This slide is based on latest BIRADS 5th edition 2013 . nice presentation and compilation for radiology resident and radiologist. Thanks.

1. ROLE OF SONOGRAPHY AND
MRI IN BREAST PATHOLOGY
Dr. Pradeep Kumar

2. APPLICATION OF BREAST USG
1. Primary screening
2. Secondary screening(following mammography)
3. Diagnosis
4. Guiding Biopsies and
5. Treatment planning for radiotherapy

3. INDICATION
1. Palpable mass
2. Discharge
3. Mammographic abnormality
❖ Specific goals of targeted diagnostic breast ultrasound-
1. To prevent unnecessary biopsies & short interval follow-up of
mammogram of benign lesion
2. To guide intervention
3. To find malignancies missed on mammography

4. ROLE OF US IN DIAGNOSIS
 Women with dense breasts
 Women with fibrocystic disease
 When mammography alone cannot classify lesion
 Young women with masses
 Pregnant women with masses
 Women with implants
 Women who refuse mammography

5. SONOGRAPHIC EQUIPMENT
 High frequency transducer optimized for near field imaging i.e. electronically
focussed linear arrays.
 All organizations involved in accreditation of breast USG (ACS,
ACR, AIUM), require minimum transducer frequency of 7Mhz.
 Focal Length – 1.5-2 cm
 Split-screen images -to compare mirror-image -asymmetrical
fibroglandular tissue

8. BIRADS LEXICON:
ULTRASOUND
• Mass
• Calcifications
• Associated
features
• Special cases
Breast Composition
Findings
Assessment Category

9. Breast composition

10. MASS

11. SHAPE
Oval: Egg shaped or elliptical
Round: Spherical
Irregular- Neither round or oval

12. ORIENTATION
• Parallel (historically,
“wider- than-tall” or
“horizontal” )
The long axis of the
mass parallels the skin
line
• Non Parallel
(historically, “taller
than wide”)
The long axis of the mass is
not parallel to the skin line.

13. MARGIN
• Circumscribed: well defined, with
an abrupt transition between the
lesion and the surrounding tissue
• Not circumscribed: any portion of
the margin is not circumscribed
• Indistinct: no clear
demarcation of the entire
margin
• Angular: sharp corners, often
forming acute angles
• Microlobulated: short-cycle
undulations
• Spiculated: sharp lines radiating
from the mass

14. ECHO PATTERN
• Anechoic
• Hyperechoic
• Complex solid cystic
• Hypoechoic
• Isoechoic
• Heterogeneous

15. POSTERIOR FEATURES
• No Posterior features
• Posterior acoustic enhancement
• Posterior acoustic shadowing
• Combined pattern

16. CALCIFICATION
• Calcification in a mass
• Calcification outside of mass
• Intraductal calcification

17. ASSOCIATED
FEATURES

18. ASSOCIATED FEATURES
• Architectural distortion
• Duct Changes
• Cystic dilatation of a duct or
ducts involving irregularities in
caliber and/or arborization,
extension of duct(s) to or from
a malignant mass, or the
presence of an intraductal
mass, thrombus, or detritus.
• Skin Changes
• Thickening: focal or diffuse, and
is defined as being > 2 mm
• Retraction: concave or ill-
defined and appears pulled in.
• Edema

19. VASCULARITY AND
ELASTICITY
• Vascularity: Absent,
Internal vascularity, vessel
in rim
• Elasticity: Soft,
Intermediate and Hard

20. Pectoralis minor muscle and levels of axillary lymph nodes. Extended-FOV sonogram shows
metastases to all three axillary lymph node levels on the left. The level of axillary lymph nodes is
determined by the pectoralis minor muscle. Lymph nodes that lie inferior and lateral to the inferolateral
edge of the pectoralis minor muscle are level 1 nodes; those that lie deep to the pectoralis minor
muscle are level 2 lymph nodes; and those that lie superior and medial to the superomedial edge of the
pectoralis minor muscles are level 3 (infraclavicular) lymph nodes.

21. SPECIAL
CASES
• Cyst
• Clustered microcysts
• Skin lesion
• Complicated cyst

22. SPECIAL
CASES
• Post surgical collection
• Intramammary lymphnode
• Fat necrosis
• Mondor’s disease

23. AXILLARY LYMPHNODES
• Size
• Shape
• Round
• Oval
• irregular
• Cortical
Thickening
• Uniform
• Focal
• Margin
• Circumscribed
• Ill defined
• Hilar Compression or
displacement

24. Category Description BIRADS PPV
SIMPLE cyst
Imperceptible wall
Anechoic content
Posterior enhancement
2 0
COMPLICATED cyst
Thin wall
Echogenic content
Fluid/fluid level
Posterior enhancement
3 < 2%
COMPLEX cystic and
solid mass
Thick wall > 0.5 mm
Thick internal septa > 0.5 mm
Intra-‐cysticmass (cystic component > 50% Doppler)
Solid cystic mass > 50%
4 2–95
BI-RADS® classification of cystic lesions.
W.A. Berg, A.G. Sechtin, H. Marques, Z. Zhang
Cystic breast masses and the ACRIN 6666 experience
Radiol Clin North Am, 48 (5) (2010), pp. 931–987

25. BIRADS ASSESSMENT :USG
CATEGORY FINDINGS REMARKS
0 PRIOR IMAGING UNAVAILABLE INADEQUATE EVALUATION
1 NEGATIVE FINDINGS
2 Simple cysts, intra mammary lymphnodes,
unchanged complicated cysts,
fibroadenoma
3 Circumscribed oval mass,parallel orientation.
E.g fibroadenoma, isolated complicated cyst
Short interval follow up
4 Indistinct margin, non parallel, duct changes
5 more than one high risk
6 Known or proven cancer

26. BENIGN
Shape Oval/ellipsoid
Malignant
Variable
Alignment Wider than deep; aligned parallel to
tissue planes
Deeper than wide
Margins Smooth/thin
echogenic pseudocapsule with
2-3 gentle lobulations
Irregular or spiculated; echogenic 'halo'
Echotexture
Homogeneity of
internal echoes
Variable to intense
hyperechogenicity
Uniform
Low-level
Marked hypoechogenicity
Non-uniform
Lateral
shadowing
Present Absent
Posterior effect Minimum attenuation/posterior
enhancement
Other signs --------------
Attenuation with obscured posterior
margin
Calcification
Microlobulation
Intraductal extension
Infiltration across tissue planes and increased
echogenicity of surrounding fat

33. Scout images
Axial T2 with fat suppression, both breasts
Sagittal T1 3D, both breasts
Sagittal T2 with fat suppression, both breasts
Axial DWI using b = 1000 sec/mm2 to improve
specificity
Precontrast axial 3D T1 with fat suppression, both
breasts (mask images for subtraction)
Postcontrast axial dynamic multiphase 3D T1
sequence with fat-suppression (6 acquisitions)
Axial 3D T1 with fat suppression, both breasts
(high-resolution scan)
Sagittal 3D T1 with fat suppression, both breasts
(high-resolution scan)
MRI : Technique and protocol:
Using breast coil, patient lying prone

47. These are benign enhancing lesions of the skin. Keloids, sebaceous cysts, and areas of
dermatitis may enhance

50. KINETIC CURVE ASSESSMENT
 SIGNAL INTENSITY (SI)/TIME
CURVE DESCRIPTION
1. INITIAL PHASE
This is the enhancement pattern within
the first 2 minutes or when the curve
starts to
change.
a. Slow —
< 50% increase in signal intensity
within the first 2 minutes

b. Medium —
50%–100% increase in signal intensity
within the first 2 minutes.
c. Fast —
> 100% increase in signal intensity
within the first 2 minutes.

51. 

52.  2. DELAYED PHASE
This is the enhancement
pattern after 2 minutes or
after the curve starts to
change.
a. Persistent —
continued > 10% increase in
signal over time

53. B. Plateau —
signal intensity does not change over time after its initial rise, flat

54. 2. DELAYED PHASE
c. Washout —
signal intensity decreases > 10% after its highest
point from its initial rise. This
indicates a suspicious finding