Keywords
breast - ultrasound - mammography - Gynecology - Radiology
1. Breast ultrasound for follow-up
1. Breast ultrasound for follow-up
1.1 General information
Definition: According to the interdisciplinary S3 guidelines on the early detection, diagnosis,
treatment, and follow-up of breast cancer (S3 guidelines), follow-up is performed
“after completion of primary local treatment”. It includes structured examinations
“with a focus on the early detection of locoregional or intramammary recurrence and
contralateral breast cancer and on the targeted search for metastases in the case
of symptoms or justified suspicion and late consequences of primary and long-term
therapy” [1].
Duration: The follow-up period was extended from 5 years to 10 years in the guidelines due
to the tumor biology of breast cancer [1].
Diagnostic imaging for follow-up: According to the S3 guidelines from 2021 and the AGO guidelines from 2023, breast
ultrasound, in addition to mammography, is an essential part of early detection of
both locoregional recurrence and contralateral breast cancer (S3 guidelines: EG B,
LoE 2) (AGO: LoE 1a, GR A, AGO ++). According to the guidelines [1], patients who have had a breast cancer diagnosis should no longer be included in
mammography screening, especially because a locoregional recurrence rate from 7 %
to 20 % must be taken into consideration and an increased relative risk for contralateral
breast cancer of 2.5 % to 5 % must be assumed [2].
Examination frequency: According to the S3 guidelines and the AGO guidelines, a breast ultrasound examination
of the ipsilateral breast should be performed “at least” once a year during the first
3 years of follow-up in combination with mammography. The first mammogram of the affected
side is performed 6 months after the end of radiation at the earliest. The contralateral
breast is also examined once a year, at the earliest 12 months after the preoperative
mammography examination. Beginning in the fourth year, mammography with supplementary
ultrasound is recommended once a year for the ipsilateral as well as the contralateral
breast. In the case of a low risk of recurrence, the mammography interval can be decreased
to every 2 years after 10 years of follow-up. In the case of an average or high risk,
annual follow-up continues [1]. In the case of ambiguities on mammography and/or ultrasound, MRI should be additionally
performed [2].
It was shown that the recall and biopsy rates increased as a result of supplementary
breast ultrasound in the follow-up period [3]. Most patients (82 %) feel positively about the additional examinations since the
increased focus is associated with a higher sense of security [3]. In contrast to patient acceptance of ultrasound, only approx. two-thirds of patients
undergo an annual mammography examination after primary surgery [4].
1.2 Specific pathologies
Detailed examination and documentation of the scars should be performed. When needed,
split image documentation with and without compression can be used ([Fig. 1]). The advantage in the case of skin retractions or folds caused by scars is that
these can usually be effectively visualized with hand-held ultrasound. It must be
taken into consideration that a significant amount of ultrasound gel is used to achieve
sufficient coupling even in the case of severe skin retractions. Doppler ultrasound
should always be performed in addition to B-mode imaging. As an optional method, 3 D
ultrasound, if available, can provide additional information like the canyon sign.
Fig. 1 Scar after breast-conserving therapy with fluid and contact to the skin, left without
compression, right with compression.
Mainly hematomas and seromas play a role in the early postoperative phase. In the case of symptoms, diagnostic
ambiguity, or if needed prior to planned radiotherapy, these can be punctured under
ultrasound guidance.
Fat necrosis (lipoid necrosis) is typically seen in the follow-up period. Its appearance is diverse
([Fig. 2]) and is usually difficult to evaluate without additional mammography information.
Fat necrosis become increasingly liquefied over time resulting in so-called oil cysts
([Fig. 3]). Symptomatic oil cysts can be punctured and drained under ultrasound guidance.
Fat necrosis can calcify over time causing persistent symptoms. Sonographic assessment
is affected by changes in sound propagation. Comparison with a current mammography
examination is recommended.
Fig. 2 Fat necrosis on a panorama scan 10 years post-operation.
Fig. 3 Oil cysts with plaque-like calcifications of the wall 8 years post-operation.
Both architectural distortion caused by scarring and fat necrosis are to be differentiated
from recurrence. Similar to its presentation on mammography, recurrence can be seen as extra tissue
as well as increased vascularization on Doppler ultrasound or contrast enhancement
on contrast-enhanced ultrasound (CEUS). In the case of suspicion of recurrence in
the area of the scar or suspicion of a second carcinoma, histological verification
is required ([Fig. 4], [5], [6], [7]).
Fig. 4 Recurrence in the scar region, NST G1. New focal finding in the former tumor bed
after breast-conserving therapy.
Fig. 5 Second carcinoma, NST G2. New focal finding after breast-conserving therapy removed
from the former tumor bed. Hard elasticity assessment.
Fig. 6 a Recurrence in the scar region, NST G3. New irregular hypoechoic focal finding with
unclear borders and with perfusion in the periphery adjacent to a large calcified
fat necrosis in the region of the scar. b Recurrence in the scar region, NST G3. Same patient as in Fig. 6a, corresponding mammography, cc projection, with calcified fat necrosis and new adjacent
areas of increased density.
Fig. 7 Epithelioid high-grade angiosarcoma. Vascularized protuberance of the skin 9 years
after breast-conserving therapy with radiation.
After the use of ablative treatment methods, ultrasound is the imaging method of first
choice to rule out recurrence in the chest wall or to confirm this suspicion ([Fig. 8]). Examination and palpation findings can by further clarified by complementary use
of ultrasound. Histological confirmation is needed in the case of suspicion.
Fig. 8 Recurrence in the chest wall. Hypoechoic focal finding in the chest wall 4 years
after mastectomy.
Even after reconstruction with the patient's own tissue or implants, fat necrosis or recurrence can occur and must be differentiated from one another.
In addition, in the case of implants, it is important to detect dislocation, rotation,
capsular fibrosis, rupture, and indications of silicone leaks. Ultrasound is the diagnostic
method of first choice for this purpose [5].
In the case of suspicion of a lymph node metastasis, it is necessary to determine whether lymph node metastasis was already detected
during the primary diagnostic workup. Lymph node levels I-III are to be examined on
a bilateral and comparative basis. In the case of abnormal lymph nodes, in addition
to breast cancer metastases, lymphoma and lymph node metastases of another primary
tumor should be considered for the differential diagnosis. Histological confirmation
via ultrasound-guided punch biopsy should be performed [2]. In the case of confirmation, additional staging examinations must be performed.
In the axilla, the examiner should also pay attention to the possible presence of
accessory breast parenchyma. Even after ablative procedures, residual breast parenchyma
can be located there.
After the introduction of the sentinel lymph node technique (SLN), lymphedema has become less common but can still be detected to varying degrees. Pronounced lymphedema
can weaken the acoustic energy to the extent that evaluation of low-lying structures
can be difficult ([Fig. 9]). Lymphedema associated with thickening of the skin can sometimes be differentiated
from cutaneous metastasis or lymphangitic carcinomatosis based on increased vascularization
in the two latter cases. The clinical course and comparison with prior imaging provides
important information.
Fig. 9 Lymphedema of the skin and breast. Skin thickening and dilation of the subcutaneous
lymph gaps after breast-conserving therapy with radiation.
After sonographic localization, suspicious skin changes can be histologically clarified
in a targeted manner with punch biopsy.
1.3 Conclusion and DEGUM recommendations
In addition to inspection and palpation, the use of ultrasound as a supplement to
mammography is an essential part of follow-up. The goal of regular follow-up is the
early detection of recurrence and second carcinomas, both ipsilateral and contralateral.
-
According to the guidelines, structured follow-up examinations are to be performed
over a period of 10 years.
-
Changes in scars should be additionally examined via Doppler ultrasound. Elastography
as a supplementary modality and 3 D ultrasound as an optional modality can provide
additional information.
-
An image comparison to mammography is to be recommended in the case of fat necrosis,
scars, and lymphedema. Combined mammography and ultrasound evaluation increases the
reliability of the differential diagnosis in the case of scars and calcification of
scar tissue.
2. Breast ultrasound in the case of breast implants
2. Breast ultrasound in the case of breast implants
2.1 General information
In addition to augmentation in plastic surgery, breast implants are used to correct
malformations of the female breast and for reconstruction after ablative treatment
of breast cancer. Globally, approx. 1.5 million implants are implanted each year,
with approx. 67.000 of those being implanted each year in Germany.
Complications that can occur with implants and be diagnosed on ultrasound include:
Implant rotation, implant wrinkling, intracapsular fluid (seroma), implant rupture,
and silicone migration.
In an FDA study regarding the use of implants for breast surgery, a 10-year observation
period showed that 5th generation implants have a defect in 12–14 % of cases and intra-
and extracapsular silicone migration can occur. The FDA recommends MRI examinations
of implants every two years so that complications, particularly implant defects, can
be detected early [6].
For pragmatic reasons (availability of equipment, economic reasons), it is not possible
to offer this examination to all women with implants. In addition, MRI examination
of all women with implants is neither practical nor recommended in Germany, is not
included in the service catalog of insurance companies, and is not logistically feasible.
Ultrasound achieves a high sensitivity (60–70 %) and specificity (80–85 %) compared
to other methods for the imaging of implants and is only surpassed by MRI (96–100 %
and 94–100 %, respectively) [5]
[7]
[8]. Therefore, ultrasound as a widely available and economical method is important
for the primary diagnostic workup.
Ultrasound examination should be used to assess implant alignment in the case of anatomically
shaped implants and to search for indications of implant defects and possible siliconomas
[9].
The surrounding tissue should be examined separately from the implant on ultrasound.
Complete examination of the implant with visualization of the anterior wall and if
possible the posterior wall should be ensured. If available, panoramic imaging can
be used for complete visualization.
2.2 Normal findings and specific pathology
Implant alignment
Implant manufacturers usually mark their products with stripes or points that can
be identified on ultrasound. The alignment of the implant and the correct positioning
can be visualized on the sagittal plane ([Fig. 10], [11], [12]) [10].
Fig. 10 Marking of points. The alignment of the implant can be checked with the help of the
two oval points.
Fig. 11 Marking of bands. Slight internal rotation of the implant in this example.
Fig. 12 Marking of points.
Intact implant
To be able to differentiate physiological from pathological changes, it is important
to be familiar with the appearance of intact implants on ultrasound ([Fig. 13], [14]). In the initial years following implantation of an implant, the body naturally
forms a fibrotic capsule around the implant. Radial folds in the implant can form
over time due to shrinkage of the capsule. These must not be interpreted as signs
of capsule rupture.
Fig. 13 Intact implant. Easily recognizable physiological fibrotic capsule (wide arrow) and
implant membrane (thin arrow), no seroma, anechoic implant.
Fig. 14 Intact implant. Minor mirror image artifacts.
The extent of mirror image artifacts in the implant is determined by the slice thickness
and density of the breast tissue. A symmetrical pattern can be expected in the side
comparison in the case of intact implants ([Fig. 15]).
Fig. 15 Intact implant. Inhomogeneous mirror image artifacts depending on the tissue structures
in the breast.
In the case of radial transducer orientation in an upper/outer preaxillary position,
the prepectoral or retropectoral position of the implant can be determined ([Fig. 16]).
Fig. 16 Retropectoral location of the implant. The major pectoral muscle runs over the implant
(arrow).
Wrinkling in the case of capsular fibrosis/capsular contracture
With progressive shrinking of the fibrotic capsule, pathological capsular contracture
with subsequent deformation and increasing pain can occur.
According to Baker, there are four clinical grades of capsular fibrosis:
-
Baker I: Implant not palpable, not visible – soft breast, natural shape
-
Baker II: Implant palpable, not visible – breast slightly firmer, normal shape
-
Baker III: Implant palpable and visible – breast firm, deformation, no pain
-
Baker IV: Implant palpable, visible, dislocated – breast hard, deformation, pain
Wrinkling of the implant under the fibrotic capsule can be seen on ultrasound ([Fig. 17]). Diagnosis and particularly the assessment of the need to treat the capsular fibrosis
are largely based on the clinical findings.
Fig. 17 Wrinkling of the implant membrane under the capsule.
Implant rupture
A differentiation is made between intracapsular and extracapsular rupture [11].
Sonographic signs of intracapsular rupture include:
-
Debris sign – variations in echogenicity within the implant (inhomogeneous content). Intracapsular
rupture results in silicone deposits within the capsule. These silicone deposits change
the acoustic properties in the implant. Mirror image artifacts appear inhomogeneous
([Fig. 18], [19]).
-
Gel bleeding – intracapsular fluid (seroma around the implant with variations in echogenicity).
The migration of silicone from inside the implant through the membrane results in
intracapsular fluid. A thin border with variations in echogenicity between the membrane
and the capsule is seen on ultrasound ([Fig. 20], [21]).
-
Stepladder sign – steps are formed in the region of the ruptured edge of the implant membrane. Discontinuous
parallel linear echoes in the lumen of the implant are seen on the ultrasound image.
This sign corresponds to the linguine sign on MRI and is considered the most reliable
ultrasound finding in the case of intracapsular ruptures ([Fig. 22]).
-
Sandwich sign – free silicone between the capsule and the implant membrane ([Fig. 23]).
-
Snowstorm sign – strong reflection, hyperechoic appearance of the silicone accompanied by dorsal
acoustic shadowing ([Fig. 24]).
Fig. 18 Debris sign. Inhomogeneous mirror image artifacts in the implant. The fibrotic capsule
and the implant membrane can no longer be differentiated due to silicone deposits
in the capsule and a change in acoustic properties in the implant.
Fig. 19 Debris sign. Silicone migration into the capsule, inhomogeneous mirror image artifacts
in the implant.
Fig. 20 Gel bleeding. Seroma in the periphery of the implant (marking).
Fig. 21 Gel bleeding. Hyperechoic region due to intracapsular silicone migration (2 D image
and 3 D correlate).
Fig. 22 Stepladder sign. The torn implant membrane is shown as hyperechoic broken lines.
Fig. 23 Sandwich sign. Free hyperechoic silicone between the membrane and the capsule.
Fig. 24 Snowstorm sign. Hyperechoic capsule and acoustic shadowing in the implant due to
silicone migration into the capsule.
Sonographic signs of extracapsular rupture include:
-
Formation of silicone granulomas – hypoechoic or hyperechoic masses. When replacing defective implants, silicone particles
can remain. Silicone granulomas of varying size form and appear as hypoechoic or hyperechoic
masses in the parenchyma. These can then be incorrectly interpreted as a sonographic
indication of a current implant defect ([Fig. 25]). Early sonographic follow-up after an implant replacement can help to avoid misinterpretation.
Any prior implant replacement must be recorded in the patient's medical history. This
minimizes the probability of misdiagnosis of an implant rupture.
-
Extracapsular migration of silicone into the tissue – snowstorm sign, hyperechoic appearance, loss of contrast enhancement. In the case
of extracapsular rupture, silicone migrates through the fibrotic capsule into the
surrounding breast tissue. The ultrasound waves are reflected in an aberrant manner
by the silicone particles. This results in a hyperechoic image with a loss of contrast
enhancement and sonoanatomy and with the snowstorm sign ([Fig. 26], [27]).
-
Migration of silicone into the lymph nodes – snowstorm sign, hyperechoic hilum, loss of sonoanatomy. Silicone migrates not only
into the surrounding breast tissue but also into the lymphatic vessels and begins
to be deposited in the hilum of the lymph node. Typical signs of silicone migration
into the lymph nodes are a hyperreflective hilum and the snowstorm sign. Silicone
migration can affect the entire lymphatic system and can travel past level III to
the parasternal region and beyond ([Fig. 28], [29], [30]). Surgical removal is only indicated in the case of symptoms.
Fig. 25 Silicone granulomas. Resulting from remaining silicone particles after implant replacement.
Fig. 26 Extracapsular silicone migration into the tissue. Initial loss of contrast enhancement
in the parenchyma.
Fig. 27 Silicone migration into the tissue. Loss of sonoanatomy in the periphery of the implant
after implant replacement.
Fig. 28 Silicone migration into the lymph nodes. Snowstorm sign, sonoanatomy of the lymph
node is no longer visible.
Fig. 29 Silicone migration into the lymph node hilum. The narrow cortex of the lymph node
is still visible.
Fig. 30 Silicone migration into parasternal lymph nodes.
Focal findings in patients with implants
The breast parenchyma is typically pressed against the skin envelope by a retroglandular
or retropectoral position of the implant. As a result, the typical malignancy criteria
on ultrasound like dorsal acoustic attenuation and vertical orientation can be falsified
or not appear clearly. Axial ratios in malignant findings can change. The horizontal
axis can then appear longer than the vertical axis ([Fig. 31]).
Fig. 31 Indifferent dorsal acoustic properties and a shift of the axes of the tumor due to
physiological pressure of the implant.
High-resolution close-up ultrasound with frequencies of over 12 MHz allows the narrow
breast parenchyma border to typically be evaluated in a more differentiated manner
than when using low sound frequencies.
Lymphadenopathy in the case of breast cancer in women with implants
As a result of silicone migration after implant rupture into the regional lymph nodes
beyond level III into the cervical and/or parasternal lymph nodes, the status of the
lymph nodes cannot be sufficiently evaluated on ultrasound. To reduce axillary morbidity,
SLN removal should be discussed. In the case of a positive lymph node, the current
clinical and morphological situation determines how to proceed ([Fig. 32]). It must be taken into consideration that the lymph nodes in women with implants
are generally more difficult to evaluate even without silicone deposits and metastasis
since reactive changes with enlargement of the cortex of the lymph nodes can often
be seen.
Fig. 32 Lymph node on level I in a patient with breast cancer. An unremarkable lymph node
and a lymph node with silicone deposits, not able to be optimally evaluated.
Follow-up of women with implants
As in the primary diagnostic workup, silicone migration complicates the evaluation
of the lymphatic system in follow-up examinations ([Fig. 33], [34]).
Fig. 33 Silicone migration into the lymph nodes on level II.
Fig. 34 Silicone migration into the parasternal lymph nodes.
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
BIA-ALCL is associated with the implantation of textured silicone implants. If a seroma
forms years after implantation of the implant (late seroma), it should be punctured
and examined cytopathologically even if this diagnosis is suspected [12]. The incidence of BIA-ALCL specified in the AGO guidelines is currently approximately
0.6–1.2 per 100 000 cases ([Fig. 35]) [2].
Fig. 35 BIA-ALCL. Pronounced seroma adjacent to the implant.
2.3 Conclusion and DEGUM recommendations
With respect to the detection of implant-related complications, breast ultrasound
has proven to be a readily available, cost-effective diagnostic method that is usually
superior to mammography. It should be used as the primary diagnostic method for evaluating
implants.
-
Complications like implant rotation, implant wrinkling in the case of capsular contracture,
and intracapsular and extracapsular rupture with silicone migration into the capsule,
breast tissue, and lymph nodes should be detected.
-
It must be taken into consideration that the typical criteria for detecting malignant
findings both in the primary situation and in the follow-up period can be affected
by the pressure of the implants on the overlying tissue.
-
In the case of an unclear late seroma around the implant capsule, rare late complications
like BIA-ALCL should be considered and diagnosed accordingly.
3. Breast ultrasound in the case of dense breast parenchyma
3. Breast ultrasound in the case of dense breast parenchyma
3.1 General information
The glandular tissue is comprised of the terminal ductal lobular units (TDLU) responsible
for lactation and the large milk ducts. Connective tissue and fat tissue surround
the glandular tissue. Glandular tissue and connective tissue appear hyperechoic on
ultrasound, while carcinomas often have hypoechoic structures ([Fig. 36]). Thus, there is echo contrast that usually allows effective diagnosis. In contrast,
carcinomas are usually isodense or hyperdense on mammography compared to the glandular
tissue and connective tissue and may be covered or masked by other tissue structures
[13].
Fig. 36 Hypo- to isoechoic small breast carcinoma in dense, hyperechoic breast parenchyma.
According to data from the German Mammography Screening Program, 46 % of women age
50 or older have heterogeneously dense breasts (parenchyma category c) ([Fig. 37]) and 6 % have extremely dense breasts (parenchyma category d) ([Fig. 38]) [14]. In the case of a dense breast parenchyma, the sensitivity of mammography can be
reduced due to overlying layers or minimal contrast between the carcinoma and the
surrounding tissue [15]. The guidelines recommend supplementary breast ultrasound to increase sensitivity
in this situation. The denser the tissue, the more limited the ability to evaluate
and detect a malignancy on mammography and the higher the risk [16]
[17].
Fig. 37 Parenchyma category c, primarily fibroglandular tissue.
Fig. 38 Parenchyma category d, extremely fibroglandular tissue.
Breast ultrasound is able to detect mammographically occult cancers in approx. 4.4
cases per 1000 examinations [18]. Digital breast tomosynthesis (DBT) detects approx. 2 additional carcinomas per
1000 examined women [19]
[20]
[21]
[22]. Ultrasound is significantly superior to DBT in the direct comparison, particularly
in dense breasts (parenchyma categories c and d) ([Table 1]) [23]
[24]. Evidence for the supplementary sonographic detection of mammographically occult
cancers in dense breasts has already been provided in meta-analyses.
Table 1
Comparison of imaging methods used in addition to mammography in women with dense
breast tissue from Mundinger A et al. Rolle der Sonografie bei der Früherkennung des
Mammakarzinoms TumorDiagn u Ther 2019; 40: 417–424.
|
Detection rate (°/00)
|
Recall rate (%)
|
Biopsy rate (%)
|
Interval cancer rate (°/00)
|
|
Digital mammography[1]
|
4.5–6.3*
|
2.6–6.1*
|
1.5–2.3**
|
2.2–2.5***
|
|
Additional detection rate (°/00)
|
Change in the recall rate (%)
|
Biopsy rate (%)
|
Interval cancer rate (°/00)
|
|
Hand-held ultrasound[2]
|
2.5–4.1
|
+ 5.9–10.1
|
0.3–8.5
|
0.5–3
|
|
Automated ultrasound[2]
|
2.2–2.4
|
+ 0.9–13
|
0.7–3.6
|
No data
|
|
Digital breast tomosynthesis[1]
|
1.9–4.1*
|
– 17–+ 46
|
1.1–2.6**
|
0.5–1.2
|
|
Abbreviated MR-mammography[3]
|
15–36.5***
|
+ 4.4–16.6
|
1.9–16.6
|
0–0.8
|
1 *6 European prospective studies: Skaane 2013, Ciatto 2018, Lang 2016, Pattacim 2018,
Caumo 2018, Hofvindh 2018. **6 retrospective US studies: Rose 2013, Destoums 2914,
Friedewald 2014, Greenberg 2014, McCarthy 2014, Conant 2016. *** Heidinger 2012.
2 Melnikow 2016, Rebolj 2018, Chong 2019, Vourtsis 2019.
3 Kühl 2014, Jam 2016, Chen 2017, Strahle 2017, Pamgrahi 2017, Choi 2018.
The increased detection rate with breast ultrasound results in the following disadvantages:
lower positive predictive values for recall and biopsies, a greater false-positive
rate, and an increase in psychological stress for the affected women compared to mammography
alone [25]
[26].
Under consideration of the necessary time, material, and personnel resources, the
additional costs, and the increased stress for the affected women, the focus is currently
on risk-adapted individual use. The ongoing DIMASOS-2 study (density-indicated mammographic-sonographic
breast cancer screening) is examining the value of supplementary ultrasound for a
dense breast parenchyma as part of the German Mammography Screening Program.
3.2 Specific case constellations
Extreme fibroglandular tissue (parenchyma category d, inhomogeneous with limited ability
to be evaluated) presents a challenge for ultrasound and mammography. [27]. In these tissue structures, pronounced mastopathic changes and multiple, partially
complicated cysts and the resulting inhomogeneities with acoustic shadowing can make
diagnosis difficult. This can result in small carcinomas being masked. With the help
of compression, color Doppler, elastography, 3 D ultrasound, and CEUS (contrast-enhanced
ultrasound), additional information can be acquired [28].
Complex cystic-solid lesions cannot always be reliably differentiated from complicated cysts in a dense breast
parenchyma ([Fig. 39], [40]). Various positions, compression, supplementary Doppler ultrasound, elastography,
and 3 D ultrasound, when applicable, can also be additionally used in these cases
[28].
Fig. 39 Complicated cyst with narrow septum, appears soft on SWE.
Fig. 40 Complex cystic-solid lesion with hard intracystic solid portion, appears hard on
SWE – intracystic papillary carcinoma.
The sonographic differentiation of lobular breast cancer or LCIS/DCIS from mastopathic dense breast parenchyma often proves to be more difficult compared
to NST cancer. MRI of the breasts can be helpful for the precise determination of
the extent.
The detection of multifocality and multicentricity presents a particular challenge, especially in the case of a dense breast parenchyma
that is difficult to evaluate. Equipment quality, optimal equipment function settings,
appropriate ultrasound frequency, and the examiner's experience play an essential
role here. Contrast-enhanced methods like MRI and contrast-enhanced MRI can also provide
supplementary information here.
3.3 Conclusion and DEGUM recommendations
The use of breast ultrasound in addition to mammography increases the detection rate
for breast cancer especially in dense breast parenchyma up to 40 % [25]
[26]
[29]. Another rationale for the use of ultrasound is to allow early detection and treatment
of the cancer. The earlier the diagnosis and the smaller the cancer at the time of
diagnosis, the better the prognosis for long-term patient survival.
The national S3 and AGO guidelines recommend supplementary ultrasound in addition
to mammography in the case of increased breast density (LoE 2a) and increased breast
cancer risk (LoE 1b) [1]
[2].
-
Supplementary breast ultrasound is to be recommended in the case of mammographically
dense breast tissue (parenchyma categories c and d).
-
Breast ultrasound should be performed by an examiner qualified and certified according
to the DEGUM multilevel concept in order to increase specificity thereby keeping the
number of unnecessary biopsies as low as possible.
-
To achieve the best possible diagnostic workup in the case of dense breast tissue
that is difficult to evaluate, optimal ultrasound equipment settings should be used
and equipment performance must be regularly checked. Supplementary breast ultrasound
modalities going beyond B-mode imaging should be used.
This article was changed according to the Correction on March 26, 2025.
Correction
In the above-mentioned article the name of a coauthor was indicated incorrectly. Correct:
Sebastian Wojcinski. This was corrected in the online version on March 26, 2025.
