ultrasound

1. ULTRASOUND OFULTRASOUND OF
BREASTBREAST
By Dr AttiyaBy Dr Attiya

2.  Breast ultrasound uses high-frequencyBreast ultrasound uses high-frequency
sound waves to map the internalsound waves to map the internal
structures of the breast.structures of the breast.

3. ApplicationsApplications
 Though ultrasound is successfully used to aid assessment ofThough ultrasound is successfully used to aid assessment of
abnormalities detected by mammography, it should not be usedabnormalities detected by mammography, it should not be used
as a sole modality for screening as ultrasound does not alwaysas a sole modality for screening as ultrasound does not always
detect cancers that are visualised mammographically.detect cancers that are visualised mammographically.
 Conversely, used in conjunction with mammography, ultrasoundConversely, used in conjunction with mammography, ultrasound
can detect clinically and mammographically occult cancerscan detect clinically and mammographically occult cancers
particularly when there is a higher possibility of cancer.particularly when there is a higher possibility of cancer.
 With new high-frequency transducers, it is also possible to detectWith new high-frequency transducers, it is also possible to detect
malignancy associated with mammographically detectedmalignancy associated with mammographically detected
clustered microcalcifications.clustered microcalcifications.
 These lesions may be evident as irregular masses, abnormalThese lesions may be evident as irregular masses, abnormal
dilated ducts or clustered foci of increased echogenicity withdilated ducts or clustered foci of increased echogenicity with
increased Doppler vascularity.increased Doppler vascularity.

4. ULTRASOUND OF BREASTULTRASOUND OF BREAST
 TechniqueTechnique
 High-quality images of the normal andHigh-quality images of the normal and
abnormal breast can be obtained with modernabnormal breast can be obtained with modern
ultrasound equipmentultrasound equipment..
Initial examinationInitial examination
–– Machine to patient’s rightMachine to patient’s right
–– Image with right handImage with right hand
–– Operate machine with left hand.Operate machine with left hand.

5. Patient PositionPatient Position
MEDIAL LESIONSMEDIAL LESIONS
 patient is supinepatient is supine
 ipsilateral arm is placed over the patient’sipsilateral arm is placed over the patient’s
head.head.
LATERAL LESIONSLATERAL LESIONS
 patient is opposite.patient is opposite.
SUPERIOR LESIONSSUPERIOR LESIONS
 patient is SITTINGpatient is SITTING

6. Equipment selection:Equipment selection:
 TransducerTransducer
 At the minimum, a 7.5At the minimum, a 7.5
MHz linear array probeMHz linear array probe
should be used.should be used.

7. Apply gentle uniform pressureApply gentle uniform pressure
with the ultrasoundwith the ultrasound
transducertransducer
Increase transducer pressure for:Increase transducer pressure for:
–– greater penetrationgreater penetration
–– scanning the subareolar region.scanning the subareolar region.
Scanning is done inScanning is done in three directions.three directions.
1.1. RadialRadial
2.2. TransverseTransverse
3.3. LongitudinalLongitudinal

8.  Localization is by theLocalization is by the
clock face.clock face.
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9. Ultrasound of the BreastUltrasound of the Breast
 Recent studies show if strict criteria forRecent studies show if strict criteria for
lesion analysis are followed, specificity oflesion analysis are followed, specificity of
ultrasound in determining benign orultrasound in determining benign or
malignant reaches 70%.malignant reaches 70%.

10.  All macroscopic breast structures can be easilyAll macroscopic breast structures can be easily
imaged with adequate sonographic equipment.imaged with adequate sonographic equipment.
The breast can be divided into four regionsThe breast can be divided into four regions
 skin, nipple, subareolar tissuesskin, nipple, subareolar tissues
 subcutaneous regionsubcutaneous region
 parenchymaparenchyma (between the subcutaneous(between the subcutaneous
and retromammary regions)and retromammary regions)
 retromammary region.retromammary region.
Sonographic BreastSonographic Breast
AnatomyAnatomy

11. Ultrasound interpretationUltrasound interpretation
 TheThe subcutaneous fat layersubcutaneous fat layer is demonstratedis demonstrated
superficially as hypoechoic tissue compared to thesuperficially as hypoechoic tissue compared to the
glandular tissue from which it is separated by a well-glandular tissue from which it is separated by a well-
defined scalloped margin.defined scalloped margin.
 NormalNormal ductsducts are often visible, particularly in theare often visible, particularly in the
subareolar region, as anechoic tubular structures.subareolar region, as anechoic tubular structures.
 Deep to the glandular tissue,Deep to the glandular tissue, a retromammary fata retromammary fat
layerlayer is usually visible and, behind this, the structuresis usually visible and, behind this, the structures
of theof the chest wallchest wall..

13. Sonographic BreastSonographic Breast
AnatomyAnatomy
 SkinSkin
 Subcutaneous fatSubcutaneous fat
 Cooper’s LigamentsCooper’s Ligaments
 Breast parenchymaBreast parenchyma
 Retromammary fatRetromammary fat
 Pectoralis musclePectoralis muscle
 RibsRibs
 PleuraPleura
 NippleNipple

15. Cooper's ligamentskin
fibroglandular tissue

16. Nipple
• Consists of both dense
connective tissue and
connective tissue of
the duct which can
cause posterior
acoustic shadowing

17. Ribs
• Easily identified bone
attenuates causing an
acoustic shadow

18. Duct
• Tubular branching
structures

19. Ultrasound showing dilated ducts (lactating)
The duct appears as branching hypoechoic structure within
echogenic glandular tissue.

20. Intramammary vessel running branching under
the skin.

21. Lymph Node
• Solid nodule
• Ovoid
• Echogenic fatty hilum

22. INDICATIONSINDICATIONS
 Symptomatic breast lumps in women aged less than 35Symptomatic breast lumps in women aged less than 35
years.years.
 Breast lump developing during pregnancy or lactation.Breast lump developing during pregnancy or lactation.
 Assessment of mammographic abnormality (± furtherAssessment of mammographic abnormality (± further
mammographic views)mammographic views)
 Assessment of MRI or scintimammography detectedAssessment of MRI or scintimammography detected
lesions.lesions.
 Clinical breast mass with negative mammograms.Clinical breast mass with negative mammograms.
 Breast inflammation.Breast inflammation.
 The augmented breast (together with MRI).The augmented breast (together with MRI).
 Breast lump in a male (together with mammography).Breast lump in a male (together with mammography).
 Guidance of needle biopsy or localisation.Guidance of needle biopsy or localisation.
 Follow-up of breast cancer treated with adjuvantFollow-up of breast cancer treated with adjuvant
chemotherapy.chemotherapy.

23. INDICATIONSINDICATIONS
 The original role of breast sonography is inThe original role of breast sonography is in
the differentiation ofthe differentiation of cysticcystic andand solidsolid lesions.lesions.
 Ultrasound complements both clinicalUltrasound complements both clinical
examination and mammography.examination and mammography.
 It is also successfully used as a 'second-look'It is also successfully used as a 'second-look'
procedure where an abnormality has beenprocedure where an abnormality has been
identified using MRI or scintimammography.identified using MRI or scintimammography.

24. INDICATIONSINDICATIONS
 Because it does not use ionising radiation, it isBecause it does not use ionising radiation, it is
the examination of choice in young women andthe examination of choice in young women and
is valuable in the assessment of theis valuable in the assessment of the
mammographicallymammographically ``dense'dense' breast.breast.
 Ultrasound plays an important role in the tripleUltrasound plays an important role in the triple
assessment of symptomatic lesions.assessment of symptomatic lesions.
 Being the only `real-time' imaging modality alsoBeing the only `real-time' imaging modality also
means it can be used to accurately localise ormeans it can be used to accurately localise or
biopsy breast lesions.biopsy breast lesions.

25. Breast Ultrasound andBreast Ultrasound and
Mammographic CorrelationMammographic Correlation
Dense breast

26. Fatty breast

27.  The echotexture of any lesion is comparedThe echotexture of any lesion is compared
relative to the echotexture of therelative to the echotexture of the
intramammary fat.intramammary fat.
 CystsCysts are typically well-defined roundedare typically well-defined rounded
anechoic lesions with posterior acousticanechoic lesions with posterior acoustic
enhancement, though the presence of debrisenhancement, though the presence of debris
can increase the overall internal echogenicity.can increase the overall internal echogenicity.
 Wall thickening, irregularity or mural nodulesWall thickening, irregularity or mural nodules
should be treated with suspicion andshould be treated with suspicion and
aspiration should be performed.aspiration should be performed.

28. Simple Cysts
– anechoic
– smooth, thin
margins
– posterior acoustic
enhancement

29.  In practice,In practice, needle biopsyneedle biopsy should be performed asshould be performed as
part of triple assessment in the presence of a discretepart of triple assessment in the presence of a discrete
solid mass.solid mass.
 Not all breast pathology presents as a discrete lesion.Not all breast pathology presents as a discrete lesion.
Inflammatory or lobular cancers may present as areasInflammatory or lobular cancers may present as areas
of scattered indeterminate attenuation.of scattered indeterminate attenuation.
 The use of colour and power Doppler can also aid inThe use of colour and power Doppler can also aid in
benign-malignant differentiation of solid masses.benign-malignant differentiation of solid masses.
 In general, malignant masses tend to show anIn general, malignant masses tend to show an
increased number of vessels that penetrate deep intoincreased number of vessels that penetrate deep into
the tumour with a branching morphology.the tumour with a branching morphology.

30. Breast UltrasoundBreast Ultrasound
Imaging CharacteristicsImaging Characteristics
 sizesize
 shapeshape
 border definitionborder definition
 internal echogenicityinternal echogenicity
 posterior enhancementposterior enhancement
 architectural changesarchitectural changes

31. Analytic CriteriaAnalytic Criteria
•• MarginsMargins
•• Retrotumoral acoustic phenomenaRetrotumoral acoustic phenomena
•• Internal echo patternInternal echo pattern
•• EchogenicityEchogenicity
•• Compression effect onCompression effect on SHAPESHAPE
•• Compression effect onCompression effect on INTERNALINTERNAL
ECHOESECHOES

32. Benign CharacteristicsBenign Characteristics
 Ellipsoid shapeEllipsoid shape
 Thin definableThin definable
capsulecapsule
 Two or threeTwo or three
lobulationslobulations
 Hyperechogenicity.Hyperechogenicity.

33. Solid Mass -Solid Mass -
MalignantMalignant
• Irregular shape
• Irregular/ill-defined
borders
• Almost anechoic
• Angular margin
• Taller than wide

34. Irregular shape
• Irregular/ill-defined borders
• Almost anechoic
• Thick echogenic rim
• Posterior shadowing

35. BenignBenign MalignantMalignant
ShapeShape Oval/ellipsoidOval/ellipsoid VariableVariable
AlignmentAlignment Wider than deep; aligned parallel toWider than deep; aligned parallel to
tissue planestissue planes
Deeper than wideDeeper than wide
MarginsMargins Smooth/thinSmooth/thin
echogenic pseudocapsule withechogenic pseudocapsule with
2-3 gentle lobulations2-3 gentle lobulations
Irregular or spiculated; echogenic 'halo'Irregular or spiculated; echogenic 'halo'
EchotextureEchotexture Variable to intenseVariable to intense
hyperechogenicityhyperechogenicity
Low-levelLow-level
Marked hypoechogenicityMarked hypoechogenicity
Homogeneity ofHomogeneity of
internal echoesinternal echoes
UniformUniform Non-uniformNon-uniform
LateralLateral
shadowingshadowing
PresentPresent AbsentAbsent
Posterior effectPosterior effect Minimum attenuation/posteriorMinimum attenuation/posterior
enhancementenhancement
Attenuation with obscured posteriorAttenuation with obscured posterior
marginmargin
Other signsOther signs ---------------------------- CalcificationCalcification
MicrolobulationMicrolobulation
Intraductal extensionIntraductal extension
Infiltration across tissue planes and increasedInfiltration across tissue planes and increased
echogenicity of surrounding fatechogenicity of surrounding fat

36. A typical fibroadenoma with homogeneous
internal echoes with an ovoid shape and
circumscribed margins -- benign.
There is posterior acoustic enhancement..

37. A typical 'tall' irregular spiculated hypoechoic
attenuating mass in keeping with a malignant
breast tumour.

38. An invasive lobular carcinoma presenting as areas of
scattered indeterminate attenuation.

39. Inflammatory breast cancer with secondary signs.
increased hyperechogenicity of the intramammary fat resulting in
loss of the normal glandular adipose differentiation Lymphatic
dilation is also apparent under the thickened subcutaneous layer.

40. A power Doppler image of an invasive grade 3 breast
cancer.
irregular tortuous and branching vessels penetrating into the
centre of the lesion.

41.  The sonographic pattern varies with ageThe sonographic pattern varies with age
and individually, and depends on theand individually, and depends on the
amount and type of contents, i.e. fat,amount and type of contents, i.e. fat,
fibrous and glandular tissues.fibrous and glandular tissues.
 The fibrous and glandular componentsThe fibrous and glandular components
are variably echogenic, while fat isare variably echogenic, while fat is
hypoechoic.hypoechoic.

42. Benign ??Benign ??
Malignant ??Malignant ??

43. Benign vs. MalignantBenign vs. Malignant

44. Benign ??Benign ??
Malignant??Malignant??

46. THANKYOUTHANKYOU