This was an intra cystic papillary lesion.

Mural Nodules and Sludge

You can also get complicated cysts with what appeared to be a mural nodule.

And just like what we do for patients with sludge in the gallbladder, we'll roll them up on their sides.

We do the same thing with these nons simple breast cysts and you can see that we just have some sludge inside of this cyst that when we rolled the patient up change position so we felt comfortable, this is not a mural nodule within the cyst.

Fibrocystic Change Paths

Now if we look at the normal TDLU and we look at the mixture of fibrocystic change that it can go through, there are two different paths that it may take.

You may have the TDLU go through fibrocystic change where it goes more through a cystic route.

If you go through more of a fibrotic route, these look much more worrisome sono graphically.

And here's just examples of a mixture of fibro cystic change.

You can see here we have the normal TDLU, these are going through cystic dilatation of the actual lole and the CYS get larger.

These I think we'd feel much more comfortable on just calling a cluster of microcyst.

However, if it takes the route of more fibrosis, you can see why we have much more worrisome and these lesions typically will get biopsied because they are going to fall more into the bio RADS four category.

And sometimes we will get back the diagnosis of just fibrosis or fibrocystic change on these types of lesions.

Clustered Microcysts vs. DCIS

Now if we look at these clustered micros, their appearance can be very similar to high nuclear grade DCIS.

So one of these is fibrocystic change, one of them is high nuclear grade DCIS.

I'll show you in just a minute which one is which.

This was a patient that came in for a breast ultrasound, indication was a palpable lump.

So on her initial ultrasound exam we could see that there was this 14 millimeter structure.

The radiologist who was reading the report that day just called it a cluster of microcyst.

The patient actually came back seven weeks later because she felt that her little cluster of microcysts were enlarging.

Seven weeks after her initial ultrasound, it was now 33 millimeters.

By the time she went through tumor board and was ready for surgery, 10 weeks had lap from her initial ultrasound and now the lesion was 50 millimeters inside.

So this is the one that's the high nuclear grade DIS.

So the images I had showed you before the fibrocystic change was on the left and the high nuclear grade DCIS was the image that was on the right.

But these can be very rapidly growing.

Color doppler can be helpful because you would probably see the presence of blood flow in looking at these types of lesions.

Complex Cysts with Internal Echoes: Tumor or Infection

So looking at complex cyst with the internal echos, we have two main concerns that we're gonna be looking at.

Either there may be tumor or the patient may have infection.

So these are the two things that we're going to look for.

Signs of Inflammation and Infection (BI-RADS 3)

Now for birads three signs of inflammation and infection, what we will see is uniform iso acholic wall thickening.

You'll notice a fluid debris level and if we use color doppler you'll typically find that there's hyperemia within the cyst wall.

Now sonography cannot distinguish between inflammation and infection by just imaging alone.

So these will need to be aspirated and gram stain and culture is required.

But if we look at wall thickening, hyperemia and fluid debris levels, usually all of these will occur together.

This is a patient we look at the image on the right hand side.

They had a normal breast cyst in the right breast.

She presented with left breast pain and you can see she has this inflamed cyst.

Now a normal simple cyst has a thin echogenic wall.

When a cyst becomes inflamed, you can see the wall becomes thick and iso coic we have this fluid debris level and when we use colored doppler we will see that there's hyperemia in the wall of the inflamed cyst.

Typically you will not see any blood flow in the wall of a normal simple cyst.

Differential Diagnosis for Uniform Iso Wall Thickening

Now some differential diagnosis for why we might see uniform iso wall thickening.

You can have acute inflammation where the wall becomes very thick.

Papillary APR metaplasia rather than just sort of being one nodule can actually form around the entire wall of the cys and have this appearance and fibrosis.

We may have an old cyst that had previous inflammation and now goes through fi fibrotic change.

And so fibrosis can also cause the wall to be thick and iso coic, the way you can tell the difference is typically if the patient is got fibrosis of the wall of the cyst, they will not be symptomatic.

If we use color doppler, we're not going to see any hyperemia within it.

So a lot of times we'll see this fibrosis is just healed stages of the inflammation or a formal formally inflamed cyst that we'll notice this.

Fluid Debris Levels

Another thing that we can see, fluid debris levels, you can see this is a patient that we change their position and we're able to see this fluid debris level rotate fairly rapidly.

So one thing we can be sure to evaluate these is just set the patient upright and see if the lesion does change.

Now some of these complicated cysts with the fluid debris level, it may take up to five minutes to get these to shift.

A lot of these are a fat fluid level.

So here you can see in the supine position.

And then as we set the patient up after two minutes, you can see after three minutes and then after five minutes we finally get it to go to the dependent portion.

So some of these do not change rapidly with motion but may take up to five minutes to notice.

One thing that you can do if you think that it might be just a fluid debris level is go in and use tus and I'll show you examples of this in the later portion of this lecture where we talk about color doppler and I'll explain how FTUs is done.

But if this lesion attaches to the wall of the cyst, then when the patient hums, you will notice that the lesion would also fill in with power doppler.

If it's not attached to the wall, you can see that there is no flow when the patient does the humming.

But we'll explain more about FTUs later.

This is that same lesion and you can see by rolling the patient here you can also prove that it is not attached to the wall.

But this took 10 minutes waiting for the fluid debris level to actually shift the non-dependent portion.

Now if you aspirate these inflamed cyst, you can see that sometimes we're going to need the gram stain in culture but not necessarily cytology.

In looking at some of these aspirated fluids.

Blood Flow Orientation

Now looking at these cysts, one way to tell the difference if we have an inflammatory process versus a neoplasm going on is with inflammation.

The blood flow will be parallel to the wall of the cyst.

If you have a true intra cystic lesion, you're going to see that the blood flow will be perpendicular to the wall.

So this is a true lesion inside the cyst.

This is just inflammation of the cyst.

So colored doppler can be helpful for looking at that.

Systematic Approach: BI-RADS 2 Findings

Now looking at this, we're going through our systematic approach.

We have tried to clear up any artifacts.

We have also looked for any birads four or five or birads three findings which would be infection.

Next thing we're gonna do is try and prove that this is a birads.

Two things such as a simple cyst.

We can have cholesterol crystals within the cyst.

We can have the fat fluid level milk of calcium.

You can get punctate calcifications within walls of cyst.

We can see calcified lipid cyst, thinly septated cyst, clusters of macro cyst and also cysts that arise from a skin.

All of these basically would be classified as a birads two finding.

Cholesterol Crystals

So the first thing we're gonna look at are cholesterol crystals.

These are fairly light particles that we'll see within the system.

As I mentioned earlier, if you do something that increases the intensity of the beam, you can actually get these cyst or these particles to start moving.

So looking at this image, what I have done is turned up the overall output power.

It's not turning up your overall game but the output power.

And you can see on the cine loop now that we're able to actually get these little crystals to move, these would be classified as a birads two.

These really do not need to be aspirated.

Now something else you can do is turn on either color or power doppler and then you can get what's sort of called color streaking.

So these cholesterol particles will start shifting because turning on color power doppler increase the intensity of the beam and it's kind of cool 'cause the patient looks over at this and goes, whoa, what's that?

It almost looks like the 4th of July when you see these cholesterol crystals with their color streaking.

Looking at this ultrasound image, you can see on this loop it almost looks like we have a mural nodule located in this area by turning on color doppler.

This just happens to be an artery going over the top that's not hyperemia within the wall.

If you notice here we have a very thin echogenic cyst, but by turning on colored doppler we can actually get these particles to start shifting now.

So we know it's not a true mural nodule, there's actually some streaking going through there.

So by increasing the intensity of the beam, these are just cholesterol crystals that appear to be clumped together on the first initial image.

If you do aspirate these, typically you're gonna get more of a greenish gray brown fibrocystic change fluid.

They will typically aspirate completely and cytology crystal seen on polarized light will have this type of appearance.

But most of the time when you get used to looking at these they really do not need to be aspirated.

Fat Fluid Levels

Now cyst that contain these fat fluid levels are also birads two and as I mentioned earlier, it may take up to five minutes to get them to shift.

So a lot of times their initial appearance will look like this.

Five minutes afterwards you can see that we have now shifted and since this is a fat fluid level, fat will be on the non-dependent portion since it's going to be floating on the top of the cyst.

So with the patients opine versus upright, we can see the difference that we will notice on these types of cysts.

Also, if we do tus, since these do not attach to the wall, we're going to see that the FTUs goes all the way around but does not highlight in the area where it does not attach to the wall.

Also, when we roll the patient up we can see that we eventually got this to shift is another way of proving that it is not attached to the wall.

Another thing that we can look at on these fat fluid levels is more of the sigmoid shape that changes.

So they start out to be sort of obliquely oriented and during the process of shifting you can see that it'll move more into that sigmoid type shape.

So if you don't wanna wait the five minutes for them to shift completely, just sort of watching the shape of it change is one thing.

Looking at these acorn or fat fluid level cyst, they are also classified as a birads too and they may aspirate completely a lot of times on these but it's a little bit thicker stuff so a lot of times you're not certain if it will aspirate completely.

Milk of Calcium

Something else that we classify as a birads two is when we see milk of calcium inside of a cyst.

You can see these two little punctate calcifications possibly three on the other view.

When we roll the patient up now to get our classic teacup appearance that we'll see with a mammogram, it typ typically will take about 15 to 20 stones to get that classic appearance on a mammogram.

With ultrasound we're able to see a single stone and this was just taking the patient and having them roll onto their side and we can see that this will actually move with repositioning the patient.

So milk of calcium, single milk of calcium in this cyst can be identified with sonography quite easily.

You can also have it, it can be difficult to keep these small cysts sort of in the field of view when you're rotating the patient, but you can see how in moving this patient with a small cyst you can definitely see there's the milk of calcium moving as the patient is rolling on their side.

As the mentioned already the advantage of ultrasound is weakened diagnosis, single stone on these and very common for us to see that on ultrasound.

If you don't have ability to store your loops you can take pictures that document on supine and then documenting by rolling the patient to cubitus that you could see the stone shift similar to what we would see with gallbladders and gallstones.

This was a patient on their mammogram, had multiple calcifications throughout the breast, taking a C loop cut.

You can notice sort of on this sweep through that every little cyst we see a tiny little milk of calcium inside the walls of these cysts.

So it kind of answered our question on ultrasound.

As you can see inside all of these fibrocystic change almost looks like a Swiss cheese appearance to the breast that there are milk of calciums located inside the cyst on this patient with the cine loop clip.

Superficial Wall Calcifications

Now another thing are superficial wall calcifications.

This is also a birads two.

This is where it's very helpful to look at the mammographic findings 'cause you will see that the wall is calcified much easier on the mammogram.

Here shadowing is something that is worrisome for ultrasound.

So a lot of times we wouldn't necessarily know if this is a true tumor or not, but comparing your mammogram we can see that it's just the wall of the cyst that is calcified causing the shadowing.

So always good to compare mammograms and ultrasound when you're making the diagnosis of these.

Lipid Cysts

Another thing that will be classified as a birads two on mammography and also ultrasound are lipid cysts.

Now they look much more worrisome sono graphically.

So once again when you see one of these mammographically, they have a classic appearance, they have the fatty pattern on the mammogram.

So you definitely know definitively that on mammography they are a birads two and they are much more benign appearing mammographically than they are sono graphically microcyst or cysts that are clustered.

You can have microcyst or macrocysts and with the volume averaging that we get on a lot of these microcysts, a lot of these we will classify as a birads four A.

So it doesn't have a 2% chance or less for being considered a birads three.

So a lot of times these will get for a, when we have more of the macrocysts, I think we feel much more comfortable in calling these a birads three, which is a probably benign classification.

Sebaceous Cysts

Now other cysts that we can evaluate that also fall into the birads two classification are sebaceous cyst.

They can be completely within the skin.

We will notice some that can be partially within the skin and some of them will appear to be deep to the skin.

But the key to diagnosing those is looking for the hair follicle that they arise from.

So all of these are cysts that completely arise within the skin.

Another thing to notice on each of these in evaluating them, we've used a big glop of gel.

Anything that's very close to the skin service, you'll need to use a standoff pad of gel to evaluate these.

But here you can see this is completely surrounded by skin.

All of these are just sebaceous or epidermal inclusion cysts that we can see within the skin.

These also get a birads two classification.

What make a little tougher is when you have lesions that are partway within the skin and partway within the subcutaneous fat.

What we look for to make that diagnosis is the claw sign.

So if something is rising from a certain structure, what you'll notice is where it grabs onto it is what we call the claw sign.

So where the green arrow is you can see is the attachment of where this originates from the skin.

And these we will classify as a birads two.

All of these lesions appear to be deep to the skin but in scanning through what we're able to notice is the hair follicle that they are coming from.

So these sebaceous cysts are just an occluded hair follicle that we can see occurring.

And looking for the neck of that is reassuring to know that these are definitely birads two findings and really nothing needs to be done further.

The other thing to know our hair follicles do not just arise straight up from the skin, they come in at an angle.

So angling your transducer to look for the neck is very helpful and reassuring in looking at these birads two.

BI-RADS 3 Findings: Acorn and Foam Cysts

So continuing on with our systematic approach, the fourth thing that we're going to look for are birads three findings.

These types of things would be what we would call our acorn cyst and our foam cyst.

So acorn cyst that we can see here is something that we typically will classify as a birads three that is probably benign, indeterminate solid versus cystic.

There's subtle differences between solid nodules.

This is a fibroid noma that we can see here.

They tend to be more oval shaped versus what we call a foam cyst, also referred to as a gel or an inspissated cyst Echo.

Texture wise they can look very similar in evaluating these.

So what we're trying to do in dealing with these indeterminant cystic versus solid lesions, once again try to clear up any internal artifacts.

Look for internal blood flow if you can't assume that it is solid and characterize it as a solid lesion.

And the last thing is go ahead and attempt to aspirate it.

Now if we have color doppler we can turn color doppler on and see if there's any blood flow.

Just because we do not see blood flow does not necessarily mean this is a cyst, but it is reassuring if you do find blood flow inside one of these lesions, you know you're not dealing with a cyst that this is truly a solid lesion.

So assume solid level two.

What we wanna do is usually it has no birads four or five findings, birads three.

What we're gonna be looking for is around our oval shape thinly encapsulated with enhanced through transmission and once again harmonics and compounding may be helpful for looking at that nice thin border that does surround it.

If you attempt to aspirate these lesions, there's three possibilities that can happen and you really can't predict which one is going to happen on one of these foam or gel cyst.

They may aspirate completely, you may only get it to partially aspirate or you might not be able to get it to aspirate at all.

So in looking at this, you really can't determine what is going to happen and the reason is it may be filled with fluid that is very simple to aspirate.

You may have some of the fat and papillary AP metaplasia cells that are within there that you may only get it to partially aspirate or it may be completely filled with papillary AP and metaplasia that the stuff is just so thick that you cannot aspirate it out through a needle.

If you send these for core needle biopsy or vacuum assisted biopsy, typically on the first or second pass, the lesion will just disappear on you.

So here we have one of these that was completely aspirated.

We see the needle coming in.

This looks like it's a solid nodule but you can see it completely aspirated and would disappear on ultrasound.

Now if you attempt to aspirate one of these lesions and you cannot get any fluid back, one thing that you can do if the needles inside of this lesion go ahead and try rocking the needle tip internally.

If it is one of these foam or gels you'll be able to move the needle tip from the posterior wall up to the anterior wall.

So you can see here on this particular lesion we've rocked the needle tip anteriorly so it's on the top of the wall.

We went ahead and moved it posteriorly.

So even though we weren't able to aspirate it, if we can see the needle tip move inside the lesion, we are much more comfortable that this is a cyst and not a true solid nodule.

Whereas if you have a solid nodule and you try rotating or rocking the needle tip, it will stay where it was and you will not get it to move in the anterior posterior wall.

So here you can see this small lesion that looks like a cyst.

We put the needle tip in, we attempted to remove it anterior and posteriorly but it would not rock at all.

Now even though you may have a failed aspiration on some of these, you might be able to look in the cap or in the cork of it and almost have like an FNA that you can evaluate some of these when you try to rock it internally and not able to aspirate any of the, the stuff that's inside there is always check into the cap or the foam that might be in the, the lesion that you aspirate out.

So sometimes we get the papillary acre AP and metaplasia.

Sometimes we get the prodius gel within these.

BI-RADS 4A Classification

So part of our systematic approach, the sixth thing that we're gonna do, if we cannot classify it as a birads two or three, then we do have to classify it at least as a birads four A.

In looking at the different types of cysts, this was taking one image of a patient with multiple breast cysts.

In fact, everywhere you scanned in the breast you would see cysts or lesions that looked just like this.

We have once with appeared to be a fluid debris level.

We have ones that appear to be foam or gel cyst.

Here we have these acorn cyst.

You can see some papillary per metaplasia here.

All far too many to aspirate these all the time.

So in looking at these non simple breast cyst, the percentages of cyst that are complex is increasing.

It's kind of complicated in dealing with these.

The gold standard is fuzzy.

What we do is use our mammographic and solid nodule algorithm for evaluating these.

We use birads categories.

If a birads foray then you need to get histology.

If it's in an inflamed cyst you need to aspir it and also send it for culture.

Role of Color Doppler in Breast Sonography

Now we're gonna talk about color doppler, what the role of color doppler in breast sonography is.

We'll use it to try and help us to determine if we're dealing with a solid versus a cystic lesion.

We'll look at solid nodules and we can look at the blood flow within it and see if it looks more worrisome.

For malignancy we use color doppler if we're looking at inflammatory processes.

And the last thing I'm gonna talk about is FTUs.

That is done with having the patient hum and it's done in using power doppler.

Principles of Color Doppler

So looking at color doppler, basically it indicates a high metabolic state which is present with a both benign and malignant conditions.

Highly cellular lesions will tend to get more flow on, also see quite a bit of flow on our inflammatory responses.

One thing to remember, color doppler is very sensitive to pressure and this is a case I can remember doing back in the early nineties.

It was a classic what appeared to be a fibroid anoma sono graphically in the early nineties a lot of work was being done.

Try to to differentiate benign versus malignant lesions using colored doppler.

People were looking at pulsatility index resistive indices, you know peak systolic velocities.

In scanning this patient we can see that we have fairly low resistant waveform pattern.

We have a peak systolic velocity of around 12 centimeters per second and a resistive index of 45.

And then when you're scanning your hand starts to get a little bit tired.

And one thing I noticed that as I was scanning I could compress on this fiber adenoma.

I took the peak systolic velocity and cut it in half, took the RI from 45 almost up to 70, pressed down a little bit more and completely ablated the flow.

And in doing this I thought man, we're onto something here.

Here's a benign lesion.

By compressing, we're able to shut the flow off.

Thought that maybe we figured out finally something that we could use doppler for to tell benign versus malignant lesions.

So the next time we had a cancer we tried the same thing.

Doesn't matter if it's benign or malignant.

If you compress you will ablate the flow and you say what about power doppler?

Power doppler is more sensitive than color doppler.

It does not matter if it's color or power Doppler if you think you have a piece of junk equipment.

'cause every time you've tried to use doppler for breast imaging and you can never see any blood flow, it may be because you're pressing too hard.

So anytime I'm looking for the presence of flow in a lesion, I put extra gel on the skin and lighten my pressure.

So I'm barely making contact.

The other thing I want you to notice are the lesions with the enhanced through transmission are the lesions that we see flow most often through your lesions that have intense shadowing.

Rarely will you see blood flow through those.

This is also just looking at an area of high nuclear grade DCIS and you can see with scanning with light pressure how much blood flow we can see within this area.

And then with compression we can completely shut that flow off.

Color Doppler for Cystic Lesions and Inflammation

So other cystic lesions that we can use, colored doppler floor.

Here's an example of looking at inflammation.

This is the same inflamed cyst I showed you before.

Typically we will not see any flow in a normal cyst, but when we have an inflammatory process, you can see there will be hyperemia within the wall.

We use it for evaluating solid nodules.

So you can see this intra cystic papilloma, we can see the vessel that coerces perpendicular to the wall whereas with an inflammatory process it was parallel to the wall.

And just because you once again do not see flow does not necessarily mean it's papillary AP and metaplasia.

But this was a case of papillary APR and metaplasia and once again to tell the difference between inflammation and a true intra cystic lesion is looking at the orientation of the blood vessels parallel versus perpendicular to the wall itself.

Color Doppler for Intraductal Papilloma

And looking at intraductal papillo, they also tend to be highly vascular color doppler can be very helpful.

A lot of times we can get inspissated secretions so it may appear to have papillary lesions.

But using color doppler we typically will find a vascular stalk feeding into the true papilloma.

So this is a long axis view of the duct that we can see the papillary lesion.

This is rotating the transducer 90 degrees, getting a short access view.

You can see that the blood vessel courses through so we know it is an intra pack, intra papillary lesion.

Also, as I mentioned before, seeing multiple branches versus a single branch is more worrisome when we do see multiple branches feeding those lesions.

Color Doppler for Clustered Cysts and Pseudo-Cystic Lesions

And I've showed you examples of a clusters of micro and macro cyst and one thing you always wanna do anytime you see something that is not a simple cyst in the breast is always use color doppler.

Even if you do not see the presence of any blood flow, take a picture of the documents that you at least turn color doppler on.

Now this looks like a cluster of macro cysts that I had showed you earlier or could it be something solid by using color doppler.

You can see this lights right up like a campfire.

We know that this is not a cystic lesion.

This was biopsied and proven to be a medullary carcinoma.

Other pseudo cystic lesions that we can see within the breast lymphoma can sometimes have this appearance.

You can have metaplastic carcinomas, your high grade invasive ductal carcinomas will have this appearance and some of our metastatic lesions, this could almost look like one of the foam cysts.

But if we look closely we notice that this lesion is micro lobulated and using color doppler, you can see there was quite a bit of flow inside the lesion.

A very large vessel that was adjacent to it.

This was biopsied and proven to be a metastatic intary lymph node.

Now this is a patient 67-year-old female who had been having her mammograms for years, had always been stable, had pretty much a fatty involuted breast.

And one thing that we noticed was she had this lesion that appeared to just pop up on her mammogram mammographically.

It looked like it was a cyst.

And one thing is, someone who's 67 years old should not be having a cyst just pop up on her breast.

So we use color doppler.

You can see that there's roaring blood flow inside this.

We sent the patient for biopsy, she had this lesion biopsy, it came back as metastasis from a uterine mosis sarcoma that she had no idea she had.

So I always say put the whole picture together even though it may look like a foam cyst.

Colored doppler was the key to making the diagnosis to knowing that this was not a cystic lesion.

But a lot of your metastatic lesions will be very well circumscribed, that we see on ultrasound.

Color Doppler for Inflammation Examples

Also using it for inflammation.

This is a patient with acute lactational mastitis.

You can see this inflamed duct right here.

In fact, it almost looks like a short axis view of a normal appendix, but you can see all the dilated ducts and looking at this one infected duct, if we turn color doppler on, here's our infected duct, the wall is thick and iso coic and you can just see all the increased blood flow, all the hyperemia within this case of acute lactational mastitis.

This is a patient that presented with bloody nipple discharge.

She has acute peri ductal mastitis.

Also notice that the wall is very thick and iso coic and we turn color doppler on.

You can see how much or power doppler, you can see how much hyperemia we see within the wall of this cyst.

And it was the explanation as to why she was having bloody nipple discharge.

Also using color doppler to tell the difference between true lesions inside of the duct versus inflammation.

With the inflammation the blood flow will be around the wall similar to what we see on cyst and a true lesion inside such as a papilloma.

You're going to see the blood vessel coursing through the lesion.

Fremitus Ultrasound (FTUS)

The last thing I wanna talk about is FTUs.

FTUs is done with power doppler.

If you look up in the dictionary, FTUs is a thrill felt by humming.

So what you wanna have the patient do is hum.

A lot of times patients do not like to hum so you kinda have to hum along with them.

One thing I found out, if they have a high pitched voice, the humming doesn't work very well, they have to have a fairly low voice hum hum fairly deep and you're gonna get much better results if the humming doesn't work.

What I'll have them do sometimes is clear their throat and sometimes that will help a little bit.

But this is a case we kinda stumbled on there, just like a lot of things that you know you do in your practice.

This patient had been, called back because they saw a suspicious area on her mammogram.

And so she came in, I did her initial ultrasound, took all the pictures, all the measurements.

Our radiologist came back in the room to remeasure and, and take another look and explain to the patient what we'd found.

And he was looking for the presence of blood flow inside the lesion with power doppler.

And this lady was someone who was very nervous.

So she started asking questions and one thing we noticed when she started talking was that the lesion, the cancer never filled in with power doppler, but as she was talking all of the area around started filling in with power doppler.

Another thing we noticed is there was an area down here in the breast that would never fill in with power doppler.

So once we reoptimize our image, moved our focal zones down where they should be, we actually found that she had multifocal disease that we had not realized at first.

So power doppler was very helpful in making that diagnosis.

And the tus. Another thing is looking at iso coic lesions.

Here we have this lesion.

It could be a fat lole, it could be a fibro adenoma.

We check compressibility.

If we're gonna call something a fat lole, we like to see it compress about 30%.

We didn't see it compressed that much.

We went ahead and in Prius you can see that the power Doppler fills in on the soft tissue.

The lesion did not fill in.

This was went for biopsy and proven to be a fiber adenoma.

Applications of FTUS

So where do we find FTUs helpful when we look for multifocal disease?

When we are trying to evaluate iso coic lesions and also with artifactual shadowing, it's not something that I use every day on every single patient that we scan, but there are certain cases that we find it can be very helpful with.

This is a multifocal disease.

On one of the cases I showed you earlier, this is a patient that had diabetic MAs osteopathy and if you scan many of these patients, you know that their mammograms are extremely dense and also on ultrasound, a lot of areas of shadowing that no matter how hard you compress, you just can't get to clear out.

I'm sure all of us have seen cancers that look even something like this on ultrasound.

So in going in and doing FTUs, one thing we noticed that, since colored doppler works from the skin down, but fremitus works from the chest wall going up, we completely filled in with fremitus and did not have any void area.

So we felt more comfortable that this was due to artifactual shadowing and not actually a true lesion.

Looking at this particular lesion, this patient came in with a palpable lump.

You can see this small nodule right here.

These are what we call one of these barely visible lesions.

But in doing Prius on this small area, what we noticed was this patient also had multifocal disease and you can see the bridging, through the ductal system we can see on this multifocal disease.

And Prius was very helpful in helping make the diagnosis of that.

Conclusion

Now in looking at colored doppler with breast sonography, breast cancer is a spectrum of lesions and we have found that no single finding is necessarily effective when we eval, evaluate an entire spectrum of lesions.

Colored doppler helps identify one part of the cancer spectrum.

You know, our sensitivity and specificity are not good enough to necessarily impact the diagnosis or treatment, but color doppler is probably no better or worse than any other single imaging and it is something we use all the time in our breast sonography.

We don't charge extra.

It is just one more tool I have to help make the diagnosis of if the lesion does need to be remic recommended for biopsy or not.

I want to thank you for your attention and hope you have a great day.