Answer
Ultrasonography is used to guide procedures such as cyst aspiration, percutaneous biopsy, needle localization of masses for surgical excision, abscess drainage in selected cases, and therapeutic radiofrequency or cryoablation.
Ultrasonography is highly accurate in diagnosing a simple cyst, and it is helpful in evaluating some complex cysts. Usually, a simple cyst is not aspirated unless they it is symptomatic or the patient has persistent psychological concerns about it. Complex cysts or suspected abscesses may be aspirated.
Berg et al reviewed their experience with the US-pathologic correlation of cystic lesions and found that all clustered microcysts were benign, but they cautioned that further study is required. [55] They recommended that biopsy be performed in cases involving (1) cystic lesions with thick, indistinct walls and/or thick septations (0.5 mm); (2) intracystic masses; and (3) predominantly solid masses with eccentric cystic foci. These recommendations were based on the fact that, in their series, 18 of 79 of such complex cystic lesions proved to be malignant.
If it is uncertain whether a nodule seen on US is a complex cyst or solid mass, US-guided aspiration of the cyst is often performed. This procedure is also performed if the appearance of a complex cyst on US is of concern. The aspirate may be sent for cytologic evaluation, though there is no general consensus about the indications for cytology. Some clinicians send only the fluid for analysis if it is bloody.
Parker et al reported excellent concordance between the results of US-guided automated core biopsy with a 14-gauge needle and surgical resection in 49 lesions. [56] US provides effective guidance for percutaneous breast biopsy without ionizing radiation. It also offers the advantages of real-time visualization of the needle and target lesion, multidirectional imaging, and low cost. With US, the patient does not need to undergo mammographic compression; in addition, with US, the examination may usually be performed with the patient recumbent rather than sitting, as is often the case with procedures involving mammographic guidance. However, US is not appropriate for guidance in all situations. For instance, microcalcifications often cannot be localized with US; in addition, not all masses seen on mammography can be seen with US.
Other biopsy devices, such as vacuum-assisted devices, have been developed for use with US guidance. Occasionally, it may be difficult to find the area in the breast where core biopsy was previously performed. This may be a problem if the pathologic results from the biopsy sample and other factors indicate that excisional biopsy or lumpectomy is needed. After a patient receives preoperative neoadjuvant chemotherapy, the tumor may become occult, making it difficult to localize for lumpectomy. For these reasons, various US techniques to mark the biopsy or tumor site have been developed. These include the deployment of coils, clips, or wires.
US-guided fine-needle aspiration biopsy (FNAB) of solid nodules has been used at many centers. Some advantages are that it is relatively easy for a skilled practitioner to perform and that the results are quickly obtained if a cytopathologist is available. For good results, the person performing the FNAB and the cytopathologist must be skilled. Some groups have achieved excellent results. However, in a study by Pisano et al involving 18 institutions, US-guided or stereotactically guided FNAB yielded a 10% insufficient-sample rate for US-guided FNAB of masses. [57] This finding does not compare favorably with results of US-guided core biopsy or US-guided needle localization. [58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71]
Several investigators have presented preliminary reports on the use of US-guided therapeutic radiofrequency ablation or cryoablation of invasive breast carcinoma. [72, 73, 74]
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Breast cancer, ultrasonography. Mediolateral oblique digital mammogram of the right breast in a 66-year-old woman with a new, opaque, irregular mass approximately 1 cm in diameter. The mass has spiculated margins in the middle third of the right breast at the 10-o'clock position. Image demonstrates both the spiculated mass (black arrow) and separate anterior focal asymmetry (white arrow).
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Breast cancer, ultrasonography. Antiradial sonogram of the spiculated mass shown in Image 1 demonstrates a hypoechoic mass with angular margins (black arrows). Cursors on the margins of the mass were used to electronically measure its dimensions of the mass, which was 0.9 X 0.8 cm.
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Breast cancer, ultrasonography. Magnified view of the mass in Image 2 is in the radial plane and perpendicular to the plane in Image 2. The 2 cursors indicate the margins of the mass, which was an infiltrating carcinoma with mixed ductal and lobular features. Sonography-guided core biopsy with a 14-gauge needle was used to initially diagnose the malignancy. A radiologist performed sonography-guided needle localization to assist the surgeon in localizing the tumor. The area of anterior focal asymmetry noted in Image 1 was also excised; this had fibrocystic changes with a 0.5-mm focus of lobular carcinoma in situ and atypical hyperplasia.
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Breast cancer, ultrasonography. This mediolateral mammogram was obtained in a 74-year-old woman with 2-week history of spontaneous discharge from the right nipple. A metal BB marker was placed on a possible lump at the 2-o'clock position. The breast is heterogeneously dense, which may decrease the sensitivity of mammography.
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Breast cancer, ultrasonography. Antiradial sonogram of the right breast (patient in Image 4) reveals a 2.2-cm-long, palpable, heterogeneous mass (horizontal arrows) at the 2-o'clock position. The mass is 3 cm from the nipple in the posterior third of the breast. It has a parallel, wider-than-tall orientation and an angular margin on its anterior edge (vertical arrow).
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Breast cancer, ultrasonography. Radial view of the sonogram in Image 5 confirms the angular anterior margin of the mass (vertical arrow) and its other angulated margins (upper horizontal arrows). Note that a portion of the margin is indistinct (question mark). The pathologic result of initial sonography-guided core biopsy with a 14-gauge needle was predominantly dense fibrosis and focal papillomatosis with evidence of prior hemorrhage. Because of the suspicious sonographic appearance, a sonography-guided needle localization and excisional biopsy was performed. It revealed invasive and intraductal papillary carcinoma.
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Breast cancer, ultrasonography. Craniocaudal screening digital mammogram in a 46-year-old woman shows a new mass (arrow) at the 7- to 8-o'clock position in the right breast. Diagnostic mammography and sonography were then requested.
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Breast cancer, ultrasonography. Radial sonogram shows a mass that is nearly isoechoic relative to breast fat. The mass has angulated and spiculated margins surrounded by echogenic fibrous tissue. The margins are marked with white electronic calipers. Its largest dimension is 0.8 cm.
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Breast cancer, ultrasonography. Color Doppler sonogram in the same orientation as Image 8 without the calipers. No blood flow is demonstrated within the mass. Sonography-guided core biopsy with a 14-gauge needle revealed predominantly fatty tissue. Because of the discordance between the imaging and pathologic findings, stereotactically guided core biopsy was performed and demonstrated invasive breast carcinoma. Partial mastectomy revealed a 0.8-cm, invasive, poorly differentiated ductal carcinoma and adjacent high-grade in situ carcinoma. In addition, 2 of 6 lymph nodes were positive for metastases.
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Breast cancer, ultrasonography. Digital spot compression view of the left breast in a 79-year-old woman who presented with a palpable lump in the upper outer quadrant of the left breast. Image shows a BB marker over the palpable high-density mass, which is approximately 2 cm in diameter and has obscured margins.
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Breast cancer, ultrasonography. Sonogram of the mass in Image 10 shows a suspicious, irregularly shaped, hypoechoic mass (arrows) that does not have a parallel taller-than-wide orientation. It has partially microlobulated and partially spiculated margins. Core biopsy revealed invasive, poorly differentiated ductal carcinoma.
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Breast cancer, ultrasonography. Right-breast mammogram in a 52-year-old woman who underwent previous left mastectomy shows clusters of microcalcification and a small mass with strong posterior acoustic shadowing. The patient was receiving heparin, which was stopped several hours prior to sonography-guided core biopsy with a 14-gauge needle.
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Breast cancer, ultrasonography. Magnified and annotated view of Image 12 shows the isoechoic mass with spiculated margins (arrows) that are made conspicuous by the prominent posterior acoustic shadowing (asterisks) deep to the mass. Core biopsy demonstrated a moderately differentiated infiltrating ductal carcinoma with focal microcalcifications.
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Breast cancer, ultrasonography. This mediolateral oblique digital mammogram of the left breast was obtained in a 48-year-old woman with a several-month history of bloody discharge from the left nipple. Image demonstrates dilated ducts extending from the nipple into the lateral aspect of the breast (asterisks) with a calcification in 1 of the dilated ducts (arrowhead).
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Breast cancer, ultrasonography. Radial sonogram of the area demonstrated in Image 14 shows dilated ducts (asterisks) extending from the nipple into the superior lateral quadrant of the left breast; these are filled with echogenic tissue. (This image and Images 16-17 are oriented with the nipple near the lower right corner to facilitate comparison with the mammogram in Image 14.)
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Breast cancer, ultrasonography. Sonogram of the same quadrant of the left breast reveals a dilated tumor filled duct with a single calcification in a duct.
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Breast cancer, ultrasonography. Color Doppler sonogram (displayed in black and white in the Doppler color box) from the same quadrant of the left breast demonstrates blood flow in the tumor within the ducts. The white oval areas (with central asterisks) represent blood flow within the intraductal tissue and thus confirms that the echogenic material within the ducts is tumor and not just intraluminal debris, blood clot, or secretions.
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Breast cancer, ultrasonography. This galactogram of the upper outer quadrant of the left breast was obtained in the patient shown in Images 14-17 before biopsy. Although unusual, this study demonstrated only normal, nondilated arborizing ducts and not the dilated ducts that contained tumor. Presumably, the orifice of the wrong duct was cannulated and injected with contrast agent, though cannulation of the ductal orifice expressing bloody nipple discharge was attempted. Incidentally noted is extravasation of contrast agent into the breast parenchyma. Cytologic results from the discharge indicated atypia with hyperplastic ductal groups, and Ian intraductal papillary lesion could not be excluded. Subsequent excisional biopsy revealed ductal carcinoma in situ with lobular extension and no invasive carcinoma. A few microcalcifications were present.
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Breast cancer, ultrasonography. Spot mammogram in a 37-year-old woman with a superficial mass of the right breast. A BB metal marker was placed on the mass, which is oval and well circumscribed.
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Breast cancer, ultrasonography. Sonogram of the mass in Image 19 demonstrates a superficial, well-circumscribed mass that was pathologically a dermatofibrosarcoma. It has a wider-than-tall orientation that parallels the skin surface.
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Breast cancer, ultrasonography. Color flow Doppler image (displayed in black and white) shows blood flow in vessels within the mass (arrows). The internal blood flow is consistent with a solid mass, such as this patient's dermatofibrosarcoma, but not with a superficial sebaceous cyst, protein-containing cyst, or hematoma.
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Breast cancer, ultrasonography. Craniocaudal spot compression view was obtained in a 60-year-old woman in whom a mass was detected on screening mammography. Image demonstrates a high-density mass (arrow), the margins of which are partly obscured by adjacent breast tissue.
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Breast cancer, ultrasonography. Sonogram of the mass in Image 22 defines a 2-cm-long, complex, oval cystic mass (arrow) that contains a 0.9-cm, solid, central mass (marginated by calipers). The margin of the mass is well circumscribed and the long axis of the mass is parallel to the chest wall. This is a benign intracystic papilloma. An intracystic papillary carcinoma could have an identical sonographic appearance.
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Breast cancer, ultrasonography. This craniocaudal digital mammogram was obtained in a 45-year-old woman who underwent 5 previous surgical biopsy procedures for fibroadenomas and who presented with a new palpable mass at the 6-o'clock position in the right breast. Image demonstrates the palpable, large, oval mass that has well-circumscribed margins (arrow). Note the linear white lines created by wire markers placed on the skin surface and overlying 2 scars from previous surgery. (Images 25-29 are all from this patient.)
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Breast cancer, ultrasonography. Sonogram of the mass in Image 24 shows the well-circumscribed, oval mass (cursors) with internal echoes. The mass was 36 mm long. The anterior edge of this palpable mass (cursor 2) extends near the skin surface. Although it has internal echoes and was found to be solid, the mass has slight posterior acoustic enhancement, or increased through transmission deep to it (arrow). This finding may be due to a homogenous population of tumor cells in the mass that have few acoustic interfaces, which would facilitate the transmission rather than the reflection of ultrasound.
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Breast cancer, ultrasonography. Color Doppler image (shown in black and white) of the same mass as in Image 25 shows blood flow in a portion of the mass (arrows). This finding indicates that the mass is solid and not a protein-containing cyst with internal echoes, though slight enhancement of the ultrasound deep to the mass is suggested. On the basis of the appearance and size of the mass, the possibility of a phyllodes tumor was suspected; therefore, surgical excision rather that a core biopsy was recommended. Surgical pathology confirmed a phyllodes tumor.
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Breast cancer, ultrasonography. One of the several other breast masses found in the patient in Image 26includes a probable fibroadenoma (cursors). This mass is oval and circumscribed and has a wider-than-tall orientation parallel to the skin line (anterior margin of the image). Note the posterior acoustic enhancement (arrows) suggesting the presence of a relatively homogenous population of cells within the mass with few acoustic interfaces.
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Breast cancer, ultrasonography. Sonogram shows another breast mass (cursor) in the patient in Images 26-27. This mass is typical of a fibroadenoma, though its sonographic appearance is not pathognomonic. The mass has a well-circumscribed margin and oval shape, as well as a parallel, wider-than-tall orientation. Note that it has no enhancement deep to the mass compared with adjacent tissue. The white surrounding tissue is echogenic fibrous tissue, which obscured the mass on mammography.
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Breast cancer, ultrasonography. The patient in Images 26-28 also had a 7-mm-diameter cyst at the 10-o'clock position in the right breast (black central structure). Note the well-circumscribed margins, thin wall, lack of internal echoes, and posterior acoustic enhancement (increased through transmission) deep to the cyst.
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Breast cancer, ultrasonography. This 49-year-old woman was found to have a mass in the right breast on screening mammography (not shown). Sonography demonstrated a well-circumscribed, oval mass with internal echoes and equivocal posterior acoustic enhancement (arrow) beneath it. To determine if this was a solid mass or complex cyst containing echogenic debris, sonography-guided aspiration was performed with an 18-gauge needle. Nonbloody fluid was aspirated. The cyst completely disappeared on aspiration; this finding was consistent with a benign cyst. It is a benign cyst. In rare cases, a carcinoma can have an identical sonographic appearance, though it would not resolve after aspiration.
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Breast cancer, ultrasonography. This 43-year-old woman had a subcentimetric lesion in her left breast, as noted on a mammogram obtained at another facility (not shown); as a result, biopsy was requested. This sonogram demonstrates a 0.6-cm, hyperechoic, well-circumscribed mass (arrow) made more conspicuous by the surrounding hypoechoic fatty tissue. The layers of echogenic skin, hypoechoic fat (which contains the echogenic, thin, linear Cooper ligaments), and the posterior echogenic fascia and pectoralis muscle are labeled. The patient and her family insisted on biopsy even though entirely echogenic breast masses are usually benign.
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Breast cancer, ultrasonography. Sonography-guided core biopsy (of the echogenic lesion in Image 31) was performed with an 18-gauge core-biopsy needle (arrows), which is shown entering the mass. Pathologic evaluation of the core samples demonstrated an angiolipoma within predominantly fatty breast tissue.
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Breast cancer, ultrasonography. Right breast craniocaudal projection from a mammogram in a 73-year-old woman who underwent a contralateral mastectomy 14 years ago shows a mass (asterisks) in the right breast that is unchanged from a mammogram obtained 3 years earlier.
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Breast cancer, ultrasonography. Spot magnification 90° mediolateral view of the mass in Image 33 demonstrates that it is heterogeneous, with a thin rim of subcapsular radiolucent fat (arrows).
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Breast cancer, ultrasonography. Sonogram of the nonpalpable mass in Image 33 demonstrates a heterogeneous mass that resembles the appearance of a "breast within a breast" and is typical for a hamartoma (arrows).
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Breast cancer, ultrasonography. The sonogram was obtained through the long axis of a normal intramammary lymph node in a woman's right breast (arrow). The normal lymph node is oval, not round, and has a normal relatively thin, peripheral, hypoechoic cortex and a prominent normal hyperechoic hilus. This appearance has been compared to the sonographic appearance of a normal kidney.
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Breast cancer, ultrasonography. This sonogram was obtained though the short axis of the intramammary lymph node shown in Image 36. The relatively hypoechoic cortex (white arrow) surrounds the lymph node except at the hilum (black arrow).
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Breast cancer, ultrasonography. Craniocaudal digital spot compression view of the lateral aspect of the left breast in a 39-year-old woman with a 3-week history of a palpable, tender, cordlike swelling in this area. A metallic BB marker is placed over the palpable, cordlike mass (arrow).
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Breast cancer, ultrasonography. Radial sonogram demonstrates the palpable mass at the 3-o'clock position shown in Image 38 and reveals a hypoechoic tubular mass with fine internal echoes. Electronic calipers are placed on this obstructed noncompressible vein, which measures 0.4 cm in diameter.
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Breast cancer, ultrasonography. Antiradial sonogram of the mass shown in Images 38-39 is a cross-section through the dilated, thrombosed, and tender vein. No blood flow was demonstrated in the mass during color flow Doppler sonography (not shown). The patient had Mondor disease.
