BREAST ULTRASOUND

Normal Breast UTZ appearance

Breast 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 appearance

1. 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 - Coopers ligament; this are highly reflective cruvilinear structures separating the fat lobules.

Breast UTZ appearance

Skin

Breast UTZ appearance

Coopers ligamnets hyper-reflective and traverse the superficial fat layer between the fat lobules.

Breast UTZ appearance

2. 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 appearance

3. 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 appearance

Normal 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 Coopers 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 US
Proper 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 labeling
Breast side Quadrant or clock position Scan plane Number of centimeters from the nipple Image of pertinent findings, with or w/o measuring calipers.

ACR BI-RADS UTZ Lexicon Descriptors

Shape Oval Round Irregular Margin Circumscribed Angular Indistinct Microlobulated Boundary Abrupt interface Echogenic halo Echo Pattern Post Acoustic Features Anechoic Hyperechoic Complex Isoechoic Hypoechoic No PAF Enhancement Shadowing Combined

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 Disease

Cysts:
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 Disease

Criteria 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 Disease

Different 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 Disease

Fibroadenoma:
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 Disease

Galactocele:
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 fatfluid 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 Disease

Intraductal 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 Disease

Lipoma:
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 Disease

Mastitis:
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 Disease

Use 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 Disease

b) 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 Disease

Non-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 Disease

Non-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 Disease

Non-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 Disease

Invasive 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 Disease

Subtypes 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 Disease

Subtypes 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 Disease

Subtypes of IDC:
c. Pagets 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

Pagets disease

Pagets disease

Erythematous, swollen, enlarged nipple with focal ulceration

Malignant Breast Disease

Pagets disease of the nipple
Advanced stages: tingling in nipple skin itchiness that doesnt 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 Disease

Subtypes 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 illdefined 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

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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.