← Back to Browse
Ask AleraHome
ULTRASOUND
BreastDemonstration data

Breast Ultrasound

Breast ultrasound is the principal adjunct to mammography for characterising masses, guiding biopsy and screening women with dense breasts. Using standardised BI-RADS ultrasound descriptors it distinguishes simple cysts from solid masses and stratifies solid lesions by malignancy risk. Elastography adds tissue-stiffness information, and the axilla is assessed for abnormal nodes.

Indications

  • Characterisation of a palpable lump or focal breast symptom
  • Further evaluation of a mammographic mass, asymmetry or architectural distortion
  • Supplemental screening in women with dense breasts or elevated risk
  • First-line imaging in young, pregnant or lactating patients
  • Image-guided biopsy, aspiration or localisation
  • Assessment of the axilla for nodal involvement

Contraindications & Cautions

  • No absolute contraindications; ultrasound is non-ionising and safe
  • Not a standalone replacement for mammography in general screening (limited for microcalcifications)
  • Operator-dependent and time-consuming for whole-breast surveys
  • Very large or fatty breasts may limit whole-breast coverage

Patient Preparation

  • No specific preparation required
  • Supine or supine-oblique position with the ipsilateral arm raised behind the head
  • Correlate with the mammogram and clinical site of concern before scanning
  • Mark and describe lesion location by clock position and distance from the nipple
  • For interventional procedures prepare a sterile field and obtain consent

Technique & Parameters

  • High-frequency linear transducer 12-18 MHz with a dedicated breast preset
  • Targeted radial and antiradial scanning of the lesion in two orthogonal planes
  • Whole-breast survey by quadrants/clock positions with overlapping sweeps when indicated
  • Colour or power Doppler to assess internal and peripheral vascularity
  • Shear-wave or strain elastography as an adjunct to increase specificity
  • Assess the axilla, infraclavicular and internal mammary regions for abnormal nodes

Systematic Review

  • Shape (oval, round, irregular) and orientation (parallel vs not parallel to the skin)
  • Margin (circumscribed vs not circumscribed: indistinct, angular, microlobulated, spiculated)
  • Echo pattern (anechoic, hypoechoic, isoechoic, complex cystic and solid, heterogeneous)
  • Posterior features (enhancement, shadowing, combined) and any calcifications
  • Vascularity on Doppler and stiffness on elastography
  • Associated features and axillary node cortical thickness/hilar effacement

Key Findings & Significance

  • Simple cyst: anechoic, circumscribed, thin wall with posterior enhancement (BI-RADS 2, benign)
  • Probably benign solid mass: oval, parallel, circumscribed, hypoechoic (favours fibroadenoma, BI-RADS 3)
  • Suspicious mass: irregular shape, non-parallel orientation, spiculated/angular margins, posterior shadowing (BI-RADS 4-5)
  • High stiffness on elastography and marked internal vascularity increase suspicion
  • Abnormal node: cortical thickening >3 mm, loss of fatty hilum, rounded shape
  • Complex cystic and solid mass warrants biopsy to exclude malignancy

Differential Considerations

  • Cystic lesion: simple cyst vs complicated cyst vs complex cystic and solid mass
  • Circumscribed solid mass: fibroadenoma vs phyllodes vs circumscribed carcinoma
  • Irregular hypoechoic mass: invasive carcinoma vs fat necrosis vs radial scar vs abscess
  • Shadowing lesion: carcinoma vs post-surgical scar vs fibrosis
  • Enlarged node: reactive vs metastatic vs lymphoma

Pearls & Pitfalls

  • Apply BI-RADS ultrasound descriptors and a final category to standardise risk and management
  • Non-parallel (taller-than-wide) orientation and non-circumscribed margins are strong malignant features
  • Confirm a suspected simple cyst by strict criteria before assigning BI-RADS 2; otherwise aspirate or biopsy
  • Elastography and Doppler raise specificity but do not override suspicious grey-scale morphology
  • Always correlate with the mammogram and inspect the axilla; microcalcifications are better seen on mammography

Structured Report

  • State indication, laterality, technique (targeted vs whole-breast) and correlation with mammography
  • Describe each lesion by BI-RADS descriptors with clock position and distance from the nipple
  • Report Doppler and elastography findings and axillary node status
  • Assign a BI-RADS final assessment category and recommend management (follow-up, biopsy, aspiration)
  • Give a concise impression addressing the clinical question

References

  • ACR BI-RADS Atlas, 5th Edition: Ultrasound
  • ACR-AIUM-SPR-SRU Practice Parameter for the Performance of a Breast Ultrasound Examination
  • Berg WA et al. ACRIN 6666: Supplemental Screening Ultrasound in Dense Breasts. JAMA/Radiology
  • Barr RG et al. WFUMB Guidelines on Breast Elastography

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.