The hypoechoic Mass – Solid breast nodule or Lump

Benign or malignant ultrasound characteristics of Solid Breast Nodules

Ultrasound is a useful diagnostic tool for breast cancer detection. Breast ultrasound is used to distinguish solid from cystic masses using sound waves. Is it a hypoechoic mass or is it a hyperechoic lesion? Is it a lesion or a mass?

For young women (younger than 30) ultrasound imaging will often be the first scan, after a clinical exam feels either a palpable mass (breast lumps) or nipple discharge.

Since breast cancer tends to happen with older, post-menopausal women, doctors try not to expose younger women to the unnecessary radiation of a mammogram.

Sonography means Ultrasound, and it can help establish the difference between benign and malignant solid tumors.

Sonogram / Ultrasound scan, can find out if a nodule on a mammogram is a solid nodule or a cystic lesion, breast cysts tend to be fluid filled.

Doctors don’t like to do mammograms first, in really young women, because of radiation. You just never know who might be just a few weeks pregnant.

Which is better? Mammogram or ultrasound?

Both are useful in their own right.

Hypoechoic nodule or solid lesion in a breast

Suppose an ultrasound report said there is a hypoechoic mass or nodule, or a hypoechoic lesion in a breast. Also perhaps the report says that the abnormal is solid. What do these words mean?

Hypoechoic means an area looks darker on ultrasound than the surrounding tissue. The surrounding tissue therefore looks brighter/lighter shades of grey. Does hypoechoic mean cancer? No.

A hypoechoic mass means that it is solid, rather than liquid. That is basically all the word means, that the lump or lesion is not a cyst.

What does the word ‘Lesion’ actually mean?

Lesion, is also a word that means simply “an area that has suffered injury or disease in the body causing damage”. So, let us give some examples using the word lesion in a sentence:

‘You scraped your knee’, the doctor says, ‘does that skin lesion hurt’?
‘There is a wart on your toe’, the doctors says, ‘I’ll put some liquid nitrogen on that lesion’.
In your facebook picture there is a lesion on your forehead. You say, ‘it is not a lesion, it is a shadow of a frisbee … that hit me one second later.

So, what is a Nodule?

On the topic of a nodule, if it is solid, an ultrasound helps to look at the characteristics. So, a lack of clear, smooth margins, heterogeneous echo patterns, and an increase in the anterioposterior dimension can indicate a higher probability of malignancy in solid breast nodules.

Wow. that ultrasound is showing a definite cancer. It’s the dark area in the center, and its edges are very hard to define. That usually means cancer.

Ultrasound studies of a Hypoechoic Mass examine margins, shape and echogenicity

The most important features on a breast ultrasound are the smoothness and contour of the mass margins and the shape of the mass.

Smooth surface is good, irregular is bad.

The echo texture and echogenicity, and the effects on distal echoes.

What do these ‘echo’ words mean?

Ultrasound uses SOUND, sound-waves that bounce back as an echo.

Like “ping” sound used by a submarine sonar?

Things that bounce back some strong echos, show-up BRIGHT on the ultrasound. Things that absorb sound and don’t bounce echos back to the scanning probe, are DARK on the ultrasound images.

Hyper means a lot of echos, made something look bright, and hypo-echoic means the nodule looks dark on the ultrasound.

Bright is good, dark is bad, usually.

Others aspects of the mass such as compress-ability and vascularity may also be noted.

Compressable: Soft and squishy is good, hard is bad.

Vascularity: When lots of extra blood vessels are seen, it’s bad.

Features of a hypoechoic mass that may cause concern

Some of the features that show as a hypoechoic mass on ultrasound that are indicative of a malignant breast mass include:

a marked hypoechogenecity,
acoustic shadowing,
a branch pattern
or microlobulation,
or a duct extension.
a ‘taller than wide’ shape,
angular margins,
the presence of microcalcifications,
and spiculation, which probably has the highest positive predictive value for malignant breast cancer.

Features of a hypoechoic mass that are signs it is benign (not cancer)

Benign breast lesions on the other hand tend to appear on ultrasound with:

intense and uniform hyperechogenicity,
as an oval shape with a thin, consistent capsule,
and they may have two to three gentle lobulations.

Summary of sonographic features of benign and malignant solid breast nodules

A breast ultrasound can help in diagnosis in differentiating between benign and malignant tumors, often without the need for a needle biopsy.

The absence of a well-circumscribed margin, heterogenous echo patterns, as well as an increased anterioposterior dimension to the image do tend to indicate a higher probability of malignant cancer in solid breast nodules.

A BI-RADS classification of 3, which means ‘probably benign’ and with a recommendation for short term follow up only, can only be given if there is an absence of any of these clearly suspicious features.

A Table Summarizing Ultrasound Findings: Benign and Possibly Malignant

Sonographic characteristics	Benign	Potentially Malignant
Absence of malignant findings	x
Hyperechoic/ intense, fibrous tissue like	x
Two or three macrolobulations	x
Ellipsoid shape/ wider than tall, parallel to the skin	x
Pseudocapsule/ thin, echogenic, well-circumscribed	x
Spiculations/ alternating hyper and hypoechoic straight lines		x
Height/ width >1 or non parallel to the skin		x
Angular margins		x
Shadowing/ through transmission attenuated		x
Branch pattern extensions / multiple radial projections, peri or intra-ductal, nipple oriented		x
Markedly hypoechoic ..		x
Microcalcifications		x
Duct extension / single radial projection, peri or intra-ductal, nipple oriented		x
Microlobulations		x
Intracystic nodule, parietal thickening		x

I hate tables.

I love tables…but only if they are full of food.

It really comes down to: irregular margins, irregular shape, dark hypoechoic.

Ultrasound characteristics typical of malignant breast masses

The most typical sonographic presentation of a malignant breast mass would probably be an irregular, heterogeneous, hypoechoic mass with spiculations and angular margins.

By ‘angular margins’, he means, not smooth ‘oval’ shape.

Malignant masses tend to have that ‘taller-than-wide‘ appearance

OK, let me digress and explain taller-than-wide. Something that isn’t cancer is going to be soft, bendy, squishy, slow-growing and “polite” to it’s neighbors.

What I mean by polite-ness, is that it’s not going to force itself through barriers, not going to invade into other tissues. Benign things “go with the flow”. What is the “flow” in a breast?

What is the normal orientation of things, the normal way things lie when relaxed? 2 answers: 1) some things flow toward the nipple, like how ducts converge behind the nipple. 2) some things like the fat in the breast, flatten and spread out due to gravity while lying down, like FAT LOBULES. Things you see on ultrasound that tend to spread out in the same direction as fat, are probably not cancer.

On the other hand, cancers grow fast and they have internal pressure to expand outward. That is a force that lets cancers grow in directions that aren’t aligned to ducts or fat. Thinking about cancer this way is much smarter than taller-than-wide.

Image of a Potential Malignant Mass

Malignant masses can show posterior acoustic shadowing on ultrasound images. The image below shows an ill-defined border, an irregular shape, microlobulations and spiculations. The lesion also appears to be ‘taller-than-wide’ with an angular margin. This would all be highly predictive of invasive ductal carcinoma, and the lesions would be need a biopsy for diagnosis.

Yes, absolutely, that cancer in the center of the ultrasound image, is dark with irregular borders. That’s a birads 5 cancer which I would core-needle biopsy.

Suggestive of malignancy: spiculations, angular margins, hypoechoic, taller-than-wide

Spiculations often represent breast tumor ‘tentacles‘ or desmoplastic reactions. On ultrasound, spiculations will often consist of straight lines that ‘radiate’ in a perpendicular fashion from the surface of the breast mass.

An ‘angular margin‘ is an angular configuration at the junction between relatively hypoechoic or isoechoic central portion of a solid mass and surrounding tissue. Sometimes, specialists refer to these features as ‘jagged’ or ‘irregular’ margins. Angular margins are quite distinct from ‘lobulations’ which tend to be smooth and rounded. Angular margins observed on breast ultrasound are highly predictive of malignancy.

If a solid breast nodule appears on ultrasound to be ‘taller-than-wide‘, this is suspicious of malignancy.

The textbook may say: when a patient is scanned by ultrasound, they are usually in a supine position, and as a result the normal ’tissue planes’ on the breast will have a horizontal orientation. If a mass or part of the mass seems longer in the anteroposterior dimension (tallness) compared to either the sagittal or transverse dimensions (depth and width) then one can conceive that this may be a malignancy ‘aggressive enough’ to overcome normal breast tissue barriers and planes and grow vertically.

Umm.. sorry, I just can’t get my brain to think of breasts as horizontal and vertical 2D. Taller-than-wide irks me. Students, learn to love the curves and flow of things – it will help you notice more abnormalities.

Light and Dark on Breast Ultrasound

Hypoechoic breast lesions are suspicious for malignancy and on ultrasound imaging they will tend to look darker than the surrounding isoechoic fat. But malignancies can also show as isoechoic or hyperechoic lesions on breast ultrasound, so it is not a rigid rule by any means.

“Hypoechoic” with “smooth margins” is probably benign.

Microlobulations and duct extensions on Ultrasound

‘Microlobulations‘ on breast ultrasound indicate the presence of lots of very small (1mm to 2 mm) lobulations on the surface of a solid breast nodule. So, these lobulations will be quite similar to mammogram findings. As the number of these microlobulations increase, the probability that the breast mass is malignant also increases.

A ‘duct extension‘ appears on ultrasound as a ‘radially oriented’ projection that seems to arise from the lesions an axis oriented towards the nipple.

These projections often occur both within or around breast duct. Sometimes, you will see a duct extensions/projection has developed as a ‘bridge’ between multi-focal malignancies. This is different from a ‘branch pattern’ in which multiple extensions arise from the mass but extend away-from the nipple. A branching pattern tends to indicate a tumor growth advancing away from the nipple. Any apparent growth that is long enough to visibly fill a duct and branch, no matter what direction is goes, will be suspicious for malignancy. So, in this case, a biopsy will be necessary.

Posterior acoustic shadowing is suspicious for breast cancer

If a breast lesion shows posterior acoustic shadowing on ultrasound this means that there is something about the mass or around the mass which attenuates (reduces) the sonic beam strength in comparison to normal adjacent tissues.

Posterior acoustic shadowing is suspicious for malignancy, but tends to be associated with low to intermediate grade breast tumors.

What may be happening is that a slow growing breast tumor causes a secondary ‘desmoplastic response’ in the surrounding tissue. That means that dense fibrous and connective tissues are growing around the tumor as a kind of defense mechanism by the body; to ‘contain’ the neoplastic growth.

High grade malignancies in the breast grow too fast for this desmoplastic reaction to occur. However, posterior acoustic shadowing caused by a desmoplastic reaction can be found in benign breast neoplasms as well.

For example, fibrosis inside a tumor can block ultrasound from passing deeper, causing acoustic shadowing. But most benign tumors do not usually shadow unless they are calcified. So, again a biopsy may be necessary.

Calcifications on breast ultrasound are also suspicious for malignancy

Mammography is more sensitive than ultrasound when it comes to the detection of microcalcifications. Calcifications on a solid mass which appear ‘punctate’ are highly suspicious of malignancy and will usually appear on ultrasound as bright, punctate foci.

Since malignant breast lesions are typically either intensely or mildly homogeneous hypoechoic solid masses, on ultrasound this provides a ‘background’ which makes it easier to view calcifications sonographically. So, while calcifications are usually not seen on ultrasound, when they do appear vividly, it is highly suspicious for malignancy.

Spiculations and irregular borders have the highest positive predictive value for breast cancer

In terms of the suggested ‘BI-RADS‘ descriptors for malignant breast nodules, spiculated margins have a positive predictive value for malignant breast cancer of about 85%.

Masses showing an irregular shape or non-parallel orientation are also quite suggestive of malignancy, with a positive predictive value in the 62% to 69% range.

Other studies place a higher predictive value on the presence of an irregular border (about 88% predictive of malignancy). In addition increase in vascularity in the hypoechoic mass predicts malignancy about 82% of the time.

The ultrasound image below shows an irregular vascularized retroareolar mass, with calcifications. This is very likely to be infiltrating ductal carcinoma and your doctor will recommend a biopsy straight away.

A Benign hypoechoic mass on ultrasound

On ultrasound, a benign breast mass will typically be well defined and with smooth margins. The lesion might also be macrolobulated or with just 2 to 4 mild lobulations.

Benign breast lesions also tend to be ovoid or round in shape, and are often ‘wider-than-tall’ (which indicates a parallel orientation to the chest wall).

The echo texture of a benign mass will usually be homogeneous with an isoechoic, hyperechoic, to mildly hypoechoic echogenicity.

Some benign lesions will also exhibit mild acoustic enhancement on ultrasound, and might be slightly compressible. Vascularity in an ultrasound of a benign mass is variable and will depend on the specific histology of the suspicious mass.

In terms of sonographic features suggestive of benign breast lesions, a well circumscribed margin has a positive predictive value for being benign about 90% of the time. Also, an ‘oval shape’ indicates a benign lesion about 84% of the time. Breast lesions with a ‘parallel’ orientation are predictive of benignity almost 80% of the time.

Medics sometimes refer to the quality of the margins of a breast lesions on ultrasound as the ‘capsule‘. If the margin of the suspected mass seems well-circumscribed in both it’s inner and outer edges and is thin and even, this tends to be a sign of a benign mass. The lesion is ‘encapsulated’ by the compressed adjacent breast tissue and the mass itself is ‘pushing against’ this tissue, rather than infiltrating and invading it.

An Ultrasound Image of a Benign Mass

Sometimes you do see a mild undulation in contour on ultrasound with a benign fibroadenoma. But there should not be many of these mild ‘lobulations’. So, doctors consider any more than three lobulations as a potentially malignant sign. Of greater concern, are more numerous, smaller and sharper microlobulations than one tends to find in benign breast cancer tumors.

Breast lesions which appear as having a marked and uniform hyperechogenicity are highly predictive of a benign lesion. This feature typically represents normal fibrous changes within the breast.

But when there are some regions that show either hyperechogenicity or iso-echogenicity that are larger than normal (larger than either normal ducts or terminal ductal-lobular units) that would indicate a ‘medium’ level of concern. Indeed, this situation will probably result in a biopsy, particularly if these areas are not contained within fat lobules.

The ‘compressibility’ of a breast lesions on ultrasound refers to changes in the shape of a lesion as a result of the pressure applied by the probe. A solid, likely malignant, breast lesion will not ‘compress’ at all from the pressure of the probe.

However, a tumor of benign fibrous or glandular tissue, such as a fibroadenoma, will show some soft tissue compressibility. A benign breast fibroadenoma is usually oriented horizontally, more wide than tall. Often the compression of the scanner will cause a ‘flattened’ oval shape of a fibroadenoma, which would not occur with solid, malignant breast lesions.

Breast ultrasound sometimes detects abnormal axillary lymph nodes

Sometimes a breast ultrasound will pick up an enlarged node in the axilla. Many breast cancer oncologists would take an enlarged axillary node on ultrasound as proof positive for lymph node metastasis, even without a lymph node dissection. (Sometimes patients will not agree to a lymph node dissection to check for breast cancer metastasis). There is also a very small chance that enlarged lymph node could be a breast lymphoma.

The ‘odds ratio’ of potentially malignant sonographic features is highest for lack of a well-circumscribed margin

If the findings of ultrasound imaging of suspicious breast nodules where expressed as an odds ratio ( the odds of a person with these features as having breast cancer, as compared to an breast ultrasound where these features are not present) it may be suggested that breast lesions without a well-circumscribed margins are almost 17 times more likley to indicate malignant breast cancer.

Breast sonograms showing a heterogeneous echo texture are about 8 times more likely to be breast cancer. The ‘incompressibility’ of a breast lesion on ultrasound would tend to be almost 9 times more likely to be malignant.

Ultrasound interpretations are not always straight forward

Not all suspicious breast lesions will be straightforward in their ultrasound appearance and diagnosis. In some cases the findings are still inconclusive.

In this case, doctors will recommend short interval follow-up, or biopsy. But, one of the reasons to use ultrasound in the first place, is because medics suspect the hypoechoic mass is benign. So, the use of ultrasound is often to confirm the cystic nature of the lesion. For example, ultrasound can not always reliably confirm the diagnosis of a breast abscess.

References

Baek SE, Kim MJ, Kim EK, Youk JH, Lee HJ, Son EJ. (2009) Effect of clinical information on diagnostic performance in breast sonography. J Ultrasound Med. (Oct. 2009) 28(10):1349-56. https://www.ncbi.nlm.nih.gov/pubmed/19778881
Hazard HW, Hansen NM. (2007) Image-guided procedures for breast masses. Adv Surg.( 2007);41:257-272 https://www.ncbi.nlm.nih.gov/pubmed/17972570

More references for this section are on this page.