Breast

sonography

 High

frequency transducers (min 7MHz) to

minimize volume averaging
The depth of focal zone must be adjusted to
the depth of any lesion to minimize volume
averaging and mischaracterization of the
lesion.
Volume averaging can alter the chogenicity
so much that cystic lesions falsely appear
solid and hypoechoic solid lesions become
isoechoic and inconspicuous.

 in

very superficially located lesion,

standoff of gel is used to minimize
volume averaging.
Misposition focal zines can lead to
severe volume averaging and
mischaracterization of even midsized
lesions, particularly if the focal zones
are positioned much too deeply.

Breast composed of :
15-20 lobes :
Lobar duct
Smaller branch duct
Lobules
Supporting stromal tissues :

Compact interlobular stromal fibrous tissue

Loose periductal stromal fibrous tissue
Intralobular stromal fibrous tissue
Fat

 Functional

unit of the breast is Terminal

Ductolobular Unit (TDLU) consists of :
Lobule, consists of :
Intralobular

segment of the terminal duct

Intralobular segment of the ductules
Loose intralobular stromal fibrous tissue
Extralobular

terminal duct

 Breast

divided into 3 zones :

Premammary zone / subcutaneous zone : lies

between the skin and the anterior mammary fascia
Mammaryzone : lies between anterior mammary
fascia and the posterior mammary fascia, contains :
lobar ducts, their branches, most of the TDLUs and
the most of the fibrous stromal elements of breast
Retromammary zones : fat, blood vessels,
lymphatics less apparent on sonogram because
sonographic compression flattens the
retromammary zones against the chest wall

 Normal

anatomic structures of the

breast :
Hyperechoic : compact interlobular
stromal fibrous tissue, anterior and
posterior mammary fasciae, coopers
ligaments, skin, duct walls (when
visible)
Isoechoic : fat, epithelial tissue in
ducts and lobule, loose interlobular
and perductal stromal fibrous tissue

 Normal

mammary ducts that are not ectatic

can appear :
Purely isoechoic, when the centrally
located hyperechoic duct wall cannot be
visualizzed because a poor angle of
incidence or suboptimal transducer
Or as a central, bright echo surrounded by
isoechoic loose tissue when the apposed
walls of the central duct can be optimally
demonstrated.

 These

are maneuvers to visualize the

ducts within the nipple:

Peripheral compression technique

Two handed compression technique
Rolled nipple technique

Useful

for evaluating patient with nipple

discharge

 Normal

TLDUs are about 2 mm in

diameter, but may be as large as 5 mm
in patients with fibrocystic change,
adenosis.
In patients who are pregnant or
lactating and adenosis, TDLUs enlarged
and increased in number

 One

of the most valuable features of

high frequency coded harmonic imaging
is that it tends to make pathologic solid
nodules appear relatively more
hypoechoic and conspicuous in a
background of isoechoic tissues.

drainage : deep superficial

subdermal lymphatic network
periareolar plexus (Sappeys plexus)
axilla
Most metastases form the breast to the
axilla, with minority occuring in the
internal mammary lymph node.
Lymphatic

3 level of axillary lymph node :

Level 1: lie peripheral to the inferolateral edge of the

pectoralis minor
Level 2 : lie posterior to the pectoralis minor
Level 3 : lie proximal to the superomedial border of
the pectoralis minor (infraclavicular nodes)

From level 3 nodes metastases may progress to

internal jugular or supraclavicular lymph nodes
Rotter nodes : lie between the pectoralis major
and minor a frequent source of chest wall
recurrences

 Metastase

can involve the

supraclavicular lymph node, but
metastases must involve levels 1,2 and
3 axillary lymph nodes or internal
mammary and internal jugular lymph
nodes first.

BIRADS
Birads

1 : sonographically normal
tissues that cause mammographic or
clinical abnormalities
Birads 2 : benign entities and include
intramammary lymph nodes, ectatic
ducts, all simple and many complicated
cysts, and definitively benign solid
nodules, such as lipoma and hamartoma

Birads 3 : probably benign lesions, and

includes some complicated and complex
cysts, small intraductal papillomas and a
subset of fibroadenomas
Birads 4 : suspicious:

4a : mildly suspicious
4b : moderately suspicious
4c : risk of malignancy is greater than 50% to
less than 95%

Birads 5 : malignant

1 and 2 routine screening

follow up
Birads 3 surgical biopsy, imageguided needle biopsy, or short interval
sonographic follow up.
Birads 4 biopsy
Birads

Special Breast Technique

Lesion

that are more than 30% compressible

are fatty with a high degree of certainty
either a normal fat lobule or a benign lipoma
Heeling and toeing of the transducer
minimizing critical angle shadowing arising
from Coopers ligaments and better
demonstrate the thin, echogenic capsule on
the ends of the solid nodules, an important
sign of a noninvasive lesion margin.

 Doppler

ultrasound assessment depends

in compression pressure blood flow
can easily be decreased if compression
is too vigorous.
Positional changes are important in
assessment of complex cyst, fluid-debris
levels, milk of calcium, fat-fluid levels

Main indication
Palpable

lump

For tiny and superficial lesion just under

the skin
Dense tissue in the area of the palpable
lump

Criteria to evaluate
Size

correlation

Measurement a lesion (which has a water

density in mammography) should be
made outside to outside to include the
capsule that surrounds the cyst and solid
nodule, because the capsule is water
density and will be included in the
measurement of the lesion on
mammogram

 Shape

Correlation

Must consider 2 phenomena :

Partial

compressibility
Rotary forces
Partially compressible lesions that appear
spherical on mammography are oval shaped
on sonography.
When the lesion is spherical in mammography
and incompressible, the shape will be
spherical in sonography

Mammographic and sonographic

compression apply different rotatory
forces on lesions that are not spherical.
compression pulls lesions
away from the chest wall, and tends to
rotate the lesion so that its long axis lies
perpendicular to the chest wall
Sonographic compression push lesion
closer to the chest wall and tends to rotate
the lesions long axis parallel to the chest
wall
Mammographic

 Location

or Position Correlation

Mammographic compression pulls a lesion

away from the chest wall
Sonographic compression pushes the
lesion closer to the chest wall
The lesion will look deeper in sonography
than in mamography

 Surrounding

tissue density correlation

Ex: a lesion that protrudes into the

subcutaneous fatfrom the mammary
zone, should lie at the junction of the
subcutaneous fat and mammary zone
also on the sonogram

Sonographic Finding

Normal tissue and variations

Including : duct ectasia, fibrocystic change,

benign proliferative disorders can cause
mammographic and sonographic abnormalities
ANDIs (Aberrations of normal
developmentand involution).
ANDIs can also presents as cysts and solid
nodule in sonography false positive result at
biopsy
ANDIs can be characterized as BIRADS 2,3, or 4.

 Simple

cyst

Definitively benign
If strict criteria for a simple cyst are met,
the lesion is BIRADS 2
Complicated and complex cyst can be
characterized as BIRADS 2,3, and 4

 Solid

Nodules

Automatically indication for biopsy

If it BIRADS 3 must have a 2% or lower
risk of being malignant.
Spiculated and circumscribed cancers
differ greatly