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    Breast Sonography: Presented by DR Livinus - Chibuzo Abonyi

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    KEN KIZITO
    This document provides an overview of breast sonography, including breast anatomy, techniques, pathologies, and the role of color Doppler. It describes the layers of the breast and notes that most cancers arise in the mammary zone. When performing sonography, the breast should be scanned in radial and anti-radial planes using high-frequency linear probes. Pathologies discussed include cysts, solid nodules/masses, fibroadenomas, and congenital anomalies. Features of benign and malignant lesions are outlined. Color Doppler is used to assess perfusion but cannot definitively differentiate benign from malignant lesions.

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    Breast Sonography: Presented by DR Livinus - Chibuzo Abonyi

    Uploaded by

    KEN KIZITO
    90 views28 pages
    This document provides an overview of breast sonography, including breast anatomy, techniques, pathologies, and the role of color Doppler. It describes the layers of the breast and notes that most cancers arise in the mammary zone. When performing sonography, the breast should be scanned in radial and anti-radial planes using high-frequency linear probes. Pathologies discussed include cysts, solid nodules/masses, fibroadenomas, and congenital anomalies. Features of benign and malignant lesions are outlined. Color Doppler is used to assess perfusion but cannot definitively differentiate benign from malignant lesions.

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    This document provides an overview of breast sonography, including breast anatomy, techniques, pathologies, and the role of color Doppler. It describes the layers of the breast and notes that most cancers arise in the mammary zone. When performing sonography, the breast should be scanned in radial and anti-radial planes using high-frequency linear probes. Pathologies discussed include cysts, solid nodules/masses, fibroadenomas, and congenital anomalies. Features of benign and malignant lesions are outlined. Color Doppler is used to assess perfusion but cannot definitively differentiate benign from malignant lesions.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    90 views28 pages

    Breast Sonography: Presented by DR Livinus - Chibuzo Abonyi

    Uploaded by

    KEN KIZITO
    This document provides an overview of breast sonography, including breast anatomy, techniques, pathologies, and the role of color Doppler. It describes the layers of the breast and notes that most cancers arise in the mammary zone. When performing sonography, the breast should be scanned in radial and anti-radial planes using high-frequency linear probes. Pathologies discussed include cysts, solid nodules/masses, fibroadenomas, and congenital anomalies. Features of benign and malignant lesions are outlined. Color Doppler is used to assess perfusion but cannot definitively differentiate benign from malignant lesions.

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    BREAST

    SONOGRAPHY
    Presented by Dr Livinus.Chibuzo
    Abonyi
    BREAST ANATOMY
    Breast is composed (Sonographically) of the:

    » Skin – usually hyperechoic and approximately 2 – 3 mm in thickness.


    » Subcutaneous fat – seen below the skin and anterior to the premammary
    fascia.
    » Coopers ligaments – usually hyper-echoic and seen coursing through the
    subcutaneous fat.
    » Mammary zone – contains fibro-glandular and ductal tissues with
    intersparsing fat deposits. The glandular parenchyma consists of
    about 15 – 20 lobes.
    » Each lobe has its own excretory duct which terminates at the nipple.
    » The excretory ducts usually branch into multiple segmental ducts which
    terminate at the extra-lobular terminal ducts. Most breast cancer emanate
    from these extra-lobar terminal ducts.
    » The intra-lobular ducts continues and branches into 10 – 100 blind ending
    ductules; called acini. The intralobular ducts and acini are surrounded by
    connective stromal tissue to form the breast lobule. Each lobe of the breast
    contain about 20 – 40 lobules while each breast contain about 15 – 20
    lobes.
    » Most of the cancerous lesion of the breast arises at the mammary zone.
    » At the 5th week of embryonic human development, a ‘milk line’ is developed
    which span from the armpit to the groin. The component ridges involute to
    remain only the upper portion which forms the breast. Failure of complete
    involution results in the development of accessory breast along the milk line.
    » Most common sites for accessory breast tissue are below the breast and the
    axilla.
    » At birth, the breast bud is developed with a network of small branching ducts.
    » At puberty, the ducts elongate and proliferate to form mature lobules.
    » As the age advances, there is growth of connective tissues and deposition of fat.
    » At the onset of menarche, normal cyclic breast changes commence due to
    stimulation by estrogen and progesterone. These changes involve the lobar acinar
    cells, stromal elements and increased breast edema and venous congestion –
    bases for menstrual breast pain.
    » In pregnancy – there is marked proliferation of the ductal and lobular elements.
     
    » Retro-mammary fascia – separates the mammary zone from the pectoral muscle.
    » Pectoralis muscle – a chest wall muscle found over the ribs.
    Arterial supply is composed of
    • Lateral mammary branch of the lateral thoracic artery.
    • Anterior cutaneous or perforating branches of the internal
    mammary artery.
    • Branches of the 2nd to the sixth intercostal arteries.
    • The venous path has an anastomotic cycle round the base of
    the nipple; called the ‘Circulus Venosus’.
    • Blood is therefore drained from the circulus venosus through
    the entire circumference of the breast by small venous systems
    and empty into the axillary and internal mammary veins.

    BLOOD SUPPLY
    LYMPHATIC DRAINAGE

     Main source of metastasis.


     Superficial and deep plexus of lymphatic vessels drain
    the breast.
    * Breast sonography requires:
    * Adequate spatial resolution: -
    Axial & Lateral
    Probe Requirement:
    * Broadband
    * Linear; electronically focused.
    * High frequency – 7.5MHz-
    13MHz.

    *TECHNIQUE
    POSITIONING
    Supine; with
    affected arm
    extended over the
    head – oblique
    positions – for
    lateral
    visualization.
    Erect, sitting
    position for
    further evaluation.
    ANNOTATION
    Location/localization of detected lesions can be by:
     Use of clock method – Used by most departments.
     Direct measurement from the nipple – in cases for biopsy.

    Further precision can be achieved using the 1, 2, 3 concentric division of the breast.
     
     Location 1 – Lesion around the areola region
     Location 2 – Lesion midway in the breast
     Location 3 – Lesion at the periphery of the breast.

    For determination of depth of lesions, they can be classified into ABC


     A – a given to lesions very close to the skin
     B – midway down the breast tissue – mammary zone.
     C – lesions located against the chest wall.
    PLANE OF SCAN
    O Breast tissues should be scanned in two planes of:
    O Radial (RAD) and Anti-radial (AR); not necessarily
    (Longitudinal x Transverse).
    O Radial plane is plane of the ductal system as it course
    towards the nipple.
    O Anti-radial is a reverse of this plane.
    O Helps to demonstrate subtle projections that may
    branch outward in the breast or along the course of
    the ducts.
    O Lesion can therefore be described as:
    O Rt “3B RAD or LT 3” 2 CAR
    Kindly decode !!
    OPTIMIZATION OF GAIN SETTING
    For optimum tissue differentiation and contrast resolution
     Set the area with fat to be medium grey in echotexture.
     Fatty tissues are found in most patients at the inner aspect of the breast.
    All other structures should be assessed in comparison with the fatty area.
     Glandular tissue and most benign lesions e.g fibroadenoma will appear
    isoechoic to mildly hypoechoic.
     Malignant lesions – can be mildly hypoechoic to markedly hyperechoic.
     Cysts are markedly hypoechoic to anechoic.
     Skin, fibrous tissue & calcifications – are hyperechoic.
     Sonography should always assess size, shape, location, outline, echotexture
    and density of surrounding tissues.
     Sonographic findings should be correlated with mammography where
    available.
    PATHOLOGIES
    » CYSTS – Can be simple, complex or complicated, depending on the internal echogenicity.

    » Simple Cysts
    » Thin-outline, with echogenic capsule
    » Enhanced through transmission
    » Anechoic centre/content
    » Simple cysts are non-malignant but surrounding tissues should be surveyed.
    » May not need aspiration unless if causing physical discomfort.

    » Complex Cysts
    » Do not meet the strict criteria for a simple cyst but with nil features of malignancy.
    » Mostly due to fibrocystic changes if without other features of malignancy.
    » May not need aspiration or biopsy.

    » Complicated Cysts – are complex cysts with potential for harboring malignancy.
    Complex cysts are characterized by:
    » Thick walls
    » Thick septations or mural nodules.
     
    » Note: High resolution system will detect internal debris in simple breast cysts due to
    fibrocystic changes.
    Internal contents within breast cysts are characteristic of fibrocystic changes and comprise of
    Protein globs
    Cellular debris
    Crystals of cholesterol
    Product of apocrine cells
    Foam cells

    All complex/complicated cysts are assessed for infection or malignancy.


    In evaluating for infection or malignancy, the following criteria are used:
    Diffuse lower-level internal echoes
    Component echotexture e.g fluid - debris levels.
    Presence & thickness of septation
    Wall thickness and echotexture.
    PATHOLOGIES

     
    Significance of observed features:
    Low-level internal echoes - require determination of wall thickness and particle mobility
    within the cyst.
    Uniformly thickened wall with hyperechoic internal debris - is considered acutely inflamed
    and infected.
    Requires aspiration
     
    A complex cyst with thin septations and thin wall can be considered a cluster of simple cysts.
    Complex cysts with thick septations require further evaluation: aspiration to be followed with
    large core needle biopsy.
    SOLID MASSES/NODULES
    All solid nodules should be evaluated for malignancy.
    Solid lesions should be classified as
     
    Benign – Absence of all malignant features +
    presence of benign features.
    Malignant – Any one malignant feature seen.
    Indeterminate – Absence of specific benign feature
    and nil categorical features of malignancy.
     
    Features of Malignancy
    Speculation – Invasive tentacles
    Angular margins – Invasive route depending or ease
    of spread.
    Micro lobulations – at least 1-2 lobulations within or
    involving the outcome. Correlates with histology.
    Duct extension – associated with DCIS, may not cast
    acoustic shadowing due to size.
    Calcification
    Taller than-width (AP distance > Transverse)
    More hypoechoic than fatty tissue (fat).
    Posterior acoustic shadowing occurs in ≈ 1/3
    Branch pattern – projection of growth along the duct
    towards the nipple in DCIS. Detected when scanned
    in a radial plane of the duct. It can be multiple and
    in different directions.
     
    BENIGNITY
    Benignity is sought for in absence of any feature
    suggestive of malignancy. Features include:
    Pure and hyperechoicgenicity: This is due to
    interlobular stromal fibrous tissue.
    Wider-than-tall (Elliptical)
    Regular, encompassing thin, echogenic capsule
    May have lobulations
    Smooth and well circumscribed.
    FIBRO-ADENOMAS

     Elliptical, wider-than-tall
     Smooth, regular outline,
    capsule
     Thin-echogenic wall
     Can be lobulated; called
    ‘gentle lobulations’
    COMPLEX BREAST MASS
    FIBROADENOMA
    INDETERMINATE BREAST MASS
    I N D E T E R M I N AT E M A C R O -
    L O B U L AT E D M A S S
    INFILTRATING DUCTAL CARCINOMA
    MALIGNANT BREAST MASS
    SIMPLE BREAST CYST
    CONGENITAL ANOMALIES
    Amastia – Complete absence of one or both
    breast – very rare.
    Accessory or Supernumerary breasts
    * Occurs in 1˚ to 2˚ of the population.
    * It may involve development of the following
    three:
    - Fibroglandular parenchyma
    - Areola or
    - Nipple

    The most common is the accessory nipple called


    polythelia. This occurs in both male & females.
    Accessory breast tissue can occur anywhere along
    the mild line; but mostly at the axillary segment.
    ROLE OF COLOUR
    DOPPLER

     Colour Doppler is used to


    determine neovascularity
    and degree of perfusion.
    Not suitable or definitive
    in differentiating benign
    from malignancy.
     Uses are in:
     Distinguishing solid from
    cystic lesions e.g solid
    nodule from complex
    cyst.
     Absence of flow do not
    confirm cystic nature but
    flow indicates solid tissue.
     A temporal seizure of
    flow in solid lesion on
    application of
    compression pressure is
    indicative of vascularity.
    Other applications include:
    • To determine inflamed versus non-inflamed lesions
    • Delineation of anatomic structures/landmarks
    • Normal from abnormal tissues
    • Intra-ductal papilloma versus mucinous secretions
    • Apply Fremitus technique to differentiate isoechoic/solid
    nodule from surrounding fat.
    • Determining whether a lesion is uni or multifocal.
    • Fremitus is the combination of power doppler in solation
    with vocal stimuli by the patient in order to assess extent
    of perfusion.
    • Vocal stimuli may be in form of continuous humming or
    pronouncement of eeee….!
    Ultrasound:
    • Characterizes lesions of the breast
    • More suitable for imaging adolescents and younger adults
    • Displays high axial & lateral resolutions especialy with
    modern machines and probes.
    • But highly operator – dependent.
    • Should be used in combination with mammography
    where necessary.

    In Conclusion

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