What are the two approaches to breast sonography in the diagnosis of disease?
- targeted
2. whole breast
🎗 This is when BUS is used to eval only a specific area of the breast, usually as a follow up to mammography.
Targeted BUS
Besides diagnosis, what’s the other use of BUS?
to guide interventional procedures with precise accuracy
How many indications for breast sonography can you name? (15 total)
- eval masses as cystic or solid
- f/u to mammo
- eval masses in <30 yo women
- eval masses in pregnant or lactating women
- eval dense breast tissue
- eval mass seen in only 1 view in mammo
- eval inflammation
- eval irradiated breast
- eval augmented breast
- eval axillary lymph nodes
- eval nipple discharge
- eval when mammo isn’t possible
- serial eval of a benign mass
- eval the male breast
- guide interventional procedures
Before beginning the scan, the sonographer should… (4)
- review priors,
- obtain a patient history,
- make a visual inspection, and
- note any palpable lumps.
🎗 Describe the ideal patient positioning for BUS.
- supine or supine oblique
2. with ipsilateral arm above the head
🎗 The right breast is best evaluated in ___ position. The left breast is best in the ___ position.
right = LPO (left posterior oblique) left = RPO (right posterior oblique)
🎗 The ___ aspect of the breast is effectively evaluated with the patient in supine position.
medial aspect
🎗 For ___ patients, lateral lesions may require steep oblique or decubitus positions.
larger breasted
🎗 How much transducer pressure should be applied during scanning and why?
moderate, helps eliminate artifacts
🎗 What scan planes are used in BUS?
sag & trans and rad & anti-rad
🎗 Which scan plan is parallel with the ducts?
Radial
🎗T/F? Radial is perpendicular to the ducts.
FALSE, anti-radial
🎗 Which scan plane does AIUM recommended for BUS?
Radial
Describe 3 o’clock transverse in rad/anti-rad.
3 o’clock radial
Describe 6 o’clock transverse in rad/anti-rad.
6 o’clock anti-rad
Describe 12 o’clock sagittal in rad/anti-rad.
12 o’clock radial
Describe 9 o’clock sagittal in rad/anti-rad.
9 o’clock anti-rad
If you find a lesion while scanning in sag/trans, you should…
switch to rad/anti-rad to assess the ducts.
What does SA denote in a BUS label?
subareolar region
What does AX refer to in a BUS label?
axillary region
123 Method: Does it indicate distance or depth?
distance from the nipple
123 Method: Which number is closest to the nipple?
1
ABC Method: Does it indicated distance or depth?
depth
ABC Method: Which letter is deepest?
C
🎗 Why use a stand-off pad?
to improve focusing and greater detail in the superficial layers of the breast when using a linear probe (not matrix)
🎗 A stand-off pad improves imaging of: (6)
- superficial tumors or cysts
- superficial vessels
- superficial ducts
- skin lesions
- skin thickening
* * 6. scanning surgical specimens**
🎗 What’s the ideal stand-off pad thickness for breast imaging?
1 cm. This places the elevation plane focus of a 10MHz transducer at approx 0.5 cm depth within the breast.
🎗 T/F? Younger women are more likely to have tissue that appears hyperechoic.
True
🎗 T/F? Older women tend to have tissue that appears hyperechoic.
False
🎗 T/F? Lactating women will have breast tissue that appears more hyperechoic.
True
🎗 T/F? Very thin patients will have breast tissue that seems more hyperechoic.
True
🎗 What are the three major types of breast tissue seen in BUS?
Fat (superficial, intraparenchymal, retromammary) Epithelium (TDLU and acini) Stromal Tissue (loose - intralobular and periductal, dense - interlobular and cooper's ligaments)
Breast skin: thickness is ___ and __echoic.
0.5 - 2mm, hyper
Breast fat is ___echoic.
iso- or midlevel. All structures use fat’s echogenicity as a reference.
Cooper’s ligaments are ___echoic and may produce this artifact.
hyper-, shadowing (because they’re so dense)
Glandular Epithelium is ___echoic and made up of ___.
iso to mildly hypo-, TDLUs and acini
🎗 Dense fibroglandular tissue is ___echoic and a combo of ___ tissues.
hyper-, glandular epithelium and connective tissue
Lactiferous ducts are ___echoic unless they’re fluid filled. Then they’re __echoic.
hypo-, an-
Pectoralis muscles are ___echoic and found ___.
hypo- with hyper- striations, deep to the retromammary layer
Ribs are ___echoic with this artifact and found ___.
hyper- with shadowing, deep to retromammary layer
🎗 Lymph nodes are ___echoic and ___ shaped.
hypo- cortex and hyper- hilum, kidney shaped
Calcifications are ___echoic.
markedly hyper-
Cysts are ___echoic if simple and ___echoic if complicated.
an-, hypo-
Benign lesions are ___echoic with similar echogenicity to __ and ___ tissues.
mildly hypo-, iso-, or mildly hyper-
fat and epithelium
Malignant lesions are ___echioc and general __ echogenic than benign lesions.
mild to markedly hypo-, less echogenic
T/F? BUS cannot distinguish between benign and malignant.
true
T/F? Benign diseases tend to cross fibrous planes.
false
T/F? 🎗 Malignant diseases tend to cross fibrous planes.
true, growing toward the skin
Cancers use these two systems to infiltrate the breast.
superficial venous and lymphatic
Name three dynamic imaging opportunities.
- compression
- echo-palpitation
- fremitus
🎗 How does a cyst respond to compression?
will change shape
🎗 How does a benign lesion respond to compression?
benign lesions tend to be soft (lipoma) so will likely change shape
internal echoes may become more uniform
🎗 How does a malignant lesion respond to compression?
malignant lesion tend to be hard - will not change shape
T/F? Debris within cysts or ducts may be better visualized with compression.
true
🎗 Echo-palpitation is a technique used to ___.
isolate a palpable mass.
Echo-palpitation allows the sonographer to ___ and to ___ simultaneously.
- be sure to be scanning the correct structure
2. assess the mobility of the lesion
Define ‘fremitus’.
the vibration of tissues during speech
Breakdown fremitus maneuver in BUS
- isolate tissue in question
- Engage power doppler
- have patient talk or hum
- normal tissue will vibrate creating a signal
- tumors do not vibrate or create a signal
Fremitus maneuver is especially helpful evaluating: (5)
- normal fat lobules
- normal tissue vs isoechoic lesion
- ill-defined borders
- non visualized posterior margin
- benign vs malignant characteristics
What’s the main benefit of using 3D breast imaging?
using the coronal plane to identify spiculation
What are the limitations of hand-held ultrasound? (3)
- operator skill level
- exam variability
- long exam times
What are the benefits of Automated Breast Ultrasound? (4)
- decreased reliability on operator skill level
- images the entire breast
- displays coronal plane
- decreased exam time
Name the three sonographic features of benign breast disease.
- rounded (cysts)
- oval/ellipsoid (benign tumors)
- horizontal orientation (wider than tall)
🎗 T/F? Benign tumors tend to grow within or along the tissue plane.
true
Smooth, well-defined, and circumscribed margins indicate that the tumor is …
… displacing adjacent tissues rather than invading them.
Why is a pseudocapsule indicative of a benign process?
Pseudocapsules are caused by the compression of adjacent tissues. Malignant processes would invade instead of compress.
What kinds of echogenicity suggest benign breast disease? (4)
- anechoic (cyst)
- hyperechoic (lipoma)
- *isoechoic (solid benign)
- *homogeneous
* sometimes
Name two artifacts that suggest benign breast disease.
- acoustic enhancement
2. edge shadowing
Enhancement artifact offers good ___ of the posterior tumor wall.
visualization
What kind of doppler flow do benign solid masses demonstrate?
little to none
maybe just a stalk/stem or feeder vessel
Ducts generally measure ___ mm and ___ in size as they run toward the nipple.
less than 3 mm; increase
🎗 What normal conditions might cause duct dilation or ectasia?
- lactation
- 3rd trimester
- peri-menopausal changes
What abnormal conditions might cause duct dilation or ectasia?
mastitis, fibrocyctic changes, papillomas, ductal carcinomas, papillary cancinomas
T/F? Large calcifications are typically malignant.
FALSE, they are a benign characteristic
Scarring, necrosis, hemorrhage, cysts, or fibroadenomas are benign causes of ___.
calcifications.
🎗 As the lymph node becomes more fatty, the __ thins and the __ is more prominent.
cortex; hilum
Size of a normal lymph node?
less than 2 cm
Normal cortical thickness of a lymph node?
less than 3 mm
T/F? Lymph nodes have low resistive doppler waveforms.
true
Name the two sonographic features of malignant breast disease.
- irregular shape
2. vertical orientation
🎗 The vertical orientation of malignant disease might also be described as…
taller-than-wide
AP>Length
Depth>Width
🎗 Why are malignant processes vertical instead of horizontal?
Because they’re invading through tissue planes
Describe margins with multiple small (<2mm) lobulations.
microlobulation
Describe obscured or indistinct margins.
ill-defined
🎗 Describe irregular jagged margins.
angular (highly sensitive for malignancy)
Describe margins with straight lines which radiate from the center of a tumor.
spiculated (most specific for malignancy)
🎗 Describe the extension of a tumor into a duct coursing TOWARD the nipple.
duct extension
🎗 Describe the extension of a tumor into a duct coursing AWAY from the nipple (tends to involve multiple ducts).
branch pattern
What plane must you be in to assess tumor extension?
radial
T/F? Malignant processes will have a thick, echogenic border.
true
🎗 What’s desmoplasia?
The fibrotic host response to tumor invasion (the development of a thick border to try and contain the disease)
A malignant process tends to be __echoic.
mildly to markedly hypoechoic
T/F? Malignant processes will be homogeneous.
FALSE, heterogeneous (excepting complex cysts and fibroids)
🎗___ may cause limited or lack of visualization of the posterior tumor wall.
shadowing
T/F? Most solid, malignant tumors demonstrate some degree of shadowing
true
🎗 What common benign structure in the breast tissue may cause shadowing?
cooper’s ligaments
What less common benign structures may cause shadowing? (3)
calcified fibroadenoma, radial scar, fat necrosis
This is the ability of a malignancy to develop new blood vessels
angiogenesis
What benign phenomenon may mimic a malignancy’s increased blood flow?
inflammation
Is a malignancy’s increased blood flow on the periphery or internal to the structure?
BOTH
T/F? Conventional and power doppler are reliable ways to distinguish benign from malignant.
FALSE
🎗Which usual layer do tumor vessels lack?
basement membrane or adventita
Name 4 examples of malignancy crossing into superficial planes.
- skin dimpling
- skin thickening
- nipple retraction
- retraction of cooper’s ligaments
T/F? malignancies only cross into superficial planes not deep ones.
FALSE
Which benign processes interrupt tissue planes?
inflammation and trauma
T/F? Sagittal scanning should be performed to assess duct extension and branch pattern
FALSE, radial
Are the microcalcifications associated with malignancy more likely to be seen in ultrasound or mammography?
mammography
At what measurement is a lymph node considered enlarged?
greater than 2 cm
At what measurement is a lymph node considered to have cortical thickening?
greater than 3 mm
What three qualities do malignant lymph nodes possess?
- loss of fatty hilum definition
- microcalcifications
- high resistive doppler waveform
🎗 As a lymph node becomes cancerous, it generally ___ and loses ___.
enlarges, loses definition of the fatty hilum
