BREAST ULTRASOUND

Normal Breast UTZ appearanceBreast Layers:

skin – echogenic (2-3 mm)

Premamary layer – hypoechoic subcutaneous fat.

Parenchymal layer and connective tissue – echogenic

Retromamary fat – hypoechoic

Ribs and intercostal muscle.

Breast layers

Breast UTZ appearance1. Premamary layer:

skin - echogenic (2-3 mm)

nipple – hypoechoic

areolar area – on doppler may have marked vacularity due to retroaleolar duct and bld vessels.

subcutaneous fat – lies immediately deep to the skin

- fat lobules

- Cooper’s ligament; this are highly reflective cruvilinear structures separating the fat lobules.

Breast UTZ appearance

Skin

Breast UTZ appearance

Cooper’s ligamnets – hyper-reflective and traverse the superficial fat layer between the fat lobules.

Breast UTZ appearance2. Parenchymal Layer

hyper-reflective with ducts visible as linear echo free structures

contains the fibroglandular breast tissue

main ducts and terminal duct lobular units

lactiferous (milk ducts) – hyporeflective or echo free tubular structures, 2-4mm in diameter.

Breast UTZ appearance

Parenchymal layer in radial scan showing a well define echo free channels that taper peripherally

Breast UTZ appearance3. Retromammary Layer:

usually thin on UTZ images

contains variable amounts of retromammary fat and some suspsnsory ligament.

Arterial Supply

Venous Drainage

Lymphatic Drainage

Ductal Architecture

Breast UTZ appearanceNormal UTZ appearance of breast tissue:

Skin: 2 to 3 mm Echogenic superficial line

Fat: hypoechoic

Glandular tissue: echogenic

Breast ducts: hypoechoic tubular structures, oval in cross section

Nipple: hypoechoic, can shadow intensely

Cooper’s ligaments: thin echogenic lines

Ribs: hypoechoic, periodic at the chest wall

Breast UTZ

7.5 to 10 MHz or greater linear array

4-5 cm tissue penetration

Proper positioning:

Breast USProper positioning:

supine position

arm raised behind the head (further reduces breast tissue thickness)

for examination of the lateral aspect: supine with arm raised behind the head and the back supported with a foam pad/ wedge.

4 quadrants

Clock, 123 and ABC method• First a clock position is stated. • Secondly, the location of the lesion is noted. If a

lesion is near the nipple, this location is 1, mid way out in the breast is 2 and in the periphery is 3. If a lesion is under the nipple it is labeled as SA for subareolar and lesions in the axilla are labeled AX.

• For the ABC; A, is if a lesion is near the surface or close to the transducer. B is mid way down (and represents the mammary zone) in the breast and C is against the chest wall.

Clock-face segmental annotation

Clock, ABC and 123 method

Different scan planes

Longitudinal and Transverse scan planes – recommended as an initial starting point in breast UTZ as it is easy and rapid survey of the breast.

solid lesions should be scanned in the plane of the ductal system (radial and anti-radial) in order to demonstrate subtle projections that course towards the nipple or branch outward in the breast, specifically employed to assess the ductal architecture

Radial and antiradial

Radial Antiradial

Longitudinal and Transverse

Transverse Longitudinal

Ultrasound labelingBreast sideQuadrant or clock positionScan planeNumber of centimeters from the nipple

Image of pertinent findings, with or w/o measuring calipers.

ACR BI-RADS UTZ Lexicon Descriptors

Shape Margin Boundary Echo Pattern Post Acoustic Features

OvalRoundIrregular

CircumscribedAngularIndistinctMicrolobulated

Abrupt interfaceEchogenic halo

AnechoicHyperechoicComplexIsoechoicHypoechoic

No PAFEnhancementShadowingCombined

Breast Disease The most frequent clinical application of breast UTZ

is to characterized a mass initially detected by mammography as cystic or solid.

Benign Breast DiseaseCysts: not premalignant.

most common breast mass (7% - 10% of all women and 20% - 50% in women of reproductive age)

causes:

a. duct obstruction and localized fluid accumulation

b. abnormal ductal dev. or secretory activity imbalance during thelarche.

lined by either apocrine cells that actively secrete material and flat epithelial lining cells that are less inactive

Benign Breast DiseaseCriteria for simple breast cyst:

1. oval or round shape with circumscribed margin.

2. anechoic

3. imperceptible black wall

4. enhanced transmission of sound

Benign Breast Disease

Breast cyst

Benign Breast DiseaseDifferent appearance of cysts.

Multilocular or septated:

Benign Breast Disease (Cyst)

Cyst containing low-level reflective material (hem0rrhagic debris)

Benign Breast Disease (Cyst)

Cyst which exhibits a fluid level. The aqueous fluid lies below the oily component.

Benign Breast DiseaseFibroadenoma:

most common benign solid tumors

most commonly diagnosed in women younger than 30 y/o (average of 20-35 y/o)

forms due to a hyperplastic or proliferative process in a single terminal duct unit.

self limiting and only reach 20-30 mm in diameter.

Benign Breast Disease (Fibroadenoma)

may involute spontaneously

commonly regress in postmenopausal

can grow rapidly during pregnancy

may have popcorn appearance on mammography

Benign Breast Disease (Fibroadenoma)

“Popcorn” calcifications in a partially calcified fibroadenoma

Benign Breast Disease (Fibroadenoma)

Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.

Benign Breast Disease (Fibroadenoma)

Well-defined smooth marginated homogenous focal lesion that exhibits edge shadowing and slight increased through transmision.

Benign Breast Disease (Fibroadenoma)a. Juvenile (giant) Fibroadenoma

Occurs in female adolescents

Has malignant potential

Grows profusely and rapidly exceeds 10cm

Often bilateral

May be locally recurrent

Presents as an oval, ruberry and extremely mobile mass.

Benign Breast DiseaseGalactocele:

milk filled retention cyst develops in pregnancy or during lactation.

milk fluid aspirate pathognomonic

well defined but internally complex cyst

hyper-reflective and patchy or particulate echo texture fluid (high fat content)

fat/fluid levels may be seen

Benign Breast Disease (Galactocele)

Milk filled cyst – the fatty fluid content gives rise to the complex internal appearance.

Galactocele

UTZ image demonstrating a fat-fluid level (long arrows), with typical high and low echogenicity. Note that the fatty component has risen and occupies the upper (nondependent) portion of the cyst, whereas the heavier water content remains in the lower (dependent) portion. Note also the clot of fatty milk (“cream”) (short arrow) floating in the nondependent portion of the cyst owing to its intermediate density.

Benign Breast DiseaseIntraductal Papilloma:

usually occurs during climacteric.

multiple lesions usually occur in younger patients.

5-10% has nipple discharge (with episodes of bloody discharge)

duct ectasia w/ a focal intraluminal soft tissue lesion

most often appears as a mass within the duct.

can progress to a more complex lesion and may even become malignant.

UTZ guided core biopsy is diagnostic procedure of choice.

Benign Breast Disease(Intrductal Papilloma)

IDP: a soft tissue intraluminal mass outlined by a fluid in a dilated duct.

Benign Breast DiseaseLipoma:

slow growing tumors that can arise in fatty soft tissue anywhere in the body.

may be palpable if in the breast.

located in the subcutaneous fat layer and are often mobile.

well defined and are more reflective than the adjacent subcutaneous fat.

Benign Breast Disease (Lipoma)

Lipoma: a hyper-reflective mass localized to the subcutaneous fat layer.

Benign Breast DiseaseMastitis:

UTZ is the imaging investigation of choice.

affects females of any age

microbial (staphylococcal) entry via the mammary ducts – most common route.

pain, swelling and erythema.

periareolar infxn is asso. With nipple discharge and possible nipple retraction.

thickened edematous skin

enlarge “reactive” lymphnodes in the axilla

Abscess appears as well circumscribed complex mass w/ thick hyperemic walls

Mastitis

Mastitis secondary to S aureus infection. Transverse UTZ image shows a complex heterogeneous mass (arrows), a finding that represents a subareolar abscess.

Mastitis:

Benign Breast Disease (Mastitis)

Breast Abscess

Mastitis:

Malignant Breast Disease used to assist in determining the presense, size,

extent distribution and location of the breast disease, and can provide in formation which

may be inicative of tumor classification and malignant disease

Malignant Breast DiseaseUse of UTZ in malignant breast disease

Diagnosis and surgical planning

a) Determine

tumor size and extent

tumor location – with particular reference to skin, nipple, and chest wall.

lymph node appearances

- needle core biopsy

- preoperative localization of impalpable lesion

Malignant Breast Diseaseb) Follow-up

adjunct to mammogarphy for screening and surveilance in high risk.

and young women

monitoring lesion size and vascularity in response to chemotherapy

Malignant Breast DiseaseNon-invasive Malignancy

15 to 25% of breast malignancy

tumor cells have malignant phenotype but lack the ability to invade surrounding tissue.

classified as either Ductal Carcinoma in Situ (DCIS)

or Lobular Carcinoma in Situ (LCIS)

Malignant Breast DiseaseNon-invasive Malignancy:

a. Ductal carcinoma in situ: most common non invasive breast malignancy

starts inside the milk ducts

most are non-palpable and asymptomatic

most detected on routine screening programs (mamo)

UTZ is not reliable and appropriate as screening

UTZ is useful as an additional examination tool

Malignant Breast Disease (DCIS)Breast profile:

• A ducts• B lobules• C dilated section of duct to

hold milk• D nipple• E fat• F pectoralis major muscle• G chest wall/rib cage

Enlargement:• A normal duct cells• B ductal cancer cells• C basement membrane• D lumen (center of duct)

Malignant Breast Disease (DCIS)

Sonographic image of DCIS: shows solid-appearing distended duct with irregular margins

Malignant Breast Disease (DCIS)

Color power Doppler sonogram of a DCIS shows multiple intralesional vessels.

Malignant Breast DiseaseNon-invasive Malignancy:

b. Lobular carcinoma in situ (LCIS)

lobular carcinoma in situ (LCIS) is not really cancer, but rather a noninvasive condition that increases the risk of developing cancer in the future

refers to a sharp increase in the number, appearance, and abnormal behavior of cells contained in the milk-producing lobules of the breast

arises in the epithelium in the blunt ducts of mammary lobules.

commonly found in younger women of reprodcutive age

often multifocal and bilateral.

Malignant Breast Disease (LCIS)

Breast profile:• A ducts• B lobules• C dilated section of duct to hold

milk• D nipple• E fat• F pectoralis major muscle• G chest wall/rib cage•

Enlargement:• A normal lobular cells• B lobular cancer cells• C basement membran

Malignant Breast DiseaseInvasive Ductal Carcinoma:

most common round breast malignancy

starts developing in the milk ducts of the breast, but breaks out of the duct tubes, and invades, or infiltrates, surrounding tissues

may feel like a hard, bumpy, irregularly-shaped lump beneath the areola or around the central area of the breast

Malignant Breast Disease

Invasive carcinomas typically have irregular margins, are hyporeflective and heterogeneous and exhibits posterior acoustic shadowing.

Malignant Breast Disease

Invasive carcinoma with microcalcification

Malignant Breast Disease

Malignant lesion showing a surrounding hyper-reflective band or “halo”.

Malignant Breast Disease

Classic spiculated appearance indicative of intraductal extension

Malignant Breast DiseaseSubtypes of IDC:

a. Inflammatory breast cancer

an advanced, aggressive form

starts out in the milk ducts and proceeds to invade the skin and lymph system

does not signal its presence with a breast lump, but with breast pain and skin changes

Inflammatory breast cancer

Enlarged right breast with nipple retraction.

Inflammatory breast cancer

Transverse US scans of a breast show marked skin thickening (*), dilated lymphatic channels (arrowheads), and focal areas of parenchymal acoustic shadowing (arrows).

Malignant Breast DiseaseSubtypes of IDC:

b. Medullary carcinoma

takes it name from its color, which is close to the color of brain tissue

tend to form a clear boundary between the tumor and healthy tissue

Medullary carcinoma

Medullary carcinoma

• Medullary carcinoma, Gross image.This tumor has a soft consistency with a fleshy gray appearance. The tumor generally has a well defined margin.

Malignant Breast DiseaseSubtypes of IDC:

c. Paget’s disease of the nipple

shows up in and around the nipple

usually signals the presence of breast cancer beneath the skin

Most cases are found in menopausal women

early signs: redness, scaly and flaky skin and mild irritation of skin

Paget’s disease

Paget’s disease

Erythematous, swollen, enlarged nipple with focal ulceration

Malignant Breast DiseasePaget’s disease of the nippleAdvanced stages:

tingling in nipple skin

itchiness that doesn’t respond to creams

very sensitive skin on the nipple

burning or painful nipple skin

ooze or bloody discharge from the nipple (not milk)

nipple retraction (pulls into the breast)

scaly rash on areola skin

breast lump beneath the affected skin

Malignant Breast DiseaseSubtypes of IDC:

d. Tubular carcinoma

cancer cells resemble small tubes.

commonly found in 50 years of age or older

usually small (1 – 2 cm diameter) and do not spread far beyond the original tumor site

Tubular carcinoma

A. Mammogram shows no definite abnormal focal lesion and both breasts are diffusely dense.

B. Sonography shows an approximately 0.9-cm sized, spiculated, irregularly shaped hypoechoic mass (arrows) in the subareolar area of the right breast.

Malignant Breast Disease Invasive Lobular carcinoma:

second most common type of invasive breast carcinoma

also known as infiltrating lobular carcinoma

commonly the tumor does not form a mass but produces an ill—defined thickening of the skin, usually the section above the nipple and toward the

arm

Malignant Breast Disease Invasive Lobular carcinoma:

starts in a lobule and spreads to surrounding breast tissue

they grow in a diffuse manner and permeate normal tissue

Women 45 and 56 y/o are the most likely to have ILC

Malignant Breast Disease (ILC)

Malignant Breast Disease

Invasive lobular carcinoma (hyporeflective focal mass w/ irregular margin and posterior sonic shadowing

Malignant Breast Disease (ILC)

Sonogram of right breast shows irregular hypoechoic solid mass in upper outer quadrant of right breast that corresponds to palpable and mammographic mass. Sonographically guided core biopsy showed infiltrating lobular carcinoma.

Benign mass char.

wider than tall

four or fewer gentle lobulations

intense homogenous

hyperechogenecity

thin, echogenic capsule

Suspiciuos UTZ char. of solid breast masses

taller than wide

acoustic shadowing

spiculation microlobulation

microcalcifications

duct extension

branch pattern

angular margins

hypoechoic

THANK YOU

Benign Breast Disease (Cyst)

Small cyst with fine homogenous echo texture and reflectivity may represent either very thick fluid or small solid fibroadenoma

• "Rt 12 2C RAD". "Lt 1:30 3C AR".

• This term means "orange skin" in French. It's when the skin of the breast looks like the skin of a navel orange: It gets swollen and the hair follicles look like lots of little dimples. This can be a sign of inflammatory breast cancer.