Diagnostic Review of Spiculated Masses in the Breast-USA

Upon completion of this tutorial, the learner will be able to: List the 2D-mode appearance of spiculated masses, Describe the methods of data acquisition used to create the elastogram, and Explain methods to improve the ultrasound image. Click on the right arrow to continue. Congratulations! You have completed the ‘Diagnostic Review of the Spiculated Mass’ 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: List the 2D-mode appearance of a spiculated mass. Describe the methods of data acquisition used to create the elastogram. Explain methods to improve the ultrasound image. 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. and syngo® is a registered trademark owned by Siemens Healthcare GmbH.   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.   ACUSON Sequoia is a trademark of Siemens Medical Solutions USA, Inc.   Copyright © Siemens Healthcare GmbH, 2019   In the global community, breast cancer is the most common malignancy occurring in women regardless of race, geography, or socioeconomic status.1 The incidence increases with age for this multifactorial cancer, with most cases occurring in women without a family history.  Though less common, men also develop breast cancer. There is a genetic predisposition towards breast cancer due to mutations on specific genes known as BRCA1 and BRCA2.1 Thus, it becomes difficult to precisely link a cause to the development of breast cancer.   Early diagnosis is the best treatment with breast malignancies, which, regardless of type, present with specific imaging findings.  This tutorial provides a high-level overview on proven cases demonstrating spiculated masses on mammography 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, mammographic abnormalities, and the need to further characterize these areas with imaging studies. In-depth explanations of normal breast anatomy or pathology comparisons are beyond the scope of this tutorial; however, you will find the following information pertinent to imaging the spiculated mass.   Click on the right arrow to continue. Mammography remains the mainstay of cancer diagnosis of the breast in both symptomatic and asymptomatic woman.1 The screening mammogram is the routine method to check for changes using craniocaudal (CC) and mediolateral oblique (MLO) views of each breast.    In the presence of clinical symptoms or suspicious findings a diagnostic mammogram becomes the next step in diagnosis.2  If the initial mammogram reveals areas of architectural distortion or was not clearly visualized, additional views may be required.  These include not only the standard screening images but magnification and spot compression views.2 3 The area of concern determines the views needed to image the breast.   Click the icon below to learn more about spot, and magnification views.   Click on the right arrow to continue. Learn More about the Mammogram Learn More about the Mammogram Tab TitleTextSpiculated Mass on MLO   This MLO shows an area of architectural distortion in the right breast (circle).  Extensions of the suspected mass (arrows) indicate growth into the surrounding tissue.  N – nipple.   When complete, select the X in the upper-right corner to close the window and continue. Spot CompressionSpot compression of an area of the breast attempts to decrease tissue overlap and minimizes patient movement.2  To perform spot compression views, the technologist utilizes a small paddle or one with a raised compression area (see photographs).4, 5  These views aid in determining the level of concern for focal asymmetries of the beast by separating overlying tissues and increasing border definition of masses.4     Compression paddles. Large – left photo, spot compression only – middle photo, and large (right photo) with centrally located spot compression.  Use of spot compression increases resolution due to the reduction of tissue thickness.  The compression area is also closer to the imaging plate further increasing resolution.4   When complete, select the X in the upper-right corner to close the window and continue. MagnificationMagnification views help with diagnosis by allowing for enlargement and increased resolution in an area of concern.2  Using a magnification stand and either a spot compression or large compression plate, this technique requires positioning of the breast on the magnification attachment.  Moving the mass further from the imagining plate brings the breast closer to the X-ray tube focal spot and allowing for magnification.3     Examples of magnification attachments (lower arrow) and compression paddles (upper arrow) on Mammomat digital mammography systems.  The mammographic system on the left shows spot compression with the magnification attachment (spot magnification).  The right shows a full-sized paddle with the magnification paddle.  Both aid in macrocalcification characterization and mass boundary detail assessment.6 This magnified spot compression view shows irregular borders of a suspicious area within the breast.   When complete, select the X in the upper-right corner to close the window and continue.    This section begins with a discussion of 2D-mode and the appearance of biopsy proven malignancies in the breast.  We will then look at how we obtain a 3D data set with the ACUSON S2000™ Automated Breast Volume Scanner, or ABVS. There is a discussion of elastography and the characteristic features of the spiculated breast masses. Actual patient case studies show malignancies using multiple ultrasound modes.   Click on the right arrow to continue. Breast malignancies have a characteristic appearance with only one needed to raise suspicion for a cancerous lesion.7 Characteristics used to determine the level of concern include the following:7-10 Angular, branching tumor extensions into tissue (spiculations and microlobulations). Anteroposterior (AP) height is greater than the transverse width (taller-than-wide). Margins with sharp angles. Hypoechoic to fat. Posterior shadowing. Calcifications. Growth through tissue planes. Echogenic halo (desmoplastic response). Compare the images below of a spiculated mass and a simple cyst.   Click the icon below to learn more about biopsy proven malignancies 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 2D-mode Learn More about 2D-mode This 2D-mode image of a breast mass shows multiple malignant characteristics.  Yellow arrows – growth through tissue planes; Orange arrow – posterior shadowing; Asterisk - heterogenous interior. Take note of the branching, angular extensions of the mass borders into the surrounding tissue. This image of a simple cyst (asterisk) has a different appearance.  Shadowing occurs with both; however, the refractive shadowing extends from the lateral borders of a cyst (yellow arrows).  Enhancement or a brightening of the image occurs posterior to a cyst (red arrow).7   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about Breast Cancer Learn More about Breast Cancer Tab TitleText2D-mode   This image shows a mass (asterisk) with a branching pattern.  Branches appear as hypoechoic extensions (open arrow) into the breast tissue. The pectoralis muscle lies posterior (double arrows) having a characteristic linear pattern.  Notice the hypoechoic, posterior shadowing over the pectoralis muscle due to the anteriorly located mass.   When complete, select the X in the upper-right corner to close the window and continue. CDV   This color Doppler image shows flow within a biopsy proven ductal carcinoma in-situ.  The presence of flow within a mass does not separate malignant from benign masses.7, 9 Flow or the absence of flow simply helps us separate solid masses from a cyst or abscess.7, 9, 11 If you image a solid mass and do not find flow it may be due to compression or technique errors.  Excessive pressure potentially collapses vessels obstructing slow flow seen in a breast mass.7  Simply decrease compression.  Technique adjustments include ensuring appropriate color box angle, decreasing the color scale, and using color Doppler energy capabilities (CDE).12   When complete, select the X in the upper-right corner to close the window and continue.  The ACUSON S2000 ABVS is a large mechanical transducer that acquires multiple sequential images to create the 3D data set.  On the 2D image we use information displayed on the X and Y plane.  When we add multiple images, we create the Z-plane going from the pixel to the voxel.13    Click the icon below to learn more about biopsy proven breast cancer when using the ACUSON S2000 ABVS.   Click on the right arrow to continue.   Learn More about How the ACUSON S2000 ABVS Works Learn More about How the ACUSON S2000 ABVS Works Pixels on the X and Y plane make up the 2D-mode image.  These two diagrams show a single pixel as a colored square. Adding the Z plane, using multiple images creates the voxel and depth of an image.14     The ABVS transducer, seen in the photo above, has a bandwidth of 5 – 14 MHz with a 15 x 17 cm field of view.15 This transducer comes with Hanafy lens transducer technology helping to increase the lateral, axial, and elevational resolution.13, 15, 16 The transducer component moves in a linear manner to obtain a volume data set.7, 17  Data acquired in this manner creates the image. The Z-plane provides the data to create a coronal image.7, 17   Note:  Data acquired results in a rectangular format parallel to the transducer.  The diagram image angle is for demonstration purposes only.   When complete, select the X in the upper-right corner to close the window and continue.  Learn More with ACUSON S2000 ABVS Images Learn More with ACUSON S2000 ABVS Images Tab TitleTextMedullary CancerAn uncommon tumor occurring in younger women, medullary cancer, has a characteristic cellular composition.   These neoplasms have plasma cells and lymphocytes resulting in a sonographic appearance mimicking a cystic structure. This round or oval mass has a hypoechoic to anechoic center with accompanying posterior enhancement. Even with these misleadingly benign sonographic characteristics, medullary cancer demonstrates at least one irregular peripheral boundary 9, 11 or focally thickened wall.18  There is also a greater chance of finding enlarged axillary lymph nodes in the presence of medullary cancer.18 In this case, CDV or CDE would identify internal vasculature with the exception of necrotic or hemorrhagic areas confirming a solid mass.9     This cropped ACUSON S2000 ABVS image shows an area of medullary cancer tumor invasion into surrounding tissue (arrow). Note the posterior enhancement that always accompanies medullary carcinoma.9 This is an image of the right breast of a 48-year-old woman showing the location and gross ultrasound appearance of a medullary cancer (calipers).  This type of neoplasm requires careful attention as similar characteristics, such as posterior enhancement, also occur with a simple cyst.9 The body marker, located in the lower left, indicates this is a transverse image of the right breast. The reverberation artifact seen at the right (R) marker indicates a lack of contact with the patient.  To remove this artifact, apply ample lotion. These are reconstructed images of medullary cancer (arrows) from the ACUSON S2000 ABVS data set using syngo®. Ultrasound Breast Analysis (sUSBA). The left is a coronal reconstruction using the Z-plane data. The top right shows the transverse plane while the bottom right is the longitudinal plane.   When complete, select the X in the upper-right corner to close the window and continue. IDC-1Invasive ductal carcinoma (IDC), is the most common breast cancer spreading into surrounding tissues. This allows metastatic spread via blood vessels and lymphatics. If palpable, this hard, fixed mass most often occurs in the upper outer quadrant of the breast.11   Sonographic features of IDC include a heterogeneous mass with a hypoechoic interior architecture and irregular, spiculated borders.  The amount of posterior shadowing depends on the tumor composition and the surrounding tissue invasion.11   This 3-on-1 hanging protocol of a 3D ultrasound of the breast shows the scanned area on three orthogonal planes. This palpable mass in the right breast shows a biopsy proven invasive ductal carcinoma with focal invasion of the skeletal muscle. IDC – asterisk; Nipple – arrowhead; Ribs - solid, double arrows; Pectoralis muscle – open arrow.   When complete, select the X in the upper-right corner to close the window and continue. IDC-2 This MultiSlice feature displays a series of biopsy proven invasive ductal carcinoma images.  Tumor extensions image on multiple areas of the mass. Small yellow boxes – nipple.   When complete, select the X in the upper-right corner to close the window and continue. IDC-3 This 3-on-1 hanging protocol 3D ultrasound display shows the appearance of biopsy proven invasive ductal carcinoma.  Use the orientation markers to help you determine the location of the mass. The body marker, found in the lower left of each image, indicates these images show the right breast. A – Anterior; H – Patient head; Small yellow square - nipple. Image courtesy of Michael Golatta, MD – University of Heidelberg, Germany.   When complete, select the X in the upper-right corner to close the window and continue. ILCInvasive lobular carcinoma (ILC), the second most common breast cancer, shows diffuse growth within the tissue.9, 11  Presenting with a range of symptoms, the patient may complain of a hard-palpable mass or a ‘thickening. The sonographic appearance of ILC includes an ill-defined, irregular, solid area with shadowing.11  A ring of hyperechoic tissue around an ILC mass represents tumor infiltration rather than the desmoplastic response seen with other cancers.9 Subtle architectural distortions also raise suspicion for ILC.9, 11   This coronal colorized view of the left breast shows biopsy proven invasive lobular carcinoma.  The cancer, located superior to the nipple (yellow square) has a stellate appearance indicating spread to the surrounding tissue.9   When complete, select the X in the upper-right corner to close the window and continue.  Virtual Touch™ technology encompasses multiple methods of determining and displaying the elastic properties or stiffness of tissue.19 Multiple studies on the breast show how malignant growths differ in stiffness compared to normal tissue.20-23  To understand how tissue stiffness translates to the elastogram, you must understand basic principles of tissue stiffness and elasticity.   Something to remember: stress and strain differ.  Stress is how much compression we use while strain is the amount of change in the mass. 20  Neither stress or strain change the masses volume.20   The elastogram measures small changes in tissue volume. Click the icon below to learn more about the mechanical properties of tissue.    Learn More About Mechanical Properties Learn More About Mechanical Properties Tab TitleTextLongitudinal StrainThe compression or stretching of tissue is what we call longitudinal strain or normal strain.19  We have all seen how a mass changes with transducer pressure on a 2D-mode image.  This represents the change in a mass on the axial plane.19 Elastography uses the amount of change to determine the stiffness of tissue. Let’s look at longitudinal strain.   To begin, we know the length of a mass before compression (dual arrow) and then use the change in length (dotted line) to determine the longitudinal strain.19, 24 Think of a rubber band and how we can change its length.   If we measure the unstretched rubber band and then measure after stretching we can calculate the amount of change. The same applies for tissue changes. To calculate the longitudinal elasticity divide the change in length by the original length.  The Formula   εl = ΔL         L εl = Longitudinal stain or longitudinal elasticity ΔL = The change in length L = The original length   Strain has no unit as it simply calculates the proportion of change. This is why eSie Touch™ elasticity imaging and  Virtual Touch™ imaging (VTi) are qualitative methods as these relative changes provide the data to create the elastogram.25    Longitudinal strain is only one type occurring in tissue.  Click the tab to see how shear strain changes a mass.   When complete, select the X in the upper-right corner to close the window and continue. Shear StrainLet’s now consider the second type of strain, called shear strain. This type of strain occurs when a mass twists or bends with anterior to posterior (AP) compression.19  Remember, shear strain changes tissue shape but not the volume. To begin, we know the angle of a mass before compression (perpendicular dotted line) and then use the angle or stress change (angled dotted line) to determine the shear strain.19, 24 We then calculate the angle to determine the change determining the shear strain.    The Formula   εs = tan (θ) εs = Shear strain or shear elasticity tan = tangent θ = cosine of the angle   Shear strain is only one type occuring in tissue.  Click the tab to see how longitudinal strain changes a mass.   When complete, select the X in the upper-right corner to close the window and continue. Tensile and Compressive StrainWe should remember that even though the elastogram displays as a 2D-mode image with a color overlay, the mass also has depth.   Any structure has a length, width, and height, thus, stress and strain act on all dimensions.  In breast ultrasound imaging, tensile strain describes length changes in a mass due to anteroposterior compression.   Compressive strain is when the breast mass returns to its original length.  In the heart, tensile strain occurs with diastole when the heart muscle relaxes while compressive strain occurs during systole when the heart contracts.   These types of strain become important when calculating Young’s Modulus also known as the modulus of elasticity.     When complete, select the X in the upper-right corner to close the window and continue.  The compression elastogram displays a qualitative color map of tissue stiffness relative to the surrounding structures. When obtaining the image, use light steady compression.   This image shows an elastogram of a biopsy proven, DCIS using eSie   Touch™ elasticity imaging. The tumor mass shows the expected stiffness when compared to the surrounding tissue.20, 24, 26 To determine stiffness, use the color scale located to the left of the image (enlarged).  This color map uses red for soft tissue and blue for stiff tissue.   We can see that the hypoechoic mass on the 2D-mode image (left dual) has a stiffer composition as shown by the blue color assignment on the elastogram (right dual).  To ensure a reproducible image, ensure the Quality Factor or QF has a value above 50.24, 27   Click on the right arrow to continue. Let’s do a quick review of how a longitudinal wave moves through tissue.  Since the transducer creates this wave, we call it a mechanical longitudinal wave.  A sound wave has high pressure areas called compression and low-pressure areas called rarefactions. The propagation of a wave through tissue results in molecule movement with more in the compression area of the cycle that includes the rarefication area. These waves travel at different velocities due to stiffness differences depending on the type of tissue.     During 2D-mode imaging the transducer continually sends and receives the waves throughout the entire image. What would happen if we were to create a push pulse designed to move the tissue? Acoustic radiation force impulse imaging or ARFI works in just this fashion.  To create a separate pulse, called a push pulse, the selected element focuses on a specific area within the region of interest. The transducer then listens, just like with 2D-mode, for the returning signal.  This process repeats throughout the elasticity box resulting in the creation of a qualitative shear wave. Click the icon below to view more information on ARFI. Once you have reviewed the material, click on the right arrow to check your understanding with the Your Turn questions. Learn More about ARFI Learn More about ARFI Tab TitleTextConceptsImportant concepts to remember: 1. ARFI produces measurable shear waves. 2. The push pulse displaces tissue within an adjustable elasticity box. 3. The transducer listens for the return signal. 4. This occurs throughout the elasticity box. 5. The push pulse is a mechanical, longitudinal wave. When complete, select the X in the upper-right corner to close the window and continue. Push Pulse This diagram illustrates the ARFI push pulse within a linear elasticity box. The ARFI push pulse (down arrows) provides the AP compression while a detection pulse tracks tissue changes.30  This sequence occurs throughout the elasticity box resulting in the final qualitative elastogram. There is one ARFI pulse for multiple detection pulses (up arrows).29  This all occurs on the axial direction extending from the transducer into the tissue.20   When complete, select the X in the upper-right corner to close the window and continue. The Image This Virtual Touch™ image (VTi) shows a biopsy proven DICS in the breast.  The elastogram (right dual) is a qualitative representation of tissue stiffness using ARFI.  The velocity scale, found to the left of the image, shows soft tissue (SF) has a white hue while stiff tissue (HD) has a black hue.   When complete, select the X in the upper-right corner to close the window and continue.  ARFI uses longitudinal strain to create the qualitative elastogram but we know tissue also undergoes shear strain.  Keeping in mind that compression simply changes tissue not the volume, we can understand that something occurs on the transverse plane at the same time.  The waves created by the tissue, called shear waves, travel perpendicular to the axial ARFI pulse.    Image creation sequence using ARFI and shear waves: Transmission of the longitudinal push pulse outside a fixed size ROI. Targeted tissue or mass changes shape due to AP compression. Shear waves created perpendicular to the ARFI push pulse. Shear wave velocity measured within an ROI with tracking beams next to the push pulse.     Click the icons below to learn more about qualitative versus quantitative elastograms created using shear waves.   Click on the right arrow to continue. Learn More about Qualitative Images Learn More about Qualitative Images Tab TitleTextThe Concept   Shear waves move lateral to the ARFI push pulse at a slower speed, thus attenuate sooner than a longitudinal wave.20, 28 Tracking of the shear waves (up arrows) helps us determine the speed and calculate tissue stiffness. This measures stress as a velocity (Vs) or kilopascals (kPa).28 Remember strain only tells us the change in length and is a unitless or qualitative method to find tissue stiffness.   When complete, select the X in the upper-right corner to close the window and continue. 2D SWE Using the transverse shear waves created by the longitudinal ARFI pulse, we can create the velocity color overlay on the 2D-mode image called a 2D SWE (shear wave elastogram).31 Since we know the speed of the shear waves, we assign a relative velocity to the adjustable scale.  To find the velocity range and color assignment, we must look at the color bar found to the left of the image (enlarged). This image uses red as the color assigned for the stiffest tissue with a velocity of 6.5 m/s.  The softer tissue has a color assignment of blue with 0.5 m/s.  Even though we have a range of velocities, this image is a qualitative presentation of tissue stiffness.   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about Quantitative Images Learn More about Quantitative Images Tab TitleTextThe Concept Two Siemens elastography technologies, VTq and Virtual Touch™ IQ (VTIQ), use an ROI box to detect shear waves created by the ARFI push pulse.  The push pulse occurs outside the ROI (down arrows).  The ROI, positioned laterally to detect the shear waves, is the sampling area.26, 30 Called a point shear wave measurement, the resulting velocity indicates the average speed within the ROI.30 The sample area has a fixed size; however, we can change the location.   When complete, select the X in the upper-right corner to close the window and continue. VTIQ This image shows point quantification measurements within the 2D SWE box of the biopsy proven DCIS seen earlier.  The shear wave measurement occurs within the yellow boxes displaying as a velocity measurement (Vs). Multiple ROIs allow measurement of both normal and abnormal tissues. The stiffest tissue has a red color hue with a point shear wave velocity highlighted as High.  This shows a stiffness above the current upper limit of 6.5 m/s.  To avoid this finding, simply increase your scale and remeasure the area.    This is an image showing the Quality map for the same mass.  To find the quality of the elastogram and the resulting measurements, use the color bar located to the left of the image. The green color coding shows high-quality while the red shows a low-quality image.  This image tells us we have high-quality of the shear waves rather than information on the stiffness of the breast mass.   When complete, select the X in the upper-right corner to close the window and continue.  This section has clinically proven case studies showing the full spectrum of sonographic modalities in diagnosing breast-related pathology.  Three types of carcinoma - IDC, ILC, and lymph node metastasis - are a few met in the clinical setting.    Note: Images have been cropped with measurement boxes 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. Click on the right arrow to continue. Learn More about Invasive Ductal Carcinoma Learn More about Invasive Ductal Carcinoma Tab TitleTextPatient HistoryAge: 84   Physical Exam: New palpable mass since previous mammogram.   Previous imaging findings: Screening mammogram BI-RADS® category 2 (Benign findings); Ultrasound findings of BI-RADS® category 4A (Low suspicion of malignancy)8   Biopsy findings: Grade 3 poorly differentiated invasive ductal carcinoma. Also present in sample were prominent focal necrosis and lymphoplasmacytic inflammation.   Differential: Fibroadenoma   When complete, select the X in the upper-right corner to close the window and continue. 2D-mode The 2D-mode image shows an oval hypoechoic mass with posterior enhancement (double arrows), posterior shadowing (arrow heads), and an ill-defined medial border (single arrow). The area of shadowing raises suspicion for a second lesion.   The Breast Imaging Reporting and Data System (BIRADS®) is a method to categorize breast masses developed by the American College of Radiology (ACR®). These categories include breast mass features appearing on mammography, ultrasound, and magnetic resonance imaging (MRI). For this mass, the irregular borders, posterior echo pattern of enhancement and shadowing, and the complex internal pattern on the medial border results in the assignment of an ultrasound BI-RADS® 4A category.8   When complete, select the X in the upper-right corner to close the window and continue. CDE   Color Doppler Energy (CDE) shows the feeder vessels and significant flow within the mass. CDE or power Doppler is a color-coded display of the amount of moving blood cells within the ROI.13, 28, 32  Since CDE uses a different method to detect flow, the amount or intensity of the signal, this mode is very good at separating flow from tissue13 which becomes important when confirming a solid mass. Though this mode displays less flow information, CDE has less angle dependence than CDV and can pick up slower flow.13, 32   When complete, select the X in the upper-right corner to close the window and continue. Elastogram   Shadow measurements allow quantification of the primary and suspected lesion on both the 2D-mode (left) and VTi (right) image. This elastogram uses the black and white color scale with softer tissue displaying white and stiffer tissue displaying dark. The softer area of the mass (arrow) images as a whiter area than the surrounding tissue. Posterior shadowing (asterisk) disappears on the elastogram as this 2D-mode artifact has no relation to tissue stiffness.   Remember, on the VTi image the mass displays relative to the surrounding breast tissue while the central portion of the mass displays realtive to the mass.  Thus, the breast tissue and central mass display similar stiffness hues.   Though still a qualitative elastogram, we can compare the size between the 2D-mode image and elastogram. The 2D-mode measurement of 23.9 millimeters (yellow line) and the VTi measurement of 24.7 millimeters (green line) results in an E / B ratio of 1.03 (insert).  An E / B ratio of less than 1 indicates a benign mass while a ratio equal to or greater than 1 indicates a malignant lesion.21, 24, 33, 34   When complete, select the X in the upper-right corner to close the window and continue. VTIQ The color bar found on the right of this VTIQ image, shows stiffer tissue represented as a red hue and softer tissue as a blue hue. The color overlay is a representation of the various tissue stiffness found in and around this IDC when using shear wave velocities. The point quantification (multiple ROI) or 2D SWE values above the upper cutoff of 7.5 meters per second (m/s) display as Vs=High (insert upper left). The absence of shear waves results in a Vs=NA.   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about Invasive Lobular Carcinoma Learn More about Invasive Lobular Carcinoma Tab TitleTextPatient HistoryAge: 78   Previous imaging findings: New right mass on mammogram classified as a BI-RADS® 0 (Incomplete: additional imaging evaluation needed).8   Surgery: Remote history of bilateral breast implants. Removal of implant and two masses with evidence of tumor growth adjacent to the implant.   Ultrasound guided biopsy: ILC When complete, select the X in the upper-right corner to close the window and continue. 2D-mode This ILC, measuring 4.2 millimeters (circle), lies adjacent to the breast implant. The anterior and posterior margins appear intact; however, the lateral borders have an indistinct appearance.    When complete, select the X in the upper-right corner to close the window and continue. CDI Color Doppler imaging allows visualization of flow confirming a solid mass. A fine needle aspiration (FNA) was used with ultrasound guidance to obtain tissue for analysis. For this mass, the irregular borders, growth through tissue planes, and the need for a biopsy results in the assignment of an ultrasound BI-RADS® 4A category.8   When complete, select the X in the upper-right corner to close the window and continue. Elastogram This black and white elastogram shows tissue with white for soft tissue and black for stiff tissue. The black mass on the elastogram (right) indicates stiffer tissue than the surrounding fat. The 2D-mode diameter (left) measures 4.5 millimeters while the elastogram measures 4.2 millimeters for an E / B ratio of 1.   The strain ratio for a breast finding requires measurement of both the mass and fatty tissue. Place the ROI at the same depth to ensure equal transducer compression between sample areas.21, 24, 33 The strain value, in this case 6.44, indicates the difference in stiffness between the multiple image frames using the ROI-selected areas. A strain ratio between greater than 4.5 suggests a malignant process.24, 35  Asterisk - Lung.   When complete, select the X in the upper-right corner to close the window and continue. VTIQ The color bar found on the right of the image indicates the maximum velocity of 6.5 m/s has a color hue assignment of red, while the lower velocity of 0.5 m/s has a color assignment of blue. Point measurements within the mass reveal a shear wave velocity of 6.1 m/s with the fat reference velocity of 2.54 m/s. This indicates the mass has a faster shear wave velocity and thus is stiffer than the adjacent sampled areas.24   When complete, select the X in the upper-right corner to close the window and continue.  Learn More about Abnormal Axillary Lymph Nodes Learn More about Abnormal Axillary Lymph Nodes Tab TitleTextPatient HistoryAge: 74   History: Left breast cancer 12-years prior treated with chemotherapy and radiation therapy.   Clinical complaint: Painful left axillary mass   Surgery: Left mastectomy   Biopsy findings: Lymph node with poorly differentiated adenocarcinoma of breast origin. When complete, select the X in the upper-right corner to close the window and continue. 2D-mode This 2-centimeter mass imaged in the left maxilla shows multiple sonographic signs of malignancy. The mass is taller-than-wide indicating growth through tissue planes, is spiculated (arrows), creates posterior shadowing, and has a heterogeneous, hypoechoic internal pattern.7, 9, 10 Asterisk - rib. Scroll to view an image of a normal lymph node.    The normal lymph node (circle) has a bean-shape with a hypoechoic periphery and an echogenic hilum.    When complete, select the X in the upper-right corner to close the window and continue. CDE The use of Color Doppler Energy demonstrates feeder vessels and flow within the hypoechoic mass.   When complete, select the X in the upper-right corner to close the window and continue. eSie Touch The color bar found on the right of the image eSie Touch elastogram (right) shows soft tissue as white and stiff tissue as black. The mass, composed of stiffer tissue than the surrounding fat, appears black on the elastogram and hypoechoic on the 2D-mode (left).  D1 obtained from the elastogram is larger at 26.9 millimeters than the 2D measurement (D2; 21.0 millimeters) resulting in a strain ratio of 1.28. This is well above the E / B ratio of 1 indicating a malignant lesion.21, 24, 33, 34     Place the first ROI in fatty tissue and the second ROI in the mass to obtain the lesion-to-fat ratio (strain ratio).  The ratio of 29.1 is well above the cutoff value (5) indicating a high probability of a malignancy.24, 35     When complete, select the X in the upper-right corner to close the window and continue. VTIQ The red color of the mass indicates that shear wave velocity exceeds the maximum of 6.5 m/s. The color bar found on the right of the image shows that the slower and thus softer tissue displays in a blue color hue.   When complete, select the X in the upper-right corner to close the window and continue.  The functional part of the breast, the TDLU, connects to the lactiferous duct becoming the lactiferous sinus which then exits the nipple.7, 9, 11  The TDLU is the location where breast pathology originates whether a benign cyst or malignancy.7 Click the icon below to view examples of normal and abnormal TDLUs. Click on the right arrow to continue.   Learn More about the TDLU Learn More about the TDLU Tab TitleTextNormal This 2D-mode image with the graphic overlay is an example of how the normal TDLU and interconnecting ducts might course through the glandular tissue of the breast. The TDLU connects to the lactiferous duct via the extralobular duct.7 The normal TDLU has a smooth, rounded contour.9   When complete, select the X in the upper-right corner to close the window and continue. Abnormal This is a cropped ACUSON S2000 ABVS image with a malignant mass.  The IDC (arrow) grows within the TDLU with the shape depending on the location.9  TDLUs extend around the lactiferous duct with tumor growth resulting in the characteristic taller-than-wide appearance.7, 9  The branching pattern is the tumor extending into the ducts and surrounding tissue.7, 9  T- Nipple location. Note:  The nipple icon size has been increased to allow for optimal visualization.   When complete, select the X in the upper-right corner to close the window and continue. TDLU The normal TDLU (left) contains an extralobular section (straight portion) containing the extralobular duct that becomes the intralobular duct (black).9, 11 The intralobular ductules extend from the intralobular duct and lie within the intralobular stroma (pink).9  The characteristic spiculated appearance of malignancies is the result of growth from the intralobular ductules into the duct.7, 9 The tumor mass grows changing the ductules to a racket or paddle shape (right, double arrows) in early invasive or DCIS.9  As the tumor invades the surrounding tissue, the ductules becomes spindle shaped (right, single arrow).9 This growth pattern expands until the gently lobulated TDLU becomes the abnormally shaped paddle or spindle shape.   When complete, select the X in the upper-right corner to close the window and continue.  The formation of fibrous tissue around a mass, desmoplasia, is normal tissue response to a slowly developing tumor growth. Though often seen as a sign of malignancy, this dense shadowing tissue can also be found in benign masses or scar tissue.     This is an eSie Touch elasticity image of a palpable breast mass. The strong posterior shadowing (arrows) is likely due to the desmoplastic response.9  The fibrous nature of this tissue results in a strong posterior shadow11 and loss of image detail on the 2D-mode image.28   The elastogram is a display of relative tissue stiffness and thus, allows for imaging of the posterior margins.9   Remember to look at the color scale to the right of the image to determine the color hue assigned to soft and stiff tissue.    Click on the right arrow to continue.   Sonographers often need to find a mass based on mammographic findings requiring an understanding of location changes occurring with compression.  The craniocaudal or CC view compresses the breast from superior to inferior with the patient in a standing position.  This pulls the mass away from the chest wall with some change in medial to lateral location.    To find a mass location from a mediolateral or MLO view, we must first know the beam path as either inferior to superior or vice versa can be used. Secondly, we must know the angle used to obtain the image. If the beam path passes superior to inferior on a medial to lateral plane, the mass projects inferior to the nipple.  How far below depends on the projection angle.  The opposite becomes true when using a beam path projecting inferior to superior on a MLO view.   When trying to determine the location of a mass, visualize a balloon with a fixed internal area.  Use the knotted stem as the nipple.  Think about how the mass changes when you compress the balloon, while keeping the stem in profile, from top to bottom.   When compressing side to side, like the MLO, also use the plane direction to figure out the final location.   Click the icon below to view examples of mass location changes.   Click on the right arrow to continue. Learn More about Mass Movement Learn More about Mass Movement Tab TitleTextCC   This balloon diagram demonstrates superior to inferior compression used with the CC mammographic view and how the mass moves away from the chest wall (left, arrows). The horizontal line represents the pectoralis muscle. The amount of medial or lateral movement depends on its relation to the nipple.9 In this example, the mass would move to the right; however, if the mass were on the other side, it would move to the left. The closer to the nipple the less a mass moves.  When compared to an ultrasound exam, the same mass would be closer to the chest wall due to both a lack of compression and the supine patient position (right).9    Tip – To locate a mammographic finding, sit the patient up while supporting the breast from below while scanning. This moves the mass into a similar position as the CC view.7, 11   When complete, select the X in the upper-right corner to close the window and continue.MLO The MLO compresses the breast resulting in a change in mass position in relation to the nipple dependent on the angle used. The steeper angle (left) moves the mass further than the smaller angle (right). 9 Black – Film; Gray – Compression plate; Arrow – Direction of the X-ray beam.   Tip – To mimic this projection, lie the patient on the side of interest and position the transducer at approximately the same angle as the X-ray beam.  For example: if this diagram represents the left breast, lie the patient on their left side and place the transducer on the medial section of the breast.9, 11   When complete, select the X in the upper-right corner to close the window and continue.Multi-modality Review   Multi-modality review allows you to place the reference image, in this case the mammogram, next to the ultrasound image on the system.    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. References / Further Reading References / Further Reading 1. Schnitt, S.J. and Lakhani, S.R. (2015). World Cancer Report 2014. In Stewart, B.W. and Wild, C.P., (Eds.),          World Cancer Report  (pp. 362-373). Geneva: International Agency for Research on Cancer - World Health Organization.   2. 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.   3. Hacking, C. and Pacifici, S. (2017). Magnification view. 2017  [cited 2017 February 10]; Available from: https://radiopaedia.org/articles/magnification-view.   4. Hacking, C. and Pacifici, S. (2017). Spot compression. 2017  [cited 2017 February 10]; Available from: https://radiopaedia.org/articles/spot-view.   5. Goodsitt, M.M., Chan, H., Lydick, J.T., Gandra, C.R., Chen, N.G., Helvie, M.A., . . . Petrick, N. (2004). An observer study comparing spot imaging regions selected by radiologists and a computer for an automated stereo spot mammography technique. Medical Physics. 31(6): 1558-1567.   6. Mesurolle, B., Mignon, F., Ariche-Cohen, M., Kao, E., Gagnon, J.H., and Goumot, P. (2004). Digital spot mammography using an add-on upright unit: diagnostic application in daily practice. European Journal of Radiology. 51(1): 61-65.   7. 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.   8. 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.   9. 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.   10. Stavros, A.T., Thickman, D., Rapp, C., Dennis, M.A., Parker, S.H., and Sinsney, G.A. (1995). Solid breast nodules: Use of sonography to distinguish between benign and malignant lesions. Radiology. 196: 123-134. 11. 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.   12. Hoskins, W., McDicken, N., and Allen, P.L. (2006). Haemodynamics and blood flow. In Allan, P., Dubbins, P.A., Pozniak, M.A., et al., (Eds.), Clinical Doppler Ultrasound  (pp. 27-40). Philadelphia: Churchill Livingstone Elsevier.   13.  Hedrick, W. (2013). Technology for diagnostic sonography. St. Louis, MO: Elsevier.   14. Lunsfort, B. (2012). 3-D and 4-D imaging in obstetrics and gynecology. In Raatz Stephenson, S., (Eds.), Diagnostic Medical Sonography: Obstetrics and Gynecology  (pp. 801-834). Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.   15. Siemens. (2011). ACUSON S2000TM Automated Breast Volume Scanner (ABVS): Mountain View.   16. Hanafy, A.M. (1999). U.S. Patent No. 5,976,091. Washington, DC: Office, U.S.P.a.T.   17. Del Prince, B. and Kari, B. (2016). 3D imaging. In Sanders, R.C. and Hall-Terracciano, B., (Eds.), Clinical Sonography: A Practical Guide  (pp. 39-60). Philadelphia: Wolters Kluwer.   18. Cho, N., Oh, K.K., and Lee, S. (2002). Medullary carcinoma of the breast: Sonographic features distinguishing it from fibroadenoma. Journal of Medical Ultrasound. 10(4): 191-196.   19. Benson, J. and Fan, L. (2014). Understanding ARFI and new elastography quantification technologies, in Siemens Medical Solutions, USA, Inc: Mountain View, California.   20. 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.   21. Barr, R.G. (2010). Real-time ultrasound elasticity of the breast: Initial Clinical Results. Ultrasound Quarterly. 26(2): 61-66.   22. Elseedawy, M., Whelehan, P., Vinnicombe, S., Thomson, K., and Evans, A. (2016). Factors influencing the stiffness of fibroadenomas at shear wave elastography. Clinical Radiology. 71(1): 92-95.   23. Itoh, A., Ueno, E., Tohno, E., Kamma, H., Takahashi, H., Shiina, T., . . . Matsumura, T. (2006). Breast Disease: Clinical application of US elastography for diagnosis. Radiology. 239(2): 341-350.   24. Barr, R.G. (2015). Breast elastography. New York: Thieme.   25. Nakashima, K., Shiina, T., Sakurai, M., Enokido, K., Endo, T., Tsunoda, H., . . . Ueno, E. (2013). JSUM ultrasound elastography practice guidelines: Breast. Journal of Medical Ultrasonics. 40(4): 359-391.   26. 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.   27. 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.   28. Kremkau, F.W. (2016). Sonography: Principles and Instruments. 9 ed., St. Louis: Elsevier.   29. Nightingale, K.R., Palmeri, M.L., Nightingale, R.W., and Trahey, G.E. (2001). On the feasibility of remote palpation using acoustic radiation force. The Journal of the Acoustical Society of America. 110(1): 625-634.   30. Shiina, T., Nightingale, K.R., Palmeri, M.L., Hall, T.J., Bamber, J.C., Barr, R.G., . . . Kudo, M. (2015). WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: Basic principles and terminology. Ultrasound in Medicine and Biology. 41(5): 1126-1147.   31. Cosgrove, D., Piscaglia, F., Bamber, J., Bojunga, J., Correas, J.M., Gilja, O.H., . . . Dietrich, C.F. (2013). EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications. Ultraschall in Med. 34(03): 238-253.   32. McDicken, N. and Hoskins, P. (2014). Physics: Principles, practice and artefacts. In Pozniak, M.A. and Allan, P., (Eds.), Clinical Doppler Ultrasound  (pp. 1-25). Edinburgh: Churchill Livingstone Elsevier.   33. Barr, R.G. (2011). Strain vs. shear wave breast elastography: Competitors or allies. Ultrasound in Medicine and Biology. 37(8): S100-S101.   34. Zhang, F., Han, R., and Zhao, X. (2014). The value of virtual touch tissue image (VTI) and virtual touch tissue quantification (VTQ) in the differential diagnosis of thyroid nodules. European Journal of Radiology. 83(11): 2033-2040.   35. Menezes, R., Sardessai, S., Furtado, R., and Sardessai, M. (2016). Correlation of strain elastography with conventional sonography and FNAC/Biopsy. Journal of Clinical and Diagnostic Research : JCDR. 10(7): TC05-TC10.   Glossary Glossary Longitudinal wave (i.e., compression wave) – A sound wave from the transducer into the tissue and vice versa. Point shear wave elastography (pSWE) – ARFI generation of shear wave within a fixed ROI that provides an average velocity measurement in m/s or kPa.   Posterior enhancement – An increase in brightness deep to a cystic structure.   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.   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.   Shear wave – Wave produced perpendicular to the transmit pulse.   Stiffness – Tissue deformation in response to force (i.e., compression).   syngo®. Ultrasound Breast Analysis (sUSBA) – Software allowing for reviewing ABVS data set.   Virtual Touch™ imaging (VTi) – The use of ARFI technology to evaluate deep tissues providing a qualitative grayscale elastogram to relative stiffness within a user-defined ROI.   Virtual Touch™ IQ (VTIQ) –Color-coding of shear wave velocities within an elasticity box combined with pinpoint quantitative measurements. Virtual Touch™ imaging (VTi) – The use of ARFI technology to evaluate deep tissues providing a qualitative grayscale elastogram to relative stiffness within a user-defined ROI. Virtual Touch™ IQ (VTIQ) –Color-coding of shear wave velocities within an elasticity box combined with pinpoint quantitative measurements.   Virtual Touch™ Quantification (VTq) – Pinpoint measurement (m/s and kPa) of shear wave velocity to obtain a qualitative measurement of tissue stiffness using a fixed size ROI.  There is no elasticity image associated with this type of tissue stiffness measurement. When complete, select the X in the upper-right corner to close the window and continue.