Breast Flashcards
(28 cards)
List the vessels responsible for artery supply of the breast
- internal thoracic artery, via the medial mammary and anterior intercostal branches;
- lateral thoracic and thoracoacromial arteries; and
- posterior intercostal arteries.
List the vessels responsible for venous drainage of the breast
- mainly to the axillary vein via the lateral thoracic and lateral mammary veins; and
- also the internal thoracic and medial mammary veins.
List the pathways of lymphatic drainage of the breast.
- from the nipple, areola and lobules of the gland to the subareolar complex;
- then, most to the axillary lymph nodes;
- some medially to the parasternal nodes or to the opposite breast; and
- some, especially from the lower quadrants of the breast, to the inferior phrenic nodes.
Describe the normal u/s appearance of glandular tissue/parenchyma
• Glandular tissue/parenchyma: usually homogeneously echogenic; some hypoechoic areas within may represent ducts or fat lobules.
Describe the normal u/s appearance of subcutaneous fat/fat lobules
• Subcutaneous fat/fat lobules: hypoechoic compared to the glandular tissue. Some striationsmay be seen within. Fat lobules are usually round but may have a variable shape. Subcutaneous fatlobules are usually larger than those in the retromammary layer.
Describe the normal u/s appearance of pectoral muscles
• Pectoral muscle: hypoechoic with striations.
Describe the normal u/s appearance of the retroareola region
• The retro-areolar region: some shadowing from the nipple may be noted; often hypoechoicducts may be seen terminating under the nipple.
Describe the normal u/s appearance of Cooper’s ligaments
thin, echogenic lines, may not always be seen as this depends on their angle relative to the probe. They may be seen extending from the glandular tissue to the superficiallayer of the superficial fascia.
Describe the normal u/s appearance of the skin
two thin echogenic lines either side of a hypoechoic band; may be thicker inferiorly in the breast at the inframammary fold, but is usually approximately 2mm in thickness.
Describe a ‘TDLU’ and discuss why it is important.
A TDLU is a terminal duct lobular unit. This is the secreting unit of the breast, containing the terminal duct and mammary lobule (oval structures composed of acini or small ductules). During pregnancy they expand and secrete milk. The milk/secretions are then delivered into the larger duct system from the TDLU to the interlobular or segmental duct, then to the lactiferous sinus and then collecting duct at the nipple. The TDLU is important because many benign and malignant lesions can arise within it. These include cysts, adenosis, hyperplasia, fibroadenoma and most carcinomas.
A) If a lesion is in the lateral portion of the breast in the CC and lies at the level of the nipple in the MLO, where should it actually lie in the breast?
Lower lateral quadrant, lateral lesions are projected higher on the MLO.
B) If a lesion is in the medial portion of the breast in the CC and in the mid part of the breast in the MLO, where should it actually lie in the breast?
Upper medial quadrant, medial lesions are projected lower on the MLO.
C) If a lesion is in the central portion of the breast in the CC and in the mid part of the breast in the MLO, where should it actually lie in the breast?
In the upper breast around 12 o’clock.
D) If a lesion is not seen in the CC and lies high in the superior part of the breast in the MLO, where could it actually lie in the breast?
It is most likely to be actually in the axilla or the axillary tail. If it was lower in the MLO, it could lie in the supero-medial portion of the breast
Describe the width X depth ratio and its significance.
The width X depth ratio is one of the many characteristics used in describing breast lesions in an effort to try to determine the potential malignancy of the lesion.
Lesions that are wider than they are high are more likely to be benign than those lying more upright (when scanning in the supine position). Therefore, a high ratio suggests a likely benign lesion, whilst a low ratio suggests malignant potential.
This type of shape suggests lesion growth that is across normal tissue planes and indicates malignant potential. Fibroadenomas usually grow within the tissue planes, flattening with the pressure of the fascial planes. Some cysts, though, may be very round. Therefore, the ratio should be used in combination with the other ultrasound characteristics when assessing a breast lesion.
List the ultrasound characteristics you would most likely find in benign lesions.
Likely benign characteristics
• shape – round, oval , eliptoid
• texture - homogeneous
• echogenicity - anechoic, hyperechoic
• internal contents – solid, cystic
• presence of calcifications - only if large and smooth
• margin definition - smooth, macro-lobulations, sharp, thin halo or capsule
• posterior sound transmission - enhancement, shadow, no change
• orientation to skin – parallel to skin, along skin planes
• width X depth ratio - wider than tall
• mobile, compressible
• no architectural distortion /Cooper’s ligament distortion
• no disruption to superficial or deep fatty and fascial layers
• no nipple inversion/retraction
• no abnormal axillary lymphadenopathy
List the ultrasound characteristics you would most likely find in malignant lesions.
- shape – round, irregular
- textures – heterogeneous
- echogenicity - hypoechoic
- internal contents – solid, mixed
- presence of calcifications – fine
- margin definition- irregular, spiculated, ill-defined, micro-lobulations, thick, irregular capsule
- posterior sound transmission - shadowing , no change
- orientation to skin, more upright
- width X depth ratio – low, more round or upright shape
- immobile, non-compressible, hard, irregular
- architectural distortion /Cooper’s ligament distortion
- disruption to superficial or deep fatty and fascial layers
- recent nipple inversion/retraction
- abnormal axillary lymphadenopathy
Discuss the pathophysiology of fibrocystic breast change and describe the common ultrasound appearances.
Fibrocystic disease in the breast is a reactive and degenerative change, partially due to the consequences of hormonal stimulation and the breast’s reaction to this, and partially due to the consequences of aging. It does not usually occur prior to puberty and any symptoms gradually improve post-menopause. Usually both breasts are affected, but there is often asymmetry. Lumps are often easily palpable and often fluctuate in size. The breasts may have a nodular feel and are usually very tender, especially premenstrually.
The normal breast tissue responds to variations in hormone levels throughout the menstrual cycle in regard to proliferation and accumulating fluid. The breast undergoing fibrocystic change does so in a hyperplastic reactive and degenerative way. The typical features of fibrocystic change include epithelial proliferation, fibrosis and cysts. A less common feature is intraductal papillomatosis. Fibrosis occurs when the loose intralobular connective tissue is replaced with dense connective tissue. The ductal epithelium proliferates, ducts dilate and become trapped by these dense connective tissue strands, leading to cyst formation. The fibrous strands also undergo degenerative change due to interruption of blood flow, presenting eventually as stromal calcification. Epithelial proliferation occurs in the form of ductal budding and crowding – sclerosing adenosis. Some breasts develop intraductal cell proliferation and may grow small intraductal papillomas (these have some malignant potential).
Common ultrasound appearances of fibrocystic change
Cysts
• Simple cysts
• echo-free contents
• round/oval (round cysts may be under tension more than flaccid/flattened cysts)
• posterior enhancement
• smooth/thin walls
• edge refraction; reverberation artefacts within are common
• usually compressible and may feel mobile
Complex cysts
• septations/lobulations
• debris (low level echoes maybe due to internal haemorrhage, milk, cellular material, inspissated/concentrated secretions)
• wall thickening, especially if infection present or recent biopsy attempt
• intracystic mass – for example, papilloma
• reduced posterior enhancement, common if small or containing low level echogenic material
Intraductal papillomas
• medium-level soft tissue mass attached to one wall of the duct; may see blood flow to it, may also cause the duct to be dilated, may obstruct and cause distal dilatation.
Fibrosis and epithelial proliferation
• increased echogenicity and often coarseness to the glandular and stromal tissue
• smooth calcifications may be present
List the generally accepted risk factors for women developing breast cancer.
- maternal relative with breast cancer (for example, mother, sister, daughter, aunt), especially if young
- increasing age – rare under the age of 30, risk increases steadily with age
- BRCA1 and BRCA2genes. BRCA1 occurs in 1:800 women. BRCA2 is less common, but is associated with early onset breast carcinoma.
- long reproductive cycle – increased risk with early period onset(<15)and/or late menopause(>50)
- obesity, high dietary fat intake in postmenopausal women
- nulliparity, increased risk if never pregnant, slightly less if previously pregnant but no live births
- late age at first pregnancy, that is, first child born to women over 30
- atypical epithelial hyperplasia, due to changes in ductal epithelium
- previous breast cancer
- previous endometrial or ovarian cancer
- previous radiation to the breast
- hormone replacement therapy
Discuss the clinical indications of an FNA
Clinical indications:
• tends to be used more as a first choice where the lesion is expected to be cystic or mainly cystic to facilitate aspiration; and
• often performed prior to a core biopsy to obtain a cytological specimen.
Discuss the clinical indications of a core biopsy
Clinical indications:
• more commonly used where the lesion is suspected to be malignant or inconclusive; and
• where a previous FNA has been inconclusive.
Discuss advantages and disadvantages of a breast FNA
Advantages:
• useful aspiration tool for cystic/mainly cystic lesions;
• relatively quick and easy to perform in trained hands;
• well-tolerated by most patients (often even without the use of local anaesthetic); and
• low chance of bleeding due to fine gauge needle used.
Disadvantages:
• yields only a cytological specimen; and
• sometimes the cellular
Discuss advantages and disadvantages of a breast core biopsy
Advantages:
• yields a histological specimen which has the potential to demonstrate the invasiveness of the tumour; and
• usually quite well-tolerated by outpatients with local anaesthetic to the breast.
Disadvantages:
• technically more demanding for the operator and patient;
• more traumatic to the patient;
• greater propensity for the breast to bleed (haematoma development due to larger gauge needle used); and
• chance of tumour seeding along track of needle possible (sometimes disputed).
Discuss the various EARLY complications and ultrasound appearances of the breast with implants, including artefacts that aid the diagnosis.
Early complications such as infection or haematoma
These are usually clinically obvious, but ultrasound appearances may show fluid collections of varying echogenicity. Sometimes small anechoic fluid collections may have a simple appearance soon after surgery. The size and position of the collection should be noted. Peri-implant fluid collections may be present for some time with the saline implant.
