|Year : 2018 | Volume
| Issue : 7 | Page : 1463-1468
Chinese association of ultrasound in medicine and engineering, superficial organs and peripheral vessels committee expert consensus on clinical frequently asked questions in breast ultrasonography, June 2018
Tian'an Jiang1, Yuxin Jiang2, Wen Chen3, Baoming Luo4, Yulan Peng5, Zhili Wang6, Jinfeng Xu7, Jianqiao Zhou8, Qi Zhou9, Lingyun Bao10, Li Chen11, Lin Chen12, Qin Chen13, Shuzhen Cong14, Kefei Cui15, Xinwu Cui16, Qinmao Fang17, Fengsheng Li18, Huiwen Li19, Jing Li20, Jianchu Li2, Junlai Li6, Quanshui Li21, Tianliang Li22, Tao Li23, Yanjiang Li24, Zhengyi Li25, Jia Liu26, Yong Liu27, Jun Luo13, Buyun Ma5, Zhe Ma28, Fang Nie29, Chengzhong Peng30, Xiufang Sui31, Hongguang Sun32, Hongqiao Wang33, Jing Wang34, Yan Wang35, Changjun Wu36, Ying Xiao37, Huahua Xiong25, Dong Xu38, Ensheng Xue39, Lifang Xue40, Songli Yan41, Lichun Yang42, Qiang Yong43, Weiwei Zhan8, Sheng Zhang44, Xuezhen Zhang45, Jianxing Zhang46, Xianli Zhou47, Xi Lin48, Shanyu Yin1, Qiyu Zhao1
1 Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
2 Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
3 Department of Ultrasound, Peking University Third Hospital, Haidian District, Beijing, China
4 Department of Ultrasound, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China
5 Department of Ultrasound, West China Hospital, Chengdu, China
6 Department of Ultrasound, Chinese People's Liberation Army General Hospital, Beijing, China
7 Department of Ultrasonography, Second Clinical College of Jinan University, Shenzhen People's Hospital, Shenzhen, China
8 Department of Ultrasound, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicineas, Shanghai, China
9 Department of Ultrasound, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
10 Department of Ultrasonography, The Affiliated Hanghzou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
11 Department of Ultrasound, The First Affiliated Hospital of Nanchang University, Nanchang, China
12 Department of Ultrasound, Huadong Hospital, Fudan University, Shanghai, China
13 Department of Ultrasound, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
14 Department of Ultrasound, Guangdong Academy of Medical Sciences and Guangdong General Hospital, Guangzhou, China
15 Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
16 Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
17 Department of Ultrasound, 3rd Hospital of Hebei Medical University, Shijiazhuang, China
18 Departments of Ultrasound and Medical Oncology, Affiliated Shaanxi Cancer Hospital of the School of Medicine, Xi'an Jiaotong University, Xi'an, China
19 Department of Ultrasound, Ordos Central Hospital, Ordos, China
20 Department of Ultrasound, Tianjin Union Medical Center, Nankai University, Affiliated Hospital, Tianjin, China
21 Luohu Hospital, Shenzhen, China
22 Department of Medical Ultrasound, Shanxi Cardiovascular Hospital, China
23 Department of Ultrasound, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, China
24 Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
25 Department of Ultrasound, Shenzhen Second People's Hospital, Shenzhen, China
26 Department of Ultrasound, Dalian Municipul Central Hospital, Dalian, China
27 Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
28 Department of Ultrasound, Qilu Hospital of Shandong University, Jinan, China
29 Department of Ultrasonography, Lanzhou University Second Hospital, Lanzhou, China
30 Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou, China
31 Department of Ultrasound, Anhui Provincial Hospital, Anhui, China
32 Department of Ultrasound, Affiliated Hospital of Yangzhou University, Yangzhou Universit, Yangzhou, China
33 Department Abdominal Ultrasound, Qingdao University, Affiliated Hospital, Qingdao, China
34 Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
35 Department of Ultrasound in Medicine, Shanghai Institute of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
36 Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
37 Department of Ultrasonography, Xiang Ya Hospital, Central South University, Changsha, China
38 Department of Ultrasound, Zhejiang Cancer Hospital, Hangzhou, China
39 Department of Ultrasound, Fujian Medical University Union Hospital, Fuzhou, China
40 Department of Ultrasound, Peking University, International Hospital, Beijing, China
41 Department of Ultrasonography, The First Hospital of Putian, Putian, China
42 Department of Ultrasound Medicine, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Center, Kunming, China
43 Department of The General Ultrasound, Beijing Anzhen Hospital, Beijing, China
44 Department of Diagnostic and Therapeutic Ultrasounography, Tianjin Cancer Hospital and Institution, Tianjin, China
45 Department of Ultrasound, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
46 Department of Ultrasound, Guangdong Pronvicial Hospital of Chinese Medicine, Guangzhou, China
47 Department of Ultrasound In-Patient, Second Affiliated Hospital of Harbin Medical University, Harbin, China
48 Department of Ultrasound, Sun Yat-Sen University, Collaborative Innovation Center for Cancer Medicine, Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, China
|Date of Web Publication||19-Dec-2018|
Department of Ultrasound, The First Affiliated Hospital of Medical College Zhejiang University, Hangzhou 310003
Source of Support: None, Conflict of Interest: None
Ultrasonography, the preferred imaging modality for breast diseases, has merits such as absence of radiation, high diagnostic accuracy, and convenience for follow-up, thus playing an important role in clinical diagnosis and management. The American College of Radiology (ACR) proposed Breast Imaging-Reporting and Data System (BI-RADS ) and has updated for several times. Gradually, the BI-RADS has been accepted and adopted by ultrasound physicians at all levels of hospitals in China, and it has played a certain role in improving the diagnostic level of breast ultrasound in China. In order to standardize breast ultrasound application and raise the status of ultrasound in clinical decision-making of breast diseases, based on the latest edition of ACR BI-RADS Atlas 2013, the committee has reached the “Expert Consensus on Clinical Frequently Asked Questions in Breast Ultrasonography”on a number of controversial Frequently Asked Questions (FAQs) in clinical practice (hereafter referred to as “Consensus”), and will be dedicated to updating the contents of the “Consensus”, through further experience in clinical practice and the advent of new information from further studies. This consensus is only for reference purposes for medical personnel, and the processes outlined are not mandatory by law.
Keywords: Breast, Breast Imaging Reporting and Data System, ultrasonography
|How to cite this article:|
Jiang T, Jiang Y, Chen W, Luo B, Peng Y, Wang Z, Xu J, Zhou J, Zhou Q, Bao L, Chen L, Chen L, Chen Q, Cong S, Cui K, Cui X, Fang Q, Li F, Li H, Li J, Li J, Li J, Li Q, Li T, Li T, Li Y, Li Z, Liu J, Liu Y, Luo J, Ma B, Ma Z, Nie F, Peng C, Sui X, Sun H, Wang H, Wang J, Wang Y, Wu C, Xiao Y, Xiong H, Xu D, Xue E, Xue L, Yan S, Yang L, Yong Q, Zhan W, Zhang S, Zhang X, Zhang J, Zhou X, Lin X, Yin S, Zhao Q. Chinese association of ultrasound in medicine and engineering, superficial organs and peripheral vessels committee expert consensus on clinical frequently asked questions in breast ultrasonography, June 2018. J Can Res Ther 2018;14:1463-8
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Jiang T, Jiang Y, Chen W, Luo B, Peng Y, Wang Z, Xu J, Zhou J, Zhou Q, Bao L, Chen L, Chen L, Chen Q, Cong S, Cui K, Cui X, Fang Q, Li F, Li H, Li J, Li J, Li J, Li Q, Li T, Li T, Li Y, Li Z, Liu J, Liu Y, Luo J, Ma B, Ma Z, Nie F, Peng C, Sui X, Sun H, Wang H, Wang J, Wang Y, Wu C, Xiao Y, Xiong H, Xu D, Xue E, Xue L, Yan S, Yang L, Yong Q, Zhan W, Zhang S, Zhang X, Zhang J, Zhou X, Lin X, Yin S, Zhao Q. Chinese association of ultrasound in medicine and engineering, superficial organs and peripheral vessels committee expert consensus on clinical frequently asked questions in breast ultrasonography, June 2018. J Can Res Ther [serial online] 2018 [cited 2020 Jul 12];14:1463-8. Available from: http://www.cancerjournal.net/text.asp?2018/14/7/1463/247721
| > Q1. The Conclusion of “mammary Hyperplasia” is Commonly Seen in Domestic Ultrasound Reports. Is This Appropriate?|| |
Mammary hyperplasia should not be included in the impression of ultrasound diagnosis. Mammary hyperplasia can present with multiple imaging pictures, such as simple cysts, adenomatous nodules, adenosis, and other changes, and these changes have been classified into different categories in BI-RADS. For mammary glands without any visible mass, whether the patient has any symptoms or not, ultrasound findings could indicate that the absence of tumor-like lesions in both breasts (BI-RADS: Category 1) [Figure 1].
|Figure 1: 1.skin 2.subcutaneous fat 3.mammary gland 4.retromammary space 5.pectoralis major. Normal breast diagram and grayscale ultrasound image. Ultrasound conclusion: No space-occupying lesion seen in bilateral breasts (Breast Imaging Reporting and Data System: Category 1)|
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| > Q2. Is it Necessary to Describe the Phase of the Female Menstrual Cycle While Mentioning the Impression of the Ultrasound Conclusion, Such as Adolescent Mammoplasia, Pregnancy, Lactation, or Menopause?|| |
Only adolescent mammoplasia and lactating breasts should be described in the first line of the conclusion. Other cycles do not need to be described. For lactating breasts, it is also necessary to describe the status of the lactiferous ducts in the report and the presence or absence of milk, siltation, or inhomogeneous echoes should be described if there is [Figure 2].
|Figure 2: Gray-scale sonogramssonogram of initial breast development adolescent mammoplasia (a) and lactating breast (b).Ultrasound conclusion: No space-occupying lesion seen in bilateral breasts. (BI - RADS: category 1).|
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| > Q3. Does Routine Examination Require Measurement and Description of Mammary Gland Thickness?|| |
Routine thickness measurement is unnecessary for normal mammary glands. Thickness of the mammary gland may be affected by race, individual differences, and menstrual cycles; therefore, such a measurement has no practical clinical significance.
| > Q4. If There is an Inconsistency between Ultrasound Images and Clinical Symptoms for Lactation Mastitis, How Should it Be Described and Diagnosed?|| |
- According to the image features, it should be described as what has been demonstrated
- If there is no obvious positive finding on imaging, the conclusion could be lactational breast and no obvious abscess being detected (BI-RADS: Category 1).
| > Q5. If There Are Multiple Lesions in One Breast, is it Necessary to Describe Them One by One; Further, How Must They Be Classified? When Using Clock Face Notation to Describe a Lesion, Is it Necessary to Mention the Distance from the Nipple?|| |
- Bilateral breast nodules should be described separately. The clock face notation of the lesion and its distance from the nipple should be recorded. If required clinically, or in case of multiple adjacent nodules appearing at the same location, the distance of these nodules to the skin should also be recorded
- For lesions of BI-RADS Category 2 and 3, if multiple lesions show the same ultrasonographic features, they can be described together. Only the largest lesions on each side of the breast are described in detail, including the three diameters. For lesions of BI-RADS Category 4 or higher, if their subcategories are different, it is recommended to record their clockwise directions, distances from the nipple and ultrasound features separately.
- Each conclusion must correspond to the description, for which nodules with the same features and subject to a common description should be categorized together, and the nodules described one by one should be categorized separately.
| > Q6. What is the Cutoff Point for Duct Diameter in the Diagnosis of Mammary Duct Dilatation? How Should it Be Described and Classified?|| |
- In asymptomatic patients, if the ductal wall is smooth, the recommendation is to describe it only if the internal diameter is >2 mm, and it should be classified as BI-RADS Category 2. If there is no solid component in the dilated duct and the patient has nipple discharge or bleeding, it is classified as Category 0 and further examination is necessary
- In case of duct dilation, if there are echogenic changes in the duct or the duct wall, it should be described in detail and classified according to the specific condition of the lesion, regardless of whether the diameter of the duct is >2 mm.
| > Q7. How Must Multiple Breast Cysts With Diameters Varying from Millimeter to Centimeter Be Described and Assessed?|| |
- If the sonographic features of multiple cystic nodules are basically the same, only the greatest diameter of the largest cyst on each side should be measured and described, and its specific location should be indicated as well
- If the cyst is which is not the largest in diameter considered to be a mass on mammogram or palpation, it should be described in detail
- If some of the cystic nodules are different from others, such as containing debris or solid components, these nodules should be described separately, and their measurements and locations should be indicated.
| > Q8. Apart from the Breast Imaging Reporting and Data System Classification, Can We Indicate the Pathological Diagnosis When the Lesion Has Typical Features, Such as in Fibroadenoma?|| |
A possible pathological diagnosis could be given for lesions with typical imaging features, based on personal experience and the BI-RADS classification. In case of fibroadenoma, ultrasound findings may belong to Category 3, and fibroadenoma could be considered.
| > Q9. How Must a Hypoechoic Lesion With an Irregular Lobulated Shape and Circumscribed Margin Be Categorized?|| |
- According to the BI-RADS lexicon, an oval shape may include two or three undulations, i.e., gently curve or macrolobulated. If an oval lesion, has circumscribed margins parallel to the skin, and without other malignant signs, it is likely to be a benign lesion. It could be classified into Category 2 (cystic nodules) or Category 3 (solid nodules). Otherwise, it should be classified into Category 4 or above. The following images show several categories, out of which only image 1 can be divided into category 3 [Figure 3]
|Figure 3: Five categories according to Breast Imaging Reporting and Data System lexicon. Oval (macrolobulated) (a), irregular (microlobulated) (b), Irregular (angular) (c) (indistinct) Irregular (Spiculated margin (d) Angular and spiculated marugin (e).:arrowheads)|
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| > Q10. Under What Circumstances are Breast Imaging Reporting and Data System Category 0 Reported on Breast Ultrasound?|| |
Category 0 is generally not reported except in the following circumstances:
- In the presence of incomplete ultrasound scanning due to special circumstances, such as a large patch of broken skin, or obscure images of deep structures due to huge breast size
- When no obvious mass is found, but there is presence of one of the following situations such as a local heterogamous area, clinical symptoms, a large number of hyperechoic dots in the gland, and nipple discharge.
| > Q11. What is the Classification if the Lesion Has Already Been Excised by a Mammotome System and is Proven to Be Breast Cancer? if the Pathology is Benign, How Must it Be Classified on Follow-Up?|| |
- If the lesion excised by the Mammotome system is confirmed to be breast cancer, Category 6 is recommended to be reported even if no nodule is detected on ultrasound
- If pathology results are suggestive of a benign lesion and only a structure distortion is found in a recent ultrasound examination, an impression of Category 2 is suggested. If there is no obvious lesion in the breast, it may be classified as Category 1.
| > Q12. If Breast Cancer Has Been Confirmed by Pathology After Surgical Resection in Other Hospitals, How Can We Classify it during Follow-Up?|| |
If the patients need a further modified radical mastectomy or extended resection for breast cancer or no definite treatment plan, a meticulous preoperative ultrasound should be performed to evaluate and record the surgical scar, subcutaneous fluid or residual tumor. The category 6 could be reported, and the excised tumor could be taken for pathological reporting of the operative specimen. If only chemotherapy or radiotherapy is needed, without any surgical intervention, then the previous surgical scar could be classified as category 3.
| > Q13. How Must the Lesion Be Assessed After Neoadjuvant Chemotherapy during Multiple Ultrasound Follow-Ups?|| |
- For patients undergoing neoadjuvant chemotherapy, the preoperative ultrasound should be reviewed. It should be noted whether the lesion is still present or has almost disappeared, and only local structure distortion is present. Category 6 is recommended to be reported, and a comparison with previous ultrasound findings should be mentioned in the report. If the curative effect is obvious, and ultrasonography does not demonstrate the original lesion, classification is not necessary. Only a comparison with previous ultrasound findings needs to be mentioned
- In case of a new lesion detected on ultrasound during neoadjuvant chemotherapy, imaging features should be assessed according to the BI-RADS, and the curative effect of the primary lesion should be evaluated and the classification is the same as above.
| > Q14. Is it Necessary to Describe Axillary Lymph Nodes With a Normal Structure and What is the Method? is it Necessary to Divide Lymph Nodes According to Their Draining Area?|| |
- In case of axillary lymph nodes, as long as they meet the ultrasound diagnostic criteria and are considered as normal lymph nodes, they need not be described
- Evaluation of draining lymph nodes is a vital part of breast sonographic examination. Draining lymph nodes mainly include regional lymph nodes (axillary and parathoracic intra-arterial lymph nodes) and distal supraclavicular lymph nodes. Axillary lymph nodes can be further divided into first, second, and third level, and they need to be scanned and described. In particular, if a malignant breast lesion is suspected, the supraclavicular lymph nodes should be scanned and described as well. If the suspected malignant lesion is located in the inner quadrant, lacteal lymph nodes should also be scanned and described (1st to 6th parasternal intercostal space should be scanned).
Q15. In Case a Mammary Gland - Like Structure is Detected in the Axillary Region Unexpectedly during Breast Ultrasonography, Should a Diagnosis of Accessory Breast Be Made ? If Symptoms of Accessory Breasts Are Obvious in Patients, but There is No Positive Ultrasound Finding, Then How Should it Be Reported?
- If a gland-like structure is found in the axillary region, its thickness should be measured and the ultrasound conclusion should be suggestive of an accessory breast gland. It should be distinguished from a mammary caudate lobe
- If symptoms of accessory breasts are apparent, but there is no positive ultrasound finding, the ultrasound conclusion should be mentioned as no obvious gland-like structure found in the axilla.
| > Q16. According to the Guideline of Breast Imaging Reporting and Data System, Do We Need to Give Advice Such as “biopsy is Recommended” After the Lesion Has Been Categorized?|| |
Relevant management in ACR BI-RADS of 2013 edition has been recommended; repetitive indications are not recommended.
| > Q17. What are the Indications for Breast Elastography? How Must a Diagnosis Be Made Based on Elastography?|| |
- Elastography includes strain elastography and shear wave elastography.,,,,,,, According to the 2015 edition of “WFUMB Guidelines and Recommendations for Clinical Use of Ultrasound Elastography,” clinical indications of elastography include (1) to assess the stiffness of the breast lesion based on gray scale ultrasound and to differentiate benign from malignant masses;,,,,,, (2) to upgrade BI-RADS Category 3 or downgrade BI-RADS Category 4A lesions for avoiding unnecessary biopsies;, to assess the curative effect of neoadjuvant chemotherapy in breast cancer;,,, and (4) to detect and evaluate nonmass abnormalities ,,
- Consensus about upgrade and downgrade: According to the guidelines of the ACR BI-RADS classification, the shape, margin, and echo of lesions on ultrasound are more significant than stiffness. Thus, assessment of elasticity cannot override morphological assessment. It is reasonable to use elastography to upgrade BI-RADS Category 3 or downgrade BI-RADS Category 4A cases. If patients of Category 3 show malignant elasticity characteristics, it is recommended to upgrade to a higher category, and biopsy should be advised. If grayscale ultrasound or other image examinations indicate a lesion of Category 2 (such as fat necrosis or cyst), elastography is not needed.
| > Q18. What are the Indications for Breast Contrast-Enhanced Ultrasound?|| |
At present, there are still some controversies about breast contrast-enhanced ultrasound.,,,,,,,,,, Based on existing research, contrast-enhanced ultrasound can provide microperfusion information of lesions, and applying contrast-enhanced ultrasound may improve the sensitivity of biopsy; for neoadjuvant chemotherapy patients, it has certain value for assessing curative effect.,, For lesions that are difficult to diagnose by conventional ultrasound and elastography, contrast-enhanced ultrasound could be performed to provide additional diagnostic information. However, its differential diagnostic value is still controversial, and further clinical research and practice is still required to prove its value.
| > Q19. Although Age-Related Factors Have not Been Mentioned in the Bi-Rads Classification, Do We Need Take the Age Into Consideration When We Make a Diagnosis?|| |
Although age-related factors have not been mentioned in the BI-RADS classification, the actual age of the patient is also an important reference in clinical practice. In particular, the average age of onset of breast cancer in Chinese women is relatively earlier than that of European and American women. Therefore, in patients above 40 years of age, it can be classified into a higher category, according to specific circumstances. As shown in [Figure 4], the lesion in a patient over the age of 40, has been appropriately assessed as category 4A.
|Figure 4: A 45-year-old woman with a benign-appearing, 2.4×1.3cm mass. BI - RADS: category 4A. Histopathology: mucinous breast carcinoma|
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| > Q20. If Patients of Bi-Rads Category 4a Refuse to Undergo the Pathologic Examination, How to Manage the Lesion With Ultrasound?|| |
- If patients of category 4A refuse to undergo the pathologic examination, other imageological examinations should be recommended such as mammogram and magnetic resonance. Refer to multiple imageological diagnosis, and make the management recommendation.
- If patients of category 4A refuse to undergo the pathologic and other imageological examinations, patient should consult the doctor and an initial short-term follow-up interval of less than 3-months is recommended. Assuming stability after two follow-up intervals (a total of 6 months), the recommended follow-up interval is lengthened to 6-month. The next management recommendation makes reference to category 3. After 2–3 years of stability, the final assessment category should be downgraded to category 2. If there is an increase of 20% or more in the volume or more malignant ultrasound features found within follow-up interval, it is recommended to upgrade to a higher category.
We sincerely acknowledge all the members and standing committee members of the Superficial Organs and Peripheral Vessels Committee, Chinese Association of Ultrasound in Medicine and Engineering. We thank Dr. Mohammad Eghtedari for editing this article and providing useful recommendations. Some deficiencies are inevitable in this article due to lack of time, and your valuable opinions are welcome and valuable for us. We will dedicatedly make corresponding modifications in future revisions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]