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Diagnostic Review of the Cystic Breast

This tutorial will help you understand the appearance of fibrocystic beast findings on a mammogram, 2D-mode ultrasound imaging, color Doppler, ABVS, and elastography.

Upon completion of this tutorial, the learner will be able to: Describe the sonographic appearance of cystic structures, Correlate mammographic, sonographic, and volume cystic structures, and Identify sonographic breast anatomy. Congratulations! You have completed the ‘Diagnostic Review of the Cystic Breast’ tutorial. Listed below are the key points for this tutorial.  Take time to review the material before you try the final quiz.   Download and print a detailed copy of the Course Review   In this tutorial, you have learned how to: Describe the sonographic appearance of a cystic structure, Correlate mammographic, sonographic, and volume cystic structures, and Identify sonographic breast anatomy.    Siemens Healthineers would like to express our appreciation to Dr. Richard G. Barr M.D., PhD. for sharing his knowledge and providing a critical review of the tutorial content.   eSie Touch elasticity imaging, SieScape imaging, Virtual Touch technologies, Virtual Touch Quantification, Virtual Touch IQ, and ACUSON S2000, are trademarks of Siemens Medical Solutions USA, Inc.   Click on the right arrow to continue. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters and configuration dependent designations are fictional and examples only.   All rights, including rights created by patent grant or registration of a utility model or design, are reserved.   Please note that the learning material is for training purposes only!   For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training.   The Operator Manual shall be used as your main reference, for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. The information in this material contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases.   Certain products, product related claims or functionalities described in the material (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information.   Copyright © Siemens Healthcare GmbH, 2019 This tutorial has images from multiple patients to show the varied appearance of cysts within the breast. Cysts, regardless of location, image within a spectrum from simple all the way to complex. This tutorial offers a high-level overview on biopsy proven cases showing both simple and complex cysts with emphasis on the sonographic appearance.     Each patient presents with their own unique set of signs and symptoms. In this case, the clinical problem includes palpable breast masses and the need to further characterize these areas with a mammogram and sonographic examination. In-depth comparisons are beyond the scope of this tutorial; however, you will find the following information pertinent to imaging the simple cyst.   Click on the right arrow to continue. Mammography is the gold standard for breast screening, and understanding of this modality aids in correlating with other imaging modalities. The mammogram shows fat as gray or radiolucent, while masses, calcifications, and fibroglandular tissue appear radiopaque (whiter) than surrounding tissue.1 The appearance of cystic structures on the mammogram is non-specific, imaging as round circumscribed masses appearing as a radiopaque (white) area on the mammogram.1, 2 As other breast pathologies have a similar radiographic appearance, follow-up with ultrasound aids in the final diagnosis.1, 3, 4   Mammography, like all imaging modalities, has specific positioning for a basic exam. There are multiple views that tailor the exam to each patient with two basic images beginning the exam. The craniocaudal, or CC view, and the mediolateral oblique or MLO are the minimum mammographic views for a routine exam. The view name describes the projection of the X-ray beam producing a characteristic image.    Click the icon below to learn more about mammogram views and the appearance of a cyst on the image.   Click on the right arrow to continue. Learn More about the Mammogram Learn More about the Mammogram Tab TitleTextCraniocaudalThe X-ray beam projects from the superior to inferior portion of the breast. The film markers, placed on the axillary side, simply use the abbreviation CC.5     The CC view of the breast begins with positioning the mammographic system perpendicular to the floor (left). The beam projects from the top to bottom (right).    The ideal CC view includes both the retromammary space and pectoralis muscles (arrow). Including this landmark ensures inclusion of all breast tissue.6   When complete, select the X in the upper-right corner to close the window and continue.MediolateralThe X-ray beam projects on an oblique plane from the upper medial breast to the lower lateral breast. The film markers, placed on the axillary side, use the abbreviation MLO.5   The MLO view of the breast begins with positioning the mammographic system 30 to 60 degrees toward the inferior portion of the breast.5  This rotation shown with this mammographic system would image the left breast. The beam projects from the top to bottom.   The MLO of the breast includes the axilla, axillary tail, and pectoralis muscle margin (arrow).5 Asterisk – lymph nodes.   When complete, select the X in the upper-right corner to close the window and continue. Cyst This MLO image demonstrates the appearance of an ultrasound-proven cyst (arrow). Palpable masses are indicated by the radiopaque markers (open arrows).5   The CC image of the same patient shows the cyst as a less defined area (arrow).   When complete, select the X in the upper-right corner to close the window and continue.  The ultrasound system sends longitudinal waves into tissue and waits for the returning wave.7  The image then displays the amplitude of the returning wave as varying shades of brightness on the image.7, 8  This basic premise is the foundation of sonographic imaging; however, the evolution of signal processing and transducers allows sophisticated use of this data.    This section begins with a discussion of the appearance of a simple cyst on the 2D-mode and color Doppler image. We will then look at images reconstructed from a 3D data set acquired with the ACUSON S2000™ Automated Breast Volume Scanner or ABVS. Finally, there is a discussion of the characteristic features of a simple cyst using eSie Touch™ elasticity imaging.   Click on the right arrow to continue. It is common for the sonographer to see patients after a mammogram to follow up on findings or palpable breast masses. Like the mammogram, fatty tissue displays as medium-gray tissue with dense tissues closer to white on the ultrasound image.9 Ultrasound helps distinguish a solid mass from cystic structures as the cyst has a characteristic appearance. Thus, the complementary imaging modalities, mammography and ultrasound, result in a high specificity and sensitivity for determining the presence of cystic structures.1, 9 The simple cyst requires the following on an ultrasound image:1, 9 Anechoic center Round or oval shaped Well circumscribed borders Thin echogenic walls Posterior enhancement Refraction shadowing Devoid of vascularity Compressible Mobile with transducer pressure Click the icon below to learn more about simple cysts found with ultrasound.   Once you have reviewed the material, click on the right arrow to check your understanding with the Your Turn questions. Learn More about Simple Cysts Learn More about Simple Cysts Tab TitleTextSimple Cyst - 1 This cyst demonstrates an anechoic center (asterisk), posterior enhancement (red arrow), and refraction shadowing (yellow arrows).   When complete, select the X in the upper-right corner to close the window and continue. Simple Cyst – 2   These two simple cysts (asterisk) have thin walls. The larger cyst lies adjacent to the pectoralis muscle (arrow). The marker in the lower right of the image indicate this image is from the left breast taken on the longitudinal plane at the 11 o’clock position.   When complete, select the X in the upper-right corner to close the window and continue. Simple Cyst – 3   These cysts (arrows) are not only anechoic, but also lack vascular flow. This helps establish that these are fluid-filled structures rather than a solid mass.9   When complete, select the X in the upper-right corner to close the window and continue.  Hand held ultrasound imaging is the gold standard for localized imaging; however, whole-breast screening becomes challenging. This is due to a lack of exam standardization and reproducibility, and operator dependence.10 Sonographic automated breast scanning provides the clinician with a method to obtain an image of the breast as a volume data set9 reducing these dependencies. The ACUSON S2000 ABVS is a large transducer unit that acquires sequential images allowing for post-processing of the data into multiPlanar images.11, 12 The ACUSON S2000 ABVS transducer moves across the breast acquiring the data set. The arrow indicates the center with the lines at the outer edges showing the full transducer footprint.   Click the icon below to learn more about simple breast cysts when using the ACUSON S2000 ABVS.   Click on the right arrow to continue.   Learn More about ACUSON S2000 ABVS images Learn More about ACUSON S2000 ABVS images Tab TitleTextImage 1 The image produced by the ACUSON S2000 ABVS when imaging a breast cyst produces the same artifacts as seen with hand held ultrasound (HHUS). On the left side of the image you see an artifact caused by loss of contact (green arrowhead). Refractive shadowing (red arrow) as well as shadowing posterior to the nipple appear. The marker (yellow arrow) indicates the location of the nipple.   When complete, select the X in the upper-right corner to close the window and continue. Image 2 The image produced by the ACUSON S2000 ABVS of normal breast tissue demonstrates the ribs (green arrowheads) and a marker (yellow arrow) indicating the nipple location.   When complete, select the X in the upper-right corner to close the window and continue.  The eSie Touch elasticity imaging creates a strain elastogram providing us with qualitative information on tissue response to strain caused by a longitudinal wave.13, 14 Needing only minimal compression eSie Touch elasticity imaging displays the tissue stiffness relative to the surrounding tissue.15 The simple cyst has a characteristic appearance.   eSie Touch elasticity imaging simple cyst characteristics include16 Bull’s-eye appearance when using Siemens ultrasound systems Posterior echo Click the icon below to learn more about simple cysts on the elastogram.   Once you have reviewed the material, click on the right arrow to check your understanding with the Your Turn question. Learn More about Elastography Images Learn More about Elastography Images Tab TitleTextComparison This dual format image shows the anechoic 2D-mode appearance of a breast cyst and the accompanying bull’s-eye seen on the elastogram (arrows). A cyst also has a bright posterior echo (arrowhead) on the elastogram.16Elastogram This is an example of the bull’s-eye appearance of a cyst (green circle) using black and white hues to create the elastogram. This mapping indicates soft tissue as light and hard tissue as dark. The cyst walls display black which tells us that the cyst walls are stiffer, relative, to the surrounding tissue. The central echo is noise rather than a true representation of stiffness.13 The QF or quality factor of 70 indicates little movement between frames.17, 18 The cyst that shows wall changes or internal echoes is classified as a complex cyst. Sonographic features include the following: Internal echoes due to1, 9 Cellular debris Cholesterol crystals Protein Infection (pus) Hemorrhage Wall changes Thick ≥ 0.5 mm Isoechoic Increased Doppler flow Internal septations ≥ 0.5 mm Fluid-debris level or fat-fluid level ​Homogeneous internal echoes This section has clinically proven case studies showing the full spectrum of sonographic modalities in diagnosing breast-related pathology. Three examples of complex cyst cases give an overview of findings encountered in the clinical setting.    Note: Images have been cropped with measurement boxes and color bars positioned for optimal viewing and resolution.   Case study images courtesy of Dr. Richard G. Barr M.D., PhD Radiology Consultants, Inc, Youngstown, Ohio USA.   Click the icons below to view ultrasound case studies.  Learn More about Apocrine Microcyst Learn More about Apocrine Microcyst Tab TitleTextPatient HistoryAge: 40   Imaging findings: Screening mammogram BI-RADS® category 0 (Incomplete: additional imaging evaluation needed) in the left breast; Ultrasound findings of BI-RADS® category 4A (Low suspicion of malignancy).19   Biopsy findings: Apocrine microcysts.   When complete, select the X in the upper-right corner to close the window and continue. 2D-mode The area of concern in the left breast showed a septated cystic lesion with extension of nodules from the posterior wall. Representative of clustered microcyst occur in approximately six percent of exams. A vacuum-assisted biopsy removed the lesion with pathology confirming apocrine microcysts.   When complete, select the X in the upper-right corner to close the window and continue. CDE Color Doppler energy (CDE) shows flow within the solid nodule. This finding resulted in the ultrasound classification of BI-RADS® category 4A (Low suspicion of malignancy).   When complete, select the X in the upper-right corner to close the window and continue. 2D SWE The 2D shear wave elastography (2D-SWE) image (right) shows the bull’s-eye appearance seen with cystic structures. The nodule appears slightly stiffer than the surrounding tissue.   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about a Complex Cyst Learn More about a Complex Cyst Tab TitleTextPatient HistoryAge: 85   Physical exam: New palpable mass in the left breast   Imaging findings: Screening mammogram BI-RADS® category 0 (Incomplete: additional imaging evaluation needed) for a 2 centimeter mass in the left breast; Ultrasound findings of BI-RADS® category 4B (Intermediate suspicion of malignancy).19   Biopsy findings: Large duct papilloma without atypia.   When complete, select the X in the upper-right corner to close the window and continue. 2D-mode The 2D-mode image shows a large mass with ill-defined borders. There are solid and cystic portions of the mass with fine septations, posterior enhancement and refractive edge artifacts. More than half of the lesion has a solid appearance.   When complete, select the X in the upper-right corner to close the window and continue. CDE CDE imaging confirms flow within the posterior solid component and wall of the mass.    When complete, select the X in the upper-right corner to close the window and continue. Strain Elastogram The bull’s-eye artifact (arrow) confirms the cystic component seen on the 2D-mode image. The solid component of the complex cyst has a darker color coding indicating a stiffer area than the surrounding tissue. This elastogram codes stiff tissue in darker hues and soft tissue as lighter hues.   When complete, select the X in the upper-right corner to close the window and continue. Shear Wave Elastography This image color codes stiff tissue as red (arrow) and soft tissue as blue (arrowheads) based on the shear wave velocity measured in milliseconds (m/s).   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about a Blending Lesion Learn More about a Blending Lesion Tab TitleTextPatient HistoryAge: 55   Imaging findings: Screening mammogram BI-RADS® category 0 (Incomplete: additional imaging evaluation needed) for a 1.5 centimeter mass in the left breast.19   Biopsy findings: Fibrocystic changes and focal fibroadenomaoid hyperplasia.   When complete, select the X in the upper-right corner to close the window and continue. 2D-mode The mass, which corresponds to the mammographic abnormality, shows a heterogenous mass with well-circumscribed borders. The hypoechoic mass also shows a possible microcalcification (arrow).   When complete, select the X in the upper-right corner to close the window and continue. CDE CDE shows flow confirming a solid mass.   When complete, select the X in the upper-right corner to close the window and continue. Strain Elastography The shadow function helps identify the lesion as the borders have less conspicuity on the elastogram (right). This lack of definition is a common finding for masses that have similar stiffness as the surrounding tissue.   When complete, select the X in the upper-right corner to close the window and continue. Shear Wave Elastography The shear wave elastogram shows the mass has similar stiffness as the surrounding tissue. The color hues used for softer tissue with a slower velocity have a blue hue as shown by the color bar to the right of the image.   The green color hues show high shear wave quality within most of the mass. Areas with low-quality shear wave production display as orange. This color mapping simply tells us the quality of the shear wave production rather than tissue stiffness as with other color mapping. If the quality map has a yellow or red hue, the results should not be used in diagnosis.   When complete, select the X in the upper-right corner to close the window and continue.  Simple cysts of the breast are part of the broad term fibrocystic changes, or FCC, of the breast. FCC is a diffuse common breast condition found in women from the third to sixth decade of life.1 Part of hormonal changes that affect the breast, a simple cyst is an epithelial fluid-filled mass arising from dilatation of the terminal duct lobular unit or TDLU.1   Cysts have varied clinical presentation from asymptomatic to palpable. If palpable, they are often mobile and may be tender to the touch. The mammogram shows areas of radiopaque ‘water-density’ with a radiolucent halo due to compression of the surrounding tissues.1 Sonography demonstrates an echo-free area we label as anechoic.    Click the icon below to learn more about ultrasound breast anatomy and simple breast cysts.   Once you have reviewed the material, click on the right arrow to check your understanding with the Your Turn questions. Learn More about the Breast Anatomy Learn More about the Breast Anatomy Tab TitleTextCriteria for Simple CystsThis is a review of the sonographic findings of a simple cyst.1, 9, 16   2D-mode Oval or round Circumscribed smooth margins Echogenic thin walls Anechoic central component Posterior enhancement Refractive shadowing   eSie Touch elasticity imaging Bull’s-eye appearance Posterior echo   Other findings Lack of Doppler flow Often compressible Mobile   When complete, select the X in the upper-right corner to close the window and continue. Ultrasound Anatomy This image demonstrates the normal adult female breast. Scroll down to view images labeled with each layer.1, 9   The skin (highlighted) is closest to the transducer.    The next layer is the subcutaneous fat (highlighted).   This is the premammary zone (highlighted) which contains fat and the supporting structures of the breast called Cooper’s ligaments. In some settings, the skin, subcutaneous fat, and premammary zone are grouped into a single layer called the subcutaneous layer.    This is the mammary zone or fibroglandular tissue (highlighted) which contains lobules radiating from the nipple, lactiferous ducts, and fatty tissue.   This is the retromammary zone (highlighted).   This is the pectoralis major muscle (highlighted) with shadowing from a rib (asterisk).   When complete, select the X in the upper-right corner to close the window and continue. Importance of the TDLUArranged in lobes within the mammary layer, the terminal duct lobular units (TDLU) are the functional component of the breast.1, 8 Most breast masses, whether benign or malignant arise from the TDLU1 which has intra- and extralobular components as well as a terminal duct, ductules and interlobular stroma.8 The normal sized TDLU is 1-2 mm and usually not seen with ultrasound. In the case of a simple cyst, TDLU obstruction and the resulting dilatation produce the characteristic imaging findings.1 It is possible to have cysts arise from central breast ducts; however, this is a less common occurance.8   Scroll down to see how a cystic structure appears as the extralobular terminal duct, or ETD, becomes obstructed.   The hyperechoic glandular layer (open arrow) contains the TDLU.  The ETD (green arrow) leads to the TDLU (arrow head).8   As the ETD (open arrow) becomes obstructed, fluid within the TDLU increases resulting in a cystic structure (asterisk).8 Double arrow – pectoralis major muscle.   This is a breast image of a lactating woman. The lactiferous duct (arrow) connects the TDLU to the nipple.8   When complete, select the X in the upper-right corner to close the window and continue.  Explore the links below for the Glossary, References, and Further Reading opportunities. Glossary Glossary 2D shear wave elastography (2D SWE) – The display of shear wave speed within a user adjustable ROI as a color overlay on the 2D-mode image.   2D-mode imaging (i.e., brightness mode, grayscale, B-mode) – Ultrasound display of the amplitude of echoes returning from the body.  The higher the amplitude, the brighter the display.   Anechoic – Devoid of echoes.   Doppler imaging – Display of motion, such as blood flow, as a spectral tracing or color mapping.   Echogenic – Having brighter / lighter appearance than the surrounding tissue on a 2D-mode image.   Elasticity – Ability of a structure to return to its original shape after compression.   Elastogram – The image demonstrating tissue strain or stiffness as a color overlay.   Elastography – An imaging method to map the elastic properties of tissue (i.e., hard vs. soft) to provide information on changes due to disease.   eSie Touch elasticity imaging - The conversion of tissue strain to an elastogram using external compression and pixel correlation between image frames. Fibrocystic changes (FCC) – Normal, age-related changes to the breast that include lumpiness and tenderness due to formation of cysts or hormonal influences.   Longitudinal wave (i.e., compression wave) – A sound wave from the transducer into the tissue and vice versa.   Posterior enhancement – An increase in brightness deep to a cystic structure.   Precompression – Compression applied to a tissue before beginning the acquisition of elastogram data.   Qualitative – Subjective assignment of value, in elastography we assign a hue to tissue stiffness changes as it relates to the surrounding tissue.   Quality Factor (QF) – Measure of movement on an elastogram between image frames.   Radiopaque – Blocking of X-rays appearing lighter on the image.   Radiolucent – Allows passage of X-rays appearing medium-gray to black on the image.   Refraction artifact – A darker area extending from the edge of structures of differing densities such as tissue and a cyst.   Region of interest (ROI) – Selection of an area on the image.   Shadowing – Blocking or reflection of sound resulting in a dark area deep to a structure.   Stiffness – Tissue deformation in response to force (i.e., compression).   When complete, select the X in the upper-right corner to close the window and continue.   References / Further Reading References / Further Reading 1. Carr-Hoefer, C. (2012). The breast. In Kawamura, D.M. and Lunsford, B.M., (Eds.), Diagnostic medical sonography: Abdomen and superficial structures  (pp. 471-527). Baltimore: Wolters Kluwer Health | Lippincott Williams & Wilkins.   2. Bassett, L. and Conner, K. (2003). Imaging of the breast. In Kufe, D.W., Pollock, R.E., Weichselbaum, R.R., et al., (Eds.), Holland-Frei cancer medicine  (pp. Hamilton: B.C. Decker Inc.   3. Berment, H., Becette, V., Mohallem, M., Ferreira, F., and Chérel, P. (2014). Masses in mammography: What are the underlying anatomopathological lesions? Diagnostic and Interventional Imaging. 95(2): 124-133.   4. Doo, M.S. (1998). Breast imaging. In Provenzale, J.M. and Nelson, R.C., (Eds.), Duke radiology case review: Imaging, differential diagnosis, and discussion  (pp. 59-104). Philadelphia: Lippincott - Raven.   5. Andolina, V. and Lillé, S. (2010). Mammographic positioning. In Andolina, V. and Lillé, S., (Eds.), Mammographic imaging: A practical guide  (pp. 100-159). Philadelphia: Wolters Kluwer | Lippincott Williams & Wilkins.   6. Popli, M., Teotia, R., Narang, M., and Krishna, H. (2014). Breast positioning during mammography: Mistakes to be avoided. Breast Cancer. 8: 119-124.   7. Hedrick, W. (2013). Technology for diagnostic sonography. St. Louis, MO: Elsevier.   8. Stavros, A.T. (2011). The breast. In Rumack, C.M., Wilson, S.R., Charboneau, J.W., et al., (Eds.), Diagnostic ultrasound  (pp. 773-839). St. Louis: Elsevier Mosby.    9. Matthew, D. and Rapp, C. (2016). Possible breast mass. In Sanders, R.C. and Hall-Terracciano, B., (Eds.), Clinical sonography: A practical guide  (pp. 713-734). Philadelphia: Wolters Kluwer.  10. Berg, W.A., Blume, J.D., Cormack, J.B., and Mendelson, E.B. (2006). Operator dependence of physician-performed whole-breast US: Lesion detection and characterization. Radiology. 241(2): 355-365.   11. Shin, H.J., Kim, H.H., and Cha, J.H. (2015). Current status of automated breast ultrasonography. Ultrasonography. 34(3): 165-172.   12. Wojcinski, S., Farrokh, A., Hille, U., Wiskirchen, J., Gyapong, S., Soliman, A.A., . . . Hillemanns, P. (2011). The Automated Breast Volume Scanner (ABVS): Initial experiences in lesion detection compared with conventional handheld B-mode ultrasound: A pilot study of 50 cases. International Journal of Women's Health. 3: 337-346.   13. Bamber, J., Cosgrove, D., Dietrich, C.F., Fromageau, J., Bojunga, J., Calliada, F., . . . Piscaglia, F. (2013). EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall in Med. 34(02): 169-184.   14. Barr, R.G., Nakashima, K., Amy, D., Cosgrove, D., Farrokh, A., Schafer, F., . . . Kudo, M. (2015). WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 2: Breast. Ultrasound in Medicine and Biology. 41(5): 1148-1160.   15. Garra, B.S. (2015). Elastography: history, principles, and technique comparison. Abdominal Imaging. 40(4): 680-697.   16. Barr, R. (2011). The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Quarterly. 27(3): 151-5.   17. Barr, R.G. (2015). Breast elastography. New York: Thieme.   18. Calvete, A.C., Rodríguez, J.M., de Dios Berná-Mestre, J., Ríos, A., Abellán-Rivero, D., and Reus, M. (2013). Interobserver agreement for thyroid elastography: Value of the quality factor. Journal of Ultrasound in Medicine. 32(3): 495-504.   19. Raza, S., Goldkamp, A.L., Chikarmane, S.A., and Birdwell, R.L. (2010). US of breast masses categorized as BI-RADS 3, 4, and 5: Pictorial review of factors influencing clinical management. RadioGraphics. 30(5): 1199-1213.   When complete, select the X in the upper-right corner to close the window and continue.

  • elastography
  • ABVS
  • ultrasound
  • sonography
  • breast