What is the role of ultrasonography in the diagnosis of breast abscesses and masses?

Updated: Jul 27, 2020
  • Author: Andrew C Miller, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Answer

Ultrasonography is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage. Simple cysts are seen on sonograms as round or oval with sharply defined margins and posterior acoustic enhancement. Complex cysts are characterized by a significant solid component, septations, lobulations, varied wall thickness, and the presence of internal debris. Abscesses usually appear as ill-defined masses with central hypoechoic areas and may display internal septations, debris, posterior enhancement, eccentrically thickened walls, and increased Doppler flow in the walls and surrounding tissue with lack of internal color Doppler flow. [44, 45, 8, 37, 31] The addition of elastography and color Doppler ultrasonography to B-mode ultrasonography has been reported to increase the positive predictive value (PPV) of screening ultrasonography in women with dense breasts (from 8.9% [95% CI: 7%, 11.2%] to 23.2% [95% CI: 18.5%, 28.5%; P< .001]) while reducing the number of false-positive findings without missing cancers. [46, 47] Thus, ultrasonography may be particularly useful in younger patients (< 40 years). [48] In addition, ultrasound-guided biopsy has been shown to be safe and effective. [49]

Breast cyst. A) A simple, fairly round breast cyst Breast cyst. A) A simple, fairly round breast cyst with hypo or anechoic contents and well-defined borders; B) Posterior acoustic enhancement is seen as well as edge shadows (arrows).

Contrast-enhanced ultrasonography has also been found to be helpful in distinguishing benign from malignant breast masses. This modality has been shown to be 86% sensitive and 79% specific for differentiating between the two types of masses. [50] For more information, see Breast Cancer, Ultrasonography.

Various types of breast masses are shown in the images below.

Ultrasonogram demonstrates a hypoechoic mass with Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.
Breast cancer, ultrasonography. Mediolateral obliq 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).
Breast cancer, ultrasonography. Antiradial sonogra Breast cancer, ultrasonography. Antiradial sonogram of the spiculated mass (shown in the image above) 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.

Schedule an outpatient mammography to further characterize the suspected breast mass. The sensitivity of mammography ranges from 74%-95%, and specificity ranges from 89%-99%. [51, 52] In a meta-analysis of more than 8.5 million patients, the AUC of mammography for breast cancer screening was 0.95 (95% CI: 0.93-0.97), the overall sensitivity was 0.81 (95% CI : 0.77-0.84), and the overall specificity was 0.96 (95% CI: 0.94-0.96). [53] A subgroup analysis of dense-breast populations showed that the combined sensitivity and specificity of mammography was 0.74 (95% CI: 0.61-0.83) and 0.93 (95% CI: 0.89-0.96), respectively. [53]

Early detection with screening mammography significantly reduces breast cancer–related mortality by 20%-40%. [54] Annual screening mammography of women aged 40-84 years prevents more deaths due to breast cancer than biennial screening of women aged 50-74 years. [54] Currently, supplemental screening with ultrasonography or MRI is recommended in addition to mammography. [54] The American Cancer Society recommends annual screening mammography and supplemental screening MRI in women with an estimated lifetime risk of breast cancer of 20%, BRCA mutation carriers, first-degree relatives of BRCA mutation carriers who remain untested, women with a history of mediastinal irradiation aged 10-30 years, and women with certain genetic syndromes. [54] With aggressive public screening, the incidence of large breast tumors may be decreasing. [55] However, with increased screening comes the risk of overdiagnosis.

Approximately 5%-10% of screening examinations are interpreted as abnormal, but 90% of women with abnormal results do not have breast cancer. [51, 52] For instance, the Canadian National Breast Screening Study concluded that approximately 30% of invasive screen-detected breast cancers in women aged 40-49 years and 20% of those screen-detected in women aged 50-59 years were overdiagnosed. [56] Moreover, a subsequent meta-analysis reported no significant effect on either breast cancer mortality or all-cause mortality when breast cancer screening was extended to women aged 40-49 years, but the rates of overdiagnosis were estimated to be 32% at 5 years following cessation of screening and 48% at 20 years following cessation. [57] For these reasons (and others), current guidelines do not recommend extending routine mammography screening to younger age groups. [57] However, when screening women with dense breasts, the addition of bedside ultrasonography may be useful. In a cohort of 66,680 women undergoing physician-performed ultrasonography in addition to mammography, the sensitivity of mammography with ultrasonography rose from 61.5% to 81.3%. [58]

Racial disparities in utilization of screening mammography are evident in black and Hispanic populations in the United States. [59] Further studies are needed to understand reasons for disparities, trends over time, and the effectiveness of interventions targeting these disparities. [59]

For more information, see Breast, Benign Calcifications, Breast, Fibroadenoma, Breast, Nipple Discharge Evaluation, and Breast Cancer, Mammography.

Supplemental ultrasonography improves cancer detection in screening of women at average risk. When comparing screening with mammography alone versus mammography plus physician–performed ultrasonography in average-risk women, the overall sensitivity of mammography alone was 86.6% (non-dense breast) and 61.5% (dense breast) versus 95% (non-dense breast) and 81.3% (dense breast) for mammography with ultrasonography. [58] Adjunctive ultrasonography increased the recall rate from 10.5 to 16.5 per 1000 women screened and increased the biopsy rate from 6.3 to 9.3 per 1000 women screened. [58] The positive predictive value of biopsy was 55.5% (95% CI: 50.6%–60.3%) for mammography alone and 43.3 (95% CI: 39.4%–47.3%) for combined mammography plus ultrasonography. [58]


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