乳腺超声课件ppt课件.pptx

BI-RADSFifth Edition:US Revisions贾化平 解放军第306医院超声医学科Tissue Compositionhomogeneous background echotexturefat,homogeneous background echotexturefibroglandularheterogeneous background echotextureMassesThe terms for describing mass shape(oval,round,and irregular),orientation(parallel and not parallel),and margins(circumscribed and not circumscribed,with the additional terms indistinct,angular,microlobulated,and spiculated)remain unchanged.The category“lesion boundary”and its descriptor terms abrupt interface and echogenic halo have been eliminated.The term echogenic rim may be included under the term not circumscribed,indistinct in the margin category because it may not be possible to distinguish an indistinct margin from an echogenic rim.MassesIn the“echo pattern”category,the term complex from the fourth edition has been changed to the term complex cystic and solid in the fifth edition.A sixth term,heterogeneous,has been added.The remaining terms anechoic,hyperechoic,hypoechoic,and isoechoic remain unchanged.The category name“posterior acoustic features”has been simplified to“posterior features,”but the terms no posterior acoustic features,enhancement,shadowing,and combined pattern remain unchanged.The“surrounding tissue”category has been slightly altered and is included in a new category,“associated features.”calcificationThe fifth edition has eliminated the micro-versus macrocalcifications distinction and focuses on generalized calcifications by using the terms calcifications in a mass and calcifications outside of a mass.It also adds a new term,intraductal calcificationsThis category was added to the fifth edition to describe a masss effect on its surroundings.Although technically a new section,this category pulls from the previous“surrounding tissue”category of the“masses”section and from the“vascularity”section,both of which are eliminated in the fifth edition.Associated FeaturesThe“associated features”category now includes the terms architectural distortion and edema,with the previous term duct now written as duct changes,and the previous terms skin thickening and skin retraction/irregularity changed to skin thickening and skin retraction under“skin changes.”The“associated features”category also pulls from the eliminated category“vascularity”and includes the term vascularity with three descriptors:absent,internal vascularity,and vessels in rim.Associated FeaturesLastly,this category adds a new section,“elasticity assessment,”with three descriptor choices termed soft,intermediate,and hard.Elasticity may be assessed by strain,which refers to manual compression of the mass and is measured in kilopascals,or by speed of propagation of shear waves,which refers to introduced ultrasonic energy into the mass and is measured in meters per second.For sites that use elasticity assessment in clinical practice,the descriptors,rather than the color seen,should be used because there is no standardized color scale.Associated FeaturesSpecial CasesThe“special cases”category has been expanded in the fifth edition.The previous terms clustered microcysts,complicated cysts,mass in or on skin,lymph nodesintramammary,and lymph nodesaxillary remain unchanged,with the term foreign body now specifically including implants.Four new terms have been added to the US“special cases”category:simple cyst,vascular abnormalities(with the additional terms arteriovenous malformations and Mondor disease),postsurgical fluid collection,and fat necrosisupdated岳林先主任解读第5版乳腺超声 BI-RADS 分类乳腺影像报告与数据系统（Breast imaging reporting and data system，BI-RADS）是美国放射学会（ACR）等几家机构共同制定的，目的是为了对乳腺影像检查的操作、肿块描述、报告等内容加以规范，降低乳腺影像解读中出现的误差和混淆。该系统最早制定于1992年，当时仅包括乳腺钼靶X线检查内容，在2003年对BI-RADS的第4次修订时加入超声内容，对超声影像词典及评估分类进行了规范，2013年再次修订时超声内容更加详尽，分为总论、乳腺影像词典-超声、报告系统、指导意见四个部分，文中用大量的图例对其内容加以阐述。以下为BI-RADS第5版超声部分的主要内容。总论（一）乳腺解剖简要描述乳房的解剖、血供、淋巴引流，着重讲述腋窝淋巴结、乳头及乳晕结构以及男性乳房发育的检查要点。（二）图像质量良好的图像质量是影像诊断准确的基础，对乳腺超声检查的仪器、探头频率、扫查范围、聚焦点的放置、灰阶增益以及复合成像技术做了规范及说明。（三）记录与测量记录内容包括仪器、医院、检查日期、患者姓名、年龄、体表标志（应标明左/右乳以及探头摆放的位置、方向）等信息，同时可以简要的文字记录患者就诊原因及体征等；病灶大小应在病灶的长轴切面进行测量，测量病灶最大径线（第一径线），同一切面上与第一径线垂直方向测量第二个径线，重要的阳性发现推荐测量三个径线，此时探头旋转90，测量不同于前两个径线的第三个径线。（四）讨论对于乳腺多发囊肿，仅需留存一幅代表性的图像，测量最大的囊肿并记录；特殊部位的囊肿（如腋尾部、腋窝等），为避免与其它疾病混淆（如转移淋巴结），这时可应用CDFI、CDE以及弹性成像等技术对二者进行鉴别并存图记录；双乳多发、形态一致的良性结节，其记录与双乳多发囊肿一样，仅记录最大的病灶，若要一一记录，推荐使用表格方式对病灶的位置（左/右乳、距乳头距离）、大小分别描述，同一部位的多发病灶还需用距皮肤距离对不同病灶加以区别。乳腺影像词典分为乳腺组织构成、肿块、钙化、相关特征、特殊病例五部分内容（一）组织构成成年女性乳腺的超声图像差异很大，不同的乳腺背景将影响超声对病灶的检出率及准确性。BI-RADS第五版将乳腺组织构成分为均匀和不均匀两种，前者包括两种情况，分别由均匀分布的脂肪和纤维腺体成分组成；后者即不均匀背景可以局限，也可以弥散分布（二）肿块对肿块的描述分为形状、方位、边缘、内部回声、后方特征等五个方面，第四版中的边界（boundary）被取消，其原因是边界特征特指病灶与周围组织过渡带的情况，这种改变仅在恶性肿瘤及炎性病变中存在，良性病变中都不存在过渡带，且恶性病灶与炎性变的过渡带并无明确的区分，因此在第五版中将这部分内容取消，但过渡带的存在对病变性质的判断仍然是重要的。形状 分为椭圆形、圆形、不规则形。方位 根据病灶的长轴与皮肤是否平行，分为平行、不平行两种。边缘 是肿块的边缘和边界特征，分为完整和不完整两种情况。后者又细分为模糊、成角、微分叶、毛刺几种类型。需要注意的是：对病灶边缘的判断重点是区分边缘是否完整，而不是对不完整边缘亚类型的具体细分。回声 乳腺内病灶的回声类型判断以乳房内的脂肪回声为标准，脂肪回声为等回声。乳腺肿块的回声类型分为无回声、高回声、囊实混合回声、低回声、等回声、不均匀回声。与肿块的其它特征相比，肿块回声类型对乳腺疾病的诊断特异性不高。后方特征 后方回声衰减及增高是判断肿块性质的主要附属特征。分为后方回声无改变、回声增高、回声减低、混合特征（两种及以上的后方回声特征）。（三）钙化与钼靶相比，超声对钙化的显示缺乏特征性，但对于低回声肿块内的钙化超声可较准确地显示。高频、高分辨力的超声探头使导管内（尤其表浅位置）的钙化得以清晰显示，纤维腺体内的簇状钙化也可能被显示并在超声引导下穿刺活检。BI-RADS对于乳腺钙化的描述分为肿块内钙化、肿块外钙化以及导管内钙化。（四）相关特征包括结构扭曲、导管改变（管径增宽、管腔内异常内容物）、皮肤改变（增厚、内陷）、水肿、血流（无血流、肿块内血流、晕环血流）、弹性成像。弹性成像是第五版新增加的内容，需注意的是当弹性成像显示的组织硬度与形态学改变不一致时，对肿块性质的判断更重要且更可靠的是其形态学的改变。肿块硬度分为软、中等硬度、硬三种。（五）特殊病例特殊病例是指具有特殊的超声表现且诊断明确的病变。包括单纯囊肿、簇状囊肿（病变由簇状的无回声组成，每个小囊肿23，囊肿间距离0.5，且无实性成分）、复杂囊肿（囊液浑浊，有点状回声漂浮，但无实性成分）、皮肤内肿物（包括皮脂腺囊肿、痣、副乳头等）、异物（包括假体）、乳腺内淋巴结、腋窝淋巴结、血管异常（动静脉瘘、Mondor病）、术后积液、脂肪坏死。报告系统（一）超声报告组成1.检查指征 可触及的肿块、钼靶X线或MRI发现异常需进一步检查、介入引导以及不适宜做钼靶X线检查的患者（年轻、怀孕、哺乳等）、钼靶检查为致密型乳腺等都可能成为患者行乳房超声检查的原因。2.超声检查的范围及所用技术，如全容积成像技术、CDFI、CDE、弹性成像技术等。3.简要描述乳腺组织构成（仅筛查时注明）。4.清晰描述阳性发现 对病变的描述，应注意以下几点：病灶的形态学描述包括形状、边缘、方位以及相关特征的表述（如结构扭曲）；病变的后方特征、回声类型、血流、以及弹性评分对于病变性质的判断都是有价值的，描述内容应包括与病变性质直接相关的特征。对于特殊病例如单纯囊肿、簇状囊肿、乳内淋巴结，异物可以在报告中列出（2类），但也可以不列出，此时相应的分类为阴性（1类）。对于重要的发现，病灶的大小至少要测量两个径线，当患者有一份或数份以前的报告需要对比时，最好测量3个径线。常规采用时钟法记录病灶位置，需标明病灶位于几点钟以及距乳头的距离，若同一位置有多个结节，还需标明距皮肤的距离，以便准确区分不同深度的结节，这点对于超声引导下的活检穿刺更为重要。在随访中，可能会因为病人体位、入射角度等技术原因使病灶在两次检查中位置不一致，如能确定为同一病灶，在报告中应注明。可采用表格记录双乳多发病灶的位置，距乳头距离、大小等。5.与之前的（包括查体、钼靶、MRI等）检查对照。在报告中应注明本次超声检查所发现病灶与以前钼靶、MRI显示的病灶是否为同一病灶；同时，超声还应详细记录病灶的形态是否发生变化，对于良性病灶，若其长径在不足6个月的时间内增加超过20%，应进行活检。6.生成报告 如同一天进行了多项影像学检查，报告中应对每种影像学检查发现分段描述，并得出一个最终的分类和管理意见。当不同的影像学评估不一致时，应采用恶性可能性最高的级别，其遵循的级别参考以下的等级：1，2，3，6，0，4，5（表-1）。但是也有例外，同一病灶一种影像检查具备典型良性特征，而另一种检查方法未显示典型良性特征，此时的最终分类为前一种检查方法的评估分类。如钼靶X线检查显示为部分边缘完整、内部无钙化的团块影而超声显示为单纯性囊肿，此时分类为2类。7.评价 每一份超声报告都应包括与本次超声检查发现所对应的BI-RADS分类（16类），这种分类与钼靶X线的分类方法是一致的。某些情况下会用到0类（不完整的评估），需要进一步做其它影像学检查方法或与之前的报告对照等。8.管理 管理建议包括对良性结节的定期随访，可能恶性结节的穿刺或切除活检等。如果建议在影像引导下穿刺活检还需注明具体的引导影像学方法（表-2）。表-1.BI-RADS 分类的异常程度表-2 BI-RADS评估分类和管理（二）乳腺恶性肿瘤的声像图特征1.实质性：指乳腺发生的病灶/病变为组织学上的实体组织2.低回声：指在声像图上乳腺病变回声低于脂肪组织。3.边界不清：病灶无明确的边界，与周围组织分界不清；具有恶性征象：恶性晕征、毛刺、微分叶。4.形态不规则：病灶形态不规整，可有大小不等的突起伸入周围组织内，大者称分叶，小的称角状突。5.微钙化：病变组织内有多个细点状强回声，大小约12mm，散在不均匀分布在低回声背景的病灶内。6.纵横比1：乳腺病变的生长方式趋向于浅层和深层，测量时病灶的前后径大于横径。对乳腺病变的恶性征象评分：低回声、无边界和形态不规则最具意义，代表包膜的边界不清分数最高，达到6分，低回声4分，微小钙化和形态不规则各2分，实质性为1分。（三）BI-RADS分类图例BI-RADS分为06类，0类是超声没有发现异常征象，但患者症状明显，临床有可疑病变，还需要X线摄影和MRI检查BI-RADS 1类是正常乳腺，影像学无异常发现BI-RADS 6类是经过病理学证实了的乳腺恶性病灶，或者已经进行了临床有关治疗BI-RADS 0类、1类和6类影像学不出具分类报告BI-RADS 2类：恶性风险=0%，包括单纯性囊肿、青年型纤维腺瘤和经过3年观察没有改变的成年人的纤维腺瘤（图1）BI-RADS 2类：A.单纯囊肿；B.箤状囊肿；C.青年型纤维腺瘤（女，17岁）；D.纤维腺瘤（女，42岁，3年无改变）BI-RADS 4类：4类再分为4a、4b和4c 3个亚类,恶性风险4a是3%10%，4b是11%50%和4c是51%90%（图3）。BI-RADS 4a类：A.增生性腺病；B.腺病瘤；C.复杂腺病；D.纤维腺瘤伴钙化BI-RADS 4b类：A和B导管内乳头状瘤；C和D浸润性导管癌BI-RADS 4c类：A.浸润性导管癌；B.浸润性导管癌；C.低分化浸润癌；D.浸润性导管癌BI-RADS 5类：恶性风险91%100%。乳腺典型的恶性病灶和/伴引流淋巴结转移BI-RADS 5类：A.典型的浸润性导管癌（低回声，边缘成角和毛刺）；B.典型浸润性导管癌（低回声伴微小钙化）BI-RADS 5类 乳腺癌腋窝淋巴结转移：A.乳腺低回声结节伴角征；B.腋窝转移淋巴结指导意见提出可能为良性病变（3类）的6种情况，包括纤维腺瘤；可能为复杂性囊肿的均匀低回声病灶；由簇状囊肿组成的椭圆形或浅分叶病灶；脂肪坏死；脂肪小叶/良性结节？不能准确判断；术后瘢痕造成的结构扭曲。针对第四版BI-RADS内容部分读者提出的常见问题，指导意见做了简要的回答。Bi-RADS for Mammography and Ultrasound 2013Updated versionHarmien Zonderland and Robin Smithuis Radiology department of the Academical Medical Centre in Amsterdam and the Rijnland hospital in Leiderdorp,the NetherlandsStandard ReportingDescribe the indication for the study.Screening,diagnostic or follow-up.Mention the patients history.If Ultrasound is performed,mention if the US is targeted to a specific location or supplementary screening.Describe the breast composition.Describe any significant finding using standardized terminology.Use the morphological descriptors:mass,asymmetry,architectural distortion and calcifications.These findings may have associated features,like for instance a mass can be accompanied with skin thickening,nipple retraction,calcifications etc.Correlate these findings with the clinical information,mammography,US or MRI.Integrate mammography and US-findings in a single report.Compare to previous studies.Awaiting previous examinations for comparison should only take place if they are required to make a final assessmentConclude to a final assessment category.Use BI-RADS categories 0-6 and the phrase associated with them.If Mammography and US are performed:overall assessment should be based on the most abnormal of the two breasts,based on the highest likelihood of malignancy.Give management recommendations.Communicate unexpected findings with the referring clinician.Verbal discussions between radiologist,patient or referring clinician should be documented in the report.Breast CompositionIn the BI-RADS edition 2003 the assignment of the breast composition was based on the overall density resulting in ACR catergory 1(75%).In BI-RADS 2013 the use of percentages is discouraged,because in individual cases it is more important to take into account the chance that a mass can be obscured by fibroglandular tissue than the percentage of breast density as an indicator for breast cancer risk.In the BI-RADS edition 2013 the assignment of the breast composition is changed into a,b,c and d-categories followed by a description:a-The breast are almost entirely fatty.Mammography is highly sensitive in this setting.b-There are scattered areas of fibroglandular density.The term density describes the degree of x-ray attenuation of breast tissue but not discrete mammographic findings.c-The breasts are heterogeneously dense,which may obscure small masses.Some areas in the breasts are sufficiently dense to obscure small masses.d-The breasts are extremely dense,which lowers the sensitivity of mammography.Notice in the left example the composition is c-heterogeneously dense,although the volume of fibroglandular tissue is less than 50%.The fibroglandular tissue in the upper part is sufficiently dense to obscure small masses.So it is called c,because small masses can be obscured.Historically this would have been called an ACR 2:25-50%density.The example on the right has more than 50%glandular tissue and is also called composition c.MassA Mass is a space occupying 3D lesion seen in two different projections.If a potential mass is seen in only a single projection it should be called a asymmetry until its three-dimensionality is confirmed.Shape:oval(may include 2 or 3 lobulations),round or irregularMargins:circumscribed,obscured,microlobulated,indistinct,spiculatedDensity:high,equal,low or fat-containing.The images show a fat-containing lesion with a popcorn-like calcification.All fat-containing lesions are typically benign.These image-findings are diagnostic for a hamartoma-also known as fibroadenolipoma.The shape of a mass is either round,oval or irregular.Always make sure that a mass that is found on physical examination is the same as the mass that is found with mammography or ultrasound.Location and size should be applied in any lesion,that must undergo biopsy.The margin of a lesion can be:Circumscribed(historically well-defined).This is a benign finding.Obscured or partially obscured,when the margin is hidden by superimposed fibroglandular tissue.Ultrasound can be helpful to define the margin better.Microlobulated.This implies a suspicious finding.Indistinct(historically ill-defined).This is also a suspicious finding.Spiculated with radiating lines from the mass is a very suspicious finding.The density of a mass is related to the expected attenuation of an equal volume of fibroglandular tissue.High density is associated with malignancy.It is extremely rare for breast cancer to be low density.Here multiple round circumscribed low density masses in the right breast.These were the result of lipofilling,which is transplantation of body fat to the breast.Here a hyperdense mass with an irregular shape and a spiculated margin.Notice the focal skin retraction.This was reported as BI-RADS 5 and proved to be an invasive ductal carcinoma.Here an example of a focal asymmetry seen on MLO and CC-view.Local compression views and ultrasound did not show any mass.Here an example of global asymmetry.In this patient this is not a normal variant,since there are associated features,that indicate the possibility of malignancy like skin thickening,thickened septa and subtle nipple retraction.Ultrasound(not shown)detected multiple small masses that proved to be adenocarcinoma.The PET-CT shows diffuse infiltrating carcinoma.Asymmetry versus MassAll types of asymmmetry have different border contours than true masses and also lack the conspicuity of masses.Asymmetries appear similar to other discrete areas of fibroglandulair tissue except that they are unitaleral,with no mirror-image correlate in the opposite breast.An asymmetry demonstrates concave outward borders and usually is interspersed with fat,whereas a mass demonstrates convex outward borders and appears denser in the center than at the periphery.The use of the term density is confusing,as the term density should only be used to describe the x-ray attenuation of a mass compared to an equal volume of fibroglandular tissue.CalcificationsIn the 2003 atlas calcifications were classified by morphology and distribution either as benign,intermediate concern or high probability of malignancy.In the 2013 version the approach has changed.Since calcifications of intermediate concern and of high probability of malignancy all are being treated the same way,which usually means biopsy,it is logic to group them together.Calcifications are now either typically benign or of suspicious morphology.Within this last group the chances of malignancy are different depending on their morphology(BI-RADS 4B or 4C)and also depending on their distribution.Skin,vascular,coarse,large rodlike,round or punctate(1mm),rim,dystrophic,milk of calcium and suture calcifications are typically benign.There is one exception of the rule:an isolated group of punctuate calcifications that is new,increasing,linear,or segmental in distribution,or adjacent to a known cancer can be assigned as probably benign or suspicious.Amorphous(BI-RADS 4B)So small and/or hazy in appearance that a more specific particle shape cannot be determined.Coarse heterogeneous(BI-RADS 4B)Irregular,conspicuous calcifications that are generally between 0,5 mm and 1 mm and tend to coalesce but are smaller than dystrophic calcifications.Fine pleomorphic(BI-RADS 4C)Usually more conspicuous than amorphous forms and are seen to have discre