1
Q
List the vessels responsible for arterial drainage of the chest
A
- internal thoracic artery, via the medial mammary and -anterior intercostal branches;
- lateral thoracic and
- thoracoacromial arteries; and
posterior intercostal arteries.
2
Q
List the vessels responsible for venous drainage of the cheat
A
- mainly to the axillary vein via the lateral thoracic and lateral mammary veins; and
- also the internal thoracic and medial mammary veins.
3
Q
Why is it important to understand lymphatic drainage of the breast?
A
Because of the role in metastasis of cancer cells
4
Q
List the lymphatic drainage systems of the breast
A
- From the nipple, areola and lobules of the gland through intramammary nodes and channels to the subareola lymphatic plexus
- medial breast medially to the parasternal nodes or to the opposite breast
- retromammary pathway, drains to the subclavicular plexus
- inferiorly may pass deeply to abdominal lymph node
5
Q
Describe the normal pre-menopausal appearance of the breast
A
Largely consists of fat and glandular tissue
6
Q
Describe the normal post-menopausal appearance of the breast
A
Decreased fat and glandular tissue, proportionally the breast is mainly fibrous tissue
7
Q
Describe the appearance of a breast in a young, non-lactating patient
A
Breast is mainly composed of hyperechoic glandular tissue with little to no subcutaneous fat
8
Q
Describe the appearance of a breast in an ageing patient with children
A
More fat will be deposited in the subcutaneous and retromammary layers
9
Q
Describe the appearance of a breast in a pregnant patient
A
- glandular tissue increases in size and gives a granular, hyperechoic pattern
- little fat is visible due to the compression of the glandular tissue
- during lactation and towards the end of pregnancy, lactiferous ducts increase in number and size
- dilation may be visible as hypoechoic linear structures running towards the nipple
10
Q
Describe the appearance of a breast in a non-pregnant patient
A
- Can have cyclical changes
- mild duct dilation in the last half of the cycle
11
Q
What is the ultrasound appearance of glandular tissue/parenchyma?
A
Usually homogeneously echogenic, some hypoechoic areas which may represent ducts or fat lobules
12
Q
What is the ultrasound appearance of subcutaneous fat/fat lobules?
A
hypoechoic compared to glandular tissue. Some striations may be seen within. fat lobules are usually round but may have a variable shape. subcutaneous fat lobules are usually larger than those in the retromammary area
13
Q
What is the ultrasound appearance of the pectoral muscle?
A
hypoechoic with striations
14
Q
What is the ultrasound appearance of the retroareolar area?
A
shadowing from the nipple may be noted, often hypoechoic ducts may be seen terminating under the nipple
15
Q
What is the ultrasound appearance of Cooper’s ligaments?
A
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 superficial layer of the superficial fascia.
16
Q
What is the ultrasound appearance of the skin?
A
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.
17
Q
What is the TDLU?
A
Terminal duct lobular unit. It is the secreting unit of the breast. It contains the terminal duct and mammary lobule. During pregnancy they expand and secrete milk.
18
Q
List the pathway of the TDLU to the nipple
A
TDLU –> interlobular/segmental duct –> lactiferous sinus –> collecting duct at the nipple
19
Q
Why is the TDLU important?
A
Because many benign and malignant lesions can arise within it. These include cysts, adenosis, hyperplasia, fibroadenoma and most carcinomas
20
Q
List common artefacts in breast ultrasound
A
- echo
- shadowing from Cooper’s ligaments
- reverberation artefact (Can mimic debris)
- indeterminate solid/cystic mass
21
Q
How would you reduce artefactual echoes?
A
Use harmonics
Use different settings or B-colour
Check that the focal zone is placed correctly
Use various patient positions
22
Q
List 4 roles of sonography in breast imaging
A
- primary screening
- supplemental screening (AFter mammography)
- diagnosis
- intervention
23
Q
Describe primary and supplementary screening
A
- currently does not have a proven role in primary breast cancer screening
- Used in supplemental screening (after mammography, as an ancillary study)
- especially in women with dense breast tissue on mammography
- expanded in recent years and its use continues to grow.
24
Q
Describe the diagnostic role of breast ultraesound
A
- more than differentiating mammographically detected masses
- now possible to define the characteristics of a mass or area
- can possible determine aetiology of the mass to steer a patient’s treatment
- does not replace mammography in many cases
- is a useful tool in younger patients, post-treatment, implants, difficult to exam breasts using conventional mammography
25
List benefits of breast ultrasound
Non-ionising
Good for dense breasts (younger patients)
Used to aid FNA and core biopsies
Good for patient reassurance
26
What is a disadvantage of breast ultrasound?
Visualisation of subtle malignant changes such as microcalcifications is rarely possible
27
List indications for breast ultrasound
- evaluate a mass demonstrated on or not fully seen mammography
- evaluation of dense breast tissue
- evaluate abscess in a patient with mastitis
- evaluate unknown densities seen on mammography
- evaluate the breast in a high risk patient
- review of patients with fibrocystic disease
- evaluate masses or pain due to trauma
- post surgery/radiation therapy
- evaluation of implants
- evaluation of the male breast
28
What are some personal observations you can make about the breast?
Should also note any personal observations on nipple retraction, asymmetry, skin deformities, thickening, irregularity, prominent veins, bruising, accessory nipples
29
List some things that can be important in patient history
age, family history of breast/ovarian cancer, stage in menstrual cycle, currently pregnant, hormone therapy, implants in situ, previous cancer, previous surgery or biopsy of the breast, any regions of interest, nipple discharge/itchiness, nipple retraction, previous imaging
30
Why is it important to feel the region of interest?
- Gain more info about the region of interest
- Mobile, fixed, smooth, irregular, size, superficial
- Need to explain procedure and gain consent
Sometimes lumps can only be felt in certain positions so important to feel when the patient can feel
31
What is the significance of the width x depth ratio?
Aids in determining the potential malignancy of a lesion. Wider than tall are more likely to be benign. A high ratio suggest benign lesion whilst low ratio suggest malignant potential. Growth across tissue planes indicate malignant potential.
32
List likely benign characteristics
- Shape: round, oval, elliptoid
- Texture: homogeneous
- Echogenicity: anechoic, hyperechoic
- Internal contents: solid, cystic
- Presence of calcifications only if they are large and smooth
- Smooth margin definition, macro-lobulations, shap thin halo or capsule
- Posterior enhancement, shadowing or no change
- Wider than tall
- Mobile, compressible
- No architectural distortion
- No disruption to superficial or deep fatty and fascial layers
- No nipple inversion/retraction
- No abnormal axillary lymphadenopathy
33
List likely malignant characteristics
- Irregular, round shape
- Heterogeneous echotexture
- Hypoechoic
- Solid/mixed
- Presence of fine calcifications
- irregular, spiculated, ill-defined, micro-lobulations, thick, irregular capsule
- posterior shadowing, no change
- more upright towards skin
- 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
34
List developmental congenital anomalies in the breast
- Idiopathic or dysfunctional hypoplasia (Turner's syndrome)
- Hyperplasia
- -> precocious puberty, gynaecomastia, early development, hypertrophy
35
List formative congenital anomalies in the breast
```
Rudimentry breast
Amastia
Absence of nipple
Absent or rudimentary mammary glands
Supernumerary breast
Affects gland, areola or nipple
Develop along milk lines from groin to axilla
Most common is an accessory nipple
Accesory glands most common in the axilla
```
36
What are the four types of inflammatory breast disease?
infectious, non infectious, acute or chronic
37
What are the causes of infectious mastitis?
Lactation
Inverted nipples
Sebaceous cysts
Infected montgomery's glands of areola
38
How may a patient with infectious mastitis present?
Diffuse swelling/cellulitis
Multiple abscess nodules
Large abscess
39
What is the ultrasound appearance of infectious mastitis?
Diffuse swelling
Skin thickening
Increased echogenicity of subcut fat
Loss of demarcation between subcut fat and glandular tissue
Abscess
Irregular walled mass with heterogeneous internal appearance of mixed cystic/solid ares
Posterior enhacement
Increased blood flow in wall with none in the centre
40
What are the causes of non-infectious mastitis?
```
Duct dilation- leads to duct ectasia/comedo mastitis
Trauma- leading to fat necrosis
Malignancy- inflammatory carcinoma
Radiation therapy
CCF
```
41
What is the ultrasound appearance of non-infectious mastitis?
Duct ectasia- dilated ducts with low level echogenic debris and or thickened walls
Fat necrosis- firm mass with fibrous margins, shadowing similar to carcinoma OR may appear as an oil cyst which is rounded, well-defined with thin echogenic borders and anechoic cerntre and posterior enhancement oR hyperechoic rounded mass with posterior shadowing OR calcified
Malignancy- diffuse change, hyperechoic compared to non-affected breast
Breast may appear red/orange and firm
42
What are some causes of breast trauma?
Biopsy
Surgery
accident.
A patient history is therefore necessary.
43
What are some ultrasound appearances of breast trauma?
fat necrosis – as discussed previously.
seroma, lymphocoele (usually post-operative mainly cystic collections).
haematoma (spontaneous bleeding is usually associated with an occult carcinoma).
44
Describe the u/s appearance of a haematoma
depends on the time frame and on the degree of organisation of the blood
very early stages hyperechoic, often ill-defined area of fresh blood within the soft tissues. The overlying skin may be thickened due to oedema.
After a few days, a mass may appear that is predominantly anechoic.
As the blood organises, the mass will show a more echogenic component, often with septations.
Much later, if the haematoma has not resolved or been drained, it will take on a more organised and almost solid appearance.
45
List diffuse benign breast disease
Fibrocystic
Sclerosing adenosis
Comedo mastitis (blackhead)
46
List focal benign breast disease
```
Cyst
Sebaceous cyst
Fibroadenoma
Lipoma
Hamartoma/fibroadenolipoma
Intraductal papilloma
Galactocele
Cystosarcoma phyllodes
Focal fibrosis/radial scar
```
47
Describe fibrocystic breast change
reactive and degenerative change
partially due to the consequences of hormonal stimulation and the breast's reaction to this
partially due to the consequences of aging
does not usually occur prior to puberty
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
usually very tender, especially premenstrually.
48
Describe the process of fibrocystic breast changes
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).
49
Describe the u/s appearance of a simple breast cyst
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
50
Describe the U/S appearance of complex breast cysts
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
51
Describe the u/s appearance of 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.
52
Describe the u/s appearance of fibrosis epithelial proliferation
increased echogenicity and often coarseness to the glandular and stromal tissue
smooth calcifications may be present
53
What are some anatomical pitfalls of breast ultraesound?
Novice breast imagers may mistake a rib for a solid breast mass.
Although the normal nipple is easily recognized at real-time sonography, on static images an inverted nipple may project beneath the skin of the areola giving the false appearance of a markedly hypoechoic, solid parenchymal breast mass with extensive acoustic attenuation
cross section of a fat lobule can be mistaken for a solid mass that is isoechoic to surrounding adipose tissue
normal-caliber ducts imaged in cross section may mimic a small cyst.
54
Describe acoustic shadowing in breast ultrasound
Shadowing due to Cooper’s suspensory ligament is often faint and narrow but can be markedly hypoechoic and wide enough to simulate a malignant tumor
Short echogenic parallel lines at fixed intervals starting at the skin and leading to the acoustic shadowing are pathognomonic for poor skin contact.
Postsurgical scar may also cause substantial acoustic shadowing without an underlying mass
Significant shadowing at the site of prior lumpectomy may be impossible to differentiate from residual or recurrent tumor, limiting the usefulness of sonography in this setting.
55
Describe edge shadowing in breast ultrasound
a thin line of shadowing seen only behind the peripheral edge of a mass should not be mistaken for a suspicious feature can be seen with cysts and benign or malignant solid masses and has no diagnostic significance.
56
Describe the artefacts associated with grey-scale gain
The gray-scale gain setting determines the amplitude of the returning sonographic signal. If the gain is set inappropriately high, spurious echoes may be displayed in a simple cyst resulting in the appearance of a complex cyst or solid mass.
57
Describe artefacts associated with the dynamic range
Setting the dynamic range too low increases image contrast but may cause the low-level echoes in a solid mass to be displayed as black pixels so that the appearance of the mass mimics that of a simple cyst. Setting the dynamic range too high results in an image with little contrast, which hinders differentiation of fat lobules from subtle masses.
58
Describe the reverberation artefact
Parallel echogenic lines caused by reflection of the ultrasound beam back and forth between the transducer and tissue interface can give the artifactual appearance of solid or complex material along the nondependent wall of a cyst. Less characteristic reverberation can be confirmed by changing the angle of insonation. Reverberation is always perpendicular to the direction of the ultrasound beam and will appear to shift position within the cyst as the angle of insonation is changed.
59
Why should the focal zone be set appropriately?
Inappropriate focal zone may cause a subtle mass to be less visible, sharp edges to appear ill-defined, and an anechoic simple cyst to appear to have internal echoes due to increased partial volume effects.
60
Describe the appearance of extracapsular silicone
A small amount of extracapsular silicone due to implant rupture may initially be mistaken for a cyst or hypoechoic solid mass with posterior acoustic enhancement
recognition of short echogenic lines paralleling the back wall of the structure allow a confident diagnosis of extracapsular silicone and, therefore, implant rupture.
61
What are some problems with breast ultrasound?
```
Unable to visualise lesion
failure to localise density
failure to localise a clinical lesion
pseudo-masses
indeterminate masses
reverberation artefact
shadowing from Cooper's ligaments
lactating breasts
accessory glandular tissue in the axillary tail
```
62
List several risk factors for breast cancer
maternal relative with breast cancer
increasing age – rare under the age of 30, risk increases steadily with age
BRCA1 and BRCA2genes
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
63
What are the 3 classifications of breast cancer?
Ductal or lobular carcinoma
Sub-types: tubular, papillary, mucinous, medullary
Undifferentiated, other and unknown groupings
64
List the types of invasive carcinoma
infiltrating ductal carcinoma (the most common type of invasive).
infiltrating lobular carcinoma (second most common)
infiltrating ductal and lobular carcinoma.
medullary carcinoma.
mucinous (colloid) carcinoma.
comedo-carcinoma.
Paget's disease.
papillary carcinoma.
tubular carcinoma (the least most common type).
adenocarcinoma, NOS (not otherwise specified)
carcinoma, NOS.
65
Where are cancers most likely to occur in the breast?
```
upper outer quadrant – 50%
central area – 20%
lower inner quadrant – 10%
upper inner quadrant – 10%
lower outer quadrant – 10%
```
66
list the types of non-invasive carcinoma
```
intraductal carcinoma.
lobular carcinoma in situ (LCIS).
intraductal and LCIS.
papillary carcinoma.
comedo-carcinoma.
```
67
What is the metastatic survival of breast cancer?
Least aggressive Cas rarely metastasise outside of breast (DCIS and LCIS)
Less common to metastasise are colloid ca, medullary ca and papillary ca
All others have a greater potential to metastasise
68
Name the stages of breast cancer
Stage 1
tumour 2cm or less in greatest diameter with no evidence of nodal or distal spread.
5 year survival 96%, 7 year survival 92%.
Stage 2
with or without regional lymph node spread but no distant metastases.
5 year survival 81%, 7year survival 71%.
Stage 3
tumours of any size with possible skin involvement, pectoral and chest wall fixation and axillary or internal mammary nodal involvement, fixed, but without distal metastases. –
5 year survival 52%, 7 year survival 39%.
Stage 4
tumours of any size with or without regional spread but with evidence of distant metastases
5 year survival 18%, 7 year survival 11%.
69
Describe the ultrasound appearance of an infiltrating ductal carcinoma
- Variable appearance
- heterogeneous with a central nidus
- outer echogenic halo
- Posterior shadowing is almost always present
- irregular margins, spiculated
- Microcalcifications may appear as punctate echogenic foci if seen
- Large tumours may show central, necrotic cystic change
- often appears to cross fascial/stromal boundaries with subsequent architectural distortion.
70
Describe the ultrasound appearance of an infiltrating lobular carcinoma
heterogeneous, hypoechoic mass
angular or ill-defined margins
posterior acoustic shadowing.
71
Describe the u/s appearance of a colloid carcinoma
fairly rare, often apparent in older women.
wide variation in ultrasound appearances.
Some appear quite dense with good posterior shadowing.
Many have an isoechoic appearance compared to the surrounding breast tissue and can blend in, or are slightly hypoechoic, being only apparent by a heterogeneous textural pattern
often have some posterior enhancement
may appear similar to a fibroadenoma
But harder and less mobile.
72
Describe the u/s appearance of a tubular carcinoma
appearance also mimics IDC not otherwise specified
hypoechoic solid mass
ill-defined margins
posterior acoustic shadowing
The lesions are often rounded tall as broad.
73
describe the u/s appearance of comedocarcinoma
irregular textural pattern with increased ducts
74
describe the u/s appearance of papillary carcinoma
hypoechoic and solid mass
often with posterior acoustic enhancement
alternatively, complex cystic and solid masses may be evident.
As they are relatively vascular, there are often colour flow components on Doppler interrogation.
There is overlap in the imaging patterns of invasive papillary carcinoma and papillary ductal carcinoma in situ.
75
describe the presentation of paget's disease
the patient presents with redness or erosion of the nipple, often with a burning sensation. (This may be due to an extension of a breast carcinoma along the ducts into the epidermis).
76
describe the u/s appearance of paget's disease
ultrasound appearances can be very non-specific with thickening of the areola and echogenic material within the ducts. Comparison with the other breast is vital, along with a good patient questionnaire.
77
describe the u/s appearance of inflammatory carcinoma
skin thickening, increasing oedema and increased echogenicity of the subcutaneous fat layer.
No tumour mass is usually seen
Increased vascularity is a good indicator.
axillary lymphadenopathy often seen.
78
Describe the u/s appearance of breast metastases
These appear as lesions often similar (but not always) to the primary from:
the opposite breast.
extramammary primary malignancies – blood borne such as melanoma, ovarian, lung, sarcoma.
breast involvement in haematological malignancies such as lymphoma.
circumscribed margins with low-level internal echoes
occasionally, posterior acoustic enhancement
Colour Doppler interrogation most often shows increased vascularity.
79
Describe the lymphatic spread of breast cancer
Often go to the axillary nodes first
Most of the breast lymphatics drain there
May also spread to dermal lymphatics
Inflammatory breast Ca
Can spread to the opposite breast via medial lymphatic drainage
Can spread distantly via supraclavicular lymph nodes
Other Sites where metastases commonly go
Lung
Bone
Liver
Not all women with nodal disease in axilla develop lymph node metastases
Distant metastases = stage 4
80
What other imaging can be done when assessing breast metastases
Liver u/s can be done to detect any liver mets, ascites, adrenal and peri-aortic lymphadenopathy
Chest xray to detect lung mets or pleural effusions
Nuclear bone scanning to detect bone mets
Ovarian metastases from breast cancer can form a krukenburg tumour of the ovary
Can obstruct ureter
Often bilateral
81
How do we assess lymph nodes?
Size is a poor criterion for metastasis.
tend to become abnormally round (this is a late findin)
The cortex becomes abnormally hypoechoic
may not be detected when using harmonics because harmonics routinely make the cortex appear more hypoechoic
Morphologic assessment of the lymph node is more effective than evaluating its size, shape, and echogenicity
Lymph nodes that demonstrate eccentric cortical thickening should be considered suspicious for metastasis.
82
List clinical indications for a post-operative breast (cancer)
Local recurrence post mastectomy usually occurs in skin
Early detection = early intervention
Post lumpectomy and breast conservation surgery can be difficult to detect
Post-operative complications of seroma, fat necrosis, local recurrence
Increased vasculairty is an important finding
Scar tissue is usually avascular
Inflammatory carcinoma is very vascular
83
List post operative masses
Haematoma
Seroma
Lymphocoele
Can be complex, preedominantly cystic appearances
Long standing collections may have an echogenic wall/capsule
Fat necrosis and oil-cysts may be present
84
What are some differences in a post-operative breast?
Large scars can be difficult to scan through
Breast thickening may be present
Textural distorition due to scarring
85
Describe u/s changes post radiotherapy
Skin thickening
Increased echogenicity of subcut fat
Thickening or distortion of Cooper's ligs
Architectural distortion of breast tissue
86
What is a stereotactic core breast biopsy?
Specialised mammographic biopsy unit
Calculations position of mammographically detected lesion within the breast by localising position in relation to horizontal and vertical axes
Available in both film screen and digital
87
What is a hookwire insertion?
Pre-operatively places a hook wire within a lesion
Commonly used for likely malignant non-palpable lesions to guide
Mammography or U/S guidance
Easier under ultrasound if the lesion can be seen on mammo and u/s
Cannula is placed into breast along the proposed line of biopsy
Shortest distance from skin to lesion
Imaging then confirms that it is within the lesion then the hookwire is inserted through the cannula into the lesion
Hook wire remains in the lesion after the cannula is removed
Then patient goes to theatre to have the lesion removed
Imaging may be done of the lesion to ensure the entire lesion was excised
88
Describe an FNA
22-25 gauge of variable length to take the sample of tissue from a solid lesion or to aspirate fluid from a cystic lesion
If fluid is thick, then might need a lower gauge needle
Smaller gauge needles are thought to give better specimens, tolerated better and fewer post-biopsy complications
Fluid aspirate is stored in a sterile container and tissue samples are placed on slides
Needle is guided under ultrasound
Free-hand approach has the advantage that the needle can often be passed at an angle close to perpendicular to the transducer
Better visualisation of needle tip
New needle combination allows a hollow needle to be passed through lesion then cutting needle passes through to perform FNA
Useful for mobile lesions and dense breast tissue
89
Describe a core biopsy
Most common method is a gun needle combination
Another method is a vacuum suction biopsy probe
Hollow needle inserted into lesion
Vacuum attached draws tissue into a side hole of the probe
Cutter cuts the core of tissue and withdraws it from breast
Gun needle combination has a variable throw
Distand the needle travels in the breast
Usually 14, 16 or 18 gauge hollow needle
Dense tissue is likely to bend a fine needle
Larger the core, better the sample, greater amount of bleeding
90
List common post-biopsy complications
Pain
Biopsies near or under nipple can be very painful
Pre-menstrual and dense breasts
Bleeding
More likely with core biopsies than FNA
Ice packs can reduce post-srugical bleeding and pain
Refrain from exercise and aspirin-based drugs for that day
Bruise is likely
Lumps (occult haematoma) may require treatment
Infection- rare occurrence
Contact doctor if breast becomes tender or redness appears
Vasovagal attack
Biopsies should always be performed lying down
91
Describe the preparation for a biopsy
Fully read previous reports and view previous examinations
Patient consent prior to biopsy
Ensure that the correct lesion is going to be biopsied
Transducer:
Cleaned
Gel on the transducer and then the sterile cover is placed over this
Patient
Patient is usually placed in a supine oblique position with the side of interest raised
Angle of obliquity and arm position depends on size and flaccidity of the breast
Foam wedge to ensure that the patient is comfortable
Blankets and sheets to keep patient warm and to maintain privacy
Skin is washed
92
What pre-biopsy imaging should be done?
Longest dimension of the lesion and at 90 degrees to that; measurements taken(cyst volume may be estimated); distance from nipple and position in breast noted.
Colour/power Doppler image to indicate general vascularity of the lesion.
93
What biopsy imaging should be done?
Needle in position within lesion (two images at right angles).
Core biopsy may require a pre and post fire image.
94
What post-biopsy imaging should be done?
Usually only required post-cyst aspiration to show the extent of drainage and if any solid component remains.
95
What are indications for a breast 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;
often performed prior to a core biopsy to obtain a cytological specimen.
96
What are advantages 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.
97
What are disadvantages of a breast FNA?
yields only a cytological specimen; and
| sometimes the cellular material may be very sparse, even insufficient, especially in some benign lesions.
98
What are some clinical indications for a breast core biospy?
more commonly used where the lesion is suspected to be malignant or inconclusive
And where a previous FNA has been inconclusive.
99
what are advantages of a breast core biopsy
yields a histological specimen which has the potential to demonstrate the invasiveness of the tumour
usually quite well-tolerated by outpatients with local anaesthetic to the breast.
100
what are disadvantages of a breast core biopsy?
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); a
chance of tumour seeding along track of needle possible (sometimes disputed).
101
list clinical indications of breast ultrasound in patients with implants
- routine
- palpable mass
?rupture, thickening or capsular fibrosis
102
Describe normal breast implants
Silicone/saline-filled prosthesis are usually anterior to the pectoralis fascia. Some are retropectoral. Older patients may present with unusual hyperechoic breast masses that are direction injections of silicone or paraffin into the breast
103
What is the normal u/s appearance of a breast implant?
Fatty and glandular tissue is stretched over implant depending on the size
Amount of glandular tissue may be thin
Filling ports may be visible as shadowing area to the side of the implant
Implant is a smooth, echogenic balloon
May have reverberation artefact in the anterior portion
Contents will be anechoic with posterior enhancement whether saline or silicone
Smooth and regular margins
Old implants may have low-level echoes present due to degeneration of silicone
104
Describe early infection or haematomas in breast implants
usually clinically obvious
fluid collections of varying echogenicity
small anechoic fluid collections may have a simple appearance soon after surgery
size and position of the collection should be noted
Peri-implant fluid collections may be present for some time with the saline implant.
105
Describe the deformities due to leakage or rupture
distortion or lobulation of the prosthesi
or as cystic spaces around the implant
Unencapsulated implants may bulge and distort under normal tissue pressures and still not be ruptured
Free silicone may be diffusely extravasated or appear in lumps
Free silicone rupture may give a classical „snow storm‟ appearance – diffuse fine low-level echo shadowing
A ruptured implant will deflate rapidly and may be due to trauma or totally unexpected.
Silicone may extravasate into the surrounding tissue (extracapsular rupture)
or be contained within the fibrous capsule formed around the implant (intracapsular rupture)
very difficult to determine whether it is an encapsulated rupture or merely a bulge in the implant.
A sign of an early rupture is the „linguine‟ sign, whereby the recoil of the envelope causes it to contract into the centre of the bag.
Implant rupture may also give the ultrasound appearance of multiple echogenic lines either within or below the anterior surface
Fragmentation of polyurethane bags may also cause long-standing fluid collections, thought to be due to a chronic inflammatory reaction.
106
Describe capsular fibrosis
more of a clinical diagnosis
implant capsule becomes firm and hard
may appear as bright parallel lines at the surfaces of the prosthesis
implant may appear distorted.
107
Describe echogenic masses that may be seen with breast implants
Calcification and oil cysts may be present.
may appear as echogenic masses of variable hyperechogenicity
Silicone granulomas are a reasonably common appearance, forming at the surface of the silicone bag
usually quite palpable
Echogenic
well-circumscribed rounded structure
close to the edge of the prosthesis
Posterior shadowing
Fragmentation of polyurethane bags may cause debris within fluid collections around the implant.
108
Describe the appearance of capsular contraction
Due to tissue pressures, undulations and folds may appear within the implant. It may be sometimes difficult to determine if the appearances are of folds or rupture of an implant. Some folds are normal due to tissue moulding.
109
Describe the anatomy of the male breast
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Rudimentary
Small ducts with no lobules or alveoli
Little fibroadipose tissue
Small areola and nipple
Ductal tissue extends beyond areola
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110
describe the u/s appearance of the male breast
Mainly hypoechoic subcut fat with faintly echogenic connective septa that permeate fat
Small amounts of hyperechoi glandular tissue may extend to nipple
Pectoralis major clearly seen behind breast
SON5020
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Decks in class (5)
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