Towards a more sophisticated use of breast ultrasound

The diagnostic role of breast ultrasound has been expanded along with the improvement of high-frequency transducers and digital technology. Vascular assessment has progressed enough to depict normal vascular anatomy of the breast and the lymph nodes. Pathologic vessels are seen in almost all the tumors, thus improving US sensitivity for nonpalpable carcinomas. New contrast agents will recirculate enough to search for vascular foci during a thorough investigation of both breasts and nodal stations. The US role in screening might be now revised. Many factors are now in favor of targeted US screening in dense and complex breasts and in high-risk patients. Screening sensitivity is significantly increased. Most of these US-detected tumors are small enough to be curable. Mammography and sonography together are a unique problem-solving and cost-effective tool. They can easily guide fine aspirations or larger biopsies reducing the cost of unnecessary surgical procedures. Accurate US investigations facilitate the surgical approach to a very conservative and cosmetic operation. High-resolution sonography can demonstrate the intraductal spread of tumors and their multiple foci more easily than mammography, but US diagnosis is less sensitive than magnetic resonance mammography in the evaluation of the real tumoral extent. Ductal branching has a complex pattern; therefore, intraductal spread and multifocal nodes are better demonstrated by multiplanar analysis of 3D ultrasound data volumes. Sonography can easily explore the different nodal chains. Metastatic disease is indicated by an enlarged and round shape and the absence of the echogenic hilum. Irregularities in the cortex are a very useful sign in metastatic nodes without total replacement of lymphoid tissue by neoplastic cells. These signs are very specific. A time-consuming, radiation-emitting and costly sentinel biopsy may be avoided in one of every five clinically node-negative patients. But preoperative US assessment is also important as sonography is very sensitive in patients with extensive nodal involvement that might result negative at the sentinel node procedure. New technologies and contrast agents allow perfusional studies that enhance the contrast resolution and will increase the sensitivity of US for small nodal metastases.