Contrast-Enhanced Ultrasound Examination of the Breast: A Literature Review

Abstract

Angiogenesis is the basis for neoplastic growth in human tissues. Nevertheless, neovascularization may be present both in benign and malignant lesions. Although microvascular density assessment is a useful tool for the study of neoplastic vascularization, it cannot be used on a large scale because of the invasiveness of the method. When contrast-enhanced ultrasonography (CEUS) was introduced in clinical practice, the initial results in the field of breast lesions were disappointing because differentiation between benign and malignant masses was not possible. Magnetic resonance imaging (MRI) assessment of the microvascular features was therefore immediately accepted because of the higher diagnostic accuracy. However, in the last decade the sensitivity and specificity of CEUS have greatly improved due to the development of more sophisticated ultrasound (US) equipment, the introduction of second-generation contrast agents and the development of dedicated software able to perform quantitative analysis. This literature review compares the main results reported in the literature regarding the use of CEUS for the characterization of neoplastic lesions of the breast. All the authors agreed that malignant lesions show early wash-in with more intense enhancement and fast wash-out in comparison with benign masses. However, there is still no observer agreement regarding vascularization patterns, and different classifications are proposed. The conclusion of this literature review is therefore that the clinical role of CEUS in the diagnostic process and in follow-up is still to be clearly defined.

Zusammenfassung

Die Angiogenese ist die Ursache für neoplastische Wucherungen im humanen Gewebe. Doch die Gefäßneubildung kann sowohl bei gutartigen als auch in malignen Herdbefunden auftreten. Obwohl die Bestimmung der mikrovaskulären Dichte ein nützliches Mittel für die Untersuchung der neoplastischen Gefäßneubildung ist, kann diese invasive Methode nicht in größerem Maßstab eingesetzt werden. Mit Einführung der kontrastverstärkten Sonografie (CEUS) in die klinische Praxis waren die ersten Ergebnisse auf dem Gebiet der Herdbefunde der Brust enttäuschend, da eine Unterscheidung zwischen gutartigen und malignen Raumforderungen nicht möglich war. Wegen der höheren diagnostischen Genauigkeit wurde die Bestimmung der mikrovasalen Merkmale durch Magnetresonanz-Tomografie (MRT) sofort anerkannt. Im letzten Jahrzehnt haben sich jedoch die Sensitivität und Spezifität der CEUS durch die Entwicklung einer technisch ausgereiften Ultraschall(US)-Ausstattung, durch die Einführung von Kontrastmitteln der zweiten Generation und durch den Aufbau einer geeigneten Software für die quantitative Analyse deutlich verbessert. Dieser Literaturüberblick vergleicht die publizierten wichtigsten Ergebnisse zur Anwendung von CEUS bei der Charakterisierung neoplastischer Herdbefunde der Brust. Alle Autoren stimmen darin überein, dass maligne Herdbefunde im Vergleich zu gutartigen Raumforderungen einen frühes Wash-in und eine etwas deutlichere Verstärkung sowie eine schnelles Wash-out zeigen. Dennoch gibt es noch keine Übereinstimmung der Beobachter, was die Vaskularisierungsmuster anbelangt, und verschiedene Klassifizierungen werden vorgeschlagen. Deshalb kommt diese Übersicht zu dem Fazit, dass der klinische Stellenwert von CEUS für die Diagnosestellung und Nachsorge noch eindeutiger definiert werden muss.

Key words

breast - ultrasound color Doppler - ultrasound - contrast agents

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