Solid Breast Nodules Benign vs Malignant - SD

Introduction

Hi, I am Cindy Rapp.

I am from the University of Colorado Hospital in Denver, Colorado.

Today I'll be talking about solid nodules, how to differentiate benign versus malignant lesions, solid breast nodules, benign versus malignant.

Common Breast Cancers on Ultrasound

If we look at the type of cancers that we see with ultrasound, the number one cancer that we'll diagnose is invasive ductal carcinoma.

You can see the second most common is invasive lobular.

We also have medullary, mucinous, DCIS and other types and metastasis.

DCIS is much more common in the mammographic role.

But with ultrasound, we typically will find invasive ductal cancer most often.

Approach to Solid Breast Nodules

Now, just the opposite of our judicial system would breast sonography.

What we wanna do when we find a solid lesion is think of it as being something worrisome.

So the first thing we're gonna do is seek malignant findings.

Once you have looked for malignant findings and you haven't seen any, then what you want to do is make sure you can classify the lesion as being benign.

If you cannot classify it as being benign, then we have to classify it as indeterminate.

And if it's indeterminate, it's recommended for a biopsy.

Heterogeneity of Breast Cancer

Breast cancer is extremely heterogeneous.

It's very important to make sure that you scan the entire nodule in two planes.

Looking for any subtle changes that you might see.

If you happen to find a mixture of benign and malignant findings, it will exclude the lesion from being benign and classify it as being something worrisome for malignancy.

And I already mentioned the heterogeneity of breast cancer, not only from nodule to nodule, but often within a single nodule.

We'll see very heterogeneous findings.

If we look at this chart, you can see the heterogeneity of breast cancer.

We've got one end of the spectrum where we'll have lesions that are very well circumscribed.

On those, we'll see lesions that are extremely cellular.

You may have high grade lesions, ones with an inflammatory reaction enhanced through transmission.

These are ones that are pop, are positive on color doppler.

On the opposite end of the spectrum, we have our speculated lesions.

They tend to be more cellular. They're low grade cancers.

They host a desmoplastic reaction.

We'll see shadowing behind those.

These are typically negative with color doppler and because of the heterogeneity of breast cancer, often we have a mixture between these two findings that we'll see within a single lesion.

Spectrum of Solid Nodule Appearances

Looking at solid nodules, the complex spectrum of the gross morphology, we can see lesions that are fairly well circumscribed that are malignant.

And then we have lesions such as fibro adenomas that can be extremely worrisome looking, especially if you're scanning a young teenage patient more often.

In black females, they can have what are called juvenile fibroadenomas.

Those look very worrisome, so graphically.

And then we have things such as radial scars that present as speculated lesions that we really won't talk about much today.

Using Multiple Findings in Ultrasound

Now, if people sometimes think that we should not use ultrasound to tie and differentiate benign versus malignant lesions, they say if you took a single finding, you can see such as shadowing, how many fibro adenomas that we could prevent a biopsy in the area of green.

But you could see how many false negatives that we would have in the area in red.

But with ultrasound, we don't take just a single finding, we take multiple findings.

We apply basically the same algorithm that we do with mammography.

And what we're able to do by doing this is get our false negative rate less than 2%, which is pretty much the gold standard for mammography.

So with ultrasound and using these multiple features, we're able to get our false negative rate of less than 2%.

These are the different things that we will talk about.

Malignant Features of Breast Cancer

Features of breast cancer, we can look at speculation, angular margins and acoustic shadowing.

These are what I call hard findings.

They tend to go along with an invasive process.

More nonspecific findings, in other words, can go along with either invasion or DCIS are micro loation taller than wide, and looking at the echogenicity of the lesion, we compare all lesions in the breast to fat.

So if I say a lesion is hypo coic, that means it is darker than fat.

More soft findings that tend to go with DCIS are things such as duct ext, extens, branch pattern and calcifications.

Speculations

So the first feature that we'll look at are speculations.

This is more of a hard finding.

Now depending upon the brat background of the tissue surrounding the lesion, we may see hypo copics.

If there is an echogenic, more of a fibro glandular background, we will notice hypo copics.

If the lesion is surrounded by fat, the S speculations that we'll see will tend to be more echogenic.

These are the ones that show up mammographically because we've got a fatty background.

So on mammogram we can see those type of speculations.

If we look at the image on the left here in this particular breast cancer, we have an area of duct extension.

This cancer is also taller than it is wide through this portion.

And here you can see these hypo copic radiating out because there is an echogenic background.

You also notice that there's a smaller cancer sitting right here, a multifocal lesion.

If we notice the image on the right, these are more echogenic speculations that we can see radiating out because there is a fatty background.

So since we have the fatty background, we can see echogenic speculations versus the hypo coic ones.

When we have the bright background, because of the heterogeneity of breast cancer, sometimes only a certain surface of the lesion may have speculations, and here we can see speculations on the anterior surface and appears a little bit more like thick halo around the lateral side of it.

Why is it sometimes that we see echogenic versus hypo copics?

Actually, we have both of them present and typically the background tissue will alternate or will eliminate one of those.

So if you notice here is the actual s**c, which is more hypo coic, which is we're seeing here on this pathology specimen.

The S speculation, the interface between one s**c and the other is more of the echogenic background.

So this is a nice example of being able to demonstrate both hypo and hyper speculations and typically we'll only see one of those when we do our imaging.

One thing that's very important when you are looking at a lesion, make sure that you optimize the image completely.

When you first start scanning, you wanna make sure you take a picture that you can see all the way from skin surface down to the chest wall.

But once you're ready to look at that, look at the surface, characteristics of this lesion, make sure that you zoom up.

And here you can see these speculations much better on a zoomed image.

So optimize your image completely when you're looking at it.

A variation of speculations are what we refer to as the thick echogenic kalo that you can see surrounding this lesion.

Now one thing that we'll notice is the thick echogenic kalo.

A lot of times we'll appear to be thicker on the edges than it is on the anterior and posterior surface.

So usually it's thicker on the anterior posterior, I'm sorry, thicker on the edges than it is anterior and posteriorly.

This is the same lesion that was scanned the same day.

The only difference is that we can see this image on the left was done on a mid-range ultrasound equipment versus scanning it on a high-end equipment.

So what appears to be a thick echogenic kalo seen here are actually individual spicules that we can see radiating out once we used our high-end equipment.

I think both of the systems will show that this is a lesion that needs to have a biopsy is just if you're using high-end equipment, you can make your diagnosis with a lot more confidence.

I think using high-end equipment.

Angular Margins

And the next finding we're gonna talk about are angular margins.

Angular margins are a hard finding.

So if we see this, we typically are dealing with an invasive carcinoma.

You can see this lesion here, all the multiple angular margins that we're able to demonstrate.

Also, notice that this lesion is markedly hypo coic compared to the fat.

There's some areas of calcification with it.

There's enhanced through transmission behind it.

So most malignant lesions have multiple features that we will be able to see in evaluating them.

Because of the heterogeneity of breast cancer, it's very important to make sure that you scan a lesion all the way through in two planes.

Don't just take one random cut transverse through here and another one longitudinal through this plane, or you will miss the angular margin scene here or the micro loation scene in this area.

So very important to make sure you scan all the way through and look for the subtle little changes that we might see on ultrasound.

Looking at this cancer, that we can see, I'm gonna show you a dotted line and a dash line right through the cancer that's just about a centimeter apart from each other.

Notice on this image on the right, right through this area, how well circumscribed this lesion can appear.

Whereas a cut just about a centimeter away, there are obviously malignant features, angular margins and shadowing that we can see that's just showing you or demonstrating the amount of heterogeneity that we can see within a single nodule.

Now in looking at breast cancer, cancer likes to take the path of least resistance.

So as a cancer becomes invasive and starts to spread, a lot of times what it'll do is when it hits up against this anterior preor fascial layer, the anterior preor fascial layer comes along.

Wherever there's a Cooper's ligament, it goes up, attaches it the skin, and comes back down.

So as cancer starts and hits up against that prem fascial layer, a lot of times it will start invading up through Cooper's Ligaments.

And one thing we learned is if we're looking for subtle changes on cancers that are fairly well circumscribed is look into the area of a Cooper's ligament and that is where we'll be able to find these little angular margins right in that area.

They tend to invade Cooper's ligaments.

So looking at this cancer, one thing you'll notice is wherever we have a Cooper's Ligaments in the base of it, we can see an angular margin.

So angular margins is everywhere.

There's a Cooper's ligament attach the cancer.

Cancer likes to take the path of least resistance when it starts to invade.

Micro lobulation

Our next feature that we're going to look for is micro loation.

That can go along with either invasion or DIS, different ways that it can present.

You can have fingers of invasive tumor.

We can have intraductal components or actual cancerization of the LOEs.

If we look at the invasive fingers of tumor, sort of an angular or also associated with the thick echogenic halo, you can see right through here we've got those areas and very similar to what we would call sort of s speculation within that.

But those are the fingers of invasive tumor that we'll see with micro loation.

Looking at micro loation, the DCIS components of the tumor are in this area here that are highlighted.

85% of ductal cancer is in mixed invasion and DCIS, the invasive cords tend to be more centrally located.

The DCIS tend to be more peripherally.

This is why it's very important when a lesion is biopsied that different areas of a lesion are biopsied and not all of them right through the same area.

If you've got a sample back of just DCIS, treatment for the patient is much different than if they know that it is in invasive carcinomas.

So very important to take different samples through a lesion when a biopsy is performed.

And the last part of micro loation is cancerization of the LOEs.

You can see here that we have actual the TDLU cancer within the lole itself.

Now depending upon the nuclear grade of the cancer, your low nuclear grade lesions tend to have small micro loation.

Your high grade lesions tend to have much larger micro loation.

Also notice with your high grade lesion that you have enhanced through transmission that we can see behind the lesion.

Very important to make sure once again that when you're looking at lesions, this lesion may appear to be fairly well circumscribed.

But once we zoom up, notice how you can see these little areas of micro loation.

So be sure optimize your image completely every time that you're looking at it.

Taller Than Wide

The next feature worries and for malignancy that we're gonna talk about is if a lesion is taller than wide.

So when it's taller in the anterior and posterior dimension versus a transverse dimension.

So a finding that tends to be more with benign lesions or when a lesion is wider than tall seen in the fibroadenoma small cancers, sometimes we will see growing in a taller than wide appearance.

So here we've got the wider than tall versus taller than wide tends to be more of a benign finding.

This tends to go along more with malignant findings.

Now, there's several theories as to why we see malignant nodules taller than wide.

I can remember doing breast lectures about 10 years ago and saying, oh, it's the gross of tissue planes.

Cancer grows against a tissue plane.

Benign lesions tend to grow with tissue planes.

Some will say it's the lack of rotation within a fixed malignant nodule, or they may say that it's only because we're measuring the central NIUs.

It may be because the compressibility of malignant nodules, but the real reason of why we see cancers taller than wide, it reflects the axis of the orientation of A-T-D-L-U terminal ductal lobular unit in which a small cancer arose.

And now you're saying, okay, Cindy, what?

What did you just say? That's sort of confusing.

I'll show you a diagram of what we're talking about.

So if we look at the ductal system and what we're gonna do is take a cut right through this portion and now look at the short axis of that duct.

If you notice, here is an anterior lole. This is A-T-D-L-U.

This is the extra lobular terminal duct coming into the main ductal system.

So if we're looking at anterior lobules, they have fairly long extra terminal ducts.

If you look at posterior lobules, they have fairly short terminal ducts.

So if we look at the poid spread of cancer, where the yellow.is, is where cancer will start.

Cancer takes to take the path of least resistance.

So as cancer starts to spread, you can see that if it arises in an anterior lole, it's got a pretty good distance that it can grow before it hits the main ductal system and starts branching out and spreading.

If you have a cancer that arises in a posterior lobule, there's a fairly short extra lobular terminal duct.

So when the cancer starts to invade or spread out, it's gonna hit the main ductile fairly soon.

If you have a cancer that arises in a terminal lole, those cancers will never be taller than white.

They start out more in a transverse orientation to begin with.

So here are examples of small cancers, all which arose in A-T-D-L-U.

Here's a cancer that arose in a posterior lobule.

You can see it looks like a tennis racket with a handle up.

Here's a small cancer that arose in an anterior lole and here's one that arose in a terminal lo.

So these are all examples of small cancers that are taller than wide.

If you notice, I keep seeing small cancer.

One reason is this is a feature that we tend to see in smaller nodules.

We don't see it as often in large malignant nodules.

If a cancer is less than 10 millimeters, we see this feature about 70% of the time.

Once a cancer gets up to two centimeters, we probably only see it about 12 to 15% of the time.

So it is something that tends to go along with smaller nodules.

The entire nodule does not have to be taller than wide, but if any portion of the nodule is taller than wide, we will use that as one of the malignant findings.

Duct Extension

The next feature we're gonna talk about is duct extension.

This is when the cancer starts to grow back towards the nipple.

So you can see this cancer here and we've got a fairly long segment of duct extending down it.

And this is very important as to why we wanna make sure we scan in a radial plane.

Radial scanning is scanning the same way like spokes of a bicycle run.

It's scanning in the ductal system.

If you look in a fairly large breast center and you have never seen duct extension like this, it may be because you're imaging more in a transverse longitudinal scan plane.

But very important to make sure that you do see duct extension.

If you've ever been into the operating room, one thing that you'll notice is when they go in and do a lumpectomy on a patient like this, what they'll do is make sure that when they remove the tissue that they have at least a one centimeter clear margin all the way around the lesion.

Now why the patient is still on the table, they'll send the specimen either for a radiograph or send it to pathology and then they'll go ahead and start doing a sentinel node procedure while the patient's still on the table.

If they send it to pathology and the pathologist is on the ball, what he'll do is say you don't have a free margin.

Let the physician know what area, tell the surgeon he'll go back in and take another cut of tissue.

If the pathologist notices that it still has got a margin that is not clear, the surgeon goes back in and takes another sample of tissue.

And a patient who went under the knife thinking they're going to have a lumpectomy has now had so much breast tissue removed that they need to convert it to a mastectomy.

But what's even worse than that is if the physician or surgeon does the first initial cut and it's never detected that there was not a free margin and say five years later, this patient may represent with quotes, recurrent breast cancer.

The majority of recurrent breast cancer is breast cancer. That was missed the first time.

Branch Pattern

Now the next finding we're gonna talk about is branch pattern.

Branch pattern is just the opposite of duct extension.

So instead of the cancer growing back towards the nipple, it branches out away from it.

This is more of a soft finding.

We tend to see this more with DCIS, but here you can see all these branches radiating out away from the nipple of cancer that has invaded.

And the main lesion is sitting in this area here, depending upon the nuclear grade of the cancer.

If you have high nuclear grade, you may see large juicy branches.

Medium branches tend to go along with your intermediate grade and small branches tend to go along more with your low grade DCIS.

Now if you find an isolated duct extens or branch pattern, this indicates a benign intraductal papilloma about 87% of the time, but 6% of the time are DCIS and another 7% can be atypical ductal hyperplasia.

So you cannot classify this as being a birads three.

We wanna make sure that we're 98% sure that it's going to be to call something a BioRad three.

So having an isolated finding of duct extension or branch pattern, tends to be benign majority of the time, but still it's not enough to call it a BioRad three.

These should be given at least a bio rads foray and should be biopsy.

Acoustic Shadowing

The next finding we're gonna talk about is acoustic shadowing.

This is a hard finding When we see acoustic shadowing, typically we're dealing with an invasive carcinoma.

Now depending upon the degree of desmoplasia is how much shadowing we will see behind a lesion.

We may have a breast cancer that shadows entirely behind it or we may have a lesion that only has partial shadowing behind it.

And it just once again depends upon the desmoplastic reaction that we'll see posterior to that lesion.

If we look at the histology grade versus sound transmission, your low grade ductal cancers invasive ductal carcinomas tend to have shadowing seen behind it.

High grade invasive ductal cancers tend to have enhanced through transmission seen behind them.

We did a study looking at 409 solid malignant nodules and we could see acoustic shadowing either partial or complete 35% of the time, normal sound transmission behind the lesion 32% of the time and enhanced through transmission about 28% of the time and mixed findings 5% of the time.

So if you're looking for the presence of shadowing to call something a cancer, you'll only be right about a third of the time.

Cancer can present itself in any way that at once, either with normal sound transmission, enhanced sound transmission or shadowing.

Dr. Stavros always called our high grade lesions poor man's color.

Doppler said that if you did not have color, you could just imagine the flow.

But the cancers that have the enhanced through transmission behind them are the ones that are gonna light up with color doppler.

So we will see quite a bit of flow.

One other thing to note is anytime you're looking for the presence of blood flow in a lesion, you wanna make sure that you scan with very light pressure.

Scanning with light pressure is when we will see flow.

If you're scanning with heavy pressure, you can temporarily ablate all the flow.

So anytime you're looking for the presence of blood flow, make sure you scan with very light pressure.

Now if we look at acoustic shadowing and enhanced through transmission differential diagnosis that we'll see with those with our low grade shadowing, we're gonna see low grade invasive ductal cancer.

Invasive lobular carcinomas also cause shadowing and tubular carcinomas once they're over one and a half centimeters in size enhanced through transmission.

We'll see with our high grade invasive ductal cancers, colloid carcinomas once they're over one and a half centimeters medullary and invasive papillary also have enhanced through transmission.

Calcifications

The next finding we're gonna talk about are calcifications.

That tends to be more of a soft finding, which we'll see with DCIS.

If you notice, we can see these tiny little calcifications inside the solid nodule.

Now a lot of times the calcifications that we see mammographically are within auc.

You're saying your Dr. May say to you, I want you to go ahead and scan this patient and you're going, but there's only calcifications.

Ultrasound is not real good at picking up calcifications, but what your doctor wants to do is see if there is any mass associated with those calcifications.

If there's a mass associated with the calcifications, it's going to be much easier to biopsy those with ultrasound guidance than it is stereotactic method.

But typically the calcification seen inside the duct, we do not see with ultrasound, the duct is echogenic.

The calcifications are echogenic.

We typically will only see ones when they are associated with a mass.

Markedly Hypoechoic

The next malignant finding we're gonna talk about is markedly hypoechoic.

Now we used to be in the old days, we would see cancers that look just like this.

This is markedly hypo coic compared to the surrounding fat.

Nowadays we don't tend to see cancers that are those dark and one reason is we're running with equipment that's so much better than we had in the old days.

Here's some more examples.

This is a cancer that is markedly hypo coic compared to the fat and one with intense shadowing that we can see is also markedly hypo coic compared to fat.

Now looking, why is it we don't see this feature as often as we used to?

I'm gonna show you the same lesion skin the same day.

The only difference is I changed the dynamic range.

Here we have a dynamic range of 68 db and then what I'm going to do is actually increase my dynamic range to 90 db.

Notice here where we have a lesion that is markedly hypo coic compared to the fat.

Now this lesion is almost iso co compared to fat and the only thing I changed was dynamic range.

Our machines that we're using nowadays run with much wider dynamic range.

We broadband technology, compound imaging, things like this that help improve our image that we're just not seeing cancer as dark as we did before.

Also, if you notice, we can see this area of central necrosis much better in the lesion running at 90 D, 90 DB compared to the one at 69 db.

I'm not saying that we need to all drop our dynamic range way back and start scanning so that we've got more contrast in the image, but just be aware that we typically see lesions a lot more iso coic currently than we used to.

Proving Benignity

You may say, Cindy, what happens if I have a really bad day and I happen to miss one of those malignant findings?

The average breast cancer has 5.3 malignant features to it.

So even if you're having a bad day, hopefully you'll be able to pick up at least one of those findings.

So once you've searched that solid lesion, you've looked for all those different malignant findings, you've not found any of them.

Now what we have to do is prove that the lesion is benign.

What we have to do is find one of the three to be able to classify it as a birads three either markedly hyper coic tissue.

We want to see an elliptical shape and we will allow up to two to three gentle loation.

Now we need to make sure that that lesion is completely surrounded by a thin echogenic pseudo capsule.

So we'll talk about these purely hyper coic.

We can have a ridge of normal fibro glandular tissue or an area of just sort of fibrosis or normal tissue.

This showed up as a mammographic nodule so we knew it wasn't a lipoma.

Sometimes like palms can appear to be echogenic like this in the subcutaneous fat, but since it showed up on the mammogram, this is just an area of fibrosis, this is something we would consider purely hyper coic and nothing else needs to be done.

Now looking at this lesion here, this is not purely hyper coic.

There is a small lesion in the center of it that is iso coic.

So we would not classify that as being purely hyper coic tissue.

Here's another finding. This is one we would consider to be purely hyper coic and this is a patient that had just a palpable ridge of normal fibro glandular tissue.

We would not be concerned with that.

If a patient presents with a palpable abnormality and this person came in, in feeling that abnormality, we could see that it was just this ridge of normal fibro glandular tissue.

Anytime we're gonna tell a patient that something is normal tissue, what we recommend is that they check that area once a month.

We told her to go back and have her clinician recheck this area in six months.

If anything was to change to have it reevaluated, well the patient came back to our department four months later and we can see kind of within this gray area here, which nobody could really make out a mass at the time this high grade invasive ductal carcinoma kind of exploded, that she had not felt previously.

So these high grade lesions are very rapidly growing.

Very important that if somebody's gonna follow up what you think is normal tissue, that they check that area at least once a month.

Now when we look at ultrasound and we're comparing it to things on the mammogram, we wanna make sure that the size, shape, location, and surrounding tissue all match up.

This lesion here was a 13 millimeter mammographic nodule.

We expect maybe a little bit of measurement error when we're comparing mammography to sonography, but they should be pretty much the same.

You can see we have almost a 50% difference in that.

So our size was not matching up going back in and rechecking this particular patient.

What had happened was the technologist had done a scan more through this area of the tissue creating this area of echogenicity and actually had missed these two small cancers sitting on top of each other and just sort of mistook this thick echogenic halo as being the mammographic nodule.

But your size, shape, location surrounding tissue should all match up.

If you have something that's 13 millimeters on the mammogram, it should be pretty much the same size when you do the ultrasound.

Looking at elliptical shape for our benign finding, it'd be wonderful if all fiber almost look like this, but we know that they don't.

They tend to be more wider than tall or elliptical shape and almost looks like a little almond sitting in there.

But this is a classic fiber adenoma.

We will allow up to two to three gentle loation of fibro adenomas.

One other thing we wanna make sure is that there is a nice thin capsule completely surrounding it.

So these are gently lobulated fiber adenomas and that is okay for calling it a birad three.

That means probably benign.

One other feature that we'll allow for is what's called a teardrop shape, where you've got one edge of the fibro adenoma that comes to just a little point.

We don't consider this to be an angular margin but more of a teardrop shaped fiber adenoma and that is something that we will allow for in calling fiber adenomas Aser mentioned.

We wanna make sure that either elliptical or gently lobulated structure also has a thin echogenic pseudo capsule surrounding it.

If you have compound imaging, it makes it much easier to be able to see these thin echogenic capsules.

If the capsule surrounded by echogenic fibro glandular tissue, it's a little bit more difficult to see the thin capsule surrounding that.

So much easier to see it if we are scanning against a fatty background.

Just the normal scan pressure of your hand resting on the breast tissue sometimes is enough to compress that fibro glandular tissue up against the capsule.

So what I'll do real time is lighten up my pressure and you can see by scanning with lighter pressure, we're able to actually see the capsule a lot better than we could with our normal scan pressure here.

So in looking at that, another thing to be aware of, once you lighten up your pressure to see the capsule better, you may cause some artifactual shadowing.

And remember, shadowing is a feature worrisome for malignancy.

So in real time it's just one thing you wanna do is scan with normal pressure and lighten your pressure to be able to see the capsule a little bit better.

So you will need a combination of both heavy and light scanning playing.

The other thing is making sure that the capsule is complete all the way around the ends of a lesion.

You can see on this fiber adenoma here, we can see the capsule very well on the anterior and posterior surface, but we don't see it very well on the ends of the lesion.

So coming in and healing from this end, you can see the capsule extending all the way around towing from the other end.

We can see the capsule coming around that way.

Is this something I take pictures of?

No, it's just something that I'll make sure I do when skinning lesions real time, any solid nodule that we have in our department, our radiologist comes back in the room and talks to the patient.

So either I'll scan and show them this during real time or something that if they're scanning they'll make sure that they can see the capsule extend all the way around the lesion.

I was in a lecture once at the RSNA and I heard this physician get up and present a paper and say, well, according to stasis criteria, this is a benign lesion because there's a thin echogenic pseudo capsule, there is a thin capsule, but this is obviously not a benign lesion.

There's micro loation, it's very heterogeneous that we put on color doppler.

You would see all kinds of flow within this.

This is a high grade lesion.

High grade lesions are very rapidly growing and we would expect to see a thin echogenic capsule.

If you look here on the specimen, you can see how thin the capsule will be because those high grade lesions grow very rapidly.

They are pushing their way through the tissue.

So anytime you see a thin echogenic capsule, don't always assume the lesion is benign.

A lot of things you wanna make sure there are no other features recent for malignancy that we'll see such in this particular lesion.

Looking at our negative predictive value, we have never seen a purely hyper coic cancer.

Now I'd say about once a year we'd get a case that would come in something like this, would be sent in to Dr.

Stavos and they would say, look, this is a purely hyper coic cancer, but is it look in the center there is a two millimeter hypo coic central portion that we can see.

And then what we're noticing is just this thick echogenic halo surrounding the lesion.

Now one thing that might happen is you have a patient that presents something like this.

This is a palpable lump.

You might think that this is just normal fibro glandular tissue right here, but this is one centimeter across here.

We wanna get this closer to the elevation plane focus where a transducer is focused.

So when we do that, we wanna use a standoff pad.

You can notice that once we use a standoff pad, you can see these two small hypo cancers in this area of the thick echogenic halo that we got some volume averaging through here.

So be sure that you optimize your image completely if anything was within that first centimeter of the transducer.

Use a standoff pad or a big glop of jilt to make sure that you get the lesion closer to the elevation plane focus that you don't get volume averaging calling something, purely hyper coic tissue.

Axillary Lymph Nodes

Now once I've seen a suspicious lesion in the breast, what I wanna do is check the axilla.

I wanna look at lymph nodes and see if there's anything suspicious in the axilla.

A normal lymph node looks just like a kidney.

Here we can see in a long axis view and a short axis view.

These were zoomed up pretty large but looks just like a kidney.

This would be our parenchyma or the cortex and our fatty central hilum.

This is a transverse U that we can see that coming around.

One question I get is we know that the center of a lymph node is fat.

Why is the fat on a lymph node more echogenic compared to normal fat?

And what it is, is the lymphatic channels running through that cause the fatty hylum to be more echogenic.

Now there's a variation of normal that we can see within lymph nodes.

We can have the perfectly normal lymph node.

We can start to get thinning of the cortex just like what we'll see with kidneys.

And at times we may actually get fatty infiltration into a lymph node.

So here you can see this is the cortex.

This is the lymphatic portion of the fat that is more echogenic and this is fatty infiltration that we see within this lymph node.

This is perfectly normal.

The only time we get more concerned about lymph nodes is when the cortex itself is thick.

We're gonna talk about lymphatic flow.

This is not the blood flow, but this is how the lymph lymphatic system will flow.

It's from the subcapsular sinusoids to the cortical sinusoids and into the medullary.

So lymphatic flow is gonna start from the outside of the lymph node and move in centrally.

And if we look at a foreign body, it affects a lymph node differently.

Foreign bodies are gonna be from the medullary sinusoids out.

So if you have a patient that had a silicone implant that ruptured, these are silicone granulomas within a lymph node.

Here you can see the cortex right there is that tiny little hypo coic line.

Whereas is when we have a tumor metastasis to a lymph node that affects from the outside of the lymph node going in.

So the cortex is what will be thickened.

So the opposite for a foreign body versus metastasis.

Foreign bodies are from medullary.

Sinusoids out metastasis are from the cardiac cortical sinusoids coming in.

Now there's a range of abnormal sonographic appearances that we'll see with a lymph node in the center.

We have a perfectly normal lymph node.

Then what we will notice is that sometimes you might see a lymph node where just the cortex is thickened all the way around.

You may have it where you see just portions of the cortex being thickened or abnormal.

You may have a lymph node that looks like there was a rat bite taken out of it.

Maybe you may have ones where the cortex gets so thick that it compresses the fatty hili centrally.

You may have it where it compresses the fatty hilum to the outside of the lymph node.

Sometimes you may have a lymph node that just looks grossly abnormal, almost like a round ball.

And at times some lymph nodes may even become very ragged and jagged and actually look just like a metastatic lesion itself.

Now beware any of these types of appearances, either this lymph node, this lymph node, or this one can go along with either metastasis or it could be an inflammatory process.

But if you're scanning the patient doing a breast ultrasound, you see a suspicious lesion in the breast, then you go scan the axi, most likely you're dealing with a metastatic lymph node.

Sometimes we are asked to scan a patient because they present with a palpable abnormality in the axilla.

If that's the case and you see the appearance of any of these types of lymph nodes, the patient definitely needs to have a breast workup to make sure that there is not a breast lesion causing it.

But if you see multiple abnormal lymph nodes, it possibly could be an inflammatory process and not a metastatic if you start looking in the axilla to begin with.

Now one thing that we have found is anytime we see a grossly abnormal lymph node sitting next to a normal lymph node, that's pretty much a malignant lymph node.

Here's another example. Here's a grossly abnormal lymph node sitting right next to a normal lymph node and another one grossly abnormal lymph node sitting next to one that's probably a little bit too thick within that cortex.

So this is also an abnormal lymph node, but if you have metastasis, you may find this type of of pattern.

If you have an inflammatory condition or inflammation, typically that's going to affect the whole range or the whole region of lymph nodes in that and not just one.

So if you see one abnormal next to a normal, that will typically be a metastatic lymph node.

What we'll do on the case of we do see these lymph nodes, we will go ahead and biopsy them.

If it's proven to be a metastatic lymph node, then the patient does not need to go, for a sentinel node procedure, they can go straight to an axillary dissection.

So seeing these types of abnormal lymph nodes can be very helpful.

Conclusion

But once you guys all understand breast sonography, you'll love it and watch out for those speed humps.

Thank you.