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The breast consist of three types of tissue: the skin subcuteneous adepose tissue and the functional glandular tissue. Centrally, there is the nipple-areolar complex. Collecting duct open onto the tip of the nipple. There are sebaceous glands within the nipple-areolar complex called montomery¶s gland. Small raised nodular structures called montomery¶s tubercle.
Deep to nipple-areolar complex, breast is divided into15-25 lobes,each consisting of a branching duct system leading from the collecting ducts to the terminal duct lobular units (TDLU), the site of milk production in lactating breast. Each duct drains a lobe made up of 20-40 lobules. The breast lies on the chest wall on the deep pectoral fascia. The superficial pectoral fascia envelops the breast. Suspensory ligaments ± Cooper¶s ligament ± connect the two layers, providing a degree of support to the breast and giving the breast its shape. The number of lobules per lobe lactation,parity and hormonal status. varies according to age,
At the end of reproductive life there is an increase in amount of adepose tissue and the main duct system is preserved, considerable loss of lobular unit.
1. Muscle of the chest wall. 2. Pectoralis muscles, these support the breast. 3. Lobules, the mammary glands that produce the milk. 4. Nipple. 5. Areola. 6. Lactiferous duct, carry the milk from the glands to the nipple. 7. Mammary fat. 8. Chest.
BREAST ULTRASOUND TECHNIQUE
Dynamically focused phased array, linear array and annular transducers of 7-10 MHz should be used. The patient is examined in supine oblique position. The side being examined is raised and the arm placed above the head to ensure that the breast tissue is evenly distributed over the chest wall. Scanning in the radial and antiradial planes are of value in demonstrating ductal abnormality.
Symptomatic breast lumps in women aged less than 35yrs. Breast lump developing during pregnancy and lactation Assessment of mammographic abnormality Breast inflammation Breast lump in male Guidance of needle biopsy or localization Follow-up of breast cancer treated with adjuvant chemotherapy Clinical mass with negative mammogram The augmented breast
The anatomic components of the breast and sorrounding structures (skin, ducts,adepose tissue, parenchyma, nipple, blood vessels, retrommary muscles and ribs) have characteristic sonographic features.
The skin complex
Is seen as two thin, echogenic lines demarcating a narrow hypoechoic band, the dermis. The normal skin measures up to 0.2 cm in thickness , may be thicker in the lower breast near the inframammary fold.
Oval in one plane of view and elongated in the orthogonal plane. They are hypoechoic relative to the sorrounding glandular tissue and may have a central echogenic focus of connective tissue. The subcuteneous fat lobules and those within the breast are usually larger than fat lobules located in the pectoral area.
Appears homogeneously echogenic as compared with fat lobules but may have hypoechoic zones caused by fatty tissue. Fibroglandular tissue appears echogenic. Found in pt of all ages, but characteristic of the breasts of very young, excessive homogenously echogenic tissue.
Appears as thin, echogenic arcs.
Terminal duct lobular units( TDLU)
Many benign ( cysts, adenosis, fibroadenoma) and malignant process arises from it. The TDLU may enlarge or involute, reflecting age and physiologic differences and proliferate in pregnancy. Hyperplastic TDLU are seen on USG image as hyechoic areas.
The mammary ducts
Visible as tubular structures measures about 0.1cm to 0.8cm in diameter.
The mammary ducts
Medium level echogenicity and attenuates sound, resulting posterior acoustic shadows. Scanning obliquely behind the nipple or using an offset pad will allow the area posterior to the nipple to be visualized. Normal nipple sometimes appear as a well-defined hypoechoic oval area resembling a superficial adenoma if imaged from an oblique angle.
The fascial envelope
Visible as thin lines, usually not seen. The superficial layer seen below the dermis, the deeper layer lies over the retromammary fat and pectoralis muscle.
Visualization of the pectoralis muscle assures that the breast
parenchyma has been adequately penetrated at that site.
Oval, hypoechoic, periodic structures behind the pectoralis muscles. They attenuate sound, causing a posterior acoustic shadow.
An ultrasonogram of a normal breast. F, subcutaneous fat; FG, fibroglandular tissue with intervening fatty tissue; P, pectoralis muscle; S, skin. The hypoechoic region beneath the pectoralis muscle represents a rib (arrow).
Benign mass lesion
Cysts Fibroadenoma and related conditions Papilloma Lipoma Hamartoma
Acute mastitis Breast abscess Mammary duct ectasia Tramatic fat necrosis
Simple fibrocystic changes Epithelial hyperplasia
Malignant mass lesion
Carcinoma of breast
Simple Breast Cyst
Simple Cyst anechoic well-marginated round, ovoid, or lobulated solitary or multiple well-defined posterior wall acoustic enhancement
Ultrasound Demonstrates Cysts in Breast
These cysts may contain internal echoes, as a result of hemorrhage or infection, and may demonstrate wall thickness.
Ultrasound image showing adjacent breast masses:one a simple cyst, the other debris filled.
A complex cyst shows low-level internal echoes/ fluid-debris level. These internal echoes may be caused by floating cholesteral crystals, pus, blood, or milk of calcium crystals.
Figures 5 and 6 demonstrate complex cystic areas with an internal soft tissue component. Biopsy was performed on both of these lesions, confirming the diagnosis of benign intracystic papilloma. These lesions occur from a growth within a duct that eventually results in ductal obstruction and cyst formation.
Ultrasonogram demonstrates 2 ovoid, smooth, thin-walled, anechoic masses with acoustic enhancement. The larger is anechoic, compatible with a simple cyst (see arrow). The smaller contains some internal echoes, although it also was shown to represent a cyst.
A fibroadenoma is the most common benign tumor in women of childbearing age. The mass presents as a firm, smooth, oval shaped, well-marginated (sometimes lobulated), freely movable mass. It is rarely tender or painful. The size is under 5cm, the number is multiple in 10-20% and bilateral in 4%. Calcifications may occur.
The texture is usually homogenous and hypoechoic with low-level echoes. In a small number of patients, the mass may appear complex, hyperechoic, or isoechoic. The solid nature of the mass prevents acoustic transmission. There may be few well-circumscribed lobulations. Growth in the horizontal plane may be greater than that in the vertical
When viewed by ultrasound, abscesses commonly have thick walls and are oval or irregular in shape. They cystic typically and contain solid
components, resulting in a complex appearance, and demonstrate enhancement acoustic
Ultrasound images of the breast reveal a rounded, almost anechoic lesion with posterior acoustic enhancement. The lesion measures 2 cms. and has walls. No internal septae are present. Color Doppler images suggest irregular but well defined
some increase in vascularity along the rim of the lesion. These ultrasound findings suggest an abscess of the breast.
Chronic Abscess Of The Breast.
Clinical symptoms include fever, pain, tenderness to touch, increased white blood count. The most common location is in the central to subareolar area. An abscess may range
from somewhat ill-defined to well-defined, anechoic to low-level echoes, with posterior enhancement.
Sebaceous cysts are formed as a result of obstructed sebaceous glands or hair follicles. These cysts contain an oily substance, and are therefore often characterized by internal echoes that may be seen on ultrasound. They are typically located at the inferior and medial breast margins, or near the axilla.
Mastitis During Breastfeeding
Mastitis is inflammation of the breast. It can be associated with lactation (puerperal) or other conditions, such as an infected cyst (nonpuerperal)
Edema affects all layers of the breast parenchyma in mastitis. The skin and subcutaneous fat become thickened and hyperechoic. In addition, the Cooper's ligaments may become more hypoechoic. Hyperemia may also be demonstrated with color Doppler.
Ultrasound images of lactating breast:
Ultrasound image shows prominent and dilated mammary ducts in the lactating breast. The ducts are seen as tubular hypoechoic structures, which widen as they approach the nipple. Sometimes, it may be possible to see fat drops within the milk secretions in the ducts. These appear as mildly echogenic debris within the ducts.
Fat necrosis occurs in a very small percentage of breast biopsies, post-surgery, or after radiation treatments. It may be found anywhere however is more common in the areolar region or near the biopsy site. The appearance is a firm, slightly fixed mass with skin retraction in half of the cases. The mass may show calcifications. On ultrasound, it appears as hypoechoic to anechoic with illdefined margins. Acoustic shadow may or may not be present. Characteristics of fat necrosis on ultrasound may vary depending on the lesion; fat necrosis may look like a simple cyst or anechoic mass with solid components.
Several lucent nodules are present in the upper outer right breast, with surrounding density, consistent with fat necrosis.
Oil cyst of breast:
The breast in this patient showed multiple cystic lesions on sonography. Remarkably, there is acoustic shadowing posterior to the cyst. Clear fluid contents are seen within the cystic lesions. Calcific oil cysts of the breast
Oil cysts are produced due to fat necrosis with liquefaction and subsequent cyst formation, usually following trauma.
This condition includes hyperplasia and hypertrophy of the glandular elements within the breast. The lobules show an increase in size and on ultrasound appear as isoechoic to mildly isochoic as compared with fat.
This condition is found in 72% of the screening population over 55 years of age. The cause is an exaggeration of normal cyclical proliferation and involution of the breast with production and incomplete
absorption of fluid by apocrine cells. Clinical symptoms include fullness, tenderness, and pain that varies with the menstrual cycle. There may be palpable nodules and thickening within the breast.
The cystic changes include round to ovid cysts with smooth margins. They may be lobulated or multilocular. These changes are well defined on ultrasound.
Galactocele of breast:
Hypoechoic (almost cystic) lesion with through transmission. Color doppler images of the breast showed no signficant enhancement of vascularity.
Galactocele with a fat-fluid level s/o galactocele. The echogenic material is seen to move with change in posture
Carcinoma of breast:
Ultrasound Appearance Of Malignant Disease Of The Breast
Hypoechoic Irregularly marginated (especially anterior margin) Heterogeneous internal echoes Acoustic shadowing
Noninvasive Breast Cancer. This type of cancer accounts for
15% of all cancers. It occurs when there is a malignant transformation of epithelial cells lining the mammary ducts and lobules confined within the boundaries of the basement membrane.
Noninvasive Breast Cancer
ductal carcinoma in situ, lobular carcinoma in situ intracystic papillary carcinoma in situ.
Invasive Breast Carcinoma. This type of malignancy accounts for the
majority of breast cancers in 85% of the population.
Invasive Breast Cancer
Infiltrating/invasive ductal carcinoma (65%) Invasive lobular carcinoma (8-13%) Tubular carcinoma (6-8%) Medullary carcinoma (2%) Mucinous carcnimoa (2%) Papillary carcinoma (2-4%)
Invasive Ductal Carcinoma
Invasive ductal carcinoma is predominantly hypoechoic, but the mass is indistinctly separated from the echogenic halo (arrow) that surrounds it. The halo may or may not contain tumor cells, but two measurements, one of the hypoechoic area alone and a second, the diameter of the hypoechoic component plus the echogenic rim, could be reported.
Ductal carcinoma in situ
This is the most common noninvasive carcinoma. It occurs in postmenapausal women over 55 years old. The mass may persist for years without a palpable abnormality. Therefore, when the mass is noted, it is usually large enough to feel by palpation; nipple discharge may be present as well as microcalcifications.
Lobular carcinoma in situ
This disease arises in the epithelium of the blunt ducts of the mammary lobules. It comprises about one fourth of the noninvasive cancers, with an increased incidence during the reproductive years. It may present as a noncalcified mass, or with calcifications and a palpable mass. It may also occur on the contralateral breast.
Intracystic papillary carcinoma in situ.
This cancer is rare and affects middle aged females with the average age 51 years. The mass is well circumscribed and freely moveable. Bloody fluid is obtained with aspiration. Ultrasound findings show a solid well-defined mass.
Invasive lobular carcinoma
This is the second most common type of breast cancer (30-50%). At least 30-50% of patients will develop a second primary in the same or opposite breast within 20 years. It is the most frequently missed cancer as it is difficult to detect on mammography and by clinical examination. Clinical findings may show architectural distortion, thickening of fibrous septa, spiculations, poorly defined borders, microcalcifications, and skin/ nipple retraction.
This cancer is a well differentiated form of ductal carcinoma occurring in the middle aged female with a positive family history. It is associated with lobular carcinoma in situ in 40% of patients.
This is the fastest growing breast carcinoma seen in the middle aged female. The mass is well circumscribed with a nodular architecture and lobulated contour. In larger tumors, a central necrosis may be seen. On ultrasound the mass appears hypoechoic with some through transmission if there is central cystic necrosis and indeterminate borders.
Mucinous colloid carcinoma This rare tumor appears in older women and shows a slow growth pattern.
Most women present with a palpable mass with a quarter showing nipple discharge. The mass is usually solitary with well-circumscribed borders. More than half will show microcalcifications. There is a 90% five year survival rate after a mastectomy
Carcinoma of breast:
These ultrasound images reveal a hypoechoic, poorly defined, irregular mass in the breast. There is also evidence of acoustic shadowing posteriorly. These findings on sonography suggest malignant mass of the breast.
Carcinoma of breast:
Left breast ultrasound shows a rounded, hypoechoic solid lesion with the borders ill-defined in part.
Carcinoma of breast:
Gynecomastia in a Young Male
Gynecomastia is a condition that results in male breast enlargement abnormal due to an of
ductal tissue, glandular tissue, and stroma. Increased subcutaneous fat
Ultrasonogram of late gynecomastia. Development of fibrosis in late gynecomastia leads to an increase in echogenicity of the breast parenchyma
may also be noted.
Solitary fibrous tumor of the male breast
Breast ultrasound showed in the right retroareolar region, a solid mass of 3 × 1 cm with homogeneous echostructure and well-defined margins.
appearance; it may be elongated and filled with fluid. Old cellular debris may appear as hypoechoic on ultrasound, however the "tubular"appearance is more typical.
This lesion is rarely seen; the mean age is 45 years. The mass is soft and nonpalpable in 60% of patients. It appears in the retroareolar and upper outer quadrant in 65% of patients. A hamartoma is round or ovoid, well-circumscribed, and less than 3 cm in size. It may contain calcifications. Ultrasound findings have shown a harmartoma to contain fibrous elements that may be specular in their reflections with hypoechoic texture. The mass is encapsulated and distinct from surround tissue.
Hamartoma: Ultrasonogram demonstrates a 3-cm lobulated circumscribed mass that is predominantly hypoechoic (arrows). Some of the fatty tissue within the lesion is hyperechoic (arrowheads), although this is not seen in all hamartomas.
This mass is a solitary, slow growing lesion that presents in the middle aged and postmenapausal female. The patient is usually asymptotic. The ultrasound appearance would be similar to normal fatty lobules found in a normal breast. The lipoma is hypoechoic in texture. The sound is attenuated and scattered similar to normal subcutaneous and intrammary fat.
A small percentage of patients have lymphoma as a primary condition, most have metastatic disease secondary to lymphoma. It usually is found in the older patient with a right side predominance. The mass varies from well defined to infiltrative with poorly defined borders. On ultrasound the texture is hypo to isoechoic without through transmission. Axillary nodes are present in 35% of patients.
Metastases To The Breast
There is a 1% incidence of metastases to the breast from primary tumors that include malignant melanoma, ovarian carcinoma, and leukemia/lymphoma. The mean age affected is 45 years. The mass is usually solitary and well circumscribed and appears in the upper outer quadrant. One fourth of the patients have skin adherence and 40% have axillary node involvement.
ultrasound from a 35 year-old patient with bilateral palpable breast masses. The ultrasound documented a 19 × 14 mm hypoechoic mass. She was found to have metastatic disease to her breast from a lung neuroendocrine carcinoma.
Sarcoma and Angiosarcoma
A sarcoma is a rare malignant mammary lesion occuring in the middle aged female. The growth is rapid. Borders are well-defined with lobulations.
Angiosarcoma is a highly malignant vascular breast tumor that affects females in the third to fourth decade of life. The mass gradually enlarges; its borders are ill-defined and there is skin thickening with nipple retraction. On ultrasound angiosarcoma presents as a well-defined multilobulated hypoechoic mass with hyperechoic areas as a result of hemorrhage.
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