Breast cancer remains one of the most common malignancies affecting women worldwide. An integral part of its early detection, diagnosis, and management involves imaging techniques like ultrasound. Ultrasound is often used in conjunction with other modalities like mammography and magnetic resonance imaging (MRI) to provide comprehensive imaging of breast tissues. 

Breast Ultrasound and its Role in Cancer Detection:

Breast ultrasound is a non-invasive imaging technique that uses sound waves to create images of the breast. It is primarily used to examine abnormalities detected during a mammogram or physical examination. It provides valuable information about the nature of the breast tissue, differentiating between fluid-filled cysts and solid masses, and aids in determining whether a suspicious area is likely benign or requires further investigation.

Suspicious Findings in Breast Ultrasound:

Several suspicious findings on ultrasound can trigger the need for a biopsy. These anomalies include irregular masses, hypoechoic lesions, posterior acoustic shadowing, calcifications within a mass, architectural distortion, and suspicious lymph nodes.

Irregular masses with indistinct or spiculated margins, rather than having a smooth, round, or oval shape, raise suspicion for malignancy. A benign lesion usually has a clear boundary while a malignant one often infiltrates surrounding tissues, leading to poorly defined edges.

Hypoechoic lesions, those appearing darker than the surrounding tissue, are also of concern. While not all hypoechoic lesions are malignant, a large proportion of invasive breast cancers are hypoechoic on ultrasound.

Posterior acoustic shadowing, where the area behind a mass appears darker on the ultrasound image, often indicates a hard mass that could be malignant. Calcifications within a mass, particularly microcalcifications, are another suspicious feature. Although calcifications can be seen in benign conditions, their presence within a solid mass warrants further investigation.

Architectural distortion refers to a disruption in the normal architecture of the breast tissue. This can present as a twisting or pulling of tissue, which can be suggestive of an underlying malignancy, especially if not associated with a discrete mass.

Lastly, the presence of abnormal or enlarged lymph nodes, especially those with cortical thickening or loss of the fatty hilum, might indicate metastasis of a cancerous process.

The Rationale for Ordering a Breast Biopsy:

The aforementioned suspicious findings are essential cues for a radiologist to order a breast biopsy. A biopsy is the gold standard procedure for diagnosing breast cancer. Imaging studies may suggest malignancy, but the definitive diagnosis lies within the microscopic examination of the breast tissue.

One reason a radiologist may order a biopsy is to establish a definitive diagnosis, especially in cases where imaging findings are equivocal. This allows for the differentiation between benign breast conditions and malignant tumors.

Another reason for ordering a biopsy is the detection of changes over time. If a previously imaged lesion shows signs of growth or transformation in characteristics, a biopsy may be ordered to reassess the nature of the lesion.

A biopsy also guides the treatment plan. Information such as the type of cancer, its grade, and the presence of hormone receptors or other markers can significantly impact treatment options. Biopsies can provide this crucial information, thereby guiding oncologists in creating an individualized treatment strategy for the patient.

Approximately 20-30% of breast biopsies result in a diagnosis of breast cancer, but this can vary widely. This percentage can be influenced by a variety of factors, including the population being screened, the specific indications for biopsy, the type of biopsy performed, and the method used to identify lesions.

Most breast biopsies result in benign (non-cancerous) findings. It's important to note that while a significant percentage of biopsies do not yield a cancer diagnosis, the purpose of performing a biopsy is to rule out cancer in suspicious cases. Therefore, the "positivity rate" should not dissuade anyone from pursuing a biopsy if one is recommended by their healthcare provider.

Breast ultrasound plays a crucial role in the detection and characterization of suspicious breast lesions. Several findings such as irregular masses, hypoechoic lesions, posterior acoustic shadowing, calcifications, and architectural distortions can indicate the presence of malignancy and necessitate further investigation through a biopsy. Biopsies not only confirm the diagnosis of cancer but also provide vital information that impacts the overall management and prognosis of the disease. Therefore, it is paramount for healthcare professionals to understand the significance of these suspicious findings and the rationale for ordering a biopsy when such findings are present.

June 2023.