Breast Ultrasound

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Continuing Education Activity

Breast ultrasound is performed due to the high incidence rate of breast cancer amongst women globally. Ultrasound is typically used as an adjunct to mammographic imaging, which remains the gold standard for breast cancer diagnosis. The main indications include palpable mass, dense fibroglandular breast tissue, and pregnant/lactating women. This activity reviews the evaluation and technique of breast ultrasound and highlights the role of the interprofessional team evaluating for and referring to this procedure.


  • Identify the anatomical structures, indications, and contraindications of breast ultrasound.
  • Describe the equipment, personnel, preparation, and technique required for a breast ultrasound.
  • Review the clinical significance of breast ultrasound as a diagnostic tool for the detection of breast malignancy.
  • Outline interprofessional team strategies for improving care coordination and communication to advance breast ultrasound and improve outcomes.


Breast ultrasound has developed into a practical solution for the evaluation of breast disease. Although mammography remains the gold standard for breast cancer screening, it presents certain imaging limitations with dense breast parenchyma. Due to this reason, ultrasound, and magnetic resonance imaging (MRI) have been expanding their role as part of supplementary breast screening procedures.[1]

The sensitivity for breast cancer detection using both mammography and ultrasound increases to 97.3%, with the false positive rate of ultrasound measured as 2.4%.[2]

Anatomy and Physiology

Breast ultrasound is often used to localize palpable and non-palpable masses before surgical excision.[3]

The basic breast anatomy comprises 15 to 20 lobules, each consisting of smaller breast ducts, known as the terminal duct lobular units (TDLUs). All the ducts drain into a single lactiferous sinus towards the nipple.

The three main anatomical zones of the breast are the pre-mammary, mammary, and retro-mammary zones, consisting of fatty tissue, fibroglandular tissue, and muscular tissue.

From a sonographic point of view (Image 2), the breast is divided into various hypoechoic and hyperechoic layers:

  • Skin (hyperechoic, white fibrous bands)
  • Fat (hypoechoic, subcutaneous fat lobules)
  • Breast parenchyma (hyperechoic, fibroglandular soft tissue)
  • Retromammary fat (hypoechoic fat lobules)
  • Pectoralis major muscle (hyperechoic fibrous tissue)[4] 


Common indications for breast ultrasound are:[5]

  • Palpable lump during clinical breast evaluation
  • Axillary lymphadenopathy present on mammogram imaging
  • Women younger than 40 years with the clinical presentation of certain anomalies
  • Pregnant or lactating women
  • Suspicious abnormality identified on mammogram imaging
  • Nipple discharge
  • Skin retraction or inversion of the nipple
  • Surgical scarring evident in mammogram imaging
  • Suspicion of rupture breast implants used to differentiate between intra-and-extracapsular ruptures
  • Needle-guided percutaneous breast biopsy
  • Follow up patients receiving neoadjuvant chemotherapy


The use of breast ultrasound as a sole screening tool is inappropriate.[6]


High-frequency ultrasound has improved over the past decade with standard linear frequency probes ranging from 7.5 MHz to 23 MHz, with high density or single crystal probe components, which improves lateral resolution. Tissue harmonic imaging (THI) is also a standard feature of most entry-level ultrasound units for a reduction in reverberation and near field artifacts. Real-time compound scanning aids in improved contrast resolution.

Panoramic imaging provides an increased longitudinal imaging perspective of breast lesions in relation to the surrounding breast tissue.

The latest technology from ultrasound vendors now also boasts stand-alone linear frequency probes connecting wirelessly to mobile imaging application software.[7]

Most ultrasound software allows computer-aided detection (CAD) to assist in the segmentation and identification of suspicious mass lesions. This technology allows for increased improvement in diagnostic proficiency.

Proper technical consideration is required to produce quality ultrasound images such as the depth of the focal zone, time gain compensation measures, and overall gain used during mass lesion assessment.[8]


Breast ultrasound is performed by an ultrasound technician, radiologist, or a referring clinician with adequate technical and clinical competency for ultrasound evaluation.


Breast ultrasound is a non-invasive procedure with none or very little special preparation required. Jewelry in the anatomical region of interest should be removed, and the patient is encouraged to wear loose clothing to be able to undress the upper half of the torso before the examination.[9]


Initial breast imaging of the patient should include a full clinical breast self-examination (BSE) to assess and validate all palpable masses, either identified by the patient or by the physician. Following BSE, a bilateral breast ultrasound is performed with a sequential sweeping of the breast surface.

The breast is assessed in the four main quadrants, namely outer upper, outer inner, lower outer, and lower inner quadrants. Any lesions identified during the examination should be marked as a breast 'o clock position for future follow up sessions.

The most common imaging technique used is a radial, star-shaped, or superior to inferior sweep of the entire breast, extending to the axillary space, parasternal, and clavicular surfaces.

The retro areolar space should also be evaluated systematically; the dense tissue causes posterior acoustic shadowing, limiting visibility posterior to its surface. This anatomical limitation can be overcome by either angling the probe upwards towards the retro areolar ducts or using a gel standoff pad with decreased focal zone and altering of the tissue gain compensation controls, visualizing the soft tissue posterior to the dense nipple tissue.[10]


Breast ultrasound is a safe, non-invasive procedure without any complications of the procedure itself.

Clinical Significance

Ultrasound as part of follow up imaging for masses reported as breast imaging reporting and data system (BI-RADS) 2 or 3 (probably benign) has shown great value in assessing morphological changes to the sonographic appearance.

Through the use of ultrasound as a standard follow up imaging tool, it could promote recharacterization of lesions during initial imaging assessment.

Full ultrasound examination requires the recording of results in a standard breast report, including the patient indications, findings, and results with differential diagnosis.

Any lesions noted during the examination should be measured in both transverse and longitudinal planes. Location, measurement, echogenicity of all masses should be described as either hypoechoic, hyperechoic, or heterogeneous.

The various mass descriptors are used according to the ultrasound breast imaging and reporting system (US BIRADS) lexicon which includes six main morphological descriptors for breast masses:[11]

The most common morphologic features associated with benign sonographic findings are:[12]

  • Smooth and well-circumscribed margins
  • Hyperechoic, isoechoic or mildly hypoechoic in echogenicity
  • Thin echogenic capsule or well-defined capsule border
  • Ellipsoid shape, wider than tall appearance
  • Macrolobulated; less than three lobulated margins
  • Posterior acoustic enhancement

The most common morphologic features associated with malignant findings are:

  • Hypoechoic mass, on occasion, hyperechoic in appearance
  • Spiculated margins
  • Ill-defined borders, architectural distortion of surrounding soft tissue
  • Posterior acoustic shadowing
  • Taller than wide appearance
  • Microcalcifications present[13]

Enhancing Healthcare Team Outcomes

As part of interprofessional education (IPE), point of care ultrasound (POCUS) has been expanding its use over many medical specialties.

For appropriate interprofessional collaboration, role clarification of each practitioner and profession should be assessed. Conflict resolution methods between learner and practitioner should be provided for the best outcomes.

Nursing, Allied Health, and Interprofessional Team Monitoring

Pre-workshop assessments should include demographics as well as the attitudes of professions regarding the use of IPE. During training and collaborative teaching events, simulation of activities could promote increased awareness and interest in ultrasound imaging. Following workshop integration, a follow up regarding attitudes of IPE should be encouraged to assess if the resulting work leads to contextual learning and assessment across all fields of medicine.

(Click Image to Enlarge)
Interprofessional education in breast ultrasound
Interprofessional education in breast ultrasound
Contributed by K Malherbe

(Click Image to Enlarge)
Sonographic cross-sectional view of benign breast tissue with typical hyperechoic, hypoechoic layers of skin, fat, fibroglandular and muscle.
Sonographic cross-sectional view of benign breast tissue with typical hyperechoic, hypoechoic layers of skin, fat, fibroglandular and muscle.
Contributed by Dr P Schoub, Parklane Radiology, SA
Article Details

Article Author

Kathryn Malherbe

Article Editor:

Dawood Tafti


9/7/2022 7:33:36 PM

PubMed Link:

Breast Ultrasound



Esmaeili M,Ayyoubzadeh SM,Ahmadinejad N,Ghazisaeedi M,Nahvijou A,Maghooli K, A decision support system for mammography reports interpretation. Health information science and systems. 2020 Dec;     [PubMed PMID: 32257128]


Berg WA, Reducing Unnecessary Biopsy and Follow-up of Benign Cystic Breast Lesions. Radiology. 2020 Apr;     [PubMed PMID: 32073379]


Toyoda Y,Oh EJ,Premaratne ID,Chiuzan C,Rohde CH, Affordable Care Act State-Specific Medicaid Expansion: Impact on Health Insurance Coverage and Breast Cancer Screening Rates. Journal of the American College of Surgeons. 2020 Mar 3;     [PubMed PMID: 32272206]


Gokhale S, Ultrasound characterization of breast masses. The Indian journal of radiology     [PubMed PMID: 19881096]


Mendelson EB,Berg WA,Gordon PB, Benefits of Supplemental Ultrasonography With Mammography. JAMA internal medicine. 2019 Aug 1;     [PubMed PMID: 31380949]


Evans A,Trimboli RM,Athanasiou A,Balleyguier C,Baltzer PA,Bick U,Camps Herrero J,Clauser P,Colin C,Cornford E,Fallenberg EM,Fuchsjaeger MH,Gilbert FJ,Helbich TH,Kinkel K,Heywang-Köbrunner SH,Kuhl CK,Mann RM,Martincich L,Panizza P,Pediconi F,Pijnappel RM,Pinker K,Zackrisson S,Forrai G,Sardanelli F, Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights into imaging. 2018 Aug     [PubMed PMID: 30094592]


Prentašic P,Heisler M,Mammo Z,Lee S,Merkur A,Navajas E,Beg MF,Šarunic M,Loncaric S, Segmentation of the foveal microvasculature using deep learning networks. Journal of biomedical optics. 2016 Jul 1;     [PubMed PMID: 27401936]


Bick U,Trimboli RM,Athanasiou A,Balleyguier C,Baltzer PAT,Bernathova M,Borbély K,Brkljacic B,Carbonaro LA,Clauser P,Cassano E,Colin C,Esen G,Evans A,Fallenberg EM,Fuchsjaeger MH,Gilbert FJ,Helbich TH,Heywang-Köbrunner SH,Herranz M,Kinkel K,Kilburn-Toppin F,Kuhl CK,Lesaru M,Lobbes MBI,Mann RM,Martincich L,Panizza P,Pediconi F,Pijnappel RM,Pinker K,Schiaffino S,Sella T,Thomassin-Naggara I,Tardivon A,Ongeval CV,Wallis MG,Zackrisson S,Forrai G,Herrero JC,Sardanelli F, Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights into imaging. 2020 Feb 5;     [PubMed PMID: 32025985]


Kaminsky O,Abdul Halim N,Zilbermints V,Sharon E,Aranovich D, Young Woman in the Breast Clinic: Ultrasound or Not? The Israel Medical Association journal : IMAJ. 2019 Sep;     [PubMed PMID: 31542907]


Pushkin J,Berg WA, Differences in Breast Density Awareness, Knowledge, and Plans. Journal of general internal medicine. 2020 Mar 27;     [PubMed PMID: 32221857]


Tutar B,Esen Icten G,Guldogan N,Kara H,Arıkan AE,Tutar O,Uras C, Comparison of automated versus hand-held breast US in supplemental screening in asymptomatic women with dense breasts: is there a difference regarding woman preference, lesion detection and lesion characterization? Archives of gynecology and obstetrics. 2020 Mar 25;     [PubMed PMID: 32215718]


Flory V,Lévy G,Viotti J,Schiappa R,Elkind L,Ghez C,Pellegrin A,Occelli A,Dejode M,Delpech Y,Fouché Y,Figl A,Machiavello JC,Haudebourg J,Peyrottes I,Chapellier C,Barranger E, [Preoperative breast imaging review: Interests and limits of specialized validation in oncology]. Bulletin du cancer. 2020 Mar;     [PubMed PMID: 32115178]


Vincent-Salomon A,Bataillon G,Djerroudi L, [Hereditary breast carcinomas pathologist's perspective]. Annales de pathologie. 2020 Mar 30;     [PubMed PMID: 32241645]