Orientation, margin and posterior features — and "taller-than-wide" is judged on the RADIAL image.
Orient first
- The strongest suspicious sonographic features are: NOT-PARALLEL orientation (taller-than-wide), an irregular or spiculated margin, marked hypoechogenicity, and posterior SHADOWING.
- Benign-leaning features are: parallel orientation (wider-than-tall), circumscribed margin, and posterior ENHANCEMENT — none of which is sufficient alone.
- Posterior features are a real discriminator here: shadowing suggests a desmoplastic reaction, enhancement suggests a fluid or highly cellular lesion.
- A complicated cyst (internal echoes, no vascularity, no mural nodule) is different from a complex cystic-and-solid mass (a vascularised solid component) — the first is usually benign, the second needs tissue.
Acquire the study
- High-frequency linear probe, 12–18 MHz; patient supine-oblique with the arm raised to flatten the breast.
- Scan in RADIAL and ANTI-RADIAL planes, which follow the ductal anatomy — orthogonal transverse/longitudinal planes cut ducts obliquely.
- Set the focal zone AT the lesion and gain so fat reads mid-grey before judging echogenicity.
- Always scan the AXILLA in the same sitting.
The manoeuvre
- Record location by CLOCK POSITION and distance from the nipple, plus depth — this is how the lesion is found again.
- Assess ORIENTATION on the radial image: parallel or not-parallel.
- Assess margin: circumscribed, indistinct, angular, microlobulated, or spiculated.
- Assess echo pattern and posterior features (enhancement, shadowing, none, or combined).
- Apply colour Doppler at low-flow settings and describe internal vascularity.
- Measure in three planes.
- Examine the axilla: cortical thickness, loss of the fatty hilum, and rounded shape.
- Assign a category with its lexicon version.
What confirms it
- A suspicious category is a conjunction of lexicon features, and the resolution is always tissue — imaging assigns probability, it does not diagnose.
What licenses you to exclude it
- ⚠️ NORMAL IMAGING DOES NOT EXCLUDE CANCER IN A PALPABLE LUMP. Report the discordance explicitly and recommend tissue sampling; a reassuring report on a palpable mass is the classic and most damaging error in this area.
- Dense breast tissue lowers mammographic sensitivity substantially — state the density category, because it qualifies the negative.
The classic misread
- Judging orientation on a transverse rather than a radial image.
- Calling a complex cystic-and-solid mass a complicated cyst without checking the solid part for flow.
- Omitting the axilla.