Breast ultrasound (or sonography) is an imaging technique for diagnosing breast disease, such as cancer. It uses harmless, high frequency sound waves to form an image (sonogram). The sound waves pass through the breast and bounce back or echo from various tissues to form a picture of the internal structures. It is not invasive and involves no radiation.
Breast ultrasound may be used in several ways. The most common application is to investigate a specific area of the breast where a problem is suspected. A palpable lump and/or a lump or density discovered by x-ray imaging (mammogram) can be further evaluated by ultrasound. It is especially helpful in distinguishing between a fluid-filled cyst and a solid mass. It also can identify small lesions that are too tiny to be felt.
Breast ultrasound is often the first study performed to evaluate masses in women under 35 whose mammograms can be difficult to interpret due to the density of their breast tissue. In 2003, a new study found that ultrasound was more accurate than mammography at diagnosing breast cancer in women under age 45. However, mammography still works as a screening tool, with breast ultrasound as the follow-up examination. Another study in that year found that combining ultrasound with magnetic resonance imaging (MRI) direction greatly improved diagnostic decisions about breast cancer lesions. The lesions detected by MRI could also be localized using ultrasound needle guidance for follow-up biopsy.
The lack of radiation used with ultrasound makes it ideal for studying breast abnormalities in women who are pregnant. Assessing breast implants for leakage or rupture is another use for ultrasound. Breast inflammation, where pockets of infection or abscesses may form, can be diagnosed and monitored by ultrasound.
Thickened and swollen breast skin may be a sign of inflammatory breast cancer. Ultrasound can sometimes identify a cancerous growth within the breast causing the thickened skin. These cases are usually followed by a core biopsy guided by ultrasound.
Cyst — A thin-walled, fluid-filled benign structure in the breast.
Ductal carcinoma — A type of cancer that accounts for as much as 80% of breast cancers. These tumors feel bigger than they look on ultrasound or mammogram.
Fibroadenoma — A benign breast growth made up of fibrous tissue. It is the most common mass in women under 35 years of age, and is found in both breasts in 3% of cases.
Infiltrating lobular carcinoma — A type of cancer that accounts for 8% to 10% of breast cancers. In breasts that are especially dense, ultrasound can be useful in identifying these masses.
Microcalcifications — Tiny flecks that are too small to be felt. They are important markers of cancer that show up on ultrasound and mammogram.
Mucinous (colloid) carcinoma — A type of cancer that accounts for 1% to 2% of breast cancers. Resembles medullary carcinoma in ultrasound and mammogram, but usually affects older women.
Nonpalpable — Cannot be felt by hand. In cancer, growths that are nonpalpable are too small to be felt, but may be seen on ultrasound or mammogram.
Papillary carcinoma — A type of breast cancer that primarily occurs in older women. On ultrasound, this type of tumor may look like a solid or complex mass, or it may show up as solid tissue protruding into a cyst.
Tubular carcinoma — A type of cancer that accounts for approximately 1% to 2% of breast cancers. Can appear small on ultrasound or mammogram.
Breast ultrasound is employed to observe and guide a needle for several interventional procedures. These include cyst aspiration, fine needle aspiration, large core needle biopsy (as a first step in determining treatment for a lesion that is likely to be cancerous), and needle localization in surgical breast biopsy. Biopsies guided by ultrasound have distinct advantages. Patients usually find that the procedure is less traumatic and more comfortable than surgical biopsies. Ultrasound is known for its accuracy in determining how far a cancerous growth extends into the surrounding tissue in lesions that cannot be felt. Biopsies guided by ultrasound are generally less costly than surgical biopsies. Additionally, if the abnormality that requires biopsy can be seen on both a mammogram and ultrasound, an ultrasound-guided biopsy is often more comfortable for the patient as no compression is necessary.
Ultrasound can be done in a doctor's office or another outpatient setting, such as a hospital or imaging center.
The patient removes her clothing from the waist up and puts on a hospital gown, open in the front. She lies on her back or side on an examining table. A gel that enhances sound transmission is spread over the area to be examined. The technologist then places a transducer, an instrument about the size of an electric shaver, against the skin. The images from reflected sound waves appear on a monitor screen.
A physician called a radiologist interprets the images obtained from ultrasound imaging. In 2003, it was reported that new computer-aided diagnosis (CAD) technology that had recently been widely added to mammography may help improve ultrasound as well. The CAD system uses computer algorithms applied to a three-dimensional ultrasound image to assign scores to mass characteristics. Though the technology will not replace human observation and judgment, it may soon be added to support the radiologist's interpretation.
A good ultrasound study is difficult to obtain if the patient is unable to remain quietly in one position. Obesity may hinder clear viewing of internal structures, and the accuracy of an ultrasound study is highly dependent on the skill of the person performing the examination. The images recorded vary with the angle and pressure of the transducer and the equipment settings. The examination may take from 30 to 45 minutes. Most insurance plans cover the cost of an ultrasound examination.
An ultrasound examination may reveal either normal tissue or a benign condition such as a cyst. Ultrasound can confidently diagnose a benign structure that has certain characteristics of a simple cyst. In the case of a simple cyst with no symptoms, additional treatment beyond continued observation is usually not needed.
A potentially malignant mass can be identified by breast ultrasound. Abnormal results fall into the following categories: benign fibrous nodule, complex cyst, suspicious lesion, and lesion highly suggestive of cancer. In cases where ultrasound shows the presence of a complex cyst or fibrous nodule, a biopsy is justified because 10% to 15% of these growths are malignant. Lesions falling into the last two categories (suspicious or highly suggestive of cancer) have a higher chance of being cancerous, and should be investigated further, either by biopsy or surgery.
Breast cancers such as the following may be identified on ultrasound: ductal carcinoma, infiltrating lobular carcinoma, medullary carcinoma, mucinous (colloid) carcinoma, tubular carcinoma, and papillary carcinoma. On ultrasound, the shape of a lesion and the type of edges it has can sometimes indicate if it is benign or cancerous, but there are exceptions. For example, benign fibroadenomas are usually oval, and some cancers can be similarly shaped. Cancerous tumors usually have jagged edges, but some benign growths can have these edges as well. Ultrasound is not a definitive test. Tissue diagnosis is often required.
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