Clinical Implementation of Ultrasound in Breast Imaging - SD

Introduction

Hello, my name is Stia Dees.
I'm a radiologist at the Elizabeth Wendy Breast Care
in Rochester, New York.
What we're gonna do today is talk about screening breast
ultrasound and specifically automated breast ultrasound.
We're going to talk about today the clinical
implementation of ultrasound in breast imaging.

Uses of Breast Ultrasound

Breast ultrasound is a very useful tool to evaluate lumps
and pain in the breast tissue.
We use it as a first line imaging tool in young women
and pregnant women in their first trimester.
Specifically where we may not want to use any x-ray imaging
advantage of ultrasound in the tissue is
that we can observe the tissue without radiation
and it can be imaged much faster than with x-rays.
There have been no substantiated ill effects documented
through the study of the use of ultrasound diagnostic.
Breast ultrasound specifically is an ultrasound exam
ordered by a physician to evaluate a symptom of concern
or mammographic abnormality.
It's also used for evaluation of lumps
and pain in the breast tissue,
and as I said on the prior slide, a first imaging tool
for young women and pregnant women.

Screening Breast Ultrasound

However, by definition, an exam is referred to
as screening when its purpose is
to learn if a breast thought
to be healthy has any signs of cancer.

Types of Ultrasound in Clinical Practice

The types of ultrasound that we use in clinical practice
are two dimensional ultrasound,
three dimensional ultrasound.
That is actually two dimensional ultrasound
with specialized software applied to form A 3D image.
This allows improved visualization of an organ.
We also have doppler ultrasound,
which measures the change in frequency of echoes
and calculates how fast an object is moving.
This is used predominantly for blood flow measuring
traditionally, and for us in breast imaging specifically,
we use high frequency ultrasound that's anywhere from seven
to 12 megahertz, or 7.5 to 13.
And what this is in measures the sound waves
and their echoes and produces a two dimensional image.
The ultrasound unit will calculate the distance from the
probe to the tissue or organ using the speed
of sound in the tissue, which is 5,005 feet per second,
and then the time for each echoes return.

Ultrasound Probes

These are the types of ultrasound probes
that we use in our facility,
linear array ultrasound.
It's an ultrasound beam that's produced by a narrow element,
and this diverges rapidly
after the sound wave travels only a few millimeters.
The smaller the face of the transducer,
the more divergent your beam
and that gets combined with adjacent elements simultaneously
with the delayed pulse.
This results in a very focused beam from the
divergent wavelengths.
Compound imaging is the acquisition
of multiple image frames from different viewing angles.
The overlapping frames are then combined
to form a real time image on your ultrasound display.
The image quality greatly is improved
with increasing frame number.
If you're interested in reading more about these different
types of imaging, you can go ahead
and read on in
by quack variable breast conditions in comparison
of conventional and real time compound ultra sonography in
the Journal of Ultrasounding Medicine.
Tissue Harmonic imaging,
however, is a generation of harmonic frequencies
as an ultrasound wave propagates through the tissue
and reduces artifacts and also improves image clarity.
The benefit of this is you utilize lower frequency sound
waves to improve your penetration
of the tissue while receiving
and processing only the higher frequency echoes produced
by your body's inherent harmonic characteristics.
The tissue beam transmits at one frequency
and receives at twice that frequency.

Patient Positioning and Documentation

On this slide, we're looking at patient positioning.
When we do ultrasound, you are able
to maneuver the patient in order to bring the lesion
or whatever area of interest you want, closest
to the skin surface and closest to your ultrasound beam.
You see that the patient has their arms over her head,
also turned to the side.
We also document using the clock face and also depth.
As you see on the sagittal view.
We have to use every modality available to us in order
to be able to document
where an abnormality is seen in the breast.
When you scan with ultrasound, you have
to scan at least two views.
Whether you use the radial
or anti radial approach or the transverse
or longitudinal approach, you have to document
how you're scanning, and take appropriate images.

ACR BI-RADS Lexicon for Ultrasound

The American College of Radiology
has the ACR BI-RADS lexicon, which is actually very helpful
for us for ultrasound.
It explains to us how we should have our dictation
so we are consistent.
Whether the patient returns to us for a follow-up visit
or may move out of town or out of the country
and need their reports and their imaging.
We have to discuss the texture of the tissue.
We have to discuss the masses.
If we do see any calcifications,
there are special cases which we'll discuss a little bit
more and also vascularity the texture.

Breast Tissue Texture

We have some images here. These are courtesy of Dr.
Mendelsohn. You see the homogeneous fat,
which is very easy to look at.
It's all the same type of gray white,
and we can see cystic spaces within this area.
Over here we have homogeneous fibro glandular tissue.
These images are courtesy of Dr. Berg,
and here we have heterogeneous tissue
where you see much more of the darker
and also the wider tissue.
So fibro glandular tissue can be homogeneous
or heterogeneous. Fatty tissue typically
will be very homogeneous.

Describing Masses

Now, for the masses when we describe them,
we can describe the shape, which may be oval,
round or irregular.
The orientation, whether it's parallel
or perpendicular to the chest wall, the margins of the mass,
the lesion boundary, the echo pattern,
posterior acoustic features
and the surrounding breast tissue.
Starting with the orientation.
When you have a benign appearing mass, such as this mass,
this is a fibro adenoma.
This is parallel to the skin and it's wider than tall.
This has ultrasound findings that correlate
with a benign entity.
When you have a carcinoma, such as in this case,
this is not parallel, this is taller than wide,
and this has decreased through transmission.
And these are findings are suspicious.
And in determinate on ultrasound, this turned out
to be a cancerous mass.
When we look at the margin of a mass,
we wanna describe whether it's circumscribed
or not, whether the margin is indistinct
or angular micro lobulated or speculated.
We wanna discuss the transition zone.
In the lesion boundary.
Is there an abrupt interface or an echogenic halo?
What is the echo pattern? Is it anechoic?
Such as we may see in cyst hypoechoic en masses, complex
cystic and solid component hypoechoic or isoechoic.
This is an null case, but it's a very good one.
This has the posterior acoustic features,
the posterior acoustic enhancement
that we found even many years ago with cystic structures.
When you look at posterior acoustic features, are there any,
is there enhancements such as in this case,
is there shadowing such as in this case
or maybe something combined in between?
This is a case of fibrosis on the right
and on the left, a typical cyst, the surrounding tissue.
We look at the ducts, the Cooper's Ligaments.
We look at is there any fluid such as edema,
is there architectural distortion of the tissue?
Is there skin thickening or skin retraction?

Evaluating Lesions: Benign vs. Malignant

When you are imaging, you wanna evaluate,
is this what you're looking at?
Benign entity, is it cystic or solid?
For cyst, we look up posterior acoustical enhancements, such
as the prior old case.
By good case that I showed you of cyst,
is it well circumscribed?
Is it anechoic? Are there echoes within it?
I'm gonna show you some examples here.
This is a 46-year-old that presents with a right lump
and pain in the 12 o'clock region.
This is her mammogram.
This is the right mediolateral oblique view.
This is the left and her one of the CC views.
Here she has dense breast tissue,
as you saw on the mammogram,
and now we move to her ultrasound.
This patient has multiple bilateral cysts on ultrasound
we talked about right, 12 o'clock lump
and pain in the right breast upper upper quadrant, she has
anechoic structure with increased through transmission.
This is a cyst, it's well circumscribed,
several cysts here in the left breast.
And these are a benign finding
and very easy to distinguish that on a
breast ultrasound of today.

Indeterminate Findings and Biopsy

This is an ultrasound set
of images from an outside facility.
The patient came to us for a second opinion.
She had an abnormality
or a questionable abnormality in outside mammogram,
and then had an ultrasound that was indeterminate.
You see that this is a poor ultrasound set of images.
It's difficult to tell what is fibro glandular tissue.
Is this a real lesion
or basically a fake out Because of the way
that this patient's breast was scanned,
we repeated the ultrasound in our facility
and within the right breast,
you see there is a hypoechoic irregular mass.
It's taller than wide. It is not well circumscribed.
It has irregular borders, it has decreased
through transmission, and this is a sagittal image of it.
And here we have a transverse image of it.
This hypoechoic mass is suspicious and required a biopsy.
And on this image here you see
that we're performing a needle biopsy
and here is a needle biopsy going through the lesion.
This was an invasive ductal carcinoma.
We were able to do this biopsy under ultrasound since
the we were able to find this mass ultrasound.

Incidental Findings

This next case is a 55-year-old that comes in
with a palpable lump in the right breast.
You see, she also has dense breast tissue.
Here is the right craniocaudal view, left right MLO view,
left MLO view.
We cannot distinguish any abnormality on this mammogram,
but her tissue is dense,
which may limit our sensitivity mammographically.
So here we have at the patient's area
of palpable thickening on ultrasound, she has a simple cyst.
It's anechoic. It has increased
through transmission well circumscribed.
So this is what she felt.
However, while we were in the right breast scanning the
whole breast, we also found an incidental cancer.
This is an irregular mass with irregular borders.
It's solid. And this turned out to be carcinoma.

Complicated Cysts

Complicated cyst may be hypoechoic.
They may have multiple low level echoes
because there's a lot of pernicious material
and debris blood within them.
They frequently may have posterior acoustical enhancement.
These may need to be aspirated to know
for sure what's going on.
This is a young patient with a strong family history
of breast cancer and presents
with a left lump to our facility.
And here you see that typical heterogeneous dense
glandular pattern of her mammogram
and her lump in the left breast Turns out to be this
complicated cyst.
It has a cystic component solid component to it.
It has mildly increased through transmission.
This a needle biopsy was just an aspirated cyst
and a benign finding.

Sonographic Features and Predictive Values

Hong published some important data in a JR in 2005
about solid masses
and he used the BI-RADS for ultrasound
and positive
and negative predictive values of sonographic features.
He had 403 solid masses by ultrasound
that had undergone biopsy
and were analyzed by the BI-RADS lexicon.
What he found was top predictors of malignancy,
which he has outlined here in this table
by using the BI-RADS lexicon.
If the lesion is round, he only had a few of those
for a hundred percent malignant.
If it's speculated 19 outta 22
or 86% of a malignant, if there's an echogenic halo,
70% malignancy rate, if it was not parallel
to the chest wall, 69% irregular border, 62%.
He also looked at top predictors
of benign findings using the BI-RADS lexicon.
If he was hyperechoic, meaning more echoic than the rest
of the breast tissue, all
of the lesions he had were a hundred percent benign.
If it was a complex
or complicated cyst, 18 outta 20 90% were benign.
If it was well circumscribed, 90% benign.
If it was oval, 84% benign.
If there was no posterior enhancement, 79% were benign.

Benign Nodules

So for the benign nodules, there's several of these.
We have lymph nodes on this list.
Fibroadenoma, lactating adenoma, galactocele, fat necrosis,
papilloma, fibroadenomas.
We're gonna talk about each one of these.
This is a young patient.
She's 32 and she's currently breastfeeding.
She presents with a right breast lump.
So we can see here,
this is the mediolateral oblique very dense breast tissue.
The same thing on the craniocaudal view.
You cannot distinguish a lump in her breast.
But when we do ultrasound, we do see this
hypoechoic region, which is smooth.
So there's a mass here, which you can see
within the right medial breast, it's ovoid shaped.
And this on small needle biopsy was a lactating adenoma,
which is a benign finding.
Another young patient breastfeeding also with mass
presenting for evaluation to our center.
And so we see here that there is a nodular region
that you can see on the craniocaudal view.
And here it is on the mediolateral oblique view.
This on ultrasound turned out to be a partially cystic mass.
You do see the cystic component, which is anechoic here,
but also there's some solid component within it.
The borders are fuzzy, they're not smooth outlined.
You see a solid component here to this.
And we aspirated this.
And this was an infected galactocele,
basically an infected pocket of milk.

Spontaneous Discharge and Ductogram

This is a patient that comes in with spontaneous discharge.
And when we do have patients that come in like that,
we evaluate them when we frequently have
to do what's called a ductogram, which is find the duct
that's leaking from the nipple and cannulate it
and inject non ionic contrast to outline
the ductal structures and see if there's a mass
or what's causing the discharge.
In this patient. You see a linear filling defect here
on this ductogram image
and it also persists on the orthogonal view.
So this patient had a mass that was causing her discharge.
So we're able to go to ultrasound next
and find the dilated duct
and the mass within the duct, which you can see here.
And here's another look at the mass
within this dilated duct.
So the mass is causing obstruction here
and it's creating fluid
and it's also causing the leakage
of the fluid at the nipple.
This on needle biopsy was a papilloma,
which is a benign growth that can occur in the duct
and can cause discharge.

Evaluation of Malignant Lesions

So when we talk about imaging
and evaluation of malignant lesions, we think of
the several important articles, specifically the article by
Tom Stavros.
That was a landmark article.
He characterized malignant benign
and indeterminate findings.
This was published in radiology in 1995.
The malignant findings are spiculation.
Angular margins, marked hypogenicity shadowing,
calcification, duct extension, branch pattern,
microlobulation.
Also, he had several benign findings.
He put everything in the benign category if he,
they didn't have any malignant findings,
if they were intensely hyperechoic,
if they had ellipsoid shape
or gentle bilobular ovations if they were thin
or had an echogenic pseudocapsule.
Indeterminate findings, well, there's a lot of things
that could be in the indeterminate category.
If there were isoechoic, if there were mildly hypoechoic,
if they had normal sound transmission,
if they had enhanced transmission,
if there were heterogeneous texture,
as I showed you earlier on some
of the earlier ultrasound images
or homogeneous texture, so many things
that don't quite fit in the malignant
or the benign category are in the indeterminate category.
But some things definitely can be in more than one.

Case Example: Multiple Lesions

This is a case of a 55-year-old
that had a history cyst presented with a palpable lump.
And you see this dense glandular tissue.
I showed you this earlier.
This is a patient that it's important
to have her in more than one category
and I'm gonna show you again why.
So this is her right breast.
The mammogram shows dense breast tissue.
We really do not see an abnormality here neither on the cran
caudal or the mediolateral oblique view.
Bilateral ultrasound was performed.
We always do bilateral ultrasound.
When we have a patient coming in with a concern,
her lump was at nine o'clock.
But we also located the second lesion at six o'clock.
So as I showed you earlier, the nine o'clock mass was cyst,
but the six o'clock was an
incidental invasive ductal cancer.
So it's important when you're there
and you're doing ultrasound not to stop
and have satisfaction of search.
You found a cyst in what she's feeling
or her area of concern, but you're holding the ultrasound.
It'll take just a few more minutes to go ahead
and image the rest of the breast.
And an incidental cancer was found.

Advantages of Ultrasound

Ultrasound advantages are many.
The low cost, no radiation, it's fast,
it's comfortable to the patient.
They're lying supine as opposed
to in an uncomfortable position for other testing that we do.
And it's real time. You're actually seeing abnormalities
or you're correlating with what you're feeling,
you're palpating the area, you're finding a cyst,
you're able to do real time on time.
Correlation, we use second look ultrasound for our patients
after we do MRI and we find an MRI abnormality.
It has helped us in many situations.
Otherwise, the patient will be subjected
to an uncomfortable MRI biopsy.
So second look ultrasound has had quite a bit published.
There is some of the landmark articles such
as enta in radiology in 2003.
Her article showed that second look ultrasound failed
to identify the abnormality in up to 77% of the cases.
So she found an abnormality with MRI in a patient
that had a reason to have an MRI and went back
and looked with ultrasound to find that MRI abnormality
and she couldn't find it in 77% of the cases.
However, when she was able to find an ultrasound correlate,
those patients had a higher incidence of cancer, 43%.
But even when she couldn't find an ultrasound
correlate, she couldn't give up.
You had to keep going because 14%
of those patients could have cancer.

Indications for Breast MRI

Indications for breast MRI is there are several,
but specifically the diagnostic arena
is for extent of disease.
And what that means is patients that just got diagnosed
with breast cancer and
before they go to surgery, you wanna really help the surgeon
plan out the surgical approach
and wanna measure the lesion in more than just
with the mammogram or ultrasound.
And these are extent of disease.
You also wanna do this preoperatively.
It's much easier to go ahead
and look for extent of disease prior to any surgical
intervention because surgery causes a lot of changes
and that makes it a bit difficult.
You also wanna do sometimes in post lumpectomy patients
if the margins are not clean
or are close, you want to see if a patient
that's on chemotherapy
for their breast cancer is responding.
You want to look for a recurrence in patient
that has a history of breast cancer in the past
and a questionable workup.
You wanna look for a primary cancer in patient
that has an axillary lymph node that's positive for cancer.
In patients that have silicone implants, you wanna look
for ruptures and sometimes in very difficult workups such
as the mammogram is confusing or not helpful.
The ultrasound and breast exam are confusing.
A biopsy was indeterminate. MRI may be helpful.
And we use it for high risk screening in patients
that have the genetic that are genetically at risk
for breast cancer or have a personal history
of breast cancer or LCIS.

Extent of Disease Case Example

So in the extent of disease patients, this is a 66-year-old,
I'm gonna show you some examples.
She presents for evaluation
of a lump she felt for two weeks.
You can see this area of coarse calcium.
This is a benign fibroadenoma,
but the patient's lump was not in that area.
Her lump on this tangential magnification mammographic views
right here, you can see lines coming out of this area.
Here is a metallic marker on the skin telling us
that this is what the patient is feeling.
This looks suspicious. Mammographically on ultrasound.
This was also very suspicious.
You see this irregular solid mass
with angular margins.
It's hypoechoic, it has decreased through transmission.
And this was carcinoma and ultrasound guided needle biopsy.
It was an invasive ductal cancer.
So as per our protocol for our center, the patient
went on to have breast MRI to really kind of plan out the surgical approach for the surgeon.
And prior to her surgery, what we saw was
here is her known cancer on the sagittal view
and here it is on the craniocaudal view.
However, this patient has other satellite lesions such
as this one and another enhancing lesion here
and another enhancing lesion here in the superiorly,
which is in the upper inner quadrant.
So she had kind of a background,
a stipple pattern also bilaterally, which speaks
of fibrocystic disease.
But this patient had more than one lesion.
So the MRI was very helpful.
This patient's not a good candidate
for a lumpectomy procedure.
However, to prove that we went ahead
and did second look ultrasound
and on second look ultrasound.
Now that we know in the upper inner quadrant
of her left breast, there is a suspicious lesion
or multiple other lesions.
We found this irregular mass
and we biopsied it under ultrasound.
And this was also invasive ductal carcinoma.
This really made it simple to know what to do
for this patient and what the surgeon had to do.
This patient needed a mastectomy.

High-Risk Screening Case

This is a 41-year-old.
She comes in for a screening mammogram.
She has a history
of prior lumpectomy a few years ago in the right breast
and she scheduled herself
as a high risk screening mammogram.
And MRI, she has a kind
of typical heterogeneously dense glandular pattern
that we see in our young patients.
Here is a magnification view,
however, near the region of her scar.
And we see this lesion. There's a mass right here,
which is medial on the craniocaudal view.
The patient was also scheduled for MRI.
So she went on after a mammogram to have her MRI
and we see this enhancing mass medially, very suspicious.
So now we go ahead and bring the patient
and do targeted ultrasound
of the inner part of her right breast.
And this lesion that's quite subtle, hypoechoic,
angular margins decreased through transmission is here.
And this required a biopsy
and you can see our needle biopsy
going right through it.
And this turned out to be invasive ductal carcinoma.
So here's a needle up here and going through the lesion.
This is a small lesion
so the ultrasound was very helpful
as a second look ultrasound
after the MRI showed us that region.
Also, we could also see it on the mammogram.

Automated Breast Ultrasound

Now automated breast ultrasound systematically scans the breast,
capturing up
to 350 ultrasound images.
These are images that can be manipulated
to produce a 3D reconstruction of the breast.
It combines the ultrasound frames together
and eliminates random variation and noise.
It allows for visualization throughout the entire breast.
Automated breast ultrasound is different than handheld
and will talk a little bit more about it here.
The technical components of this are,
and here you can see what the ultrasound probe looks like,
how the image is obtained.
It obtains a transverse image,
which we're familiar with with our handheld.
This is a cyst here.
It also obtains a sagittal image, which is right here,
which we are also familiar with.
But it obtains a coronal image, which is something new.
And you can see that this patient's very cystic
'cause you kind of get a good look at the entire breast
with this coronal image.
This is a coronal reconstruction.
You see nodules which are in this patient.
And we'll talk a little bit more about the coronal image.
The technical components are we obtain a lateral view,
an AP or frontal view, and also a medial view.
Why do we have to do actually three views per breast?
Sometimes in small breast the patients,
you may not need the medial view,
but in most patients, to make sure
that you don't miss any lateral tissue
or axillary tail tissue
or the far medial tissue, you
probably do need the three views per patient per breast.
So the data acquisition, it's connected to our PACS
and our RIS, allowing us to work list our patient.
We cannot view the images on our PACS currently as of yet.
So we have to read,
although it's connected to the PACS, we have
to do primary read on the proprietary workstation
prior to the scan.
A membrane screen is attached to the end
of the scanning probe.
Here's our scanning probe right here.
And here you see one
of our technologists placing the probe on the patient
to start the image acquisition.
The patient is lying supine very comfortably.
The stabilizing membrane is applied to the scanning probe
and then you use coupling lotion, which is basically,
some ultrasound cream
and that's applied to the breast.
A preview scan is automatically performed by the
by the probe by the station
to determine the patient's breast tissue.
This evaluation is used
to determine the ideal ultrasound imaging parameters.
This is all automatic
so you don't actually have to do anything.
And then you start the actual image
acquisition of that breast.
Here are what the ultrasound unit looks like.
The patient's lying here, the probe will come down
and the technologist will hold it
on top of the patient's breast.
Here is the unit.
You can actually see your images right there.
You're able to do 3D simulated real time interaction,
patient convenience here for sure because they're resting.
And it also does give you some scheduling flexibility.
You can schedule these patients
for the automated breast ultrasound.
Your technologist can do it.
The images are stored
and you can review them later so the radiologist can
be doing other things whether they're biopsies
or MRIs or reading screening mammograms.

Advantages of Automated Breast Ultrasound

So the advantages of using the automated breast ultrasound,
you theoretically because you're doing a lateral, a medial
and also an AP view,
you're demonstrating the entire breast anatomy.
You're also doing proper orientation
and documentation of lesions
and you have better reproducibility.
It may be good for follow-up studies here
where you may detect an abnormality you wanna follow
such as the fibroadenoma.
You wanna follow it over time
to make sure it's remaining stable in size.
You are also getting volumetric data,
which potentially there's a lot of information there
when you're thinking about computer aided detection
of breast lesions down the line.
And also it's easy for our technologists to use
and you don't need long periods of training.
It's time efficient for the radiologist.

Implementation in Workflow

Now how do you implement automated breast
ultrasound in your workflow?
Well you may wanna use it for your high risk patients.
These are patients that have prior history of breast cancer
and the lesion was only seen on ultrasound.
The mammogram did not reveal their cancer to begin with.
In patients that have dense breasts, in patients
that have had prior atypical or precancerous lesions,
you may wanna use it for your diagnostic patients.
For the 3D reconstruction, ultrasound images
of the breast may assist you in identifying in localizing
lesions that could be missed
by conventional breast imaging technology.

History of Automated Breast Ultrasound at Elizabeth Wende Breast Care

The history of automated breast ultrasound in our facility
at the Elizabeth Wende Breast Care,
it started several years ago.
We presented a hot topic at the Radiological Society
of North America in 2005.
These are patients that went onto biopsy
and we did handheld ultrasound, the standard ultrasound,
also automated breast ultrasound.
We also followed up with a pilot study in 2006,
which was conducted under IRB approval.
The hot topic had 41 lesions in 40 patients
and the study cohort was predominantly heterogeneously
dense, dense breasts.
And that's the category
where you really do need the ultrasound
because those are the type of breast density
that you may miss lesions on the mammogram, 93% of them were
that type of breast tissue.
There was a 91% concordance between handheld
and automated breast ultrasound.
Two cases were downgraded from BI-RADS category three
to two one case was upgraded from a BI-RADS three to four.
None of these three cases that were upgraded
or downgraded were cancerous.

Case Example: Concordance

This is an example. This is a 49-year-old presenting
with a history of bilateral cyst.
She has had heterogeneously dense breast.
She has a nodule within the inner part of her left breast.
On the craniocaudal view,
the handheld ultrasound revealed a cyst.
This patient also had automated breast ultrasound
and here's a cyst in the AP projection seen very nicely
in the transverse sagittal image.
Here you see it on the coronal image also very nicely.
So you're able to distinguish this cyst in all three projections.
Here's in the medial projection.
You remember we do an AP lateral and a medial projection.
And here we can see the cyst nicely
when we are scanning the medial part of the breast.
And here's the lateral projection.
Also seeing the cyst nicely in the lateral projection.

Cancer Findings

When we looked at our automated breast ultrasound cancer
findings, we had 15 lesions
that were highly suspicious for cancer.
When we looked at the automated breast ultrasound, 13 out
of 15 were core biopsy proven carcinomas.
The handheld size was 14 millimeters with a range of six
to 31 54% of them were non palpable
and the automated device illustrated all the cancers
on at least one view.
This is another patient, this is a 67-year-old.
She came to us for a second opinion
of a mammographic abnormality.
This is a spiculated mass in the right 12 area.
Here's a handheld ultrasound,
irregular hypoechoic mass on core biopsy.
This was an invasive ductal carcinoma.
Here it is on the automated breast ultrasound
and you see this hypoechoic mass.
So you can see it on the coronal, transverse
and sagittal images.
Here it is on the medial projection
and also on the lateral projection.
So we were able to see it in all three projections.
So we had good correlation between handheld and automated.

Pilot Study Results

The pilot study
that we initiated in 2006 was phase two over our clinical
evaluation with automated breast ultrasound.
The results of that we had 292 screening breast ultrasounds
in 147 participants.
98% were dense breasts.
We looked at the non-recall patient's time that it took us
to do the examination.
And also for the recall patients, it took me longer
to interpret the exam obviously when I was going
to recall a patient that was an average
of 17.5 minutes per breast as opposed to
for the non-recall patients five minutes per breast.
The interpretation time also increased with the breast size
because we had to do additional views
to ensure total breast imaging.
We did find some new findings.
This is a 66-year-old that came in
for a screening mammogram.
She did have the heterogeneously dense breast tissue.
When we did do the automated breast ultrasound,
we identified this hypoechoic area
that you can see on the coronal view here it is on the
transverse and also sagittal images.
And we recall the patient for physical exam
and handheld ultrasound.
On the handheld we saw this kind of partially cystic
and solid region, which on biopsy turned out
to be complicated cyst.

New Findings and Recalls

This is another patient, 36-year-old comes
in for a screening mammogram.
She does have a heterogeneously dense breast.
We were able to see on the AP view here a subtle area
of hyperechogenicity near the nipple
and we can see the ducts
that come in at the nipple here.
So this patient was also recalled
because we wanted to make sure we're looking
at duct ectasia.
Was it the area close to the nipple?
What were we looking at?
So we brought the patient back for a handheld ultrasound
and we did not find an abnormality.
And this was just shadowing
and hyperechogenicity possibly secondary
to the area near the nipple and Cooper's ligaments.

Confirming Known Findings

We were also able to confirm known findings in our patients
that we've been following for years.
This is a 52-year-old that comes in
for a screening mammogram.
She does have dense breasts bilaterally.
We've documented in the past on handheld ultrasound
that she has a prior complicated cyst.
We're able to also find this on automated breast
ultrasound and correlate.
This is a 71-year-old
that came in for a screening mammogram.
She has a known mass in the inner part of the breast
that's been biopsied in the past on handheld ultrasound.
And you see this kind of hypoechoic ovoid structure.
And here we see it in automated breast ultrasound.
And you can see it on the coronal view and also on your trans
and sagittal views.

Recall Workflow

For us
at our center.
Our recall patients, these are patients that are screening
that require additional imaging
to clarify a suspicious area we felt would really benefit
from automated breast ultrasound.
Typically in our facility,
the radiologist will perform the handheld ultrasound.
This way if a patient comes back for additional workup
with mammographic images, a technologist may be able
to scan the patient using the automated
breast ultrasound unit.
And if the exam is normal,
that may eliminate the radiologist having
to spend additional time
and do additional handheld ultrasound.
Of course, if there's a suspicious finding on the
full breast ultrasound, then that patient will go on
to handheld by the radiologist.

Diagnostic Workflow

The diagnostic workflow in our clinic was such as like this.
If the patient has screening mammogram in a normal
exam, they go home.
If there's an abnormal mammogram
and they're here, we'll recall them and do additional views.
If that's benign, they may go home.
The suspicious area doesn't go away.
The radiologist may order automated breast ultrasound
and that's a benign, the patient goes home,
the suspicious area doesn't go away,
or there's a question of the automated device,
then the patient goes to handheld ultrasound
and a breast exam.
That may be okay.
And then the patient goes home or the finding persistent.
We go to core biopsy and possibly MRI if we need to.
If the over here the mammogram's abnormal
and highly suspicious, the patient may go straight
to handheld ultrasound and physical exam
and onto core biopsy and MRI.
So we have found a way
to utilize the automated breast ultrasound in our workflow.

Annotation and Reading

This patient here, you can see that we're able
to annotate right on the coronal view.
You can see the nipple marker.
We're able to annotate an area in question right on the
workstation while we're reading so we can annotate.
This is the patient that we called back
because we didn't know if this was a real finding
or duct ectasia,
the workstation will tell you what breast you're in.
You're able to measure you're, it tells you
how far you are from the nipple.
So the workstation's very helpful as you're reading.
So this is a small hypoechoic area
that you can see on the coronal
and also on the subsequent transverse and longitudinal images.
You can also see it on the medial view and the lateral view.
So when you do find it on every single projection,
definitely that documents
that this needs to come back.
Most of the time this may be in specific material index
or fibrocystic changes,
but you do need to bring the patient back
and do a needle biopsy and make sure
that this is nothing to worry about.

Additional Case: Calcifications

I do have some images.
This is courtesy of Sweden
and the font center hospital.
This is a 50 year old woman comes in for a screening exam.
She was called back for additional exam
because she had several calcifications
in the upper portion of her left breast.
Here is a magnification view
of the upper portion of her left breast.
She does have dense breast tissue
and diffuse calcifications all
through the entire upper quadrant.
The craniocaudal view also
shows diffuse calcifications throughout the right breast.
Views are remarkable.
The patient had three dimensional automated breast
ultrasound and you can see here this is a cross section
of the superior area.
You see distended milk ducts here containing these echogenic
material within there are calcifications.
And you can see that confirmation here
that these distended ducts are full of calcium deposits and inspissated material.
And this is a very suspicious finding on the multi-slice.
You see that this extends throughout these dilated ducts
with the echogenic material within their calcium deposits.
And here this continues on.
It goes from nipple all the way back to chest wall.
These are two millimeter thick slices
and we're deeper closer to the chest wall here.
And this abnormal finding continues in this patient.
And you see that these are hypoechoic regions are a mass like all
through the entire breast.
This is an MRI. And this is courtesy of Dr. Reon.
And you can see that the enhancement here is
diffused in this breast.
There's background enhancement in both breasts
'cause the patient is quite fibrotic.
Here is a sagittal image of this cancer,
which is quite large, measuring 10 by six centimeters
grade three DCIS carcinoma
and also 1.8 by 1.2 centimeters invasive ductal cancer.

Recent Literature on Automated Breast Ultrasound

The recent literature, there's been quite a bit
of literature out about automated breast ultrasound.
This was a paper
that was presented at RSNA in 2008 by Dr.
Hovanesian. And what she found was
that automated breast ultrasound should not necessarily
replace handheld but rather be used in conjunction.
They found that the automated breast ultrasound device
did not identify 9% of the lesions seen on handheld, two
of which were high risk.
They concluded that full field breast ultrasound is time
efficient for the radiologist and
because it's very difficult with handheld
to scan the entire breast.
And it's also time efficient
for the radiologists themselves.
They don't have to be there scanning.
They can read these images later,
however they felt that it may, it should not replace
handheld because it doesn't identify every lesion.
Also, implementation into workflow is difficult
because currently,
although this is changing,
a screening ultrasound is not typically performed
for women with dense breast.
We did look at some additional literature such as
by Kelly.
He actually published this article
on breast cancer detection using automated whole breast
ultrasound and mammography in radiographically dense breast
European radiology this year.
They found that automated ultrasound resulted in significant
cancer detection
improvement compared with mammography alone.
The additional detection in the smaller size
of the invasive cancers may justify the technology's expense
for women with dense breast
and are a high risk for breast cancer.
So these authors clearly understand that it's helpful.
It may find additional small cancers
that will not be perceived for years possibly
until they're larger and more serious.
But they do realize the expense to healthcare that
this device may cause as screening ultrasound currently
is not covered by most insurance companies.
And that may be a cost that the patient may have
to take on.

Future of Automated Breast Ultrasound

So the future of full field breast ultrasound currently we
don't have computer aided detection.
That would really help speed interpretation
because there are several hundred images to sort through.
And workflow continues to be problematic
as we're not necessarily able
to read the images on our third party workstations.
So while we're reading our mammograms,
our handheld ultrasound, our MRIs, we should be able
to read our automated breast ultrasound images too,
but we have to read that on our,
the proprietary workstation for the unit.
And the third thing is there is a learning curve in order
to learn how
to interpret the automated breast ultrasound images.
While it takes a long time early on,
you do get better at identifying lesions,
at identifying Cooper's ligaments or duct ectasia,
but there's definitely a learning curve, a curve like
with any other modality.

Conclusion

And that brings us to the end of our talk.
Thank you very much.