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DOI 10.1007/s10911-006-9018-0
Abstract Frequent advances in transducer design, electronics, computers, and signal processing have improved
the quality of ultrasound images to the extent that
sonography is now a major mode of imaging for the
clinical diagnosis of breast cancer. Breast ultrasound is
routinely used for differentiating cysts and solid nodules
with high specificity. In combination with mammography,
ultrasound is used to characterize solid masses as benign or
malignant. There is growing interest in using Doppler
ultrasound and contrast agents for measuring tumor blood
flow and for imaging tumor vascularity. Ease of use and
real-time imaging capability make breast ultrasound a
method of choice for guiding breast biopsies and other
interventional procedures. Breast ultrasound is used in
many forms. B-mode is the most common form of imaging
for the breast, although compound imaging and harmonic
imaging are being increasingly applied to better visualize
breast lesions and to reduce image artifacts. These developments, together with the formulation of a standardized
lexicon of solid mass features, have improved the diagnostic performance of breast ultrasound. Several approaches
that are currently being investigated to further improve
performance include: (1) computer-aided-diagnosis; (2) the
assessment of tumor vascularity and tumor blood flow with
Doppler ultrasound and contrast agents; and (3) tissue
elasticity imaging. In the future, ultrasound will play a
greater role in differentiating benign from malignant masses
and in the diagnosis of breast cancer.
Introduction
Since early attempts in 1953 by Wild and Reid to build a
real-time handheld ultrasound scanner to image breast
lesions [1], ultrasonic imaging has undergone several
transformations, both in instrument design as well as in
clinical applications. In the 1980s, dedicated water bath
scanners using ultrasound-computed tomography (UCT)
gained popularity for imaging the breast [27]. These
scanners provided high resolution images in the reflection
and transmission modes, but they did not prove to offer
significant clinical advantages over real-time sonography
due to several factors [8], including the inconvenience of
using water baths for scanning and significant refraction
artifacts in the transmission mode. Today, handheld systems
are predominantly used in clinics for scanning patients.
Modern ultrasound scanners are digital systems. The
scanners digitize the acoustic signal immediately after it is
received by the transducer, and focus and steer the beam
using high speed digital electronics. Unlike early scanners,
which constructed images by a moving single-element transducer, modern sonographs use a multi-element ultrasound
transducer that does not involve physical movement of the
imaging transducer. The beam is focused and steered
electronically by broadcasting ultrasound from the member
elements of the multi-element array at different times, so that
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Table 1 Sensitivity, specificity, PPV, and accuracy of nodule features measured by two independent studies [28, 31].
Feature
Spiculation
Taller than wider
Angular margins
Shadowing
Branching pattern
Hypoechogenicity
Calcifications
Duct extentions
Microlobulation
Sensitivity
Specificity
PPV (%)
Accuracy
[28]
[31]
[28]
[31]
[28]
[31]
[28]
[31]
36.0
41.6
83.2
48.8
29.6
68.8
27.2
24.8
75.2
59 11
49 18
99.4
98.1
92.0
94.7
96.6
90.1
96.3
95.2
83.8
97 5
91 4
91.8
81.2
67.5
64.9
64.0
60.1
59.6
50.8
48.2
97 5
90 4
88.8
88.7
90.5
87.1
85.5
87.2
84.8
79.3
82.4
73 8
64 12
59 8
72 10
48 17
51 20
77 1
86 5
95 5
84 3
82 2
91 2
95 5
82 10
65 5
77 6
65 12
63 12
In [28] the term markedly hypoechoic instead of hypoechogenicity. Values quoted in [28] represent mean STD of four observers.
PPV Positive predictive value, STD standard deviation
Compound Imaging
Despite advances, B-mode images contain inherent artifacts
which degrade image quality. Speckle due to interference of
coherent ultrasound waves [55] causes small-scale brightness fluctuations, giving a granular appearance to otherwise
homogeneous tissue. The side lobes and grating lobes of
ultrasound beams result in multi-path reverberations that
often lead to spurious echoes from the tissues. High
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(b)
(c)
(d)
(e)
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Figure 4 Images of biopsy-proven DCIS obtained using (a) conventional B-mode and (b) compound mode. The tumor margin and the
internal structure of the lesion are better delineated in the compound
Harmonic Imaging
(c)
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c - c
Fundamental
c + c
f0
2f0
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(d)
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(b)
3f0
Fundamental
f0
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3f0
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Figure 6 Tumor vessels imaged by Doppler ultrasound. Biopsy proven DCIS (arrows) imaged with (a) color Doppler and (b) power Doppler
ultrasound. The two images show comparable vascularity.
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Figure 7 The left panel shows a power Doppler image of a lesion with
a blood vessel (arrows) leading to the nodule. The lesion (dotted circle)
appears avascular. The right panel shows the same lesion after Optison
contrast injection. The relationship between the feeder vessel and the
mass can be better appreciated in the contrast-enhanced image. The
Conclusions
Breast ultrasound is multimodal and can map blood flow
and mechanical properties of the tissue. Consistent
improvements in image quality over the years have
expanded the role of ultrasound in the detection and
diagnosis of breast pathology, and sonography is routinely
used as an adjunct to X-ray mammography. There are
attempts to combine ultrasound imaging and mammography in one instrument to facilitate scanning and to improve
diagnosis [102]. Ultrasound is also a method of choice for
guiding biopsy needles and various therapeutic interventions. We believe that newer techniques will continue to
improve the sensitivity and specificity of breast ultrasound.
Acknowledgments The authors gratefully acknowledge the assistance from Susan M Schultz and Theodore W Cary in preparing this
manuscript. This work was in part supported by NIH grants CA-85424
and CA-87526.
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