Abus A User Guide

Automated
Breast
Ultrasound
A USER’S GUIDE
Ian Grady, MD, FACS

Foreword by A. Thomas Stavros, MD, FACR, FSRU, FRANZCR
© Copyright 2020 by Ian Grady – North Valley Breast Clinic

“
What we have learned
is not ours to keep.
Medical knowledge
belongs to all.
Ian Grady, MD, FACS
“
i
FOREWORD
This new book about automated breast ultrasound (ABUS) by Dr. Grady for relatively inexperienced ABUS readers and to decrease false positive
is particularly timely and useful now. As Professor László Tabár has always callbacks and also to reduce the percentage of biopsies that reveal benign
said, “screening is not diagnosis and diagnosis is not screening.” Just histology for more experienced ABUS users. Yet another headwind that
as managing and reading screening mammograms presents a completely adjunctive breast ultrasound screening has faced is the misconception that
different problem from managing and reading diagnostic mammograms, tomosynthesis can somehow make adjunctive breast ultrasound screening
managing and reading screening ultrasound examinations differs greatly unnecessary. The ASTOUND study proved this idea wrong by finding 3
from reading targeted diagnostic ultrasound examinations. There is a learning per thousand cancers more than were found with tomosynthesis in women
curve to get from diagnostic ultrasound to screening ultrasound. And as with dense breasts. Yet, paradoxically, the authors concluded that
noted by Dr. Grady, there is also a learning curve in going from hand-held the ASTOUND study showed that tomosynthesis might make
adjunctive screening to automated screening. ultrasound unnecessary.
This book is timely for the following reasons. Most of us who have been Finally, ACR BI-RADS audit rules for ABUS differ from those of hand-held
performing breast ultrasound for decades thought that by now adjunctive adjunctive screening ultrasound. The audit rules are advantageous to
breast ultrasound screening would be much more readily accepted and ABUS in comparison to hand-held screening. On a hand-held adjunctive
widely used than it currently is. However, adjunctive breast ultrasound screening breast ultrasound exam, any views other than routine views
screening after mammography in women with dense breasts has encountered (usually only 5 or 6 captured views) are considered “callbacks” and
many headwinds in the past decade that have slowed its acceptance and increase the false positive rate for hand-held, regardless of how the study
delayed its widespread use. One of the headwinds that adjunctive breast is interpreted by the physician. For example, if a sonographer took two
ultrasound screening has faced is the real limitation in physician and orthogonal views of a benign simple cysts, ACR BI-RADS would consider
sonographer resources available to perform hand-held scanning. ABUS that a “callback”, even if the physician correctly read the examination
directly addresses this concern by requiring fewer physician and sonographer as BI-RADS 2 and did not actually call the patient back for a targeted
resources. Another headwind has been the great variability and limited diagnostic examination.
documentation and reproducibility of hand-held adjunctive breast ultrasound
screening. ABUS also addresses this concern by producing more complete Furthermore, if the sonographer took only one view of the same simple
and reproducible records of the exam. The ABUS examinations are reproducible cyst, but placed calipers and measured it on a single view, the ACR would
enough that comparison with previous ABUS examinations can be used to consider that a callback, even if the physician appropriately read the study as
reduce false positives and also to document suspicious changes that help BI-RADS 2 and did not actually call the patient back for a targeted diagnostic
improve sensitivity. Another headwind has been a general lack of comfort examination. ABUS might record 3 slices through the same benign cyst in
of many breast imagers in performing and interpreting adjunctive breast each of 3 planes, 9 total views, and the ACR would not consider it a callback,
ultrasound screening examinations. The implementation of Q-View CAD because all 9 views through the cyst would be routine views. While the audit
when interpreting ABUS examinations has helped to address this concern. rules for hand-held screening are unreasonable, they are what they are, and
CAD has been shown to shorten reading times and improve sensitivity do favor ABUS.
FOREWORD & WHY ABUS? SCREENING DIAGNOSIS PLANNING SURVEILLANCE ANATOMY ARTIFACTS
INTRODUCTION
FIBROCYSTIC LACTATIONAL BENIGN INFLAMMATORY EVALUATING SOLID BENIGN SOLID BREAST LYMPH POST-TREATMENT OTHER
CHANGE CHANGES CHANGES MASSES MASSES CANCER NODES CHANGES FINDINGS
ii
FOREWORD
There is also a less formalized difference in audit rules between 2D and 3D This book is useful because, like interpreting screening ultrasound differs
automated breast ultrasound examinations. For a 2D automated ultrasound from interpreting diagnostic ultrasound, interpreting automated ultrasound
study, like for screening mammography, only BI-RADS 1,2, or 0 should be differs from interpreting hand-held ultrasound. It is easier to learn from 10
used. A BI-RADS 0 report should always lead to a formal targeted hand- years of someone else’s experience with ABUS than it is to have to learn
held diagnostic examination from which other BI-RADS categories might from one’s own 10 years of experience. It is especially useful to know what
be assigned. With 3D automated ultrasound, because multiple views of a we gain from having 3D ABUS, and in particular, what we gain from having
lesion are available, it is more likely that one can assign the full range of the coronal plane. The coronal plane is very important in characterizing
BI-RADS and not be limited to just BI-RADS 1,2, and 0 categories. Thus, masses because the tissue planes of the breast are oriented in a roughly
3D ABUS has an advantage over 2D automated ultrasound in offering us coronal plane that is slightly slanted posteriorly toward the periphery of
the use of the full range of BI-RADS categories. This can be very important the breast. The path of low resistance for invasive cancers is between
to patients, who do not understand the difference between screening and the tissue planes, and therefore, signs of invasion are best seen in the
diagnostic breast ultrasound examinations, and who are often upset when coronal plane. In Dr. Grady’s experience, and in my experience, angles,
informed that their 2D automated scan has necessitated a second diagnostic microlobulations, and spiculations (whether hyperechoic and/or hypoechoic)
ultrasound examination that will require a second billing. 3D automated is are best seen in the coronal plane. In both of our experiences, many masses
more likely to be able function as a combined screening and diagnostic that might be classified as only BI-RADS 4A, or even BI-RADS 3 in native
examination than is 2D automated ultrasound. scan planes will appear to be BI-RADS 4C or BI-RADS 5 in the coronal
plane. Thus, we can characterize many invasive malignant masses more
This book is also timely because a large meta-analysis of ultrasound used accurately from the coronal plane than we can from the native acquisition
for both adjunctive screening after mammography and primary screening scan planes. His recognition that the better demonstration of internal
without mammography that just was recently published showed that primary septations within fibroadenomas in the coronal plane is a particularly useful
screening ultrasound had sensitivity and specificity that did not differ tip that goes beyond the Stavros criteria and the 5th edition of BI-RADS and
significantly from the sensitivity and specificity of screening mammography. can help reduce false positives. The coronal plane is also useful in detecting
While authors were Chinese, the articles reviewed all met strict criteria for in situ components of mixed invasive and in situ malignant breast masses,
inclusion and were from all over the world, including the USA, Europe, since the major ducts tend to be oriented within the slanted coronal plane.
Japan, Korea, and Taiwan, in addition to China. The articles reviewed This can help us better determine the true extent of malignant breast disease.
included both hand-held and ABUS studies. Thus, we might consider It is also important to appreciate the posterior artifact of enhanced sound
designing large prospective studies to evaluated use of ABUS for primary transmission that occurs behind some cysts and grade III IDCs creates a
breast ultrasound screening rather than only for adjunctive screening hyperechoic pseudo-mass deep to the lesion of interest.
after mammography.*
INTRODUCTION
iii
FOREWORD
Dr. Grady’s discussion of ABUS-mammographic location correlation is very

cogent and well-written.
I also found this book useful because, with 10 years of experience in ABUS,
Dr. Grady has chosen to expand indications beyond just adjunctive breast
ultrasound screening. Dr. Grady discusses and presents using ABUS for
targeted diagnosis, for short interval follow-up, for determination of extent
of malignant disease and surgical planning, and for evaluation surgically-
altered breasts. Of particular note, is that Dr. Grady has adapted ABUS
scan techniques to get a better look at axillary lymph nodes, an important
part of determination of extent of disease, staging, and surgical planning.
While neither of us is advocating replacing staging MRI in all cases, ABUS
does offer a chance to locoregionally stage and plan cancer surgery even
from the basic ABUS screening examination, since it shows the entirety of
both breasts and the regional lymph nodes of the breast.
In summary, I enjoyed reading this book and looking at the illustrations. It

does not take long to read from cover to cover and has many useful tips.
I think that if you are using ABUS or are considering starting to use ABUS,
you will find it useful as well.
Tom Stavros
A. Thomas Stavros, MD, FACR, FSRU, FRANZCR
Professor Specialist, Department of Radiology
University of Texas Health Sciences Center, San Antonio, TX
* Yang L, et al. Performance of ultrasonography screening for breast cancer: a systematic

review and meta-analysis. BMC 2020; 20:499-514.
INTRODUCTION
iv
INTRODUCTION
FORWARD
At the North Valley Breast Clinic, we are just finishing our 11th year and artifacts that you must learn. These coronal signs and their use
of experience with automated breast ultrasound. I have learned a in the interpretation of findings is presented through illustrative
thing or two over that period of time and that, more than anything cases.
else, has resulted in this book.
The cases presented were imaged on an Invenia ScanStation
This book assumes familiarity and some experience with hand-held (GE Healthcare, Waukesha, WI). All malignant cases presented are
ultrasound for diagnostic evaluation. I had over 10 years of experi- biopsy proven. All benign cases are either biopsy proven or have
ence with focus ultrasound before starting to use ABUS. I thought been followed for a year.
that I was well prepared for the experience and was unpleasantly
This book will be an ongoing effort. As new
surprised by the steepness of my ABUS learning curve. With that
techniques are discovered and new
said, it is now time to share what I have learned in the hope that
illustrative cases are found, the book will
your climb up the curve will be easier.
be up-dated to reflect this experience.
The techniques you will see were, for the most part, developed here.
Your feedback about cases or techniques
Methods for imaging the axilla, for evaluating palpable masses, for
will be always appreciated and incorporated
preoperative staging, and surgical planning are the result of
whenever possible. Enjoy...
research performed here at the Clinic.
Most of the book concerns the perception and characterization of

imaged findings. This is where you will find that your learning curve
is getting steep. Interpretation of ABUS studies takes place in the Ian Grady, MD, FACS
coronal plane and the coronal plane has its own unique set of signs
INTRODUCTION
v
WHYABUS?
WHY ABUS?
Automated breast ultrasound studies have been shown to increase additional imaging. If the finding is malignant, you can go back to
diagnostic yield when performed with mammography in screening. the ABUS study to perform your staging workup and preoperative
More recently, ABUS, when combined with mammography, in the planning. Everything you need to do, you can often accomplish in
screening of high-risk women has been shown to decrease stage at one study. All you need is real-time mammography reading and you
diagnosis over mammography alone. And, of course, all the benefits have an imaging practice that can complete anyone’s imaging in
of screening come from this decrease in stage at diagnosis. less than two hours.
Traditionally, breast imaging is divided into separate screening and Of course, other imaging technologies can be used with
diagnostic evaluations. Women are seen for screening, but then mammography for supplemental screening. MRI requires an
have a “callback” if there is a finding. This happens days to weeks intravenous heavy-metal contrast and requires insurance
later. This can be followed by a callback for an ultrasound or authorization. This makes same-day imaging difficult. Moreover,
possibly a biopsy. In my community, it is very common for women women just don’t like MRI. Given the choice between an MRI and
with cancers to arrive at a surgeon’s office for treatment eight weeks ultrasound, women invariably choose ultrasound.
or more after their cancer was initially seen.
Nuclear medicine techniques such as positron-emission
Automated breast ultrasound disrupts this model. Since automated mammography and molecular breast imaging also increase
ultrasound can image the entire breast and axilla, ABUS studies can diagnostic yield. Although these techniques are better accepted,
be used for more than just screening. Say you perform an ABUS they still require authorization, precluding same day imaging.
study and you find something. You can often characterize the lesion
Contrast-enhanced spectral mammography shows great promise in
working from the same study. Often, findings are sufficiently suspi-
both diagnostic evaluation and screening. As a diagnostic problem-
cious on ABUS that you can proceed directly to biopsy without
solving tool, CESM rivals MRI in both sensitivity and specificity.1
INTRODUCTION
vi
WHY ABUS?
Screening with CESM is an area of active investigation. The only

drawback to CESM is the need for intravenous iodinated contrast.
Hand-held ultrasound whole-breast imaging is equivalent to

automated breast ultrasound, provided that the study is physically
per-formed by the person who reads the study. Diagnostic yield for
hand-held ultrasound is roughly half that of ABUS when the study is
performed by technologists.
Reader performed hand-held ultrasound is not cost-effective. A

trained professional can read several ABUS studies during the time
it takes to perform one hand-held ultrasound study. Hand-held
ultrasound screening studies are not archived in their entirety,
making comparisons to prior imaging difficult. This makes the final
interpretation limited.
Ultrasound will soon become the secondary screening technology

of choice simply because the economics of ABUS are more
favorable. Low cost and a favorable reimbursement to reading time
ratio, without the need for authorization, will drive adoption.
ABUS is the future.
INTRODUCTION
1
CHA P T E R 1
SCREENING
Detecting asymptomatic cancers
INTRODUCTION
2
0.6 0.6
0.5 0.5
Proportion
Proportion
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 1 2 3 4 Sojourn Time 0 1 2 3 4
Stage Stage
Inception Detected Symptomatic
Detectable
Lead Time
The time required for a cancer to progress from detectable to symptomatic is its sojourn time.2,3 Screening that leads to detection during sojourn results
in an earlier stage breast cancer. This lead time results inThe
a lower
timestage at diagnosis
required for a and bettertosurvival.
cancer progress from detectable to symptomatic is its sojourn
time2,3. Screening that leads to detection during sojourn results in an earlier stage breast
cancer. This lead time results in a lower stage at diagnosis and better survival.
SCREENING THEORY
Breast cancer screening is based on the premise that breast cancer 1960s and the 1990s, there were several major clinical trials of
is a progressive disease and that earlier detection will result in a breast cancer screening. Together referred to as the randomized
lower stage breast cancer at diagnosis. This reduction in stage is controlled screening studies, these trials prospectively compared
the source of all the benefits of screening. groups of women who received an invitation to screening with
women who were not invited to screening.
This premise has held up through multiple clinical trials. There is
concern, however, regarding the possible harms of screening and With the exception of the two Canadian National Breast Screening
how those harms balance the benefits of screening. In other words, Studies8, all of these trials showed a reduction in mortality for
do the benefits of screening outweigh the harms for everyone. screening asymptomatic women for breast cancer. And this benefit
was seen in every age group studied. From age 40 until at least age
Despite concerns about the harms of screening, there is remarkable
75, breast cancer screening saves lives. Some age groups have
unanimity of opinion as to the benefits of screening. Between the
more benefit than others, but everybody benefits.
INTRODUCTION
3
Trial Year Age Attendance (%) N Mortality (OR) Advanced CA (OR)

HIP4 1963 40-64 67 60,995 0.76 (NR) 0.82 (0.66-1.00)
Malmo5 1976 43-70 75 60,076 0.82 (0.67-1.00) 0.83 (0.68-1.00)
Two-County6 1977 40-74 89 133,065 0.69 (0.56-0.85) 0.69 (0.61-0.78)
Edinburgh7 1978 45-64 61 44,268 0.79 (0.60-1.05) 0.87 (0.73-1.04)
Canadian 1&28 1980 40-59 100 50,430 1.05 (0.85-1.30) 1.27 (1.02-1.57)
Stockholm9 1981 40-64 81 60,117 0.91 (0.65-1.27) 0.82 (0.67-1.01)
Gothenburg10 1982 39-59 84 51,611 0.76 (0.56-1.04) 0.80 (0.61-1.04)
Age11 1991 40-48 81 160,921 0.83 (0.66-1.04) 0.89 (0.72-1.10)
The Randomized Controlled Screening Trials
This benefit comes through the early detection of breast cancers, The lower the proportion of advanced breast cancers seen, the
before they progress to advanced stage breast cancers. For lower the mortality rate.
screening theory purposes, advanced stage cancers are those that
are stage 2 or greater at diagnosis. Mortality vs. Advanced Cancers in the Randomized Screening Trials12
With modern treatment, there is no difference in mortality between

Canadian
0
early stage breast cancers (stage 0-1) and the population without Canadian
for Mortality)
breast cancer. Mortality starts to increase at stage 2. 0
Mortality)
UK Age Trial
The magnitude of the benefit a woman receives from screening −0.2
Malmö 1
UK Age
Gothenburg
ratio
depends on the effectiveness of the screening program in which she Trial
Ratio for
-0.2 Malmö 1 Edinburgh
HIP
is enrolled. This can be quantified by looking at the proportion of
Ln (Odds
Two-CountyGothenburg Edinburgh
advanced cancers diagnosed during screening. HIP Stockholm
Ln (Odds
−0.4
Two-County Stockholm
If you look at the randomized controlled screening trials listed -0.4
above, you will note that the odds-ratio of mortality in the screened
population varies from trial to trial. This reduction in mortality −0.4 −0.2 0 0.2
Ln (Odds Ratio for Advanced Cancers)
correlates with the reduction seen in advanced breast cancers. -0.4 -0.2 0 0.2
Mortality vs. advancedLncancers inforthe

(Odds Ratio randomized
Advanced Cancers) screening trials12.
INTRODUCTION
4
This result suggests that new imaging technologies that decrease chemotherapy, and post surgical radiation. All of this is
the incidence of advanced cancers will have a mortality benefit over unnecessary in women with early breast cancers.
and above that seen with mammographic screening alone.
Mortality, of course, is not the only endpoint. Cost is an important

endpoint as well. Reduction in stage at diagnosis has been shown
to correlate with significant treatment cost savings13.
$200K All-cause Cost Over the First Two Years of Treatment

for Women with Breast Cancer, by Stage
$200 K
$150K
$100K
$150 K
$50K
$100 K
$0K
$50 K
Stage 0 Stage 1/2 Stage 3 Stage 4
All-cause cost over the first two years of treatment for women with
$0 K breast cancer, by stage
Stage 0 Stage 1/2 Stage 3 Stage 4
The last endpoint is the one we know the least about, but is arguably
the most important. Human suffering. As a practitioner you can see
the tremendous burden of human suffering that women with
advanced breast cancers experience. Extensive surgery, cytotoxic
INTRODUCTION
5
BREAST DENSITY AND SECONDARY SCREENING

Increased breast density is the single factor most responsible for These facts have led to the development of additional, or
missed or interval breast cancers. Interval cancers are those which supplemental imaging to detect missed mammographic cancers in
pop up as symptomatic cancers between mammographic screening women with increased breast density.
intervals. As such, the are usually advanced stage cancers with a
Technologies studied for supplemental breast cancer imaging
reduced survival prognosis.
include mammographic tomosynthesis, hand-held ultrasound,
Breast density also is an independent risk factor for the ABUS, MRI, molecular breast imaging, positron emission
development of breast cancer. The mechanism for this is not mammography, and contrast-enhanced spectral mammography.
currently known, but may have a genetic component. Increased
Of these technologies, ultrasound and MRI have been studied the
density, like breast cancer risk, tends to run in families.
most and both have been found to be effective in the detection of
mammographically occult breast cancer.
INTRODUCTION
6
Two stage 1 breast cancers found on screening in women in their 50s. The lesion on the right was seen on mammogram only after
it was diagnosed on ABUS. The mammogram on the right was initially read as negative. Finding it on mammogram
required myself, two radiologists, and 15 minutes, even though we knew roughly where it was to start with.
INTRODUCTION
7
Screening Ultrasound Since breast cancer is a progressive disease, for the most part, any
Ultrasound was initially studied in the ACRIN 6666 trial that was supplemental imaging technology that detects additional cancers
published in 200814. In this trial, mammography showed a before they become symptomatic will decrease stage at diagnosis.
diagnostic yield of 7.6 cancers/1,000 asymptomatic women with
We looked at this in a retrospective study published in late 201715,
either increased breast density or a high risk of developing breast
based on our own clinical experience. We found that the addition of
cancer. The addition of hand-held ultrasound in this population
ABUS to mammographic screening decreased the incidence of
increased screening yield by an additional 4.2 cancers per women
advanced cancers cancers by about 10% over mammographic
screened. These additional, or supplemental cancers were not seen
screening alone.
on mammogram.
Moreover, ultrasound screening, with ABUS alone, turns out to be a
This study also included an MRI arm. Women who had participated
very good screening option. In our 2017 paper15, we were able to
in three rounds of screening under the ACRIN 6666 protocol were
show that screening with ABUS alone reduced advanced cancers
offered an MRI. Screening yield in this population was 14.7/1,000
by 31% versus 32% for mammography alone. This difference was
women screened. Despite the fact that the study was free of
not statistically significant.
charge, almost half (42%) of women who were eligible refused to
participate. ABUS screening alone may prove to be very useful in resource poor
areas of the world, especially in Asia where the proportion of women
Since 2008 several other studies have shown supplemental yields
with dense breast tissue exceeds 95% of the population.
for ultrasound in the range of 4/1,000 women screened. These are
summarized below. Selecting Secondary Screening Technologies
The choice of secondary screening ultimately comes down to an
Year Criteria N Yield
economic decision. All imaging technologies that detect cancers not
Kelley et. al.16 2010 >35y and 3-4 density 6,425 3.6 seen on mammogram will improve stage at diagnosis.
Giuliano et. al.17 2013 Density 3-4 3,418 7.7
Somo-Insight18 2015 >25 and 3-4 density 15,318 1.9 Stage at diagnosis is an excellent surrogate endpoint for screening
EASY19 2016 >40 and 3-4 density 1,668 2.4 techniques, since avoidance of advanced cancers has been shown
to correlate with improved mortality, decreased cost, and reduction
ASTOUND20 2016 >38 and 3-4 Density 3,231 7.1
in human suffering. All the benefits of screening come from a
Grady et. al.15 2017 Risk>15% or 3-4 density 3,435 4.2
reduction in stage at diagnosis.
ABUS Screening Studies
INTRODUCTION
8
Given these facts, it makes sense to assume that screening technolo- fered an MRI at no charge. Despite the fact that there was no out of
gies that maximize diagnostic yield will minimize stage at diagnosis. pocket expense or issues with insurance coverage, less than 50% of
This however, may not be the case. women who were invited for an MRI actually showed up.14
In order to benefit the patient, the secondary screening study Tomosynthesis has been shown to detect cancers missed on
chosen actually needs to be performed. Whether or not this happens standard 2-D mammography. This yield, however, was just over half
depends not on clinical criteria, but economic criteria. of that of ABUS in the same cohort. One thing that came out of the
ASTOUND trial is that all but one of the cancers detected on
The most common secondary screening technique in use today is
tomosynthesis were also seen on ABUS. On the bright side, the
MRI. MRI is very effective at finding occult cancers missed on
study can be performed same day and does not require contrast.
mammogram. MRI is unique among secondary screening
technologies in that it has been shown to have a
mortality benefit over mammog- Technology Yield Cycle Limited Contrast Authorization Same Day Acceptance
raphic imaging alone in women ABUS 4 No None No Yes High
with a Tyrer-Cuzick risk of 20% MRI 12 Yes Gadolinium Yes No Poor
or greater. Tomosynthesis 1.2 No None Variable Yes High
MRI is menstrual cycle limited MBI 8 No Tc-99m Yes No Variable
and, in the United States, PEM - No 18-FDG Yes No Variable
requires insurance CESM - No Iodine Variable Yes High
authorization. This authorization Clinical and economic characteristics of secondary screening technologies
is very difficult to obtain if breast
density is the only indication. Molecular breast imaging has been successful in detecting
mammographically occult cancers. The technique requires a
Another potential issue is the accumulation of heavy metal radioactive tracer. In areas of the country, such as the Pacific Coast,
gadolinium. When you are using this in a screening program, you this limits patient acceptance. The technique requires authorization.
need to think about 20-40 studies over the course of a patients life. This limits same-day imaging. That being said, however, MBI has
The effects of gadolinium accumulation over this time frame are not been used very effectively, in certain areas of the country, to screen
known. Also, gadolinium is contraindicated in women with renal women with increased breast density, but a low Tyrer-Cuzick risk.
insufficiency.
Positron emission mammography is under study as a secondary
Moreover, women just don’t like MRI. In the ACRIN 6666 study, screening tool. The technique is expensive, since it depends on a
selected women who completed three rounds of screening were somewhat exotic tracer. Additionally, the tracer is expensive and a
INTRODUCTION
9
significant delay prior to imaging is required after injection. As a

result PEM is effectively limited to preoperative staging at this time.
The technique, I believe will eventually find an indication in women in
whom gadolinium is contraindicated. Patient acceptance is
variable, depending mainly on geography.
Contrast-enhanced spectral mammography is the new imaging

technique on the block. CESM uses an iodinated contrast agent
similar to CT scan contrast. This limits use in women with certain
medical problems. CESM is under study as a screening tool and has
a lot of potential. In diagnostic workups it is as effective as MRI.1
Insurance coverage is variable.
Overall, the economics favor ultrasound, and in particular, ABUS.

ABUS does not require authorization, is well reimbursed, and can be
performed same day. These factors greatly increase the chances
that a secondary screening study will actually be performed.
Hand-held ultrasound has about the same diagnostic yield as

ABUS, provided that the study is performed by the reader. Hand-
held ultrasound studies performed by ultrasound technologists
have about half the diagnostic yield as those performed by the
radiologists who actually sign out the study.21
This fact will greatly limit hand-held ultrasound adoption. It can

take upwards of 20 minutes for a reader to perform a hand-held
screening study. In that time, the same reader can sign out up to 10
ABUS studies. Since the reimbursement in the United States is about
the same for both studies, hand-held screening will never be widely
adopted.
INTRODUCTION
10
RISK-STRATIFIED SCREENING
Integration of secondary screening into your practice can be provide for same-day mammographic reading and you have an
challenging. The workflow for this type of practice requires practice imaging practice that is second to none.
and there are a lot of moving parts.
In my practice, we have been providing same-day service since
On the bright side, ABUS technology can be the tip of your lance 2011. Say we see a new screening patient. They have their
in developing an imaging practice that not only has outstanding mammogram. We get a read back from our radiologists in about 10
clinical outcomes, but service outcomes that are far above the minutes. If they are dense or are at an elevated risk, they get an
standard of care in your community. ABUS study immediately. This also read in less than 10 minutes. If
they need additional views, they get them. Right away. If they need
The key here to success is to add a secondary screening
a biopsy, they get that too. Today. If they need to see a surgeon,
technology to mammography that allows for same-day imaging.
they see one. Right now is good.
For this, ABUS is the obvious choice. Then all you have to do is to
INTRODUCTION
11
Everybody leaves with a radiologic diagnosis and a treatment Imaging Workflow in Risk-stratified Screening
plan. The same applies to diagnostic patients because, in reality,
there is no difference between screening and diagnosis.
Presentation
This is way better service than you get at a conventional imaging
center. No callbacks, no anxiety, no treatment delays. It is an Screening Diagnostic
unbelievable marketing advantage.
The downside is that you have to develop a lot of capability to

track patients through their work-up. When we first started, Mammogram Clinical Evaluation
developing this capability was our rate-limiting step. Only after we
had developed a workable system, could we increase our volume.
The key to tracking was to develop an easy to understand,

Risk Imaging
protocol-based system of imaging that could apply to screening
patients, diagnostic workups, anyone.
For this, we selected the Society of Breast Imaging’s 2010 Low Moderate High
Low Risk
Screening Recommendations. The basis of the SBI <15%, not dense
recommendations is the concept of risk-stratification. Women at Moderate Risk
>15% or dense
average risk of breast cancer, meaning that they have no special ABUS MRI or ABUS
High Risk
risk factors and no increase in breast density do very well with >20%
annual mammographic imaging alone.
For women at a high risk of developing breast cancer, that is a

life-time risk of greater than 20% by the Tyrer-Cuzick, or similar
model, do best with a combination of mammographic and their Results
choice of sonographic or MRI imaging.
Women who are at a moderate risk of breast cancer, that is a

BI-RADS 3 BI-RADS 4-5 BI-RADS 1-2
Tyrer-Cuzick risk of 15-19% or increased breast density, are
adequately screened with a combination of mammographic and
Imaging workflow in Risk-Stratified Screening
sonographic imaging. Short-term F/U Biopsy Return 1 yr
INTRODUCTION
12
For women who present with symptoms or imaged findings that

require a diagnostic work-up, a clinical evaluation is performed and
then appropriate imaging is prescribed by the clinician, based on
the patient’s presentation.
The advantage of a protocol-based system is that the techs and

clinic staff can predict what steps the patients will take as they
progress through the clinic.
Imagine that you have 3-4 new diagnostic patients and perhaps
8-10 screening patients working their way through your clinic in a
morning. You can’t keep track of everybody's progress yourself, you
will need your staff to pilot these patients through their individual
workups. A protocol-based system makes this possible.
INTRODUCTION
13
QUALITY MEASURES
In order to improve, you have to know where you are. This means Since ultrasound is not regulated under the MQSA, there are not
measurement of your outcomes. You want to know how many clearly defined standards to benchmark yourself against. I will share
cancers you are diagnosing, but also how many times you are with you what measures we have adopted. For the most part, they
bringing your clients back for additional imaging to diagnose those are extensions of accepted MQSA measures.
cancers. Above all, you want to track how many cancers you have
Generally, I recommend that you report your mammographic and
missed.
ABUS measures separately, with aggregate totals for your program
For screening practices based on mammography alone, there as a whole. You sort of have to do it this way because the FDA is
are well defined and accepted quality measures. Many of these going to ask only for your mammographic statistics. Also, if you are
measures must be reported to the FDA pursuant to the using RIS software to calculate your statistics, it will do it this way.
Mammography Quality Standards Act of 1992.
INTRODUCTION
14
With that said, we mainly focus on three statistics for ABUS. The first significantly after moving from the Somo-V platform to the Invenia,
is the cancer detection rate (CDR), which is often referred to as and then again when we added QView VCAD. Comparing priors
diagnostic yield. The second is the abnormal detection rate, has also favorably affected our callbacks.
sometimes referred to as a callback rate. The last is PPV3, the ratio
PPV3 is also useful as a measure of ultrasound interpretation. To
of cancers detected to biopsies performed.
start with, your PPV3 will be lower than it will be after you gain some
These measures are objective and, for the most part, under your experience. Again, PPV3 is a range variable. If you are either too low
control. Be aware that CDR is dependent on the risk of cancer in or too high, you may need to rethink your life.
your population. If you have a high-risk population, your CDR will
Note that sensitivity and specificity are not as useful because, in
be higher. To adjust for this, centers that calculate risks on their
Breast Cancer Surveillance Consortium 201722 North Valley Breast Clinic

Measure Criteria Value Benchmark Mammographic ABUS Combined
CDR Cancers/1,000 screened 5.1 > 2.5 7.4 4.2 11.6
AIR Abn interpretation rate 11.6% 5-12% 11.4% 3.2% 14.6%
PPV1 Cancers/Abn mammograms 4.4% 3-8%

PPV2 Cancers/Bx recommended 25.6% 20-40%
PPV3 Cancers/Bx performed 28.6% 23-39% 26.5% 28.4%
Sensitivity 0.869 > 0.75

Specificity 0.889 0.88-0.95
2017 BCSC values and benchmarks for mammographic screening compared to selected mammographic and sonographic
outcomes from my clinic
screening patients tend to report the CDR for their average risk order to calculate these values correctly, you need to have perfect
patients. knowledge of every biopsy performed on each patient you have
screened. This data is hard to come by.
The abnormal interpretation, or callback, rate is more tricky. You
want a certain number of callbacks to ensure that you are not Our statistics represent a source of pride for me. A
missing cancers, but not an excessive number. mammographic CDR of 7.4 is better than average, while our
mammographic callback rate is in the standard range. I am
This value depends not only on experience, but on your technology
especially proud of our
and patient population. Our ABUS callback rate dropped
INTRODUCTION
15
ABUS CDR that leads to a combined diagnostic yield of 11.6. Our a long process of importing previous studies. This allowed
PPVs are also in the acceptable range. prefetching and realtime comparison with prior studies. Again,
this resulted in a significant drop in callbacks.
This is all good, but note our combined ADR. At 14.6%, it exceeds
the desirable range. This is something of an unavoidable downside In late 2016, our QView CAD system was approved by the FDA and
to supplemental screening. The more imaging you do, the more we immediately moved it into production. Callback rates again
callbacks you will get. dropped. As a bonus, reading times also dropped from about 5-7
minutes to less than 2 minutes for a normal study.
Personally, I think that increased callbacks are a small price to pay In early 2017, GE Healthcare published a software update that
for a lower stage at diagnosis, but I appreciate that my clients and further increased resolution for the Invenia. Since then, we have run
referring providers may not share this opinion. a callback rate of about 2-3%. This is where it should be.
In 2014, we were running an ABUS CDR of about 4 cancers/ 1,000
women screened. That figure is acceptable and
fairly middle-of-the-road. It has been our average
12 Invenia 12
yield ever since 2011, when we started the program.
Yield (Cancers/1,000 women screened)

Recall Rate (per 100 women screened)
The problem was my callback rate. It was simply 10 10
too high. High enough that our clients were
complaining about it. Now in my defense, I must 8
8 EA Server
point out that reported ABUS callback rates in
the clinical trials of the time were about the 6
same,10-14%, but it still was not acceptable. 6
Accordingly, in 2015, I began a concerted effort 4

4
to reduce our callback rate. I traded in my
venerable first generation Somo-V ABUS for a 2
new Invenia, which has far superior resolution. 2
This resulted in a significant improvement almost CAD 0
overnight. Jul Jan Jul Jan Jul Jan
2014 2015 2016 2017
In early 2016, I brought our EA Server online after
ABUS CDR and Callback Rate at the North Valley Breast Clinic Over Time
INTRODUCTION
16
We now have a new version of the Invenia called the Invenia 2. This
has improved resolution another 20-30%. With this, I look forward to
further improvements in our callback rate.
All of this illustrates the importance of tracking your statistics. Only

by measuring your outcomes, can you improve the quality of your
care. Now there are not currently established benchmarks for ABUS
screening, but don’t let that stop you. Feel free to use the same
benchmarks I use, or pick your own. The important thing is to pick
measures that have meaning for you and then use them to improve
your outcomes.
INTRODUCTION
17
CHA P T E R 2
D I AG N O S I S
Working up symptoms and findings
INTRODUCTION
18
COMBINING SCREENING AND DIAGNOSIS

Traditionally, screening and diagnosis are looked on as separate In most cases, the high resolution of modern ABUS imaging will
endeavors. If something is found on screening, the patient is called allow you to characterize the finding as benign, probably benign,
back for a separate diagnostic work-up. People were either in a or suspicious. Unless you have a borderline finding that requires
screening track or a diagnostic work-up. There was really no Doppler flow imaging or elastography for additional evaluation, you
in-between. can make your decision based on ABUS imaging alone.
ABUS imaging changes that paradigm. Progressive improvements So, say you are screening a client for dense breast tissue. You find a
in ABUS resolution over the last three years have resulted in an small hypoechoic lesion. On the ABUS study you see an irregular
imaging technology that can combine screening, diagnosis, and border and posterior shadowing. Your diagnostic workup is done.
treatment planning in one study. The lesion is suspicious, proceed directly to biopsy.
INTRODUCTION
19
If you find a cancer on biopsy, you can return to the original ABUS You can see the advantage of increased resolution in the figure
study to perform your staging and treatment planning. No need for below. I first saw this patient in 2015. At that time, we were using the
an additional imaging. Somo-V ABUS scanner to obtain images. The patient had a
hypoechoic finding in the left UOQ that generated a diagnostic
All you need to do is arrange for realtime mammogram reading and
callback. It turned out to be cyst on handheld ultrasound.
you can perform all of your diagnostic and screening work-ups
during one appointment. During the same day. Same day The same finding is seen in 2016, after we upgraded to an Invenia
evaluations reduce anxiety and are a tremendous marketing ABUS scanner. In 2017, a software upgrade improved resolution
advantage for your practice. In addition to caring for patients in further. If I was seeing this patient today as a new patient, the finding
your own community, you will see a lot of patients from out of town would not generate a callback. It would be recognized as a cyst and
because women can get worked-up faster by traveling to see you no further action would be needed.
than they can in their own communities.
ABUS imaging is an enabling technology, a force multiplier that
allows you to streamline and, in most cases, combine both screening
2015 2016 2017
The improvement in resolution of ABUS imaging between 2015 and 2017 allows for screening, diagnostic, and staging work-ups
to be performed all on the same study. Resolution is now comparable to handheld ultrasound, eliminating the need for
diagnostic ultrasound callbacks.
INTRODUCTION
20
and diagnostic work-ups into a single study. ABUS is a very cost-

effective way to build an imaging program that is far superior, both
in outcomes, and service, to anything available in your community
today. This will earn you referrals and marketshare, even when you
face entrenched and longstanding competition. Those of you who
are surgeons will find that this type of imaging program rapidly
becomes your premiere referral source.
INTRODUCTION
21
WORKING UP A SYMPTOMATIC FINDING

No matter how you structure your practice, even if you are only On mammography, this is accomplished with mammographic
doing screening, you will see lots of women who have symptoms. markers. The mammography tech will place a radiopaque sticker
on the symptomatic area before she shoots her images.
There are methods that I have developed to facilitate the work-up of
a symptomatic finding using ABUS. These methods will save you About 12 years ago, now, I developed a technique to do this for
time, give you confidence in your results, and improve your ABUS studies that I still use today. Essentially, it is the same
diagnostic accuracy. technique that the mammogram techs use. The surprisingly difficult
part, in developing this technique, was to find a sticker that would
The tricky part of a diagnostic work-up is to ensure that what you are
not float off the patient when it was covered by ultrasound gel. This
seeing, or not seeing, on ultrasound and mammogram correspond
took six months of trial and error.
to the symptomatic finding.
INTRODUCTION
22
I finally found a marker that sticks to the patient so well that the
moving scanner head will not cause it to move, even when it is
covered in gel.
This marker is made by InterMark, a British company. You can order

them either directly from InterMark, or through McKesson, a medical
supply company, based in San Francisco.
The marker works because it casts a shadow that you can see on
both the coronal and transverse views of an ABUS volume. To use
the marker, you place it over a symptomatic finding and obtain a
ROI ABUS volume with the marker in place and as close to the
center of the volume as possible. Then you remove the marker and
repeat the same volume. Then you can compare the two volumes in
The InterMark Marker in place over a palpable finding.
the coronal comparison and the transverse comparison view.
Synchronizing the two volumes will place you close to the location
of the finding in the non-marked volume.
This technique works well for essentially any focal finding. Masses,
focal areas of pain, dimpling, or other focal skin changes all image
well with a marker.
This technique does not work well for diffuse findings like diffuse
breast pain or nodularity.
For diffuse findings, I have found it best to just perform the standard
set of volumes that you would normally perform for a screening
exam, and add any ROI volumes needed to ensure that you are
imaging the entire symptomatic area.
If the symptomatic area is close to the nipple, you can simply use
the nipple as your marker. Multiple markers can be used if the
The InterMark Marker (Bromley, Kent, UK) patient has more than one finding
INTRODUCTION
23
Marker Shadow
Marker Shadow
Tumor
Working up auppalpable
Working cancer
a palpable cancerusing bothmarked
using both markedand
and unmarked
unmarked volumes
volumes
Tumor
Tumor
INTRODUCTION
24
WORKING UP A MAMMOGRAPHIC FINDING

Often times during diagnostic work-ups, you will be called upon Usually, the radiologist who reads the mammogram can give you a
to evaluate a mammographic finding. That will involve not only reliable, ballpark, location for most findings. If correlation is difficult,
characterizing the finding and assigning a BI-RADS score to it, but there are a couple of techniques that you can use to pin a
proving that the lesion that you identified on sonogram is, in fact, the mammographic finding down.
mammographic finding. Remember, there is no reason why the
Both techniques involve measuring the location of the finding on the
patient cannot have two findings.
patients mammogram, then calculating the position of the lesion,
The process of establishing whether or not the mammographic and and then placing a marker on the patient’s skin at that location. With
ultrasound findings are one and the same is called correlation. the marker in place you proceed with your ABUS imaging as you
Correlating mammographic and sonographic findings can be tricky, would for a palpable mass.
especially when your patient is dense, or large, and the lesion is far
from the nipple, or deep.
INTRODUCTION
25
The first technique developed is a graphical technique. Whoever ML Axis

actually developed this is lost in the mists of history. It has been MLO Axis
handed down from generation to generation of mammogram techs
to help localize findings at stereotactic biopsy. I learned the
technique in 2000 from a very charming and helpful radiologist who
came to our facility to certify us in stereotactic biopsy under the old
ACR/ACS program.
MLO
This is sometimes called the minimum skin distance technique

O
because it locates the MSD point; the point on the skin of the
M
patients breast that is closest to the mammographic target.
q
This technique was developed in the days of film-screen
mammography. As you may remember, back when we were using Distance M
mammogram films, they were actual size. So you would simply place
the film on the patient and draw your vectors on the patient with a
Sharpie. Now we are using digital films, doing it this way is more Nipple is 0,0 Distance D
problematic. This has led to the development of mathematical
solutions. Distance X
CC Axis
For the graphical technique, we will measure two distances, M and X
from the mammograms. This is shown in the figure for a left upper-
outer quadrant finding. M is the distance from the target to a line
drawn at right-angles to the chest wall and passing through the
nipple. X is the distance from the nipple to the target drawn on a line
that is along the 9:00-3:00 radian. X
CC
Once you have these distances you mark the distance M on a line
parallel at angle Φ from the 12:00 radian. For a standard MLO film,
use 15 degrees (𝜋𝜋/12 radians). For a true ML image, use 0 degrees
Graphical technique for finding the location of a mammographic
(0 radians). finding. Measurements are taken directly from the mammogram films
and drawn on the patients breast.
INTRODUCTION
26
Distance X is marked on the medial-lateral line that passes through

the nipple.
10cm
Now, with these distances marked, you simply drop a right-angle

line from each vector. Where these lines intersect is the MSD point.
This will make more sense when you review the figure.
6X
You can use the graphical technique with digital mammograms, if
you want. Basically, you measure distances M and X using the
caliper tool on your mammographic reading station and write them Distance M
down. Then you grab your Sharpie and draw the distances on your 5 6Y
patient directly. Fifteen degrees turns out to be fairly easy to
Distance Y'
guesstimate. Then you drop your right-angle lines, and where they
intersect is the MDS point. Easy!
Distance Y
O
The same technique works for the right side, just the angles are q Distance D
mirror image to the left.
Now, for those of you who are more mathematically inclined, you can
solve for the MSD point trigonometrically. Here you are calculating 0
0 5 Distance X 10cm
an angle Θ from the 12:00 radian and a distance D from the nipple.
As you can see from the figure, you are essentially calculating the
angle and hypotenuse of a right triangle. Trigonometric method for finding the location of a mammographic
finding. Distances X and M are measured on the patient’s
Euclid did this 2,300 years ago, and you can too! mammogram. Distance D and angle Θ are calculated
There are some things you need to keep in mind while doing this. (-π/12 radians). Anyway, with that all said, here are the formulas
First, the 0,0 origin point is the nipple. Second angles that are drawn and their derivation:
in a clockwise direction from the 12:00 radian are positive. Counter-
clockwise angles are negative. This applies on both the right and left
breast. To get results that make sense, you need to keep the signs
of the angles straight. For example, on the right, Φ = -15 degrees
INTRODUCTION
27
X is known. To calculate Y:
Y = Y’ - ΔY
Y’ = M cosφ
ΔX = X - M sinφ
ΔY/ΔX = tanφ Clock Degrees Radians

ΔY = ΔX tanφ 12:00 0 0
1:00 30 𝜋𝜋/6
ΔY = (X - M sinφ)tanφ 2:00 60 𝜋𝜋/3
3:00 90 𝜋𝜋/2
Therefore 4:00 120 2𝜋𝜋/3
Y = M cosφ - (X - M sinφ)tanφ
5:00 150 5𝜋𝜋/6
6:00 180 𝜋𝜋
Then to calculate D and Θ: 7:00 210 7𝜋𝜋/6
Θ = arctan (Y/X) 8:00 240 4𝜋𝜋/3
D = X/sinΘ 9:00 270 3𝜋𝜋/2
10:00 300 5𝜋𝜋/3
11:00 330 11𝜋𝜋/6
You can use either degrees or radians in these calculations, as you
prefer. I did the math on this myself and I have tested it out, but
please feel free to forward any corrections. Also, if you have a
Clock positions and their equivalent angles in
simpler way to do this, please forward it to me and I will publish it
degrees and radians
in a future edition of this book.
With D and Θ, you can get the Sharpie out and measure the MSD
out on your patient directly. For those of you who don’t have a
protractor handy, I have included a table below with clock positions
that you can convert. Enjoy!
INTRODUCTION
28
CHA P T E R 3
PLANNING
Treatment planning with ABUS
INTRODUCTION
29
LOCATION OF DISEASE
Traditionally, treatment was not planned, because everybody got Treatment planning boils down to two tasks, finding the location of
the same treatment, a modified-radical mastectomy. These days, the tumor, and finding the extent of disease. Once you know these
things are a little more complicated. With conservative surgery, two things, intelligent treatment planning becomes possible.
oncoplastics, and, especially, partial breast radiation, planning
ABUS is a tool that is ideally suited to treatment planning. ABUS
your patient’s treatment has become much more important.
images in the coronal plane, which is anatomic position and the
What type of procedure is best? Where to you want to place your same position that your patient is in when they are having surgery.
incision? Will your patient fail conservative therapy and ultimately Therefore, measurements that you make on your ABUS study can
require a mastectomy due to positive margins? How do you treat be directly translated into your surgical planning.
the cancer while getting the best cosmetic outcome possible? Does
The first step is to determine the location of your patient’s tumor. In
your patient need neoadjuvant chemotherapy? Answering these
doing this, you must be aware of parallax shift. Parallax shift occurs
questions is treatment planning.
INTRODUCTION
30
because the scan head can push your patient’s lesion out of its true usually establish tumor location using target ultrasound. The relative
position. This is a problem in all but the AP volume. distances seen between different foci usually hold up in this
circumstance. You can also measure from the humoral head if you
In the MED volume, your target will shift laterally. In the UOQ and
are doing an axillary view. Remember, when in doubt, it never hurts
LAT volumes, your target will shift medially. If the lesion is close to
to just wire localize it.
the nipple, the amount of shift will be minimal. Parallax shift is worse
if your patient has a large breast or if the target is far from the nipple.
The best way to avoid parallax shift is to work from the AP volume
when you are doing your planning. Positions here are the closest to
the true position of your target.
If your target is not seen on AP, for example, it is in the far UOQ,
then using this technique is more problematic. In these cases, I
An example of parallax shift. The same mass seen in the MED and UOQ volumes appears to be in different quadrants. The AP volume
reflects the true position of the mass and should be used, whenever possible for treatment planning.
INTRODUCTION
31
EXTENT OF DISEASE
The next step is determining the extent of disease. The use of If you find an additional focus of disease on a staging work-up that
imaging to determine the extent of disease, sometimes called a would change your surgical plan, particularly if you are thinking of
staging work-up, is controversial. There are authorities, particularly doing a mastectomy, I strongly recommend that you biopsy it prior
within the surgical community, who feel that this type of work-up to surgery.
leads to unnecessary mastectomies.
MRI has been the traditional way of performing a staging work-up,
Personally, I believe that a knowledge of the extent of disease but it has some disadvantages. The primary disadvantage is that
ultimately leads to better outcomes, including less risk of positive MRI is notorious for false positives. This, more than anything
margins and the preoperative identification of individuals who are else, has created the impression that staging work-ups lead to
going to fail conservative therapy. However, you must be careful unnecessary mastectomies. MRI is also not done in anatomic
when you do this. position, making the interpretation of the results challenging.
And remember, women just don’t like MRI.
INTRODUCTION
32
ABUS turns out to be a great tool for determining the extent of

disease. There are still false positive results that can occur, but less
than occur with MRI. ABUS studies are also done in anatomic
position, meaning that your results will be directly applicable to
your patient at surgery.
One thing to keep in mind is that you can’t see calcifications well on
ABUS studies. So, don’t forget to review your patient’s mammogram
as part of your work-up. Any findings here that would change your
plan should be biopsied under stereotactic guidance.
The key here is to identify findings that would change your treatment
plan. If you have a small focus within a centimeter of the main tumor,
no need to worry, you’ll get it when you do the lumpectomy. It
doesn’t change your plan.
A separate focus 8 cm away is a different story. In this case you

might need to do a second incision or possibly a mastectomy. This
is the type of finding that you are looking for.
There are four types of findings that can change your treatment
plan. These are extension, multifocal disease, lymphadenopathy,
and contralateral disease.
Extension is the finding of an area of tumor branching where the Using the coronal view to plan a conservative resection of a
tumor extends beyond the area that you would remove with a multifocal low-risk luminal carcinoma. A 3 cm diameter lumpectomy,
normal lumpectomy. An example of this would be a distended duct as sketched out above, recovered both lesions with clear margins.
with tumor heading toward the nipple. A finding of extension can
usually be treated by tailoring your lumpectomy to obtain extra How you deal with this, of course, depends on the details. In some
tissue in the direction of tum or extension. cases you can plan a conservative resection that will encompass all
the foci. In other cases, your patient will need a mastectomy.
Multifocal disease is the most common finding you will see. Here
there are areas of tumor separate from the primary, or index, lesion. Malignant lymphadenopathy is the most difficult finding to diagnose.
Most positive lymph nodes look perfectly normal on ultrasound. The
INTRODUCTION
33
lymph nodes you will see are the ones that are grossly abnormal. Contralateral disease is less common, but certainly does happen.
As a result, you cannot use ABUS staging to avoid a sentinel node Treatment here, of course, depends on the extent of the contralateral
biopsy or whatever axillary staging you would do if you didn’t have disease. You can do bilateral conservative treatment, if the patient is
the ABUS results. Note that the new Invenia 2 scanner is a candidate for this. One thing to consider is multigene sequencing
significantly better at picking up abnormal lymph nodes than either in these women. a surprising number will have a pathogenic
the Invenia or Somo-V scanners susceptibility mutation and this will also influence your treatment plan.
Vessels Fascia
Pec Minor
Treatment planning on the coronal view to localize a malignant Further localization on the transverse view. The lesion is immediately
axillary node. The finding is 33 mm below the humoral head. posterior to the thoracodorsal vessels and the clavipectoral fascia.
INTRODUCTION
34
Treatment planning in a young woman

with a palpable mass and an A/B cup
size. Biopsy revealed papillomatosis
with DCIS. Since the affected area
exceeded 5 cm, a nipple-sparing
mastectomy was performed with
excellent cosmetic results. Without a
knowledge of the extent of disease,
this woman would have failed
conservative treatment and would
have had a very poor cosmetic result.
INTRODUCTION
35
All told, you will find additional disease that influences your
treatment plan in about 25% of your cancer cases. Unappreciated
additional disease will result in additional surgeries for positive
margins, early recurrences, and failed conservative treatment.
Failed conservative treatment happens when you intend to do a
lumpectomy, but end up doing a mastectomy, because you can’t
get clear margins.
You can improve the quality of your outcomes with staging, but
again, you have to be careful in how you perform your work-up to
avoid unnecessary mastectomies.
INTRODUCTION
36
SURGICAL PLANNING
Once you have defined the location and extent of disease, you can on the coronal view of the AP volume of your study. You can then
proceed with developing a treatment plan. In most cases the first print this out on any standard printer and take it with you to the
therapy you pursue will be surgery. In any case, virtually everybody operating room. With your patient in position, you can transfer your
gets surgical treatment at some point. Planning your surgery will be measurements directly to the patient and draw your incisions. All you
an important part of the overall treatment plan. need is a ruler and a Sharpie.
Here you will decide about conservative versus radical surgical Unless my client requests a mastectomy, I plan a conservative
treatment. You will plan your incisions and plan how you want to resection first. I will only recommend a mastectomy if I cannot
stage the axilla. Your ABUS staging study will be invaluable here. develop a surgical plan that allows removal of the tumor with
adequate margins and an acceptable cosmetic outcome. Here
Because your ABUS study is done in anatomic position, you can
follows an example of conservative surgical planning:
measure out the location of resection and plan your incisions directly
INTRODUCTION
37
A 74 year old female presents with a mammographic finding. The patient is asymptomatic
A suspicious lesion is identified corresponding to the mammographic finding in the left

lower-outer quadrant. Biopsy demonstrates a high-grade invasive carcinoma. There is
no evidence of extension, multifocal disease, or contralateral disease.
INTRODUCTION
38
Treatment planning for a lumpectomy is

straightforward. A 2 cm lumpectomy
centered on the tumor results in clear
margins and a good cosmetic
outcome.
INTRODUCTION
39
Pectoralis Latissimus
A suspicious lymph node is identified in the LUOQ axillary volume.
INTRODUCTION
40
Vessels Fascia
Axillary surgical planning using the coronal and transverse views of the axillary volume.
First locate the humoral head (point 1). Then measure from the humeral head to the
lymph node (point 2). Then measure the distance from the lymph node to the
thoracodorsal vessels (point 3). Make a transverse incision 5 cm below the humoral
head. Divide the fascia and find the vessels. The target lymph node will be 2 cm lateral
to the vessels.
INTRODUCTION
41
Again, be careful when using this technique. I always have

intraoperative ultrasound capability available when I do this. If I
have difficulty finding something, I use ultrasound to point me in the
right direction. Also, ultrasound of the specimen is very useful to
ensure that you have your target and that you have a good margin.
If you don’t have intraoperative ultrasound capability, I would

recommend using the traditional technique of wire localization. You
can do this in your office prior to the procedure and wire both the
tumor and any lymph nodes that you want to sample.
Above all, remember that the node you see on ABUS may not be
the sentinel node. You should always perform whatever staging
technique that you would use if you didn’t have the ABUS study to
guide you. If you find that your target is the sentinel node, then
great. But, if not, you still have the sentinel node.
Warning – It is common for abnormal nodes in a cancer patient

to be benign. This can happen as a result of other disease, for
example rheumatoid arthritis or even benign reactive changes from
a recent biopsy. So never assume that the abnormal node you see
is the sentinel node.
INTRODUCTION
42
CHA P T E R 4
SURVEILLANCE
Follow-up imaging with ABUS
INTRODUCTION
43
BENIGN LESIONS
Sickles’ Law
Bilateral circumscribed lesions
There are many clinical applications where you will are benign in 98% of cases.
wish to follow a benign clinical finding. This will include
surveillance of complex cysts, fibroepithelial lesions,
and other BI-RADS 3 findings.
Surveillance is based on the principle of stability.

Things that are stable are less suspicious. Things that
are progressing, i.e. enlarging, changing in character,
etc. are more suspicious.
Like everything in medicine, you must be careful with how

you apply this. If you see something that looks even a little
suspicious, biopsy it, don’t follow it. Only follow things that
you are very sure are benign.
BENIGN LESIONS
There are many clinical applications where you will wish to follow a
benign clinical finding. This will include surveillance of complex
cysts, fibroepithelial lesions, and other BI-RADS 3 findings. Sickles’ Law
Surveillance is based on the principle of stability. Things that are Bilateral circumscribed lesions are
stable are less suspicious. Things that are progressing, i.e. benign in 98% of cases.
enlarging, changing in character, etc. are more suspicious.
Like everything in medicine, you must be careful with how you apply
this. If you see something that looks even a little suspicious, biopsy
it, don’t follow it. Only follow things that you are very sure are benign.
INTRODUCTION
44
Use of the T-C Comparison view to follow a BI-RADS 3 lesion. The increase in size between 2017 and 2018 led to a biopsy that showed the
finding to be a benign phyllodes tumor.
INTRODUCTION
45
Often the safest, most conservative course is to intervene. This, of You need to use your clinical judgment here, or at least some
course, is the prima lex of surgery. When there is doubt, there is no common sense. Before you start following a finding, make sure that
doubt. Act decisively. your clinical impression correlates with your interpretation of the
imaging.
On the other hand, bear in mind that not all benign findings may
require follow-up. Edward Sickles of the University of California, San If you see a finding that looks like a traumatic change, but there is
Francisco, is famous for, among other things, Sickle’s law. Sickle’s no history of trauma, don’t follow it, biopsy it. If you see a lesion that
law states that multiple, bilateral, circumscribed lesions, seen on looks like a fibroadenoma, but the patient gives you a history of rapid
mammogram, are benign in 98% of cases.23 growth, biopsy it... You get the idea.
Wendy Berg, in a recent analysis of the ACRIN 6666 data, found that Surveillance and follow-up is not an area where you can get away
Sickle’s law also held up for solid sonographic findings.24 with comparing annotated images from six months ago with your
current study. You really need to have your prior ABUS studies in
Like all laws in medicine, apply this with caution. Personally, I am
their entirety and access them every time you do a new study.
fairly comfortable with observing, and not immediately performing a
biopsy, for bilateral circumscribed solid findings, provided that none Most of the time you will be comparing today’s result with a known
of them look suspicious. I am not, however, comfortable with calling finding from last time. But you will also need previous studies to see
them BI-RADS 2 and simply returning the patient to screening. if something new that you appreciate today was there last time. If it is
there, why didn’t you appreciate it then? Is it more noticeable now?
So, what I do represents a sort of middle path. I don’t biopsy every
Has it progressed? Of course, if it wasn’t there last time, you know
solid finding, nor do I ignore bilateral solid findings. I follow them.
what to do. You can’t answer these questions without reviewing the
ABUS is the ideal tool for this. You can easily differentiate cystic from last study in its entirety.
solid masses and you can then compare studies with solid lesions
to prior studies to confirm stability.
Another common clinical presentation is the BI-RADS 3 finding.

Perhaps you have a single solid mass that appears benign, a post-
traumatic change, or a low-suspicion complex cyst.
You can follow this finding with serial ABUS studies until you are sure
that the lesion demonstrates long-term stability.
INTRODUCTION
46
CANCER SURVEILLANCE
Surveillance is an important part of breast cancer care. The idea lumpectomy cavities can be detected and second primaries,
behind surveillance is to detect recurrences early or follow a tumor’s remote from the site of the initial tumor can be spotted as well.
response to neoadjuvant chemotherapy. Regional lymph node recurrences can also be seen.
Small local recurrences can often be treated with fairly minimal In cases where mammographic surveillance is not possible, such as
therapy and no change in prognosis. Advanced recurrences can be after implant-based reconstruction, ABUS imaging can be used for
worse than the initial tumor and can kill. surveillance.
The idea then, is to detect local and regional recurrences as early As mentioned in the previous section, to do good cancer
as possible. Here ABUS can be a valuable tool. surveillance, you must have your prior studies available in their
entirety. Comparisons to annotated images is not adequate.
You can use ABUS imaging after both conservative and radical
surgery to assess for recurrence. Local recurrences near
INTRODUCTION
47
Stable post therapeutic changes on the left seen on the T-C Comparison view in a conservatively treated cancer patient.
INTRODUCTION
48
Axillary recurrence seen in a

patient initially treated with a
mastectomy.
INTRODUCTION
49
Neoadjuvant surveillance is used primarily to assess tumor response

to treatment. This is especially useful in the treatment of Basal-Like
tumors. Some Basal-Like tumors do not respond to standard AC-T
chemotherapy and may require a different regimen. The only way to
determine this is by measuring response of the primary tumor.
Similarly, ABUS imaging can be used to assess the response of

HER2 positive tumors. Neoadjuvant treatment can be used to
down-stage large tumors to the point where they can be treated
conservatively. ABUS imaging facilitates this by determining if
conservative treatment is possible, based on the remaining extent
of disease.
INTRODUCTION
50
A HER2 positive cancer seen on the left before and, on the right, six months after
initiation of anti-HER2 directed therapy. Note that the tumor has had almost a complete
clinical response, indicating good effect of the patient’s treatment.
INTRODUCTION
51
CHA P T E R 5
A N AT OMY
Normal anatomy, seen with ABUS
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52
BREAST ANATOMY
You already know your anatomy, but visualizing it in the

coronal view can be disorienting. That being said, a good
understanding of normal structures is needed before you
can appreciate pathologic findings.
You can divide coronal breast anatomy into zones, the skin
and nipple, the subcutaneous tissues, the breast parenchyma,
and the chest wall. I will cover these individually.
INTRODUCTION
53
The Skin – Coronal View

In the first 1-2 coronal slices, you will
see the epidermis, dermis, the nipple-
areolar complex and the nipple itself.
Some readers skip the skin and

nipple, but this is an error. Important
pathology such as cutaneous satellite
le-sions, inflammatory changes, and
edema can influence your assessment
as to cancer stage.
Dermatologic malignancies such

as melanomas and cutaneous
lymphomas can also be found.
Lesions within the nipple, a frequently

overlooked source of nipple discharge
can be seen. These lesions are very
difficult to appreciate on mammogram
and hand-held ultrasound.
Note the homogeneous appearance

of the dermis, areola, and nipple.
Pathologic findings cause an
interruption in this homogeneity.
INTRODUCTION
54
Transverse View
Note the uniformity of the dermis. The
thickness will vary from individual to
individual, but will be consistent
Dermis Areola throughout the breast. Changes in the
Nipple
thickness of the dermis are indicative
of pathology.
The dermis smoothly blends into

the areola. The skin of the areola is
normally thickened. This causes
shadowing.
The nipple itself is visualized as a

convex density that projects into the
breast parenchyma. The nipple is
normally homogeneous. Any visible
mass or dilated duct represents a
pathologic finding.
Ductal ectasia, dilation of ducts

posterior to the nipple is usually a
normal finding, particularly in young
women. Any asymmetry, intraluminal
masses, or shadowing relating to
these ducts can represent a
pathologic process.
INTRODUCTION
55
Subcutaneous Tissue – Coronal view

Just posterior to the skin is the
subcutaneous tissue. Normally mid-
level grey and homogenous, the
subcutaneous fat is interrupted by
Cooper’s ligaments.
Anything that interrupts the

homogeneous grey density of the fat
is pathologic. This can include
hyperechoic lesions such as lipomas,
as well as hypoechoic lesions, such as
cancers.
Cooper’s ligaments are white and

linear, but they may be accompanied
by shadows, causing a parallel white
and dark linear density.
Prominent Cooper’s ligament shadows

are a frequently occurring artifact that
can make cancers more difficult to find.
INTRODUCTION
56
Transverse View
In the transverse view, fat shows up as
a mid-level grey density with a ground-
glass appearance. This varies from
Cooper’s Ligament individual to individual.
The pattern of the subcutaneous fat is

useful in identifying fat islands. Fat
islands can look very similar to
hypoechoic tumors. If the suspected
tumor shows a ground-glass pattern
similar to the subcutaneous fat, it is a
fat island.
Cooper’s ligaments show up as gently

arching white lines between the
dermis and the breast parenchyma.
Areas where Cooper’s ligaments
intersect is a frequent source of
shadowing.
Comparing the pattern of Cooper’s

ligaments between different volumes of
the same area of the breast is helpful in
localizing breast lesions, particularly
in areas far from the nipple where
parallax shifts can make lesions hard
to pin down.
INTRODUCTION
57
Breast Parenchyma – Coronal View

The breast parenchyma shows up as
mixed hyper/hypoechoic zone just
deep to the subcutaneous tissue.
The hypoechoic areas represent

ductal and lobular structures, such
as TDLUs. The pattern varies from
individual to individual, but is usually
consistent throughout the breast.
This is where most cancers arise.

Generally, any hypoechoic or mixed
echogenicity structure within the
parenchyma is suspicious.
INTRODUCTION
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Transverse View
The breast parenchyma extends
from the subcutaneous tissue to the Retromammary Space
retromammary space.
The retromammary space is an

avascular plane just anterior to the
muscle consisting of loose areolar
tissue and fat
Ductal structures and TDLUs can be

seen within the parenchyma.
INTRODUCTION
59
The Chest Wall – Coronal View

Pectoralis Retromammary Space Parenchyma The structures of the chest wall are
visible in most women.
Rib Pathologic changes that can be

appreciated in the chest wall include
level 3 lymph nodes, rib metastases,
rib fractures, and in very thin women,
intrathoracic pathology.
Intercostal Muscles
Sternum
INTRODUCTION
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Transverse View
Retromammary Space Pectoralis Major Pectoralis Minor
Rib Pleura
INTRODUCTION
61
AXILLARY ANATOMY
Axillary anatomy can be a little tricky when visualized

by ABUS imaging. The patient is imaged in the decubitus
position with her arm extended straight up. So, what looks
anterior on ABUS is actually lateral. Similarly, anything that
looks posterior is actually medial.
Once you get used to the orientation, however, everything

will seem straightforward. The key to the axilla is the
ability to identify two landmarks, the humeral head and
the thoracodorsal vessels. Once you have these two
structures you can locate any axillary finding.
INTRODUCTION
62
The axilla is bounded by the pectoralis

minor muscle on the anterior side
and the latissimus dorsai muscle
Humeral Head
posteriorly. Laterally the clavipectoral
fascia divides the axillary fat from the
subcutaneous fat.
Free Border Free Border

The superior extent is defined by the
of Pec of Lat
axillary vein and just above that is the
humeral head, which is palpable.
These fat structures have a different

consistency from each other that can
be easily seen at surgery or on a CT
scan. Most of the lymph nodes, but not
all, are deep to the clavipectoral Thoracodorsal 
fascia. Vessels
Running deep to the fascia and close

to the center of the axilla are the thora-
codorsal vessels. These branch from
the axillary vessels, traverse the axilla
and then course into the breast paren-
chyma in the upper-outer quadrant.
INTRODUCTION
63
The Humeral Head – Coronal View

The humeral head is found at the
Humeral Head superior boundary of the axilla. The
humerus is palpable, when your
client’s arm is extended and,
accordingly, makes a very
reproducible landmark.
Often, the nipple is not visible on the

axillary view, so the humeral head is
used as the 0 point for measuring out
where abnormal lymph nodes are
located.
The humeral head is a fairly frequent

focus of metastatic disease to bone
and occasionally you can see a lytic
lesion within the bone.
INTRODUCTION
64
Transverse View
Humeral Head
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65
The Axillary Vein – Coronal View

The axillary vein emerges from behind
Axillary Vein
the pectoralis muscle on the medial
side of the axilla, just inferior to the
humeral head.
Remember that your patient is on her

side with her arm extended when the
axillary view is obtained.
Accordingly, the axillary vein courses

around the lateral side of the humeral
head before entering the medial arm.
The axillary vein represents the most

superior extent of the surgical axilla.
Level I/II axillary dissections stop at the
axillary vein.
INTRODUCTION
66
Transverse View
Thoracodorsal Vein Axillary Vein Here you can see the takeoff of the
thoracodorsal vein from the axillary
vein, just lateral and inferior to the
humeral head.
Humeral Head
INTRODUCTION
67
Mid-Axillary Structures - Coronal View

Here you can see the anatomic
structures that comprise the mid-
axilla.
These include the thoracodorsal

Pectoralis Latissimus
vessels, the clavipoectoral fascia, the
latissimus dorsai muscle, and the
pectoralis major and minor muscles.
These landmarks define the extent of

the axillary dissection and, therefore,
are well known by surgeons.
They can be readily seen on ABUS

imaging and used to define the
Thoracodorsal  location of abnormal lymph nodes in
Vessels the axilla.
INTRODUCTION
68
Transverse View
Notice the clavipectoral fascia. The
fascia forms a bridge connecting the Pec Major Pec Minor Clavipectoral Fascia Latissimus
pectoral muscle to the latissimus
dorsai muscle.
The fascia separates the axillary from

the subcutaneous fat. The fascia is
easily appreciated at surgery. The
thorascodorsal vessels are below the
fascia, as are most lymph nodes.
Thoracodorsal Vessels
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69
CHA P T E R 6
A RT I FAC T S
Artifacts that interfere with interpretation
INTRODUCTION
70
CONTACT SHADOWS
Contact Shadows
• Linear or circular
Contact shadows result from poor contact between the • Start at the epidermis
ultrasound probe and the patient. This happens with
• Extend into the parenchyma
hand-held ultrasound also, but the shadowing artifacts
seen in the coronal view can be confusing.
Contact shadows can be confused with skin lesions

and superficial hypoechoic breast masses.
INTRODUCTION
71
A linear contact shadow resulting from inadequate gel application. The shadow starts at the epidemis and continues deep into the breast
INTRODUCTION
72
Contact Shadow vs. Skin Lesion

Telling the difference on coronal view
Contact Shadow Skin Lesion between a contact shadow and a skin
lesion can be challenging. Generally,
there is skin thickening with skin
lesions that show up on ABUS scans.
Shadowing is variable.
By scrolling toward the chest wall in

the coronal view, you can assure
yourself that the finding is a skin
lesion if there is skin thickening.
The difference is easy to see on the

transverse view.
Of course, if there is doubt, you can

always go look at the patient.
INTRODUCTION
73
A skin Lesion demonstrating skin thickening A contact shadow
INTRODUCTION
74
COOPER ’S LIGAMENTS
Cooper’s Ligaments
• Lenticular shape
Cooper’s ligaments will be the most common artifact that • Start at the dermis
you will encounter in reading your ABUS studies. Cooper’s
• Extend into the parenchyma
ligaments generally form areas of shadowing that are
lenticular, or lens shaped.
Cooper’s ligaments, or more specifically, the shadowing

that they cause, are easily mistaken for solid masses,
especially in the coronal view.
CAD image processing has been a huge step forward in

eliminating Cooper’s ligament shadows. Eliminating these
shadows decreases reading time, by allowing the reader
to focus on genuine hypoechoic lesions.
INTRODUCTION
75
Cooper’s Ligament Shadows

Note the lens shaped hypoechoic
Cooper’s Ligament Shadow lesions seen in the left lower-outer
quadrant. In the coronal view, these
are easily mistaken as hypoechoic
solid masses.
On transverse view, these findings

are shown to be shadowing related to
Cooper’s ligaments.
In patients with a large number

of Cooper’s ligament shadows,
evaluating them all in the transverse
view can significantly increase
reading time.
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76
Transverse View
Here the shadow can easily be
identified as related to a Cooper’s
Ligament.
INTRODUCTION
77
CAD View
On CAD, the Cooper’s ligaments are
eliminated. At a glance, the LAP volume
can be seen as normal. This greatly
reduces reading time and improves your
confidence in the results.
INTRODUCTION
78
FAT ISLANDS
Fat Islands
• Circumscribed
Fat islands are something unique to ABUS imaging. They • No posterior shadowing
are circumscribed lesions that appear to be either faintly
• Identical to subcutaneous fat
hypoechoic or isoechoic.
• Bridges to subcutaneous fat
It is unusual to mistake them for a cancer, but they can
often be mistaken for fibroepithelial lesions. Fat islands
are essentially an optical illusion formed by the projection
of subcutaneous fat into breast parenchyma.
Suspected fat islands are best evaluated on the transverse

view, where they are found to be identical in appearance
to the surrounding subcutaneous fat.
INTRODUCTION
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Fat Islands – Coronal View

Fat islands are often seen in women
with very dense breast tissue, as in
this case. They can be multiple.
Usually carefully scrolling back and

forth in the coronal view will reveal a
bridge between the island and the
subcutaneous fat, as is seen in this
case (arrow).
INTRODUCTION
80
Transverse View
Here multiple islands are seen, but

the pattern of echoes within the
islands is the same as is seen in the
subcutaneous fat, allowing them to be
identified definitively as islands.
CAD images also tend to filter out fat

islands.
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SKIP LESIONS
Skip Lesions
• Truncated hypoechoic lesion
Skip lesions are caused by palpable masses that interfere • Transverse line
with the passage of the ultrasound probe. When the probe
• Not easily seen on CAD
encounters a palpable mass it tends to snowplow, or push
the mass forward. After a while tension on the mass causes
it to snap back. This is imaged as a truncated finding with
an associated transverse line. The line is the clue that you
have a skip lesion.
Cysts can cause skip lesions, but palpable cancers can as

well. Careful attention to the transverse view is needed to
rule out malignancy.
Warning – Skip lesions are not easily seen on CAD.
INTRODUCTION
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Skip Lesion – Coronal View

Skip lesions are easy to underestimate
on the coronal view. Often the
transverse line that accompanies
them is the only indication of a finding.
The finding is usually easy to see in

the transverse view.
It is imperative that you evaluate every

transverse line on the transverse view
to rule out a suspicious finding.
Here you see a 2 cm (!) high-grade

basal-like tumor (arrow).
INTRODUCTION
83
Transverse View
Here is the same lesion seen on the
coronal view. It is amazing that it
appeared so benign on the
coronal view.
INTRODUCTION
84
CHA P T E R 7
F I B R O C YS T I C
CHANGE
Common, benign, and easily
seen with ABUS
INTRODUCTION
85
PROMINENT
Fibrocystic Lobe
FIBROCYSTIC LOBES
• Isolated parenchymal island
• Dense tissue
You are going to see more fibrocystic changes than • No hypoechoic lesions
anything else. Fibrocystic changes can cause lumps,
increased density, asymmetric areas, focal pain,
and cyclic pain.
Fibrocystic changes increase tissue stiffness. Stiff lobes

of fibrocystic tissue can easily be perceived as a
palpable mass.
Palpable mass markers are very effective in proving that

a palpable mass is, in fact, a prominent fibrocystic lobe.
INTRODUCTION
86
Fibrocystic Lobe - Coronal View

This palpable mass is a prominent
fibrocystic lobe.
INTRODUCTION
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Transverse view
Here the fibrocystic lobe can be
seen projecting upward into the
subcutaneous tissues and under the
skin, where it can be felt as a mass.
Noite the lack of suspicious
hypoechoic lesions within the lobe.
INTRODUCTION
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SIMPLE CYSTS
Simple Cyst
• No internal echoes
Simple cysts are very common and, with practice, can • Smooth complete borders
spotted with ease from the coronal view.
• Posterior enhancement
Simple cysts have no internal echoes to suggest solid • Edge Ring

material within the cyst.
INTRODUCTION
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Simple Cyst – Transverse View

Here you can see a classic simple
cyst. There are no internal echoes Ring-Down
with smooth and complete borders.
There is edge shadowing, and
posterior enhancement.
This is exactly what you see on

hand-held ultrasound.
Ring-down is an artifact that occurs

as a result of ultrasound waves
reflecting back and forth between the
cyst walls. It can be seen on hand-
held ultra-sound, but is more easily Edge Shadows
seen on the transverse images of
ABUS studies.
Ring-down forms a cloudy grey

density at the tops of cysts or breast
implants. Note that ring-down follows
the contour of the cyst.
Posterior Enhancement
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Coronal View – Anterior Cyst

As you scroll through the cyst from
anterior to posterior, you see the same
findings in the coronal view as you
would on a hand-held ultrasound, only
in three dimensions.
Here you see the most anterior aspect

of the cyst. The grey density you see
within the cyst is the cyst’s ring-down
Ring-Down artifact.
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Coronal View – Posterior Cyst
This is a coronal section through the

posterior aspect of the cyst. The dark
cyst is seen in the center. Surrounding
this is a white ring. This is posterior
Edge Ring enhancement.
Surrounding the posterior

enhancement is a dark ring. This
is edge shadowing. In coronal
ultrasound, this is sometimes referred
to as an edge ring.
INTRODUCTION
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Coronal View – Posterior Artifacts

This coronal image is deeper, below
the level of the cyst. Here you can see
posterior enhancement projecting as a
light circle surrounded by an edge
ring.
On hand-held ultrasound, you are,

Edge Ring
in fact, seeing a two-dimensional
projection of the three dimensional
posterior enhancement and edge ring
that you see on the coronal view.
By scrolling through the finding from

anterior to posterior, you can see these
findings in sequence. This way you
can determine that your finding is a
simple cyst without ever having to
review it in the transverse view.
INTRODUCTION
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COMPLEX CYSTS
Benign Complex Cyst
• Smooth complete borders
Complex cysts are cysts with internal echoes. These • No posterior shadowing
include internal debris floating around the cyst or polypoid
• Internal debris only
excrescences that suggest a papilloma or an intracystic
• No polypoid excrescences
papillary carcinoma.
The rule-of-thumb for complex cysts is to biopsy them, using

a vacuum-assisted technique. In the case of internal debris,
observation as a BI-RADS 3 finding may be undertaken.
Observation should be performed with caution. I would

recommend a focus ultrasound to ensure that the debris are
freefloating prior to doing this. As always: When there is
doubt, there is no doubt, act decisively: biopsy the lesion.
INTRODUCTION
94
Internal Debris – Coronal View

Here you can see internal echos.
There is also a septation. Otherwise
the cyst has a smooth border.
Prior ultrasound examinations demon-

strated that this finding is unchanged,
making it less suspicious.
INTRODUCTION
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Transverse View
Here again, you can see internal
echoes. Note that there is no
posterior shadowing and borders
are smooth.
Warning – There are cancers with

internal calcifications that can look
very similar to a complex cyst.
Exercise great caution in following
these findings.
At a minimum, perform a focus

ultrasound with color Doppler flow
imaging. A lack or color flow within
the lesion and active streaming of the
debris with pressure suggests
benignity.
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Polypoid Excrescence – Coronal View

Here you can clearly see a cystic
structure, but within the cyst is a large
intracystic hypoechoic mass.
These types of findings are fairly rare.

I do somewhere between 12 and 20
ABUS studies a day and see one of
these maybe every two years or so.
All complex cysts with an intracystic

mass are at least BI-RADS 4 findings
and should undergo biopsy on sight,
with either a vacuum-assisted
instrument, for large lesions or surgical
excision if you have a small polyp in a
large cyst.
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Transverse View
Just in case there was any doubt, here
is the transverse view. This turned
out to be a 3 cm intracystic papillary
carcinoma.
Contrary to popular belief, the majority

of intracystic papillary carcinomas are
invasive, as this one was.
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DUC TAL EC TASIA

Benign Ductal Ectasia
• Centrally located
Ductal ectasia is, in most cases, a fibrocystic finding, • Low density
but can also occur as a result of a pathologic process.
• No shadowing
Maintain a high index of suspicion when evaluating your
• No intraluminal masses
clients with ectasia. Papillomas, papillomatosis, obstructing
ductal lesions, intracystic papillary carcinomas, and ductal
carcinoma-in-situ can all present with ectasia.
Ectasia in women who are young, pregnant, or lactating

is not suspicious. Ectasia in anyone else should be
considered at least a BI-RADS 3 finding. Any suspicious
features associated with ectasia, such as shadowing
or intraluminal masses mandates biopsy.
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Benign Ductal Ectasia – Coronal View

Here you can see centrally located
ductal ectasia.
The ducts are enlarged, but are low

density. There is no peripheral ectasia,
shadowing, or intraluminal debris or
masses.
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Transverse View
In young women, pregnant, or
lactating women, ductal ectasia is
a normal fibrocystic finding.
Ductal ectasia, without suspicious

features, should be considered a
BI-RADS 3 finding and followed in
everybody else.
Suspicious features include

intraluminal masses, shadowing, and
ectasia that occurs distant from the
nipple.
This patient has demonstrated stable

ectasia over a 2-year period and is
now followed in routine surveillance.
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Peripheral Ectasia – Coronal View

Here you see a few dilated ducts
located far from the nipple.
This finding looks like a cluster of

cysts but, in fact, is an area of
ductal ectasia.
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Transverse View
On the transverse view, you can see
that this structure is actually a coiled
duct with two intraluminal masses.
For this reason, you must be careful in

the interpretation of these findings.
Clusters of cysts can be deceptive.
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Intraluminal Masses – Coronal View

Intraluminal masses are a highly
suspicious finding.
Here you can see small intraluminal

masses on the coronal view.
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Transverse View
Intraluminal masses are usually best
seen in the transverse view. Here you
can see several in a patient with a
spontaneous and sanguineous nipple
discharge.
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Shadowing – Coronal View Warning – This is why you should compare bilateral films side-by-
Shadowing is a very suspicious finding. Shadowing implies high side when you read. If you read these volumes individually, you will
density fluid within the ducts. This is commonly seen with ductal miss this finding.
carcinoma-in-situ and with Paget’s disease.
Right
Right Left
Left
There is bilateral ductal ectasia, but notice the darker periareolar density on the left. This
is indicative of ductal shadowing, a very suspicious finding.
INTRODUCTION
106
Transverse View
Here you can see the finding on the left
in the transverse view. Note the dilated
ducts casting a dense shadow. Also
note multiple small intraluminal masses
within the ducts.
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107
PSEUDOANGIOMATOUS
PASH
STROMAL HYPERPLASIA
• Smooth echogenic borders
• Dense shadowing
Pseudoangiomatous stromal hyperplasia (PASH) was • Can be palpable
considered a subtype of angiosarcoma until 1986. PASH • Isolated or extensive
results in densely shadowing hypoechoic mass lesions with
associated palpable findings.
PASH is very difficult to evaluate on ultrasound. An isolated

finding that suggests PASH is best evaluated by biopsy.
Often PASH is extensive and, in this case, I will obtain
an MRI. PASH generally will not enhance.
After a benign MRI, PASH can be followed with serial

ABUS studies.
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Focal PASH – Coronal View

This is a focal area of PASH in a
55-year-old client imaged for
increased density and a palpable
mass corre-sponding to this
finding.
Note the dense shadowing

associated with the finding.
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Sagittal View
Here you can see why this finding
presented as a discrete mass. Inferior
to the palpable finding (to the right of
the arrow) is a more diffuse area of
PASH.
Note the prominent echogenic

anterior border (arrow). This finding is
characteristic of PASH, but may also
be seen in high-grade cancers.
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Extensive PASH – Coronal View

Here you can see a more extensive
area of PASH, encompassing almost
the entire lateral breast. The dense
shadowing is characteristic.
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Transverse View
Here is the same extensive area of
PASH in the transverse view. Note,
again, the anterior echogenicity and
dense shadowing.
The dense shadowing makes a

meaningful evaluation for cancer very
difficult. Here is an area where an MRI
can be very useful.
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112
2018 2017
The stability of this focal area of PASH can easily be seen by comparing coronal views of the AP volumes over the last year
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CHA P T E R 8
L AC TAT I O N A L
CHANGES
The changes of pregnancy and
lactation as seen on ABUS
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INCREASED VASCULARIT Y
Greatly increased vascularity is characteristic of pregnancy

and lactation. These changes are best seen in the dermis
and subcutaneous tissues, but extend throughout the
breast parenchyma.
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Skin – Coronal View

Note increased vascularity in the
dermis and subcutaneous tissues.
This can be problematic when
performing a biopsy.
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Deeper blood vessel – Coronal View

Here is a large blood vessel just
anterior to the parenchyma.
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DUC TAL EC TASIA
In pregnancy and lactation, ductal ectasia is a normal

finding. Ectatic changes are often profound and can
extend several centimeters from the nipple.
Prior to performing a study in a lactating female, having

them breastfeed or pump is useful in minimizing their
ductal ectasia.
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Ductal Ectasia – Coronal View

Here you can see significant ductal
ectasia, particularly medial to the
nipple on the left.
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Transverse View
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PARENCHYMAL CHANGES
Needless to say, the breast parenchyma undergoes changes

with pregnancy and lactation. The breast tissue hypertrophies,
replacing a significant fraction of the subcutaneous tissue.
The density of breast parenchyma also increases, causing

signal attenuation and making hypoechoic lesions more
difficult to spot.
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Breast Parenchyma – Coronal View

In pregnancy and lactation, the breast
parenchyma shows a homogeneous
gray consistency.
This results in signal attenuation

that can make hypoechoic lesions,
particularly cancers and lactating
adenomas, hard to spot.
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Transverse View
Here you can see the homogeneous
gray appearance of the parenchyma.
The interspersed small hypoechoic

lesions are areas of ductal ectasia.
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GALAC TOCELES
Galactoceles are the cysts of pregnancy and lactation. They

are essentially a normal variant. You will find at least one
galactocele in almost every lactating female that you study.
Galactoceles are high-density findings. They often contain

debris and can have irregular margins. They do not cause
posterior shadowing.
Hand-held ultrasound is very useful in evaluating suspected

galactoceles, since they never have increased Doppler flow.
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Galactocele – Coronal View

Here is a medium sized galactocele.
Most galactoceles are less than 2 cm
in diameter. Note the irregular borders
and high density fluid. This is typical.
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Transverse View
Again, note the irregular borders.

This is not a suspicious finding
during,lactation.
Posterior shadowing, however, is a

suspicious finding and should prompt
biopsy.
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ACCESSORY
BREAST TISSUE
Accessory breast tissue can be found in women of all ages,

but it usually does not become symptomatic until pregnancy.
During lactation, accessory breast tissue can form a large
ad painful mass.
Accessory breast tissue can be associated with an accessory

nipple, but usually is not. Breast cancers are a fairly
common finding within accessory tissue, so careful
evaluation is required.
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Accessory Breast Tissue –

Coronal View
Accessory breast tissue can be
dramatic in women who are lactating,
as in this case. Note that the finding
is sharply demarcated from the
surround-ing breast tissue.
Within the lesion is normal breast

parenchyma. Any hypoechoic findings
are suspicious for cancer.
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Accessory Breast Tissue – Transverse

Here again, the lesion is sharply
demarcated. Note that this finding is
above the clavipectoral fascia (arrow),
typical for accessory breast tissue.
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CHA P T E R 9
BENIGN
INFLAMMATORY
CHANGES
The changes seen with benign
inflammation
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MASTITIS
Mastitis
• Subcutaneous echogenicity
Mastitis is fairly common, especially in young women. • Duct effacement
Clinical presentations vary, but range from asymptomatic
• Skin thickening
erythema to profound redness and pain.
• Peau d’orange
ABUS is useful in the diagnostic evaluation of suspected
mastitis by helping rule out inflammatory cancers as well
as abscesses, which require special management.
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Mastitis – Coronal View

The predominant finding on ABUS of
mastitis is increased subcutaneous
echogenicity, seen here in the left
lower-outer quadrant of the periareolar
area.
Notice also the effacement of ductal

structures, which are difficult to see
in the affected area compared to the
normal ductal structures in the left
upper-inner periareolar quadrant.
Warning – Inflammatory breast cancer

can be mistaken for mastitis fairly
easily. Inflammatory cancers are often
painless, but not always.
Exercise caution in the management

of mastitis. If treating with antibiotic
therapy, be sure to follow-up to ensure
that the clinical and radiologic findings
resolve. If follow-up is problematic,
perform a biopsy.
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Transverse View
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ABSCESS
Abscess
• Complex cystic fluid
Abscesses are a frequent complication of mastitis. They can • Surrounding inflammation
be challenging to diagnose, especially in lactating females.
• Variable skin changes
Clinical correlation and a focal ultrasound can very helpful
• Focal pain
in diagnosing a breast abscess.
• No shadowing
Generally, abscesses will present with pain. Skin changes are
variable, depending on how close the abscess is to the skin.
The most useful clinical sign is seen on focus ultrasound.
Compression of the suspected abscess with a focus

ultrasound probe will reproduce the patient’s pain. This
finding, together with inflammatory changes are sufficient
to make the diagnosis.
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Coronal View - Abscess On the right, deep to the inflammatory changes is the abscess
Here you can see two coronal images of an abscess. On the left, itself. The irregular borders and internal echoes are characteristic.
you can see inflammatory changes anterior to the abscess in the Sonographic pressure reproduced this patient’s pain.
subcutaneous fat.
Superficial Deep
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Transverse View
In the transverse view, note the inflam-
matory changes anterior to the lesion.
Also, there is no posterior shadowing.
Warning – Posterior shadowing raises

suspicion of a cancer. If shadowing is
present, a biopsy is required.
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FISTULA
Abscess
• A plausible history
Fistulas are communications from the skin to a retroareolarduct. • A sinus opening on the skin
Typically, fistulas present as a chronically or intermittently
• A tract from skin to nipple
draining sinus on the skin. They are easily mistaken for
• Inflammatory changes
recurrent abscesses.
• No posterior shadowing
Although a fistula can occur spontaneously, this presentation
is fairly rare. Fistulas are usually a complication of surgical
incision and drainage using a circumareolar incision.
Note that fistulas and also abscesses, for that matter, are
much more common in smokers.
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Fistula – Coronal View

This is a good example of a fistula.
Notice the fluid collection tacking
toward the nipple.
Warning – A fistula can be very

similar in appearance to a dilated duct
occurring as a result of ductal
carcinoma-in-situ. Generally fistulas
will exhibit inflammatory changes in
the surrounding tis-sue and will not
cast a shadow.
The best clue will be your client’s

history. A previous abscess or a history
of intermittent purulent drainage will
give you the diagnosis.
As always, if there is doubt, there is no

doubt. Biopsy the finding.
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Fistula - Transverse View

The transverse view is very helpful in
evaluating a suspected fistula. Note the
tracking of the fluid collection up to
Nipple
both the skin and the nipple. Also note
Skin Sinus
the surrounding inflammatory changes.
Warning – Fistulas are a complication

of circumareolar incision and drainage
procedures.
When you perform an I&D, orient your

incision radially (toward the nipple).
This decreases the incidence of fistula
formation. If a fistula does occur after a
radial incision, the tract is shorter and
easier to manage.
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TRAUMA
Abscess
• Subcutaneous echogenicity
Traumatic changes are highly variable, both in quality and • Cyst formation
distribution. These changes can be confused with the changes
• Large calcifications
seen in high-grade cancers. A history of a plausible injury
• Space occupying lesions
that accounts for the radiologic findings is necessary to
make the diagnosis. As always, when there is doubt, there • A plausible history
is no doubt – biopsy.
Shortly after injury you will see hyperechoic changes,

including mass lesions. Later, small cysts, called cystic voids,
form. These are typically less than 1 cm in diameter. Later
still, you will see the changes of fat necrosis, hypoechoic
shadowing lesions with large calcifications.
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Early Changes – Coronal View

Early after a traumatic event you see
primarily hyperechoic changes in the
breast tissue and subcutaneous fat.
These changes occur because

extravasated blood in the breast or
subcutaneous tissues is echogenic.
In this client, we see a hematoma. This

image was taken three days after our
client was in a high-velocity motor
vehicle deceleration accident. There
was a palpable mass and a visible
ecchymosis associated with this
finding.
Warning – The echogenic changes

seen after trauma are almost always
associated with a visible ecchymosis.
If you don’t see an ecchymosis, then

the echogenic changes are probably
not related to trauma.
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Transverse View
Here is a transverse view of the
hematoma.
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Midterm Changes – Coronal View

Here you can see traumatic changes
two weeks after a high-velocity
deceleration injury. The patient had
a palpable mass and a fading
ecchymosis.
There are residual echogenic

changes and multiple cystic voids.
Note the linear pattern of the changes,

following the path of the client’s
driver’s side shoulder belt.
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Midterm Changes – Transverse

Note the residual hematoma and the
beginning of cystic changes. The
hematoma correlated with this client’s
palpable mass.
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Late Changes – Coronal View

This image is obtained two years after
a traumatic injury on the left. Note the
hypoechoic lesion with a large central
calcification. This is consistent with fat
necrosis, a late traumatic change that
can take years to develop.
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Late Changes – Transverse View

This is the area of fat necrosis in the
transverse view. The central, anterior
calcification with posterior shadowing
is characteristic. Not that fat necrosis
is more easily diagnosed on
mammogram.
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Late Changes – Comparison

Note the stability of these changes over time
2017 2018
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CHA P T E R 10
E VA LU AT I N G
SOLID MASSES
The ABUS findings associated with
benign and malignant solid masses
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LIPOMAS
A probably benign solid mass: All
of of the following:
In 1995, Dr. Thomas Stavros, et. al. described a set • Pure hyperechogenicity
of sonographic signs that could be used to distinguish • 2-3 gentle lobulations
benign from malignant solid masses with a high degree • Ellipsoid shape
of accuracy. • Thin, echogenic capsule
Now known as Stavros’ criteria, these signs are still

used today to avoid the unnecessary biopsy of benign
solid masses. Stavros’ criteria were described as handheld A suspicious solid mass:
ultrasound findings, but are easily adapted for interpretation Any of the following:
in the coronal view. • Spiculation
• Taller-than-wide
• Angular margins
• Posterior shadowing
• Branching
• Dense hypoechogenicity
• Internal (small) calcifications
• Duct extension
• Microlobulation
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Applying Stavros’ Criteria

The process that you go through when you are reading an ABUS I guarantee that if you read enough ABUS studies you will, sooner
study can be summarized as perception, interpretation, and action. or later, see a lesion that you are sure looks probably benign, but is
Stavros’ criteria are a guide to help you with interpretation. For solid actually malignant.
masses, interpretation is sometimes referred to as feature analysis.
Most of these lesions will be phyllodes tumors, but you will also see
You are looking for morphologic features that will classify the lesion
very benign looking adenocarcinomas.
as probably benign or suspicious.
Phyllodes tumors are notoriously difficult to spot on ultrasound. They
Like everything in medicine, Stavros’ criteria must be applied with
are also difficult for pathologists to spot on needle biopsy. The only
caution. Never assume that a lesion you see that meets Stavros’
reliable imaging sign of a phyllodes tumor is rapid growth. All the
Criteria for benignity is, in fact, benign. It is probably benign. In
more reason to follow these findings. Fortunately, truly malignant
other words, BI-RADS 3.
phyllodes tumors are relatively rare. I see 3-4 fibroepithelial lesions
A probably benign lesion has to have all probably benign features on ABUS every day, but I see a malignant phyllodes tumor once
and no suspicious features. Even one suspicious feature is sufficient every year or two.
to proceed to immediate biopsy.
High-grade cancers can look surprisingly benign on ultrasound.
BI-RADS 3 lesions must be followed over time to assure that they High grade tumors often do not display architectural distortion,
are, in fact, benign. Most authorities recommend imaging follow-up spiculation, or posterior shadowing. Careful attention to the capsule
every six months for two years prior to diagnosing a BI-RADS 3 of these lesions is the best way to appreciate their true nature.
lesion as benign or BI-RADS 2.
What you are looking for here is progression. Is the lesion enlarging?
Is it developing suspicious morphologic features? A truly benign
lesion will be stable under observation. Accordingly, you will sleep
better if you observe the following rules:
If there is any doubt as to the lesion’s morphology, biopsy it.

If your client may not follow-up, biopsy it.
If a lesion progresses under observation, biopsy it.
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Benign Findings
Pure Hyperechoic A pure hyperechoic lesion in a 69-year-old female with multiple lipomas.
Note the thin echogenic capsule and uniform texture. These are findings
characteristic of lipomas.
2-3 Gentle Lobulations 3 gentle lobulations seen on the coronal view in a 47-year-old female with a
palpable left UOQ mass. Note the internal septations, which positively
identify this finding as a fibroepithelial lesion
Ellipsoid Shape A palpable ellipsoid fibroepithelial lesion in a 40-year-old female. In the

coronal view, the major axis of the ellipse may be oriented in any direction,
but is usually transverse, as it is in this case.
Thin Echogenic Capsule A 40-year-old female demonstrating a fibroepithelial lesion with a thin
echogenic capsule. The capsule must be complete. Although usually
better seen in the transverse view, an echogenic capsule may also be
seen in the coronal view.
Click images to enlarge
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Suspicious Findings
Branching Branching refers to extension of the primary tumor across tissue planes.
This may be seen in either the coronal or transverse views. This finding is
suspicious for an invasive carcinoma.
Dense (Hypoechogenicity) Very dense hypoechoic findings are suspicious for invasive cancers,
typically low grade lesions. This finding is subjective and there are lots of
benign lesions that also display very dense hypoechoic findings.
Internal Calcifications Calcifications are subjective, of course. Small calcifications are a

(Small) suspicious findings, but large calcifications can indicate degenerating
fibroadenmomas or fat necrosis. When in doubt, biopsy.
Posterior Shadowing Posterior shadowing is often seen in low-grade cancers. Note that this
finding is often absent in high-grade cancers. Most benign solid masses
will exhibit posterior enhancement and edge shadowing.
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Suspicious Findings
Spiculation Often referred to as architectural distortion, spiculation is seen in a 7mm

screen detected cancer. This cancer was not seen on mammogram. It was
the prominent architectural distortion seen here in the coronal view that led
to the discovery of the tumor.
Taller-Than-Wide Sometimes referred to as antiparallel orientation, a taller-than-wide finding

implies invasion across fascial planes and is very suspicious. This is best
seen in the transverse view. Note also the very dense hypoechoic lesion
with posterior shadowing. Most low-grade cancers, such as this, display
more than one finding.
Angular Margins Angular margins are a very suspicious finding. Here they are seen in two
adjacent cancers in a 69-year-old female. these findings may be
appreciated in both the coronal and transverse views.
Duct Extension Duct extension is caused by tumor infiltrating along ductal structures.
Typically, this represents a non-invasive component, but is a common
cause of positive margins after lumpectomy. Careful attention to duct
extension during treatment planning results in decreased re-operations for
positive margins.
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Suspicious Findings
Microlobulation Microlobulation seen in a high-risk luminal carcinoma found in a 72-year-

old female. This findiong is best appreciated in the coronal view, but can
also be seen in the transverse view.
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THE BI-RADS LEXICON

BI-RADS Finding Categories
• Mass
The BI-RADS ultrasound lexicon was added to the overall • Asymmetry
BI-RADS specification beginning with the 4th edition, initially
• Architectural distortion
published in 2003. This was a result of a collaboration
• Calcifications
between the American College of Radiology and the Society
of Breast Imaging. The lexicon is a list of standardized • Associated Features
descriptive terms in-tended for use in report writing. • Special cases
Note that a large number of radiologists volunteered

countless hours of their free time to set up not only the
BI-RADS ultrasound lexicon, but the entire reporting
and data system.
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The system has saved countless lives by providing direction to An isoechoic finding, in my experience, can be benign or
referring providers as to what to do. The radiologists who and malignant. The finding is essentially indeterminate.
everyone who worked to develop BI-RADS deserve our appreciation
Clustered microcysts, especially if they occur in the periphery, are
and thanks.
frequently associated with DCIS.
The lexicon parallels Stavros’ Criterea, but includes additional
You get the idea. Working with ultrasound findings has given me a
findings. The lexicon was updated with the publication of the 5th
lot of sympathy for my radiology colleagues.
edition in 2013.26
Of course, you are responsible for doing the right thing, even if you
The prominent feature of the 5th edition is “harmonization,” the
don’t have complete information. So, don’t be shy about performing
use of common terms to describe common findings seen on
a biopsy.
mammography, ultrasound, and MRI. For example, the descriptive
terms for mass lesions are the same across all imaging modalities. The Prima Lex always applies. When there is doubt, there is no
This makes reporting and report interpretation much easier. doubt. Act decisively.
Use the same technique for feature analysis as you would with
Stavros’ Criteria. If a suspect lesion has benign features and no
suspicious features, it is BI-RADS 3. Follow it. If there are suspicious
features, then consider biopsy.
In doing this, a little more judgement comes into play. With Stavros’
criteria, pretty much any suspicious finding warrants a biopsy.
But with the BI-RADS lexicon, not all of the suspicious findings
necessarily require sampling. Conversely, there are benign
appearing findings that, under certain circumstances, warrant a
biopsy.
It is fairly common to see fibroadenomas with increased internal

vascularity. So if I find a circumscribed lesion that demonstrated
increased vascularity, but otherwise looks benign, I will sometimes
follow it. Especially if I see internal septations.
Increased tissue hardness is not always an indication for biopsy.

Cysts, for example, usually will display increased tissue modulus.
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Category Descriptor Value Category Descriptor Value

Mass Shape Oval Associated Features Architectural Distortion
Round Duct Changes
Irregular Skin Changes Skin Thickening
Margin Circumscribed Skin Retraction
Not Circumscribed Edema
Indistinct Vascularity Absent
Angular Internal
Microlobulated Vessels in Rim
Spiculated Elasticity Assessment Soft
Orientation Parallel Intermediate
Not Parallel Hard
Echo Pattern Anechoic
Hyperechoic
Isoechoic Special Cases Simple Cyst
Hypoechoic Clustered Microcyst
Heterogenious Complicated Cyst
Complex Mass in or on Skin
Posterior Features No Features Foreign Body/Implant
Enhancement Intramammary LN
Shadowing Axillary LN
Combined Vascular Abnormalities AVMs
Calcifications In mass Mondor’s Disease
Outside Mass Seroma
Intraductal Fat Necrosis
The BI-RADS 5th Edition Ultrasound Lexicon - Suspicious findings are noted in Red
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OTHER SIGNS
Other Signs
• Internal Septations
There are signs that indicate a solid mass is suspicious • Bilateral circumscribed lesions
that are not covered under Stavros’ Criteria. Some of these
• Skip lesions
findings are best seen in the coronal view. Some are not
• Anterior Echogenicity
visible on ABUS imaging, but can be seen on focus,
hand-held ultrasound. • Increased Doppler Flow
• Increased Tissue Modulus
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Suspicious
Benign Findings
Findings
Bilateral Circumscribed
Branching Multiple circumscribed
Branching refers to extension
lesionsofseen
the primary
on mammogram
tumor across
or ultrasound,
tissue planes.
when
Lesions This may are
bilateral, be seen
usually
in benign.
either the
This
coronal
is known
or transverse
as Sickle’sviews.
law. This finding is
suspicious for an invasive carcinoma.
Dense (Hypoechogenicity)
Internal Septations Internal
Very dense septations
hypoechoic
indicate
findings
a fibroepithelial
are suspicious
lesion.
for They
invasive
showcancers,
up very well
typically
on MRI, which
low grade
is howlesions.
radiologists
This finding
can call
is subjective
these lesions
andbenign
there are
on MRI,
lots of
benign
even if they
lesions
enhance.
that also
They
display
are best
veryseen
dense in hypoechoic
the coronal view
findings.
Internal Calcifications Click images to enlarge

(Small)
Posterior Shadowing Posterior shadowing is often seen in low-grade cancers. Note that this
finding is often absent in high-grade cancers. Most benign solid masses
wil exhibit posterior enhancement and edge shadowing.
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Suspicious Findings
Branching
Skip Lesions Skip lesionsrefers
Branching are anto artifact
extensionthatofoccurs
the primary
when tumor
the ABUS
across
probe
tissue
runs
planes.
into a
This may mass.
palpable be seen The in probe
either the
snowplows
coronal the
or transverse
lesion, which
views.
thenThis
snaps
finding
back.
is
suspicious
As a result the
for an
majority
invasive
of the
carcinoma.
lesion is not imaged, leading it to appear
more benign than it is. Any palpable lesion can cause a skip, but the
presence of a skip line should alert the reader.
Dense (Hypoechogenicity)
Anterior Echogenicity Anterior
Very dense
echogenicity
hypoechoic refers
findings
to a bright
are suspicious
or hyperechoic
for invasive
findingcancers,
anterior to
typically
the tumor.low
This
grade
is a highly
lesions.suspicious
This findingfinding
is subjective
and usually,
and as
there
in this
are case,
lots of
benign lesions
indicates a high-grade
that alsocancer.
displayThe
veryetiology
dense hypoechoic
of the findingfindings.
is increased
blood flow around the tumor.
Doppler Calcifications
Internal Flow Increased Doppler flow is not visualizable on ABUS imaging, but usually
(Small) can be obtained on focus ultrasound imaging. Increased Doppler flow is
associated with high-grade tumors, but can also be seen in benign
findings.
Tissue Modulus Posterior

Posterior Shadowing
Increased Tissue modulus
shadowing
refersisto
often
the stiffness
seen in low-grade
of the tissue
cancers.
imaged.Note
Thisthat
is an
this
finding isproperty
intrinsic often absent
of theintissue.
high-grade
Tissuecancers.
modulusMostimaging
benign
is only
solidavailable
masseson
wil exhibit
select focus
posterior
ultrasound
enhancement
systems. Elevated
and edge tissue
shadowing.
modulus is associated
primarily with low-grade tumors.
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CHA P T E R 11
BENIGN
SOLID MASSES
Diagnosing benign solid masses
with ABUS
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STAVROS ’ CRITERIA
A benign lipoma:
All of the following:
Lipomas are very common benign solid masses and, generally, • Pure hyperechogenicity
can be diagnosed from the coronal view. • Smooth borders
• No internal echoes
Occasionally, you will see large lipomas. These findings
• Thin, echogenic capsule
often have hypoechoic components, often areas of fat
necrosis. If present, these areas may require biopsy.
There is a malignant variety of lipoma, called a liposarcoma.

A suspicious lipomatous
As the name suggests, these lesions are soft tissue sarcomas
lesion: Any of the following:
of variable malignant potential. These tumors are rare,
• Mixed echogenicity
but also fairly easy to spot.
• Thick borders
• Invasion of surrounding structures
• Intramuscular location
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Benign Lipoma – Coronal View

Note the pale hyperechoic finding in
the left lower, inner quadrant. A pure,
smooth, circumscribed, hyperechoic
finding with a thin echogenic capsule
is a benign lipoma. No additional
additional views or imaging are
necessary to make this diagnosis.
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Benign Lipoma – Transverse View

In the transverse view the thin capsule
is easily seen.
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Suspicious Lipoma – Coronal View

Here is a large, palpable lipoma. This
finding is suspicious mainly due to a
hypoechoic finding within the lipoma.
Notice also that the lesion is
multilobulated.
On biopsy, the hypoechoic lesion

turned out to be an area of fat
necrosis, a common finding in large
lipomas. The surrounding lipomatous
tissue was benign as well.
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Suspicious Lipoma – Transverse View

Here is the same finding in the
transverse view. Note the
homogeneous, bland fat density with
subtle lobulations.
The area of fat necrosis can be seen

in the center of the image. Note also
compression of the underlying breast
parenchyma, without invasion.
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Suspected Sarcoma – Coronal View

This soft tissue mass within the axilla is
suspicious for a sarcoma. Note the
very thick capsule (short arrows) and
the way the lesion cannot be separated
from the latissimus dorsai muscle (long
arrow). This suggests invasion.
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Suspected Sarcoma – Transverse View

Again, the very thick capsule is seen,
particularly posteriorly. The capsule
cannot be separated from the medial
aspect of the latissimus muscle.
Warning – DO NOT attempt to perform

a needle biopsy on a suspected
sarcoma. Sarcomas are notorious for
seeding the needle biopsy tract,
resulting in early recurrences,
particularly if they are high grade.
Suspected sarcomas require surgical

resection with an appropriate margin.
Surgical referral, particularly to a center
experienced in the multi-speciality
treatment of sarcomas is indicated.
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FIBROEPITHELIAL LESIONS
Fibroepithelial Lesions
• 2-3 gentle lobulations
Fibroepithelial lesions include, of course, fibroadenomas, • Ellipsoid shape
but also phyllodes tumors of various malignant potential.
• Thin, echogenic capsule
Stavros’ Criteria (Chapter 10, section 1) were designed
• No posterior shadowing
to spot fibroepithelial lesions and avoid large numbers of
unnecessary biopsies. • Internal septations
• Often multiple
Be aware that phyllodes tumors, including malignant tumors,
usually meet these criteria. Also be aware that phyllodes
tumors are difficult to diagnose on needle biopsy. Phyllodes
tumors must be expected when a benign appearing solid
mass enlarges over time.
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Septation – Coronal View

Here you can see a large fibroepithelial
lesion, in this case a fibroadenoma.
Note the internal septations, a sign
that is essentially pathognomonic for
a fibroepithelial lesion.
Three gentle lobulations can be seen,

as well as a thin echogenic capsule.
This lesion was removed because it
was symptomatic.
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Septation – Transverse View

Here you can see that fibroepithelial
lesions are much easier to evaluate on
the coronal view. Although you can
appreciate the capsule, the internal
septations are much more difficult to
see. Posterior shadowing can be ruled
out in the transverse view, but this
finding can also be evaluated on the
coronal view.
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Multiple Fibroepithelial Lesions

It is fairly common for women who have
fibroepithelial lesions to have more
than one. Here you can see a female
with six fibroepithelial lesions in a
portion of the left breast.
In my experience about one-third of

women with fibroepithelial lesions have
one lesion, another one-third have two
lesions, and the rest have multiple
lesions. I have seen up to 15
fibroepithelial lesions in one client.
Without the use of ABUS imaging,
following women with multiple lesions
is virtually impossible.
Here is where the coronal view comes

in handy. Using the CC comparison
view of today’s coronal view to a
previous coronal view, you can see at
a glance which lesions are stable and
which are not.
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Phyllodes Tumor – Coronal View

This finding was removed because it
was symptomatic. Although initially
assumed to be a fibroadenoma,
pathology showed a low-grade
phyllodes tumor.
Note how similar it is to a benign

fibroadenoma on the coronal view.
The lesion does have a somewhat
thicker capsule, but otherwise is
circumscribed and has internal
septations.
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Phyllodes Tumor – Transverse View

This is the same lesion pictured on the
previous page. The lesion has a very
benign appearance with a capsule,
gentle lobulations, a septation, and no
posterior shadowing.
This illustrates the importance of tumor

growth in assessing fibroepithelial
lesions. This patient gave a history of
rapid growth and it was this history
that resulted in surgical removal of
the tumor.
Warning – Progression of
fibroepithelial lesions, either by history
or by progression under ultrasound, is
an indication for surgical removal. Yes,
surgical removal. Needle biopsies are
notoriously inaccurate in differentiating
fibroadenomas from phyllodes tumors.
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193
Assessing Stability
Here you can see the same fibroepithelial lesion on the coronal view reliable diagnostic criteria for a benign fibroadenoma, other than
of two ABUS studies performed one year apart. The lesion is stable, surgical excision. Lesions that progress under observation are
suggesting a benign fibroadenoma. Stability over time is the only suspicious for phyllodes tumors.
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PAPILLOMAS AND
Papillary Lesions
PAPILLOMATOSIS
• Suspicious solid mass
• Ductal ectasia with intraluminal
masses or debris
Papillomas are benign polypoid tumors that occur within
breast ducts. Multiple papillomas within a ductal structure • Radial, ductal ectasia pattern
is referred to as papillomatosis. Papillomas are associated • Complex cysts with polypoid
with ductal carcinoma-in-situ. This association is stronger if excrescences
the papilloma demonstrates atypical features.
Papillomas increase lifetime risk of breast cancer and

require biopsy on discovery. Atypical papillomas require
surgical excision to guard against underestimation.
Papillomas can present as solid masses or as intraluminal
masses The malignant variant of the papilloma is the
papillary carcinoma, which are often found within cysts.
INTRODUCTION
195

Here you can see an area of ductal
ectasia with at least one intraluminal
mass in a female with a spontaneous,
clear nipple discharge. Pathology
showed papillomatosis.
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196
Intraluminal Mass – Transverse View

The same dilated duct is seen on the
transverse view. Multiple intraluminal
masses can be appreciated.
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197
Radial Distribution – Coronal View

Papillomatosis often affects a single
duct and its branches resulting in a
radial distribution of ductal ectasia.
This can be appreciated on a
treatment planning coronal view of a
young woman with papillomatosis and
associated ductal carcinoma-in-situ.
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Radial Distribution – Transverse View

OIn the transverse view, you can
appreciate multiple intraluminal masses
within the client’s dilated ducts.
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199
Intracystic Polyp - Coronal view

Intracystic polyps are highly
suspicious. They often prove to be
intracystic papillary carcinomas.
While these malignancies are often
assumed be non-invasive, the
majority are actually invasive, as
this lesion was.
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Intracystic Polyp – Transverse View

Here is the transverse view of the intra-
cystic papillary carcinoma seen on the
previous page.
Warning – Needle biopsy of these

lesions can be challenging as the
solid component, which is what you
actually want to sample, often
disappears as soon as you puncture
the cyst. Consider either a vacuum-
assisted biopsy or surgical excision of
these lesions to guard against
underestimation.
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201
CHA P T E R 12
B R E AS T
CANCER
Diagnosing breast cancer with
ABUS imaging
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202
IN-SITU CARCINOMA
In-Situ Carcinoma
• Ductal ectasia with intraluminal
In-situ carcinomas are usually diagnosed on mammogram. masses
Occasionally they can present clinically with sanguineous • Peripheral ectasia
nipple discharge. In this case, retroareolar ductal ectasia • Clusters of cysts
with intraluminal masses can often be seen on ABUS.
Asymptomatic in-situ cancers in the periphery can present

with custers of cysts or small areas of peripheral ectasia.
These findings can look deceptively benign on ABUS imaging.
INTRODUCTION
203

We saw this case earlier in the
chapters on treatment planning and
papillomatosis. There is ductal ectasia
extending from the nipple into the
periphery. A closer examination reveals
intraluminal masses, more easily seen
on he transverse view. Papillomatosis
is frequently associated with DCIS
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204
Intraluminal Masses – Transverse View

The intraluminal masses are more
easily seen here.
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205
Intraluminal Masses – Treatment Plan

As seen previously for this case,
treatment planning can be carried out
in the coronal view. In this case, a
lumpectomy could not be performed
to remove the abnormal areas with a
adequate cosmetic result. A nipple-
sparing mastectomy was performed
with excellent oncologic and cosmetic
results.
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Intracystic Carcinoma – Coronal View

This was a very subtle finding seen on
a screening study. It was picked up
due to an angular margin seen on this
view. The lesion is a non-invasive intra-
cystic papillary carcinoma.
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Intracystic Carcinoma – Transverse

Careful examination of the lesion
shows internal cystic spaces
consistent with a papillary lesion.
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208
Peripheral Ectasia – Coronal View

This lesion initially resembled a cyst,
but scrolling through the finding
showed that it was a dilated duct. Like
clusters of cysts, dilated ducts are
very suspicious. Suspicious
calcifications in the area of this finding
on mammogram increased suspicion.
A stereotactic biopsy showed high-
grade DCIS.
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Peripheral Ectasia – Transverse View

On transverse view, you see the dilated
duct, but also small intraluminal
masses.
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210
LOW-GRADE
Low-Grade
INVASIVE CANCER Invasive Cancer
• Architectural distortion
Low-grade invasive cancers have a classic appearance • Dense shadowing

on ABUS imaging and are generally easy to spot. • Angular margins
• Taller-than-wide
Architectural distortion, seen in the coronal view, is their
classic presenting feature. Angular margins and dense
posterior shadowing are also commonly seen.
Most ABUS detected cancers that are missed on

mammographic screening are low-grade invasive
cancers that are less than 1 cm in size.
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Screen Detected - Coronal View

Here is the classic ABUS screening
detected breast cancer. Measuring 7
mm, this low-grade invasive cancer
was missed on mammogram. An ABUS
study was performed due to density.
Note the radial light and dark lines.

This is architectural distortion and is
much more easy to see than the dark
tumor mass.
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212
Screen Detected - Transverse View

In the transverse view, the tumor
displays the classic features of a
low-grade invasive cancer. Note the
angular margin and the dense posterior
shadowing.
Warning – Histologic tumor grade does

not correlate with the probability of local
or distant recurrence. Genomic tumor
analysis is necessary, regardless of
grade, to ascertain the degree of
aggressiveness and to plan
treatment.
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Screen-Detected – CAD View

Here is the same finding on CAD. Notice
that the finding is more noticeable
because the CAD system has filtered out
the Cooper’s ligaments.
The lesion is marked with a CAD marker

circle. Notice the black hole in the center
of the finding. Also seen are white radial
lines. These lines represent architectural
distortion. Architectural distortion is high-
lighted by the CAD system. The other
marked finding turned out to be a
Cooper’s ligament shadow.
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Screen-Detected – Hover View

The hover view on the CAD system shows both a coronal and
transverse view of the lesion. The suspicious nature of the finding is
easily confirmed.
INTRODUCTION
215
Taller-Than-Wide – Coronal View

Here is a low-grade invasive carcinoma
seen on the coronal view. The finding
appears solid, but is otherwise bland.
There are indistinct margins, which
make this finding suspicious.
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216
Taller-than-wide – Transverse view

On the transverse view the taller-than-
wide appearance of the finding is
striking. This is characteristic of low-
grade invasive cancers. Note that the
margin is indistinct here as well.
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217
Architectural Distortion – Coronal

View
Architectural distortion is best seen
on the coronal view and is often the
finding on screening that leads to
the diagnosis.
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218
Architectural Distortion – Transverse

Although clearly suspicious, there is
minimal architectural distortion on this
view. This finding is much better
appreciated on the coronal view.
INTRODUCTION
219
HIGH-GRADE
High-Grade
INVASIVE CANCER Invasive Cancer
• Irregular margins
High-grade invasive cancers can be very deceptive. • Anterior echogenicity

• Internal calcifications
High-grade cancers can look surprisingly benign and are
• Posterior enhancement or minimal
commonly mistaken for fibroepithelial lesions. They can shadowing
present as circumscribed lesions, which often do not shad-
ow. Careful attention to the margins of the lesion will usually
reveal the supicious nature of the finding.
INTRODUCTION
220
CAD-Detected – CAD View

This is a very subtle metaplastic cancer
detected by CAD. The finding was
missed on mammogram and is very
subtle on ABUS. I found this lesion by
reviewing this client’s CAD images.
Note the white areas seen on the

CAD view. These are subtle areas of
architectural distortion. Further evaluation
of this finding led to the discovery of the
tumor.
INTRODUCTION
221
CAD-Detected – Coronal View

On the coronal view this lesion is very
subtle. Careful review shows subtle
architectural distortion.
INTRODUCTION
222
CAD-Detected – Transverse View

On transverse, the lesion is more
apparent. Here you can see the
anterior echhogenicity that is
characteristic of high-grade cancers.
There is also fairly dense posterior

shadowing. It is very difficult to discern
the border of this lesion.
INTRODUCTION
223
Node Positive – Coronal View

This is a very aggressive, node positive
cancer. The patient presented with
symptoms that led to a diagnosis of
metastatic breast cancer.
A search for the primary uncovered

this lesion, which was 1.3 cm in
diameter and asymptomatic.
Note the irregular borders. Otherwise,

this lesion looks fairly benign. There is
no architectural distortion or posterior
shadowing evident.
INTRODUCTION
224
Node Positive – Transverse View

Here you can again see the irregular
borders. Also note anterior
echogenicity at the superficial margin
of the tumor.
There is posterior enhancement seen

in the center of the tumor, a finding
often seen with benign fibroepithelial
lesions.
INTRODUCTION
225
Node Positive – Axillary View

On the ipsilateral coronal axillary view,
you can see a morphologically
abnormal lymph node.
INTRODUCTION
226
Node Positive – Transverse Axillary

There are two suspicious lymph nodes
seen, both with significant cortical
thickening. One is below and the other
is above the clavipectoral fascia. An
FNA of the deeper node was positive.
INTRODUCTION
227
Irregular Margins – Transverse View

This is a classic high-grade invasive
carcinoma.
Note the posterior enhancement

and edge shadowing and gentle
lobulations.
Apart from faint anterior echogenicity,

there are no findings seen here
that would lead you to think it was
malignant. High-grade cancers can
be very deceptive.
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228
Irregular Margins – Coronal View

There is no visible architectural
distortion. Note the irregular
microlobulated margins. This is the
finding that led to biopsy. If not for a
careful examination of the margins, this
lesion could easily have been assumed
to be a fibroepithelial lesion.
INTRODUCTION
229
Internal Calcifications – Coronal View

Internal calcifications, particularly
microcalcifications, are a suspicious
finding. Some judgement is required in
the interpretation of calcifications,
since this finding is also seen in
degenerating fibroadenomas.
Generally, the suspicious calcifications
seen in cancers are smaller than the
popcorn calcifications seen in
fibroadenomas, but there is a lot of
overlap.
Note the use of rotation in the coronal

view to view both findings in the same
plane.
INTRODUCTION
230
Internal Calcifications – Transverse

Here, the calcifications are well seen.
The improved resolution of the Invenia
ABUS often makes the evaluation of
microcalcifications possible without a
focus ultrasound callback. Note also
the angular margins. No need for
further work-up. Proceed directly to
biopsy.
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231
Internal Calcifications – Treatment Plan

This is the treatment plan for this breast
cancer. Careful examination of the ABUS
study showed no evidence of other
foci, malignant lymphadenopathy, or
contralateral disease. A lumpectomy
planned from this image recovered both
lesions with clear margins.
INTRODUCTION
232
INFLAMMATORY
Inflammatory Cancer
CANCER
• Skin thickening and edema
• Inflammatory changes
Inflammatory cancers can be surprisingly difficult to • Often multifocal
diagnose. Although most are symptomatic at diagnosis, • Often with positive nodes
their resemblance to other benign inflammatory conditions
can prove challenging.
ABUS imaging makes the diagnosis of inflammatory cancers

much easier. Skin biopsies for inflammatory cancers are
notoriously inaccurate. Sonographic findings can also be
subtle and obscured by inflammatory changes. Whole-
breast imaging with ABUS often allows identification of the
most prominent part of the tumor. This is the area to biopsy.
INTRODUCTION
233
Unifocal – Coronal View

Note the marked peau d’orange
changes centered in the right lower-
outer quadrant. There was no palpable
mass, These changes were assumed
result from a mastitis and two courses
of antibiotics were prescribed without
effect. This is a common clinical
presentation.
INTRODUCTION
234
Unifocal – Deep Coronal View

Deep to the inflammatory skin changes
is a subtle suspicious finding. This
underwent ultrasound-guided biopsy,
leading to the diagnosis. A skin biopsy
was negative, as is often the case.
Other than inflammatory changes there

were no other suspicious findings
within the breast.
Warning – The location of the

underlying tumor often does not
correlate with the location of the skin
changes. Whole breast ultrasound is
needed to evaluate for the best
location to biopsy.
Often the best location is in the axilla,

since most IBC clients will have
positive nodes.
INTRODUCTION
235
Unifocal – Transverse View

Sonographic findings in women with
inflammatory cancer are often
surprisingly subtle. Inflammatory
changes often obscure the underlying
tumor.
An isolated unifocal tumor associated

with inflammatory cancer is somewhat
rare. Most inflammatory cancers are
multifocal.
Note the marked skin thickening due to

edema. The subcutaneous tissue and
breast parenchyma shows
hyperechoic inflammatory changes.
This makes the tumor more subtle.
INTRODUCTION
236
Unifocal – Axillary Coronal View

Inflammatory cancers are usually
node positive. Here you can see a
hypoechoic finding in the low axilla on
coronal view. Notice the eccentric
hilum at the lateral edge of the lesion.
INTRODUCTION
237
Unifocal – Axillary Transverse View

On transverse view, this finding is
clearly an abnormal lymph node just
deep to the clavipectoral fascia. Note
the small eccentric hilum on the lateral
side.
INTRODUCTION
238
Multifocal – Spot Coronal View

Notice the classic peau d’orange
skin changes in this inflammatory
breast cancer. This finding
indicates inflammation and is not
specific to IBC.
INTRODUCTION
239
Multifocal – Transverse Spot View

Here you can see marked skin thicken-
ing as well as the classic inflammatory
changes that characterize the disease.
Note the small fluid collections under

the thickened dermis. This represents
edema.
INTRODUCTION
240
Multifocal – Deep Coronal View

This is a more typical presentation of
inflammatory breast cancer. You can
see multiple foci, the largest of which
is in the left lower-outer quadrant. A
biopsy of the left upper-inner quadrant
lesion led to the diagnosis.
INTRODUCTION
241
Multifocal – Deep Transverse View

This is a transverse view of the
lower-outer quadrant lesion. The
inflammatory changes make the solid
tumor mass difficult to visualize.
Note, however, the angular margin on

the medial side.
INTRODUCTION
242
Multifocal – Coronal Axillary View

As with most inflammatory cancers,
this cancer was node positive. Here
you can see a prominent axillary mass.
INTRODUCTION
243
Multifocal - Transverse Axillary

View
This turned out to be a 3 cm axillary
node. Note the absence of a hilum.
INTRODUCTION
244
RECURRENCE
Breast Cancer
Recurrence
Recurrent breast cancers exhibit the same findings that The same findings seen in primary
primary breast cancers display. cancers. Recurrences can be
ipsilateral or contralateral. If not
Recurrences are best spotted in the coronal view. in the same quadrant as the initial
tumor, a second primary must
Comparisons to prior studies are especially helpful in be considered.
differentiating recurrences from postoperative changes.
In addition to recurrences, breast cancer survivors are

susceptible to second primaries. These can be ipsilateral
or contralateral. By convention, a cancer that occurs in
the same quadrant as the initial tumor is considered
a recurrence.
INTRODUCTION
245
Multifocal Recurrence – Coronal Views

Here is a recurrence with multiple foci. Since one of the lesions is in
the right upper-inner quadrant, the site of the initial primary, this is
considered a recurrence. Note that the findings in the right upper-
outer quadrant are positive lymph nodes.
INTRODUCTION
246
Multifocal Recurrence – Transverse views

Several abnormal lymph nodes are seen on the left. On axillary
dissection, the patient was found to have six positive nodes. On the
right is the patients lesion in the lower-inner quadrant. Biopsy of this
lesion resulted in the diagnosis.
INTRODUCTION
247
Local Recurrence – Coronal View

Here is a small local recurrence that
was detected on screening in a client
with a left upper-inner quadrant cancer,
treated conservatively over 20 years
ago. Note the surrounding architectural
distortion.
INTRODUCTION
248
Local Recurrence – Transverse View

The finding is about 4mm in diameter.
Prompt recognition led to surgical
treatment. Chemotherapy was not
required.
INTRODUCTION
249
CHA P T E R 13
LYM P H
NODES
Evaluating intramammary and axillary
lymph nodes with ABUS imaging
INTRODUCTION
250
OTHER LYMPH NODE

Suspicious Lymph Nodes
PATHOLOGY
• Cortical thickening
• Absent or abnormal hilum
Lymph nodes can be appreciated and evaluated on ABUS • Size (if combined with other findings)
studies. Use of the axillary view is necessary to see axillary
findings. Of course, not all abnormal lymph nodes denote
breast cancer. Normal variants, infectious diseases, and
hematologic malignancies can be seen on ABUS studies.
INTRODUCTION
251
Intramammary Lymph Node – Coronal

Intramammary lymph nodes are
common and can be seen anywhere
in the breast.
They are best seen on mammogram.

In most cases you will find them when
performing a diagnostic evaluation for
a mammographic finding.
Usually they are less than 1 cm in

diameter. If they exhibit cortical
thickening or an abnormal hilum,
they should undergo biopsy.
INTRODUCTION
252
Intramammary Lymph Node

Intramammary lymph nodes are best
appreciated on the transverse view.
This lymph node demonstrates a

normal size, hilum, and cortical
margin. No further evaluation is
needed.
INTRODUCTION
253
Normal Axillary Nodes - Coronal

Normal axillary nodes in the coronal
view often identified by a series of
convex margins between the
pectoralis and latissimus muscles.
The hila are visible surrounded by a

darker cortical margin (see arrows that
outline one node’s cortex).
INTRODUCTION
254
Normal Axillary Nodes – Transverse

Here you can see several if the nodes
seen in the prior coronal view.
Most nodes are seen below the

clavipectoral fascia, but some are
above the fascia, particularly lower in
the axilla. These nodes are
morphologically normal.
INTRODUCTION
255
Fat Replaced Lymph Nodes – Coronal

Fat replaced lymph nodes are a normal
finding with aging and are present in
over half of postmenopausal women.
They exhibit an enlarged hyperechoic

hilum and a thin cortical margin., They
can be quite large, up to 3cm. The
hilum can be appreciated in the axilla
on the coronal view.
INTRODUCTION
256
Fat Replaced Lymph Nodes

On the transverse view, the hilum is
easily appreciated. The cortex can be
so thin as to be almost invisible.
Increased cortical thickness is an

indication for biopsy
INTRODUCTION
257
Lymphoma – Coronal View

This is a markedly abnormal
intramammary lymph node. The
hilum is almost invisible.
Note the large blood vessel

approaching the node. a small
needle biopsy revealed lymphoma.
INTRODUCTION
258
Lymphoma – Transverse View

Here is the same finding as on the
previous coronal view. There is marked
cortical thickening. The large blood
vessel seen on the coronal view, and
can also be seen here, was followed
all the way to the hilum.
INTRODUCTION
259
Necrotizing Granulomatous Change

Needless to say, this patient was
symptomatic.She presented with an
axillary mass.
Note the markedly increased cortical

margin. An excisional biopsy showed
necrotizing granulomatous disease.
Subsequent serologies showed
cat-scratch disease. Antibiotic
treatment resulted in resolution of the
patient’s lymphadenopathy and
imaged findings.
INTRODUCTION
260
Absent Hila – Coronal View

These large lymph nodes were
discovered during an imaging workup
for trauma. The nodes are not only
markedly enlarged, but they exhibit
no hila, a very suspicious finding.
INTRODUCTION
261
Absent Hila - Transverse View

Here are the same lymph nodes in
the transverse view. Again, no hila is
visible.
Note that this node is just beneath the

clavipectoral fascia, which is bulging
upward. Additional nodes can be seen
deep to the larger node.
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262
Absent Hila – Treatment Planning

Much to my surprise, these lymph
nodes were not palpable, with the
exception of non-specific axillary
fullness. The patient was
asymptomatic.
Measurement of the location of the

largest lymph node from the humeral
head facilitated surgical biopsy. The
node displaced the thoracodorsal
vessels medially.
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263
Absent Hila – Doppler Flow

Note the markedly abnormal Doppler Flow
seen in this lymph node. Although not needed
for diagnosis, this finding dissuaded me from
performing a core needle biopsy.
Warning – Abnormal lymph nodes can be

very vascular. Biopsy them with care. Check
for Doppler flow first. Bleeding can be profuse
and difficult to control. Since these nodes are
harder than the surrounding fat, direct
pressure may not be effective.
Fine needle aspiration with flow cytometry is

notoriously inaccurate. It was negative in this
case. If you elect to proceed with a needle
biopsy, use a small core needle, no more than
16-18 gauge.
Needle biopsy specimens of lymph nodes

need to have at least one core sent fresh
(immediately and not in formalin) for flow
cytometry. Consult your pathologists as to
when they can receive your specimen and
how they would like it to be prepared.
For large and vascular nodes, often surgical

excision is the safest and most accurate
option.
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264
CHA P T E R 14
POST-
T R E AT M E N T
CHANGES
Post-treatment changes as seen
on ABUS
INTRODUCTION
265
AFTER CONSERVATIVE
Changes with
TREATMENT Conservative Treatment
• Seroma
Surgical changes seen after conservative diagnosis and • Architectural Distortion

treatment include not only post-surgical changes, but • Fat Necrosis
radiation related changes. • Skin Thickening
• Retraction
There is a lot of variation in normal post-treatment change.
Differentiating these changes from recurrence can be
challenging. Correlation with mammographic imaging
and especially with prior ABUS studies is very helpful.
INTRODUCTION
266
Seroma – Coronal View

This is a typical post-treatment seroma
in a client treated for an early-stage
breast cancer with segmental resection
followed by whole-breast radiation.
Note the prominent architectural

distortion seen on this view. This is
seen almost universally after surgical
biopsy.
Also note the hyperehoic flecks within

the seroma cavity. These are specks of
clotted blood. These are characteristic
and non-suspicious following breast
surgery.
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Seroma – Transverse View

Essentially a seroma is fluid that fills
the space left after surgical resection.
Seroma formation is encouraged at

surgery by closing the skin and
subcutaneous tissue over the empty
space left behind after resection.
This technique is highly effective in

preventing contour deformities after
treatment, provided that the surgery
takes place superior to the nipple.
For treatment of cancers inferior to the

nipple, contour deformities often occur
despite the use of this technique.
Oncoplastic techniques provide a

better cosmetic outcome for lesions
inferior to the nipple
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Symptomatic Seroma – Coronal View

This client was treated with a
segmental resection followed by
accelerated partial breast irradiation
for a small right upper-outer quadrant
breast cancer. Subsequently, she
developed this seroma, which is
symptomatic.
Seromas are very common after

conservative treatment, but
symptomatic seromas are not. APPI
treatment is somewhat notorious for
this complication, one of the reasons
why is not extensively used today.
INTRODUCTION
269
Symptomatic Seroma – Transverse

In comparison to the previous
example, this seroma is round,
indicating high fluid pressure with the
cavity. This is why the lesion is
symptomatic.
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270
Hematoma – Coronal View

This postoperative hematoma occurred
following a segmental resection and
radiation treatment for cancer.
Note the complex internal densities

without attachment to the cavity wall.
This is characteristic.
This client had a good cosmetic

outcome and was asymptomatic, so
no treatment of the hematoma was
needed.
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271
Hematoma – Transverse View

On the transverse view you can see
that the internal hyperechoic debris is
free-floating, or not attached to the
cavity wall. This finding is
characteristic or hematomas.
Notice also the skin thickening anterior

to the cavity. This is a common finding
after radiation therapy.
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272
Oncoplastic Closure – Coronal View

This client underwent resection of a
small tumor just inferior to the level of
the nipple.
To avoid a contour deformity, I

performed an adjacent tissue transfer,
a type of rotational flap, to obliterate
the space. The patient had whole
breast radiation and very good
oncologic and cosmetic outcomes.
Note the architectural distortion and

the Double S-shaped hypoechoic line
marking the junction of the rotated
flap with the more medial breast
parenchyma.
There is no seroma. The entire space

is filled with tissue.
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273
Oncoplastic Closure – Transverse View

Here is the same area of postoperative
change in the transverse view. You can
follow the hypoechoic scar tissue right
up to the skin. An important clue that this
is post-treatment change.
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274
Fat Necrosis – Coronal View

Fat necrosis results in calcification
and very dense shadowing.
Fat necrosis can be very difficult to

differentiate from a recurrence.
Mammographic imaging can see
characteristic large calcifications and
can be very helpful.
In the long-term, comparison to prior

studies showing stability is the most
reliable indicator of benign fat
necrosis.
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275
Fat Necrosis – Transverse View

Note the dense shadowing. Also note
the extension of these changes up to
the skin. This is characteristic of post-
treatment change.
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276
AFTER RADICAL
TREATMENT
Surveillance after mastectomy can be especially challenging.

Recurrences after mastectomy can be very subtle. ABUS
imaging with reference to prior studies can be very helpful
in distinguish-ing post-therapeutic changes from recurrences.
Post-mastectomy surveillance is performed using the standard
AP, MED, and Axillary volumes.
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277
Local Recurrence – Coronal View

This is a recurrence after mastectomy.
It’s very subtle, but notice the faint
architectural distortion and hypoechoic
findings just below the skin.
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278
Local Recurrence – Transverse View

This client’s recurrence is more easily
seen on the transverse view. Note the
localized skin thickening and small
hypoechoic densities in the
underlying subcutaneous tissues.
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279
Axillary Recurrence - Coronal View

This is an axillary view of a patient
treated for a stage I breast cancer with
a mastectomy and a sentinel lymph
node biopsy 10 years prior.
Note the large axillary mass high in the

axilla. This finding was not palpable.
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Axillary Recurrence – Transverse View

Note the large structure medial to the
mass (arrow). This is the axillary vein, A
finding that resulted in a lot of discussion
at tumor board.
After a very careful needle biopsy of the

lateral-most aspect of the lesion,
neoadjuvant chemotherapy resulted in
enough of a response to allow for
surgical resection. Subsequently, the
patient underwent radiation therapy and
has done well.
INTRODUCTION
281
AFTER COSME TIC AND

RECONSTRUCTIVE SURGERY
Cosmetic procedures performed on the breast include

mastopexies, reductions, and augmentations in various
combinations.
Reconstructive procedures can include various flaps as well

as implant-based techniques. Reductions use internal pedicle
flaps to support the nipple-areolar complex. Mastopexy
procedures use a similar technique.
Implants are often used and these devices have their own
set of imaging signs.
INTRODUCTION
282
Reduction – Coronal View

This is a typical Wise Pattern
reduction. Note the internal pedicle
flap extending from the inferior
medial breast to the retroareolar
area. This is the flap on which the
nipple is based.
INTRODUCTION
283
Reduction – Transverse View

Here is the pedicle flap in the
transverse view.
Warning – Be very careful performing

a biopsy of findings within a flap
pedicle within the first few weeks of a
client’s surgery. Disruption of blood
vessels within the pedicle can result in
loss of the flap.
After 2-3 months, collateral vasculature

should be adequate to support biopsy.
INTRODUCTION
284
Implant Anatomy – Coronal View

Note the capsule surrounding the
implant. This is formed by the wall of Capsule Fold
the implant and associated scar
tissue.
The hazy density within the implant

itself is a ring-down artifact. This
occurs because ultrasound waves
echo back and forth between the
walls of the implant. Ring-down is also
seen in large cysts (chapter 7).
The linear structures are implant folds.

These can easily be confused with
areas of implant rupture.
INTRODUCTION
285
Implant Anatomy – Transverse View

Many implant related findings are easy
to appreciate in the transverse view.
Capsule Folds
Folds are easily seen, as is the
capsule.
The ring-down artifact follows the

contour of the capsule
Ring-Down
INTRODUCTION
286
Implant Rupture – Coronal View

This is an intracapsular rupture of a
20-year-old silicon implant. Note the
thick hyperechoic line. This is the
edge of the implant within a pool of
extravasated silicone.
INTRODUCTION
287
Implant Rupture – Transverse View

On the transverse view, the capsule is
folded. Extravasated silicon is still
contained within the capsule.
This patient was asymptomatic, so

treatment of the rupture was not
required.
Warning – Implant folds are easily

confused with wrinkles and are only
seen with silicon implants. Saline
implants when ruptured deflate over
2-3 days as the saline is absorbed.
Before you consider surgery to replace

a suspected silicon implant rupture,
perform an MRI to ensure that the
finding is not a fold.
INTRODUCTION
288
CHA P T E R 15
OTHER
FINDINGS
Evaluating intramammary and axillary
lymph nodes with ABUS imaging
INTRODUCTION
289
OTHER FINDINGS
These can run the gamut and include mass lesions,

vascular findings and musculoskeletal findings.
INTRODUCTION
290
Thrombosis – Coronal View

Here is a young woman who
presented with focal pain of 5 days
duration. You can see a serpiginous
structure structure with surrounding
inflammatory changes. Note the
use of a palpable mass marker to
localize this client’s symptomatic
area.
INTRODUCTION
291
Thrombosis – Transverse View

Again you can see the dilated vessel
with surrounding inflammatory
changes.
Thrombosis are associated with a

history of trauma, but they also can be
a symptom of breast cancer. careful
examination of the entire length of the
vessel is required to rule out a mass.
Warning – Findings associated with

thrombosis can be very similar to
findings seen with DCIS. Exercise
great care in following these lesions.
Thromboses will usually resolve in 7-10
days with oral aspirin. At a minimum,
re-image your client after treatment to
en-sure that her findings resolve. As
always, the prima lex applies.
INTRODUCTION
292
Rib Fracture – Coronal View

This client was taking anastrozole for
breast cancer treatment was hit with a
golf ball, while driving her golf cart
down the 6th fairway. She had been
experiencing persistent pain for over
two months, when she saw me for
evaluation.
Note the 5th rib fracture anteriorly. I

was concerned about a pathologic
fracture from metastatic disease, and
got a CT scan. This also showed the
fracture, but no associated rib lesion.
Anastrozole is associated with

nonunions following fracture, so I
stopped the anastrozole for 4 weeks.
This resulted in resolution of the client’s
symptoms and imaged findings.
I am not recommending ABUS imaging

as a diagnostic tool for rib fractures.
The point of this case is to look at
everything when you read one of these
studies, something our radiologist
colleagues well understand. You never
know what you might find.
INTRODUCTION
293
Sternal Metastasis - Coronal View

This client has a remote history of
breast cancer and presented with a
painful mass just to the left of the
mid-line.
The hypoechoic finding is easy to

see and correlates with the palpable
finding
INTRODUCTION
294
Sternal Metastasis – Deep Coronal

As you scroll deeper, you can see that
the mass arises from the sternum, near
the manubriosternal junction.
INTRODUCTION
295
Sternal Metastasis – Sagittal View

In case there is any doubt, check out
this sagittal view. Here you can see
the mass clearly arises from the
underlying sternum.
A needle-core biopsy, under

ultrasound guidance, revealed an
adenocarcinoma consistent with a
breast primary. This is an isolated
metastasis. The client responded
well to chemotherapy and radiation.
INTRODUCTION
296
REFERENCES 1-26
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Resonance Imaging in Breast Lesions. J Comput Assist Tomogr 2019;43(2):245-51. doi: 10.1097/RCT. Screening Decreases Stage at Diagnosis. Academic Radiology 2017;24(12):1570-74. doi: https://doi.org/10.1016/j.
0000000000000832. acra.2017.06.014
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Mammography-Negative Dense Breasts: Interim Report of a Prospective Comparative Trial. Journal of Clinical Oncology
8. Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian 2016;34(16):1882-88. doi: 10.1200/jco.2015.63.4147.
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13-20. doi: 10.1111/tbj.12354. lesions. Radiology 1995;196(1):123-34. doi: 10.1148/radiology.196.1.7784555.
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© Copyright 2020 by Ian Grady – North Valley Breast Clinic

igrady@breastpractice.com
All rights reserved under International and Pan-American Copyright conventions.
Published in the United States of America.
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Ian Grady, MD, FACS

© Copyright 2020 by Ian Grady – North Valley Breast Clinic

Dr. Grady’s discussion of ABUS-mammographic location correlation is very

In summary, I enjoyed reading this book and looking at the illustrations. It

* Yang L, et al. Performance of ultrasonography screening for breast cancer: a systematic

Most of the book concerns the perception and characterization of

Screening with CESM is an area of active investigation. The only

Hand-held ultrasound whole-breast imaging is equivalent to

Reader performed hand-held ultrasound is not cost-effective. A

Ultrasound will soon become the secondary screening technology

ABUS is the future.

Inception Detected Symptomatic

Trial Year Age Attendance (%) N Mortality (OR) Advanced CA (OR)

With modern treatment, there is no difference in mortality between

If you look at the randomized controlled screening trials listed -0.4

Mortality vs. advancedLncancers inforthe

Mortality, of course, is not the only endpoint. Cost is an important

$200K All-cause Cost Over the First Two Years of Treatment

BREAST DENSITY AND SECONDARY SCREENING

signiﬁcant delay prior to imaging is required after injection. As a

Contrast-enhanced spectral mammography is the new imaging

Overall, the economics favor ultrasound, and in particular, ABUS.

Hand-held ultrasound has about the same diagnostic yield as

This fact will greatly limit hand-held ultrasound adoption. It can

The downside is that you have to develop a lot of capability to

The key to tracking was to develop an easy to understand,

For women at a high risk of developing breast cancer, that is a

Women who are at a moderate risk of breast cancer, that is a

For women who present with symptoms or imaged ﬁndings that

The advantage of a protocol-based system is that the techs and

Breast Cancer Surveillance Consortium 201722 North Valley Breast Clinic

PPV1 Cancers/Abn mammograms 4.4% 3-8%

Sensitivity 0.869 > 0.75

Yield (Cancers/1,000 women screened)

Accordingly, in 2015, I began a concerted effort 4

All of this illustrates the importance of tracking your statistics. Only

COMBINING SCREENING AND DIAGNOSIS

2015 2016 2017

and diagnostic work-ups into a single study. ABUS is a very cost-

WORKING UP A SYMPTOMATIC FINDING

This marker is made by InterMark, a British company. You can order

WORKING UP A MAMMOGRAPHIC FINDING

The ﬁrst technique developed is a graphical technique. Whoever ML Axis

This is sometimes called the minimum skin distance technique

Distance X is marked on the medial-lateral line that passes through

Now, with these distances marked, you simply drop a right-angle

ΔY/ΔX = tanφ Clock Degrees Radians

ABUS turns out to be a great tool for determining the extent of

A separate focus 8 cm away is a different story. In this case you

Treatment planning in a young woman

A suspicious lesion is identified corresponding to the mammographic finding in the left

Treatment planning for a lumpectomy is

A suspicious lymph node is identified in the LUOQ axillary volume.

Again, be careful when using this technique. I always have

If you don’t have intraoperative ultrasound capability, I would

Warning – It is common for abnormal nodes in a cancer patient

Surveillance is based on the principle of stability.