¹Associate Professor, Department of Radiology, MIMSR Medical College, Latur, Maharashtra, INDIA.

²Professor, Department of OBGY, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, INDIA.

Email: drshrikantmaniyar@gmail.com shalinikarad787@gmail.com

Table 4: Distribution of Sonographic Parameters

DISCUSSION

Majority of the breast carcinomas are usually asymptomatic and the usual mode of presentation is an incidental palpable lump or pain and rarely, they present with nipple discharge and skin changes.⁶ With the development of various adjuvant treatment methods including chemotherapy, endocrine therapy, and radiation therapy, the treatment outcome for patients with breast cancer has improved. Ultrasound is used in many ways, not only as an initial diagnostic tool for confirmation of pathology determined from biopsies of the breast but also staging of breast cancer. It is also combined with mammography, a procedure called sonomammography to aid in better detection of breast cancer.^7,8 Tumor size, lymph node status, histological type, histological grade, and lymphovascular invasion are the important prognostic histologic features. Breast ultrasound criteria for characterisation of malignant lesions are mass having ill-defined borders, spiculated / angular margins, grossly hypoechoic lesion, taller than broader-the maximum diameter in the longitudinal plane, associated posterior acoustic shadowing and microcalcifications.^9,10 It has been suggested that “neoductgenesis” may be the underlying mechanism responsible for this worse outcome. This process promotes vascular invasion and consequently excessive lymphatic and hematogenous spread in breast cancer. In a study conducted by Wendie et al. showed that pleomorphic calcification seen within a mass was mostly proven on histopathology to be a typically invasive ductal carcinoma.¹¹ While Kini et al.,¹² demonstrated that calcifications on preoperative mammography appeared to be associated with an increased risk of local recurrence and that fine linear branching microcalcification observed on mammography was associated with a poor survival rate. In spiculated margins strands of tissues are seen radiating out from an ill marginated mass producing a stellate appearance. Spiculations represent retraction of tissue strands towards the tumor due to fibrosis - as a result of desmoplastic reaction. Posterior acoustic properties of a mass are based on multiple factors like cellular components, stromal reaction and number of histological interfaces between fibrous and cellular components.¹³ Fine stands of cancer cells infiltrating into the surrounding tissue appeared to cause backscattering, resulting in posterior shadowing. Posterior enhancement is usually due to fluid component within a mass. Some of the solid cystic malignant masses were seen to be accompanied by both enhancement (from cystic part) and shadowing (from the solid component).¹⁴ Most commonly encountered gray scale ultrasonographic features for malignant breast masses in this study were hypoechoic mass, taller than wide with irregular shape and spiculated margins, having neither posterior acoustic enhancement nor posterior shadowing, presence of intralesional microcalcifications and surrounding echogenic halo. Other associated findings frequently noted were skin thickening, thickened Cooper's ligament, nipple retraction, architectural distortion and axillary lymphadenopathy.¹⁵ In a similar Indian study authors noted that masses with complex solid cystic mass with heterogeneous echotexture, abrupt interfaces, calcifications and/or presence of reversal/lack of diastolic flow may suggest high grade of tumors. The finding of reversal/lack of diastolic flow in a breast mass was the strongest predictor of high grade of tumor in our study and warrants early lymph nodal sampling.¹³ Similar findings were noted in present study. Lamb et al.,¹⁶ investigated the relationship between imaging characteristics and histologic grade. Contrary to expectations that more malignant masses would show spiculated mass margins and acoustic shadowing, they found that higher-grade tumors were significantly more likely than lower-grade ones to display poorly defined margins and posterior acoustic enhancement. The new vessels in malignancy are tortuous, non-hierarchical and disorganised with frequent stenosis, occlusions and arteriovenous shunts. Tumour cells produce protein angiogenin, thus correlating with tumor growth and producing new vessels that are tortuous, of irregular caliber and thin walls with no smooth muscle.^17,18 Strain elastography (SE) and shear-wave elastography (SWE) are the two most frequently used ultrasound elastography techniques in the breast. In Strain elastography (SE), stress is applied by repeated manual compression of the transducer, which provides a measurement of the deformed lesion relative to the surrounding normal tissue with a color display.¹⁹ The other technique, shear-wave elastography (SWE), uses an acoustic radiation force impulse created by an ultrasound beam, which allows for the measurement of the propagation speed of shear waves within the tissue and quantifies the stiffness in either kilopascals or meters per second.²⁰

CONCLUSION

Malignancy grade of invasive ductal carcinoma can be predicted by heterogeneous echotexture of mass, abrupt interfaces, calcifications, posterior acoustic enhancement and/or presence of reversal/lack of diastolic flow margins.

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