The benefits of using ultrasound in screening for breast cancer

Ultrasound imaging or ‘sonography‘ tends to be used in breast cancer screening as a ‘second look‘ or follow up application. The usual indications for breast ultrasound would be a suspicious finding on mammography or for further diagnostic evaluation of a palpable lesion felt on a clinical breast exam.

However, just because a woman is sent for a follow up sonogram is no reason to have elevated anxieties about breast cancer. Ultrasound is particularly helpful in distinguishing between a solid mass and a fluid-filled cyst, which is what a majority of breast lesions turn out to be.

Ultrasound is also useful in finding very small lesions that are too small to be felt at a clinical exam.

breast-carcinoma-ultrasound-2

Dr. Halls Dr. Halls
The ultrasound picture shows a dark area just below the skin. I’m not certain what it is. In this case, inflammation is more likely than cancer.



 
 

Ultrasound imaging uses high frequency sound waves to form an image, called a ‘sonogram‘. The sound waves it uses are harmless and pass through the breast and bounce back or ‘echo‘ from various tissues to form a picture of the internal structures. An unexpected ‘echo‘ means that there is a solid nodule of some kind within the tissue. There is no radiation involved in ultrasound imaging, which makes it a preferred method of diagnostic imaging for pregnant women.

I have created a new page involving more up-to-date information on Ultrasounds, it’s benefits, and more. However, this page is still pretty great for research material. I would still use it.

Ultrasound and breast density

Women with high breast density are often screened with ultrasound, because mammograms of women with dense breast tissue tend to be harder to interpret. For this reason, ultrasound if frequently a ‘first‘ diagnostic imaging method for women under 35.

Whether or not an ultrasound can ‘stand alone‘ as a screening method versus combining it with mammography or MRI is still a subject of debate. At present, there is no study which definitively proves that ultrasound screening alone lowers mortality rates for breast cancer, unlike mammography, which does.

It used to be believed that a screening mammogram with ‘no abnormalities seen’, and dense breast tissue, was not a reason enough for a breast ultrasound. But more and more, when mammograms have very dense tissue, ultrasound is being added.

Combining ultrasound with MRI or biopsy

The combination of ultrasound with Magnetic Resonance Imaging has been found to be a particularly good combination in followup evaluation of lesions found on mammography. The detail of MRI greatly assists diagnostic and treatment decisions. Ultrasound is also very useful in ‘guiding the needle‘ during a followup biopsy.

breast-mass-ultrasound

Dr. Halls Dr. Halls
Here’s a hypoechoic solid nodule. Could be benign, could be cancer. I would probably ask to biopsy it.



 
 

Screening and detection rates using ultrasound

The rate at which lesions discovered by screening are shown to be malignant breast cancer is actually very low. The rate of detecting malignancies using mammography (x-ray) is about 5 cancer per 1000 women screened. When ultrasound is used alone to determine malignancy, the rate is slightly lower. This does tend to suggest that mammography is slightly more reliable. But it must be emphasized that even the combination of ultrasound and even MRI with mammography cannot completely exclude the possibility of breast cancer. Up to 3% of women with negative mammograms and sonograms of suspicious lesions may still have breast cancer.

Expense and pragmatic considerations

Ultrasound imaging is not really any more expensive than mammography, and in many ways it is more convenient. The problem is, almost all suspicious ultrasound findings are inconclusive and end up being referred for biopsies anyways. This must be weighed against the cost and effectiveness of mammographic screening as a whole, which tends to provide better assurance of the nature of a lesion with respect to the need for a biopsy.

Typical categories of breast ultrasound results

Abnormal results of an ultrasound will tend to fall into four categories. A radiologist can usually tell if the echoes are caused by benign fibrous nodules (breast fibrocystic disease, papillomas, fibroadenomas). Of slightly greater concern are sonographic indications of a ‘complex cyst‘ . The third and fourth informal categories of increased likelihood of malignancy are ‘suspicious lesion‘, and ‘lesion highly suggestive of cancer‘.

What can an ultrasound reveal about a potential breast cancer lesion?

A sonogram gives a good indication of the liquid or solid nature of a lesion, or perhaps a combination. Liquid masses (cysts) tend to be darker in color, and homogeneous. An experienced radiologist gains a ‘feel‘ for what the different ‘textures‘ of a sonogram tend to represent. The shape of a lesion and also its ‘margin‘ (the characteristics of its ‘edges’) are also quite evident on sonograms. This helps determine whether a lesion is cancerous or benign (cancerous lesions tend to have jagged edges). Breast cancer lesions also tend to be somewhat random in shape, but not always. Benign fibroadenomas are usually round or oval. But ultrasound is not a definitive test, and tissue analysis via biopsy is usually required. Even when ultrasound suggests the presence of a fibrous nodule or complex cyst, a biopsy is still justified. Up to 15% of these types of growths end up being malignant.

Any ‘echoes‘ on the sonogram (a change from the sound on its way back compared to on it’s way in) indicates that a solid nodule of some kind has blocked the path of the sound wave. Analysis of the solid nodules on a breast sonogram requires considerable expertise, and can give further clarity as to the benign or malignant nature of the lesion.


Let’s go over some Q&A…

  • Why is a breast ultrasound performed? A breast ultrasound will be performed if you or your doctor discovered a suspicious mass in your breast. The ultrasound will help determine the location and the size of the mass. While a breast lump may be frightening, approximately 4/5 breast lumps are benign (non-cancerous).
  • What are some risks of a breast ultrasound? Because this imagine technique uses absolutely no radiation, a breast ultrasound carries no risks what-so-ever. Radiation tests aren’t considered safe for pregnant women, so an ultrasound is the preferred method of breast exams for women who are pregnant. In fact, the test involves the same kind of ultrasound waves used to monitor the development of a fetus.
  • How do I prepare for a breast ultrasound? Preparation for a breast ultrasound is minimal. Because you’ll need to expose your breasts during the test, it’s best to wear a two-piece outfit to your appointment. Also, don’t apply any creams, lotions, or other cosmetics on the skin of your breasts. This can interfere with the test procedure.
  • What are some of the results of a breast ultrasound? The images from a breast ultrasound are in black and white. Cysts, tumors, and growths will appear dark on the scan. Just because there is a dark spot on your ultrasound, doesn’t mean that you have breast cancer. The majority of breast lumps are noncancerous, so more testing is needed to determine whether the lump is malignant. Several conditions that can cause benign breast lumps include adenofibroma, fibrocystic breast disease, intraductal papilloma, and mammary fat necrosis.

References

  1. Sickles EA , Wolverton DE, Dee KE. Performance Parameters for Screening and Diagnostic Mammography: Specialist and general Radiologists. Radiology 2002; 224: 861-869
  2. Gordon PB. Ultrasound for breast cancer screening and staging. RCNA, Volume 40, Number 3, May 2002
  3. US: Breast Ultrasound/Mammography Correlation – Registry Review. GE Healthcare; August 31, 2006
  4. Kopans DB, Sonography Should Not be Used for Breast Cancer Screening Until Its Efficacy Has been Proven Scientifically. AJR 2004; 182: 489-491
  5. HoggeJP, Shaw de Paredes E, Magnant CM, Lage J. Imaging and management of breast masses during pregnancy and lactation. Breast J 1999; 5: 272–283
  6. American College of Radiology. Standard for the performance of the breast ultrasound examination. Reston, Va: American College of Radiology, 2002
  7. Odle, T.G. ; Breast Ultrasound Radiol. Technol., January 1, 2007; 78(3): 222M – 242M
  8. Smith, LaNette F., et al. "Intraoperative Ultrasound-guided Breast Biopsy." The American Journal of Surgery 180 (December 2000): 419-23
  9. Velez, Nitzet, et al. "Diagnostic and Interventional Ultrasound for Breast Disease." The American Journal of Surgery 180 (October 2000): 284-7
  10. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA. (2008);299:2151–2163
  11. Crystal P, Strano SD, Shcharynski S, Koretz MJ. Using sonography to screen women with mammographically dense breasts. AJR Am J Roentgenol.( 2003);181:177–182
  12. Gordon PB, Goldenberg SL. Malignant breast masses detected only by ultrasound (A retrospective review). Cancer. (1995);76:626–630
  13. O’Driscoll D, Warren R, MacKay J, Britton P, Day NE. Screening with breast ultrasound in a population at moderate risk due to family history. J Med Screen. (2001);8(2):106-9.

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