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Diagnosis of Breast Cancer: Contribution of US as an Adjunct to Mammography¹

¹ From the Departments of Radiology (H.M.Z., A.E.v.V.), Medical Statistics (J.H.), and Pathology (M.J.v.d.V.), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; and the Department of Radiology, Medical Center Haaglanden-Westeinde, The Hague, the Netherlands (E.G.C.). Received August 11, 1998; revision requested September 25; final revision received February 16, 1999; accepted June 8. Address reprint requests to H.M.Z.

View larger version (29K): [in a new window]   Figure 1. Graph shows the distribution and stages of 338 breast cancers as a function of patient age (in years) by decade. White bar = ductal carcinoma in situ, gray bar = stage T1, stippled bar = stage T2, black bar = stage T3 or T4. The number in parentheses is the number of cases.

View larger version (28K): [in a new window]   Figure 2. Graph shows the distribution of parenchymal density for the 4,811 cases as a function of patient age (in years) by decade. White bar = low density, gray bar = medium density, black bar = high density. The number in parentheses is the number of cases.

View larger version (27K): [in a new window]   Figure 3. Graph shows the percentages of cases in which mammography alone (white bar) or mammography and US (black bar) were performed, according to patient age (in years) by decade. The number in parentheses is the number of cases.

View larger version (21K): [in a new window]   Figure 4. Graph shows ROC curves for the results of mammography (MAM) and the combined results of mammography and US (MAM + US) for all 4,811 cases. The combined results after US show an increase in Az (AUC) from 0.94 to 0.97. The increase in Az is significant (P < .001). The diagonal line represents the combinations of sensitivity and specificity of a test, without discriminative power. "100 - specificity" is given as a percentage.

View larger version (22K): [in a new window]   Figure 5. Graph shows ROC curves for the results of mammography (MAM) and the combined results of mammography and US (MAM + US) for the 1,103 cases in which mammography and US were performed. The combined results after US show an increase in Az (AUC) from 0.92 to 0.97. The increase in Az is significant (P < .001). "100 - specificity" is given as a percentage.

View larger version (156K): [in a new window]   Figure 6a. Mammogram and US scans in a 40-year-old patient with bloody nipple discharge. (a) Craniocaudal collimated mammogram of the retroareolar region does not show an abnormality. (b) Sagittal US scan of the retroareolar region shows branching structures (arrowheads), described as ductal ectasia. (c) Transverse US scan shows a 5-mm hypoechoic mass (calipers) in one of these structures. It was presumed to be a papilloma and was classified as a probably benign lesion. The pathologic diagnosis was a 3-cm ductal carcinoma in situ. In b and c, * = chest wall.

View larger version (155K): [in a new window]   Figure 6b. Mammogram and US scans in a 40-year-old patient with bloody nipple discharge. (a) Craniocaudal collimated mammogram of the retroareolar region does not show an abnormality. (b) Sagittal US scan of the retroareolar region shows branching structures (arrowheads), described as ductal ectasia. (c) Transverse US scan shows a 5-mm hypoechoic mass (calipers) in one of these structures. It was presumed to be a papilloma and was classified as a probably benign lesion. The pathologic diagnosis was a 3-cm ductal carcinoma in situ. In b and c, * = chest wall.

View larger version (169K): [in a new window]   Figure 6c. Mammogram and US scans in a 40-year-old patient with bloody nipple discharge. (a) Craniocaudal collimated mammogram of the retroareolar region does not show an abnormality. (b) Sagittal US scan of the retroareolar region shows branching structures (arrowheads), described as ductal ectasia. (c) Transverse US scan shows a 5-mm hypoechoic mass (calipers) in one of these structures. It was presumed to be a papilloma and was classified as a probably benign lesion. The pathologic diagnosis was a 3-cm ductal carcinoma in situ. In b and c, * = chest wall.

View larger version (116K): [in a new window]   Figure 7a. Mammograms and US scan in a 46-year-old patient who presented with a palpable mass in the medial (MED in a) upper quadrant of the right breast. (a) Craniocaudal mammograms of the right (R) and left (L) breasts. The glandular tissue was considered to be of high density. Except for asymmetric distribution of the glandular tissue in the medial upper quadrant of the right breast, a mass could not be recognized. (b) Sagittal US scan of the medial upper quadrant shows an ill-defined 22-mm hypoechoic mass (calipers), with infiltration into the surrounding fatty tissue (arrowheads). It was classified as malignant. Pathologic diagnosis: stage T2 ductal carcinoma.

View larger version (111K): [in a new window]   Figure 7b. Mammograms and US scan in a 46-year-old patient who presented with a palpable mass in the medial (MED in a) upper quadrant of the right breast. (a) Craniocaudal mammograms of the right (R) and left (L) breasts. The glandular tissue was considered to be of high density. Except for asymmetric distribution of the glandular tissue in the medial upper quadrant of the right breast, a mass could not be recognized. (b) Sagittal US scan of the medial upper quadrant shows an ill-defined 22-mm hypoechoic mass (calipers), with infiltration into the surrounding fatty tissue (arrowheads). It was classified as malignant. Pathologic diagnosis: stage T2 ductal carcinoma.

View larger version (110K): [in a new window]   Figure 8a. Mammograms and US scan in a 57-year-old patient with a family history of breast cancer. (a) Craniocaudal mammogram shows a small density (arrow) within the low-density glandular tissue. (b) Craniocaudal collimated mammogram still shows some overlying tissue. The visible margins (arrows) are smooth. The lesion was classified as probably benign. (c) Oblique US scan of the medial upper quadrant of the breast reveals a 7-mm hypoechoic solid lesion (calipers) with ill-defined margins (arrowheads). It was classified as equivocal. The pathologic diagnosis was a stage T1 invasive ductal carcinoma.

View larger version (120K): [in a new window]   Figure 8b. Mammograms and US scan in a 57-year-old patient with a family history of breast cancer. (a) Craniocaudal mammogram shows a small density (arrow) within the low-density glandular tissue. (b) Craniocaudal collimated mammogram still shows some overlying tissue. The visible margins (arrows) are smooth. The lesion was classified as probably benign. (c) Oblique US scan of the medial upper quadrant of the breast reveals a 7-mm hypoechoic solid lesion (calipers) with ill-defined margins (arrowheads). It was classified as equivocal. The pathologic diagnosis was a stage T1 invasive ductal carcinoma.

View larger version (146K): [in a new window]   Figure 8c. Mammograms and US scan in a 57-year-old patient with a family history of breast cancer. (a) Craniocaudal mammogram shows a small density (arrow) within the low-density glandular tissue. (b) Craniocaudal collimated mammogram still shows some overlying tissue. The visible margins (arrows) are smooth. The lesion was classified as probably benign. (c) Oblique US scan of the medial upper quadrant of the breast reveals a 7-mm hypoechoic solid lesion (calipers) with ill-defined margins (arrowheads). It was classified as equivocal. The pathologic diagnosis was a stage T1 invasive ductal carcinoma.

View larger version (125K): [in a new window]   Figure 9a. Mammograms and US scans in a 44-year-old patient who presented with painful swelling of the lateral upper quadrant of the left breast. (a) Craniocaudal mammograms of the right (R) and left (L) breasts. The glandular tissue was considered to be of high density, without abnormalities. MED = medial. (b) Transverse oblique US scan of the lateral upper quadrant (LUQ) shows diffuse infiltration of hypoechoic tissue (arrowheads) over a length of 4.5 cm (calipers). The lesion was classified as probably malignant. (c) In comparison, the oblique US scan of the lateral lower quadrant (LLQ) shows normal hyperechoic tissue. The pathologic diagnosis was stage T3 infiltrating lobular carcinoma.

View larger version (168K): [in a new window]   Figure 9b. Mammograms and US scans in a 44-year-old patient who presented with painful swelling of the lateral upper quadrant of the left breast. (a) Craniocaudal mammograms of the right (R) and left (L) breasts. The glandular tissue was considered to be of high density, without abnormalities. MED = medial. (b) Transverse oblique US scan of the lateral upper quadrant (LUQ) shows diffuse infiltration of hypoechoic tissue (arrowheads) over a length of 4.5 cm (calipers). The lesion was classified as probably malignant. (c) In comparison, the oblique US scan of the lateral lower quadrant (LLQ) shows normal hyperechoic tissue. The pathologic diagnosis was stage T3 infiltrating lobular carcinoma.

View larger version (173K): [in a new window]   Figure 9c. Mammograms and US scans in a 44-year-old patient who presented with painful swelling of the lateral upper quadrant of the left breast. (a) Craniocaudal mammograms of the right (R) and left (L) breasts. The glandular tissue was considered to be of high density, without abnormalities. MED = medial. (b) Transverse oblique US scan of the lateral upper quadrant (LUQ) shows diffuse infiltration of hypoechoic tissue (arrowheads) over a length of 4.5 cm (calipers). The lesion was classified as probably malignant. (c) In comparison, the oblique US scan of the lateral lower quadrant (LLQ) shows normal hyperechoic tissue. The pathologic diagnosis was stage T3 infiltrating lobular carcinoma.