Q4 - Breast (Week 1)

Breast Ultrasound Exam Indications

• General Indications for performing a breast ultrasound exam include:

  • Breast enlargement

  • Nipple discharge

  • Tenderness

  • Palpable mass

BI-RADS (Breast Imaging and Reporting Data System)

• Definition: A standardized reporting system established by ACR (American College of Radiology) for breast findings.

• Purpose: To assess and categorize the suspicion of malignancy and to enter reports into a national database.

• Categories: BI-RADS has five categories based on suspicion for malignancy:

  1. Category 1: Normal tissue; causes mammogram/clinical abnormality.

  2. Category 2: Benign findings, such as:

     • Intramammary lymph nodes

     • Ectatic ducts (dilated duct)

     • Simple cysts

     • Benign solid nodules (e.g., lipoma)

  3. Category 3: Probably benign (<2% risk). Includes:

     • Complex cysts

     • Small intraductal papillomas

     • Subset of fibroadenomas

  4. Category 4: Suspicious findings with risk categorized into:

     • 4a: Mildly suspicious (2-10% risk)

     • 4b: Moderately suspicious (10-50% risk)

     • 4c: Highly suspicious (50-95% risk)

  5. Category 5: Highly suggestive of malignancy (90%+ risk).

• Management Options for BI-RADS 3:

  • Surgical biopsy

  • Image-guided biopsy

  • Short interval sonogram follow-up

Patient Management Based on BI-RADS

• BIRADS 1 & 2: Patients return for routine screening.

• BIRADS 3: Optional biopsy, either surgical or image-guided, or short interval follow-up.

• BIRADS 4 & 5: Require biopsy.

Indications for Male Breast Sonogram

• Evaluation for:

  • Breast enlargement

  • Nipple discharge

  • Tenderness

  • Palpable mass and pain

• Factors Increasing Risk for Breast Cancer in Males:

  • Klinefelter's disease (XXY)

  • Previous chest wall irradiation

  • History of orchitis or testicular tumor

  • Liver disease

  • Male-to-female transsexuals

  • BRCA 2 gene mutation.

• Gynecomastia: Male breast enlargement due to:

  • Hormonal imbalance

  • Use of hypertension and antidepressant medications

  • Long-term estrogen therapy (e.g., for prostate cancer).

Sonographic Performance and Characteristics

• Dense vs Fatty Breast Evaluation:

  • Younger breasts are typically dense, while post-menopausal breasts are often fatty.

  • Ultrasound is better at visualizing dense tissue compared to fatty tissue.

• Targeted Sonogram Goals:

  • Follow-up on mammogram findings to identify malignant lesions obscured by dense tissues.

• Reporting Negative Sonogram Results:

  • Must assign a BI-RADS category to maintain clinical relevance.

Specific Sonographic Features

• Associated Features with Sono and Mammogram:

  • Mass density

  • Size, shape, location

  • Surrounding tissue density

• Key Suspicions on Ultrasound:

  • Irregular borders and angular margins

  • Spiculation and microlobulation which indicate malignancy.

Fibroadenoma Features

• Most Common Benign Solid Breast Tumor: Fibroadenoma presented as:

  • Firm, round/oval, smooth mass

  • Usually freely mobile with clear delineation from surrounding tissue.

Diagnostic Criteria for Breast Cancer

• Suspicious Sonographic Signs:

  • Taller than Wide: Indicating likely malignancy.

  • Angular or Spiculated Margins: High sensitivity for malignancy.

  • Acoustic Shadowing: Associated with invasive cancers.

Specific Imaging Techniques in Breast Evaluation

• Doppler Studies: Used to assess blood flow and hypervascularity indicative of malignancy.

• Interventional Procedures:

  • Cyst aspiration

  • Fine needle aspiration cytology (FNAC)

  • Vacuum-assisted needle biopsy

  • Sentinel node biopsy

Clinical Findings and Breast Pathologies

• Common Findings:

  • Discrete breast lumps

  • Unilateral discharge, especially if spontaneous and bloody.

• Management & Evaluation: Focused on patient return for regular screenings and biopsy/treatment if necessary.