Breast

Question 1

What are the vessel responsible for arterial supply of the breast?

Answer 1

nternal thoracic artery, via the medial mammary and anterior intercostal branches;
lateral thoracic and thoracoacromial arteries; and
posterior intercostal arteries.

Question 2

What are the vessels responsible for venous drainage of the breast?

Answer 2

mainly to the axillary vein via the lateral thoracic and lateral mammary veins; and
also the internal thoracic and medial mammary veins.

Question 3

Describe the lymphatic drainage of the breast

Answer 3

from the nipple, areola and lobules of the gland through intramammary nodes and channels to the subareolar lymphatic plexus (Sappey’s Plexus).
then, most to the axillary lymph nodes (75%) especially from the lateral breast;
Most remaining, particularly from the medial breast, medially to the parasternal nodes or to the opposite breast; and
retromammary pathway, Lymph from the deeper portion of the breast, drains to the subclavicular plexus
inferior quadrants may pass deeply to the abdominal lymphnodes.

Question 4

What does the pre-menopausal breast look like

Answer 4

Largely consists of fat and glandular tissue.

Question 5

What does the post-menopausal breast look like

Answer 5

Decreased fat and glandular tissue. Proportionally the breast is mainly fibrous tissue.

Question 6

Describe the young, non-lactating patient breast

Answer 6

Breast is mainly composed of hyperechoic glandular tissue with little to no subcut fat

Question 7

Describe the breast as patient ages and has children

Answer 7

Fat is deposited in subcut and retromammary layers

Question 8

Describe the pregnant breast

Answer 8

Glandular tissue increases in size
Gives a granular, hyperchoic pattern
Little fat visible due to the compression of the glandular tissue
During lactation and towards the end of the pregnancy, lactiferous ducts increase in number and size
Dilation is visible as hypoechoic linear structures running towards the nipple

Question 9

Describe the breast of a non pregnant patient

Answer 9

can have cyclic changes
Mild duct dilation in the last half of cycle
Glandular prominence with or without associated tenderness

Question 10

What happens to the breast as it ages?

Answer 10

Glandular tissue slowly regresses with age and there is increased fatty replacement

Question 11

Describe Glandular tissue/parenchyma of the breast

Answer 11

usually homogeneously echogenic; some hypoechoic areas within may represent ducts or fat lobules.

Question 12

Describe Subcutaneous fat/fat lobules of the breast

Answer 12

hypoechoic compared to the glandular tissue. Some striations may be seen within. Fat lobules are usually round but may have a variable shape. Subcutaneous fat lobules are usually larger than those in the retromammary layer.

Question 13

Describe the appearance of the pectoral muscle

Answer 13

hypoechoic with striations.

Question 14

Describe the ultrasound appearance of coopers ligaments

Answer 14

thin, echogenic lines, may not always be seen as this depends on their angle relative to the probe. They may be seen extending from the glandular tissue to the superficial layer of the superficial fascia.

Question 15

Describe the ultrasound appearance of breast skin

Answer 15

two thin echogenic lines either side of a hypoechoic band; may be thicker inferiorly in the breast at the inframammary fold, but is usually approximately 2mm in thickness.

Question 16

Describe the TDLU

Answer 16

Terminal duct lobular unit (TDLU)
secreting unit of the breast
containing the terminal duct and mammary lobule (oval structures composed of acini or small ductules).
During pregnancy they expand and secrete milk
TDLU -> interlobular or segmental duct -> lactiferous sinus ->collecting duct at the nipple
important because many benign and malignant lesions can arise within it.
These include cysts, adenosis, hyperplasia, fibroadenoma and most carcinomas.

Question 17

How does compound imaging assist breast scanning

Answer 17

Compound imaging has transmit and receive echo beam forming to gather echoes of anatomy at several angles in real time
Identifies echo artefacts more easily
Discards during signal processing

Question 18

How does harmonic imaging assist breast scanning?

Answer 18

Fewer artefacts
More contrast
However some spatial resolution is lost and detail in superficial areas is reduced
Good for assessing generally dense breasts or masses
Contour and solidity

Question 19

What are the four main roles for sonography in breast imaging?

Answer 19

primary screening;
supplemental screening (after mammography)
diagnosis—for example, evaluation of palpable mass or other breast-related symptoms
interventional breast procedures.

Other uses include evaluation of problems associated with breast implants and treatment planning for radiation therapy.

Question 20

In what areas is breast ultrasound becoming an increasingly used tool?

Answer 20

becoming an increasingly used tool in the younger patient, where palpable masses are present, in post-treatment cases, and with implants – all areas that often prove difficult to examine using conventional mammography

Question 21

What are the benefits of breast ultrasound over mammo?

Answer 21

Non-ionising radiation
Good for dense breasts
Younger, denser breasts are more suited to U/S
Used to aid FNA and core biopsies

Question 22

What are some indications for breast ultrasound?

Answer 22

to evaluate a mass demonstrated on mammography (palpable or impalpable, that is, cystic orsolid)
to evaluate a mass not fully or poorly demonstrated on mammography (palpable or impalpable);
in the evaluation of dense breast tissue (palpable)
to evaluate an abscess in a patient with mastitis
to evaluate an asymmetrical density noted on a mammogram (? mass, ? glandular asymmetry)
for the assessment of a painful or lumpy breast in a young, pregnant or lactating patient
to evaluate the breast in a high risk patient
for the review of patients with fibrocystic disease
to evaluate masses or pain due to trauma
in the evaluation of masses/pain/recurrence post breast surgery and/or radiation therapy
for the evaluation of implants for silicone leakage, rupture, or other mass
in the evaluation of the male breast for enlargement, mass or pain
to guide interventional procedures such as FNA or core biopsy

Question 23

What are some aspects of patient hx you should find out

Answer 23

patient age (the older the patient, the greater the risk)
any family history of breast or ovarian cancer (increased risk with family history)
stage at present in menstrual cycle (increased tenderness and density premenstrually)
? pregnant/lactating at present (increases breast density)
number of pregnancies and children, age of first pregnancy (reduced risk if more children at an earlier age)
hormone therapy, for example, HRT, thyroid hormones
implants in situ – if so, silicone or saline filled
any previous breast or other cancer
any previous surgery or biopsy to the breast (for example, FNA, breast reduction)
any palpable lumps, ridges (some may feel like grains of rice or small peas – note their positionon a diagram)
length of time the palpable region has been present
any discharge from the nipples, seepage, itchiness (bloody discharge is a concern for intraductal papilloma, a pasty-yellow discharge may be present with intraductal carcinoma)
any recent nipple retraction (may indicate breast inflammation of malignancy – if longstanding may be congenital or acquired post-surgery)
any previous/recent mammogram and/or ultrasound (these must be viewed to correlate with the area of interest today).
Should also note any personal observations on nipple retraction, asymmetry, skin deformities, thickening, irregularity, prominent veins, bruiseing, accessory nipples

Question 24

Why is examination/palpation important

Answer 24

Important to feel the region of interest
Gain more info about the region of interest
Mobile, fixed, smooth, irregular, size, superficial
Need to explain procedure and gain consent
Sometimes lumps can only be felt in certain positions so important to feel when the patient can feel

Question 25

Briefly go through scanning technique

Answer 25

``` Suggested scanning technique Divide the breast in quadrants Scan each quadrant ensuring appropriate overlap for complete investigation of the breast. When pathology is noted, additional radial and anti-radial images are taken Long and trans Measurements Vascularity Any duct extension Each lesion should have the following labels: Clock face Distance from nipple Plane Dimensions Any detected lymph nodes ```

Question 26

Primary characteristics to assess in a breast lesion are:

Answer 26

presence of a mass – number, location, size. shape – round, oval, eliptoid, irregular. texture – homogeneous, heterogeneous. echogenicity – anechoic, isoechoic, hypoechoic, hyperechoic. internal contents – solid, cystic, mixed. presence of calcifications. margin definition – smooth, lobulated (micro/macro), irregular, spiculated, ill-defined. posterior sound transmission – enhancement, shadow, no change. orientation to skin. width X depth ratio.

Question 27

What is the significance of the width to depth ratio?

Answer 27

Aids in determining the potential malignancy of the lesion wider than high are more likely to be benign a high ratio suggests a likely benign lesion, whilst a low ratio suggests malignant potential. growth that is across normal tissue planes indicates malignant potential (higher than wide). Fibroadenomas usually grow within the tissue planes, flattening with the pressure of the fascial planes (wider than high). Some cysts may be very round. Therefore, the ratio should be used in combination with the other ultrasound characteristics when assessing a breast lesion.

Question 28

What are some likely benign characteristics of breast lesions?

Answer 28

shape – round, oval , eliptoid texture - homogeneous echogenicity - anechoic, hyperechoic internal contents – solid, cystic presence of calcifications - only if large and smooth margin definition - smooth, macro-lobulations, sharp, thin halo or capsule posterior sound transmission - enhancement, shadow, no change orientation to skin – parallel to skin, along skin planes width X depth ratio - wider than tall mobile, compressible no architectural distortion /Cooper's ligament distortion no disruption to superficial or deep fatty and fascial layers no nipple inversion/retraction no abnormal axillary lymphadenopathy

Question 29

What are some likely malignant attributes of breast lesions

Answer 29

shape – round, irregular textures – heterogeneous echogenicity - hypoechoic internal contents – solid, mixed presence of calcifications – fine margin definition- irregular, spiculated, ill-defined, micro-lobulations, thick, irregular capsule posterior sound transmission - shadowing , no change orientation to skin, more upright width X depth ratio – low, more round or upright shape immobile, non-compressible, hard, irregular architectural distortion /Cooper's ligament distortion disruption to superficial or deep fatty and fascial layers recent nipple inversion/retraction abnormal axillary lymphadenopathy

Question 30

What are some developmental abnormalities of the breast?

Answer 30

``` Hypoplasia- idiopathic or due to ovarian dysfunction (eg. Turner's syndrome) Hyperplasia Precocious puberty Gynaecomastia Early development Hypertrophy ```

Question 31

What are some formative abnormalities of the breast?

Answer 31

``` Rudimentry breast Amastia Absence of nipple Absent or rudimentary mammary glands Supernumerary breast Affects gland, areola or nipple Develop along milk lines from groin to axilla Most common is an accessory nipple Accesory glands most common in the axilla ```

Question 32

What are some causes of infectious mastitis?

Answer 32

Lactation Inverted nipples Sebaceous cysts Infected montgomery's glands of areola

Question 33

What is the patient presentation for infectious mastitis?

Answer 33

Diffuse swelling/cellulitis Multiple abscess nodules Large abscess

Question 34

What is the ultrasound appearance for infectious mastitis?

Answer 34

Diffuse swelling Skin thickening Increased echogenicity of subcut fat Loss of demarcation between subcut fat and glandular tissue Abscess Irregular walled mass with heterogeneous internal appearance of mixed cystic/solid ares Posterior enhacement Increased blood flow in wall with none in the centre

Question 35

What are some causes of non infectious mastitis?

Answer 35

``` Duct dilation- leads to duct ectasia/comedo mastitis Trauma- leading to fat necrosis Malignancy- inflammatory carcinoma Radiation therapy CCF ```

Question 36

What is the ultrasound appearance of non infectious mastitis?

Answer 36

Duct ectasia- dilated ducts with low level echogenic debris and or thickened walls Fat necrosis- firm mass with fibrous margins, shadowing similar to carcinoma OR may appear as an oil cyst which is rounded, well-defined with thin echogenic borders and anechoic cerntre and posterior enhancement oR hyperechoic rounded mass with posterior shadowing OR calcified Malignancy- diffuse change, hyperechoic compared to non-affected breast Breast may appear red/orange and firm

Question 37

What is the cause of a traumatic breast injury

Answer 37

Biopsy Surgery accident. A patient history is therefore necessary.

Question 38

What are some ultrasound appearances of breast trauma

Answer 38

fat necrosis – firm mass with fibrous margins, shadowing similar to carcinoma OR may appear as an oil cyst which is rounded, well-defined with thin echogenic borders and anechoic cerntre and posterior enhancement oR hyperechoic rounded mass with posterior shadowing OR calcified seroma, lymphocoele (usually post-operative mainly cystic collections). haematoma (spontaneous bleeding is usually associated with an occult carcinoma).

Question 39

What re the ultrasound appearances of a breast haematoma

Answer 39

depends on the time frame and on the degree of organisation of the blood very early stages hyperechoic, often ill-defined area of fresh blood within the soft tissues. The overlying skin may be thickened due to oedema. After a few days, a mass may appear that is predominantly anechoic. As the blood organises, the mass will show a more echogenic component, often with septations. Much later, if the haematoma has not resolved or been drained, it will take on a more organised and almost solid appearance.

Question 40

What are some focal benign breast diseases?

Answer 40

``` Cyst Sebaceous cyst Fibroadenoma Lipoma Hamartoma/fibroadenolipoma Intraductal papilloma Galactocele Cystosarcoma phyllodes Focal fibrosis/radial scar ```

Question 41

Discuss fibrocystic breast change

Answer 41

reactive and degenerative change due hormonal stimulation and aging does not usually occur prior to puberty symptoms gradually improve post-menopause. Usually both breasts are affected, but there is often asymmetry Lumps are often easily palpable and often fluctuate in size. The breasts may have a nodular feel usually very tender, especially premenstrually.

Question 42

What are the typical features of fibrocystic change?

Answer 42

The breast undergoing fibrocystic change does so in a hyperplastic reactive and degenerative way typical features epithelial proliferation Fibrosis Cysts. A less common feature is intraductal papillomatosis.

Question 43

Discuss the pathophysiology of typical fibrocystic change features

Answer 43

Fibrosis - loose intralobular connective tissue is replaced with dense connective tissue ductal epithelium proliferates, ducts dilate and become trapped dense connective tissue strands, forming cysts. Fibrous strands undergo degenerative presenting eventually as stromal calcification. Epithelial proliferation results in ductal budding and crowding – sclerosing adenosis. Some breasts develop intraductal cell proliferation and may grow small intraductal papillomas (these have some malignant potential).

Question 44

What are the common ultrasound appearances of fibrocystic change?

Answer 44

Simple cysts Complex cysts Intraductal papillomas Fibrosis and epithelial proliferation

Question 45

Common ultrasound appearance of a simple breast cyst

Answer 45

round/oval (round cysts may be under tension more than flaccid/flattened cysts) posterior enhancement smooth/thin walls edge refraction; reverberation artefacts within are common usually compressible and may feel mobile

Question 46

Common ultrasound appearance of complex breast cysts

Answer 46

septations/lobulations debris (low level echoes maybe due to internal haemorrhage, milk, cellular material, inspissated/concentrated secretions) wall thickening, especially if infection present or recent biopsy attempt intracystic mass – for example, papilloma reduced posterior enhancement, common if small or containing low level echogenic material

Question 47

Common ultrasound appearance of intraductal papillomas

Answer 47

medium-level soft tissue mass attached to one wall of the duct; may see blood flow to it, may also cause the duct to be dilated, may obstruct and cause distal dilatation.

Question 48

Common ultrasound appearance of fibrosis and epithelial proliferation

Answer 48

increased echogenicity and often coarseness to the glandular and stromal tissue smooth calcifications may be present

Question 49

Describe common anatomical breast artefacts

Answer 49

Novice breast imagers may mistake a rib for a solid breast mass. Although the normal nipple is easily recognized at real-time sonography, on static images an inverted nipple may project beneath the skin of the areola giving the false appearance of a markedly hypoechoic, solid parenchymal breast mass with extensive acoustic attenuation cross section of a fat lobule can be mistaken for a solid mass that is isoechoic to surrounding adipose tissue normal-caliber ducts imaged in cross section may mimic a small cyst.

Question 50

Describe common acoustic shadowing artefacts

Answer 50

Shadowing due to Cooper’s suspensory ligament is often faint and narrow but can be markedly hypoechoic and wide enough to simulate a malignant tumor Short echogenic parallel lines at fixed intervals starting at the skin and leading to the acoustic shadowing are pathognomonic for poor skin contact. Postsurgical scar may also cause substantial acoustic shadowing without an underlying mass Significant shadowing at the site of prior lumpectomy may be impossible to differentiate from residual or recurrent tumor, limiting the usefulness of sonography in this setting.

Question 51

Describe breast edge shadowing artefacts

Answer 51

a thin line of shadowing seen only behind the peripheral edge of a mass should not be mistaken for a suspicious feature can be seen with cysts and benign or malignant solid masses and has no diagnostic significance.

Question 52

Describe grey scale gain artefact

Answer 52

The gray-scale gain setting determines the amplitude of the returning sonographic signal. If the gain is set inappropriately high, spurious echoes may be displayed in a simple cyst resulting in the appearance of a complex cyst or solid mass.

Question 53

Describe dynamic range artefact

Answer 53

Setting the dynamic range too low increases image contrast but may cause the low-level echoes in a solid mass to be displayed as black pixels so that the appearance of the mass mimics that of a simple cyst. Setting the dynamic range too high results in an image with little contrast, which hinders differentiation of fat lobules from subtle masses.

Question 54

Describe reverberation artefact

Answer 54

Parallel echogenic lines caused by reflection of the ultrasound beam back and forth between the transducer and tissue interface artifactual appearance of solid or complex material along the nondependent wall of a cyst can be confirmed by changing the angle of insonation. Reverberation is always perpendicular to the transducer so will change

Question 55

Describe focal zone artefact

Answer 55

Inappropriate focal zone may cause a subtle mass to be less visible, sharp edges to appear ill-defined, and an anechoic simple cyst to appear to have internal echoes due to increased partial volume effects.

Question 56

Describe some foreign body artefacts in the breast

Answer 56

retained cuff from a central venous catheter may look like a solid mass with remarkably intense and sharp posterior acoustic shadowing easily confirmed by correlation with mammograms. extracapsular silicone due to implant rupture may initially be mistaken for a cyst or hypoechoic solid mass with posterior acoustic enhancement recognition of short echogenic lines paralleling the back wall of the structure allow a confident diagnosis of extracapsular silicone and, therefore, implant rupture.

Question 57

Describe some artefacts caused by intraparenchymal air

Answer 57

occurs after intervention may obscure visualization of the needle may need to be withdrawn and reinserted at a second site Air persisting along a biopsy tract after removal of the biopsy needle may look like a thin echogenic line closely mimic the appearance of a needle for subsequent sampling, it may be difficult to differentiate a prior needle tract from an actual needle. Rapid back-and-forth motion of the needle tip may allow differentiation of the two.

Question 58

Why may you be unable to visualise a lesion?

Answer 58

Poor resolution Poor positioning Unable to correlate mammographically detected mass with US mass Isoechoic can be difficult to differentiate

Question 59

Why might you fail to localise a density?

Answer 59

May not be real May be an area of dense parenchymal tissue May be too small to localise within large breast

Question 60

How can lactating breast prove difficult on ultrasound?

Answer 60

May have milk-filled ducts | Not an intraductal tumour

Question 61

What is the incidence of breast cancer in australia?

Answer 61

Incidence- second most common diagnosed cancer in Australia Most common cause of death from cancer in women worldwide 1 in 13 under 74 1 in 25 will die Due to early intervention and improvement in treatment, incidence has increased but mortality has not Prevention of death is achievable with early detection Breast screen has increased incidence of detecting non-invasive breast Ca

Question 62

List the risk factors for breast cancer

Answer 62

maternal relative with breast cancer increasing age – rare under the age of 30, risk increases steadily with age BRCA1 and BRCA2genes long reproductive cycle – increased risk with early period onset(<15)and/or late menopause(>50) obesity, high dietary fat intake in postmenopausal women nulliparity, increased risk if never pregnant, slightly less if previously pregnant but no live births late age at first pregnancy, that is, first child born to women over 30 atypical epithelial hyperplasia, due to changes in ductal epithelium previous breast cancer previous endometrial or ovarian cancer previous radiation to the breast hormone replacement therapy

Question 63

List some invasive breast cancers

Answer 63

infiltrating ductal carcinoma (the most common type of invasive). infiltrating lobular carcinoma (second most common) infiltrating ductal and lobular carcinoma. medullary carcinoma. mucinous (colloid) carcinoma. comedo-carcinoma. Paget's disease. papillary carcinoma. tubular carcinoma (the least most common type). adenocarcinoma, NOS. carcinoma, NOS.

Question 64

What are the positional statistics for breast cancer

Answer 64

``` upper outer quadrant – 50% central area – 20% lower inner quadrant – 10% upper inner quadrant – 10% lower outer quadrant – 10% ```

Question 65

What are some non invasive carcinomas

Answer 65

``` Ductal carcinoma in situ (DCIS) lobular carcinoma in situ (LCIS). DCIS and LCIS. papillary carcinoma. comedo-carcinoma. ```

Question 66

What is breast cancer grading

Answer 66

The grade is used to help predict your outcome (prognosis) and to help figure out what treatments might work best. Least aggressive Cas rarely metastasise outside of breast (DCIS and LCIS) Less common to metastasise are colloid ca, medullary ca and papillary ca All others have a greater potential to metastasise

Question 67

Describe the ultrasound appearance of Infiltrating ductal carcinoma (most common invasive)

Answer 67

Variable appearance heterogeneous with a central nidus outer echogenic halo Posterior shadowing is almost always present irregular margins Microcalcifications may appear as punctate echogenic foci if seen Large tumours may show central, necrotic cystic change often appears to cross fascial/stromal boundaries with subsequent architectural distortion. ``` ill-defined lesion hypoechoic mass hyperechoic angular margins posterior acoustic shadowing ductal extension may be seen which is extension of the lesion into surrounding parenchyma branched or spiculated pattern microcalcifications ```

Question 68

Describe the ultrasound appearance of Infiltrating lobular carcinoma (second most common invasive)

Answer 68

May have similar appearances to invasive ductal carcinoma ultrasound appearances may be less obvious with architectural distortion being one of the major findings. Distortion of the mass is usually easily apparent, but often posterior shadowing is not very dense. heterogeneous, hypoechoic mass angular or ill-defined margins posterior acoustic shadowing. An ill-defined heterogenous infiltrating area of low echogenicity with disproportionate posterior shadowing is one of the sonographic characteristics of invasive lobular carcinoma.

Question 69

Deescribe a Mucoid/colloid carcinoma (rare)

Answer 69

fairly rare, often apparent in older women. wide variation in ultrasound appearances. Some appear quite dense with good posterior shadowing. Many have an isoechoic appearance compared to the surrounding breast tissue and can blend in, or are slightly hypoechoic, being only apparent by a heterogeneous textural pattern often have some posterior enhancement may appear similar to a fibroadenoma But harder and less mobile.

Question 70

Ultrasound appearance of a mucoid/colloid carcinoma

Answer 70

``` mixed echogenicity mixed solid and cystic components Posterior acoustic enhancement is common Microlobulated margins lesion can be isoechoic to breast tissue on ultrasound which can make diagnosis difficult. ```

Question 71

Describe tubular carcinoma

Answer 71

Usually small with long echogenic spicules, looking like a radial scar. Imaging appearance mimics IDC hypoechoic solid mass ill-defined margins posterior acoustic shadowing The lesions are often rounded tall as broad.

Question 72

Describe papillary carcinoma

Answer 72

These rare tumours may appear as a solid or complex mass, or with solid tissue projecting into a cyst. hypoechoic and solid mass often with posterior acoustic enhancement alternatively, complex cystic and solid masses may be evident. As they are relatively vascular, there are often colour flow components on Doppler interrogation. There is overlap in the imaging patterns of invasive papillary carcinoma and papillary ductal carcinoma in situ.

Question 73

Describe pagets disease

Answer 73

redness or erosion of the nipple, often with a burning sensation. (This may be due to an extension of a breast carcinoma along the ducts into the epidermis). ultrasound appearances very non-specific thickening of the areola and echogenic material within the ducts. Comparison with the other breast is vital, along with a good patient questionnaire.

Question 74

Describe inflammatory carcinoma

Answer 74

skin thickening, increasing oedema and increased echogenicity of the subcutaneous fat layer. No tumour mass is usually seen Increased vascularity is a good indicator. axillary lymphadenopathy often seen.

Question 75

Describe spread of breast cancer

Answer 75

Often go to the axillary nodes first Most of the breast lymphatics drain there spread to dermal lymphatics (Inflammatory breast Ca) opposite breast via medial lymphatic drainage spread distantly via supraclavicular lymph nodes Other Sites where metastases commonly go Lung Bone Liver Not all women with nodal disease in axilla develop lymph node metastases Distant metastases = stage 4

Question 76

What is some follow up imaging that can be done for breast cancer to detect spread

Answer 76

Liver u/s can be done to detect any liver mets, ascites, adrenal and peri-aortic lymphadenopathy Chest xray to detect lung mets or pleural effusions Nuclear bone scanning to detect bone mets Ovarian metastases from breast cancer can form a krukenburg tumour of the ovary Can obstruct ureter Often bilateral

Question 77

How do you assess the malignancy of lymphnodes

Answer 77

``` Suspicious Size is a poor criterion abnormally round (this is a late findin) abnormally hypoechoic eccentric cortical thickening ```

Question 78

What are some post operative complications?

Answer 78

seroma, fat necrosis, local recurrence

Question 79

What is an important finding in the post operative breast that may indicate malignancy?

Answer 79

Increased vasculairty is an important finding Scar tissue is usually avascular Inflammatory carcinoma is very vascular

Question 80

What are some post operative changes/masses that may be seen on ultrasound?

Answer 80

Changes to normal breast architecture imaged with ultrasound Post-operative masses Haematoma Seroma Lymphocoele Can be complex, preedominantly cystic appearances Long standing collections may have an echogenic wall/capsule Fat necrosis and oil-cysts may be present Large scars can be difficult to scan through Breast thickening may be present Textural distorition due to scarring

Question 81

What are some ultrasound changes associated with radiotherapy?

Answer 81

Skin thickening Increased echogenicity of subcut fat Thickening or distortion of Cooper's ligs Architectural distortion of breast tissue

Question 82

What are some interventional procedures in breast imaging?

Answer 82

Stereotactic core breast biopsy Hook wire insertion Fine needle aspiration Core needle biopsy

Question 83

Describe hook wire insertion

Answer 83

Pre-operatively places a hook wire within a lesion Commonly used for likely malignant non-palpable lesions to guide Mammography or U/S guidance Easier under ultrasound if the lesion can be seen on mammo and u/s Cannula is placed into breast along the proposed line of biopsy Shortest distance from skin to lesion Imaging then confirms that it is within the lesion then the hookwire is inserted through the cannula into the lesion Hook wire remains in the lesion after the cannula is removed Then patient goes to theatre to have the lesion removed Imaging may be done of the lesion to ensure the entire lesion was excised

Question 84

What are some common biopsy complications

Answer 84

``` Pain Bleeding Bruise is likely Lumps (occult haematoma Infection- rare occurrence Vasovagal attack ```

Question 85

What would you image during a biopsy?

Answer 85

Pre-biopsy Longest dimension of the lesion and at 90 degrees to that; measurements taken(cyst volume may be estimated); distance from nipple and position in breast noted. Colour/power Doppler image to indicate general vascularity of the lesion. During biopsy Needle in position within lesion (two images at right angles). Core biopsy may require a pre and post fire image. Post-biopsy Usually only required post-cyst aspiration to show the extent of drainage and if any solid component remains.

Question 86

What are the clinical indications for FNA?

Answer 86

lesion cystic or mainly cystic to facilitate aspiration; | prior to a core biopsy to obtain a cytological specimen.

Question 87

What are the advantages of FNA?

Answer 87

useful aspiration tool for cystic/mainly cystic lesions; relatively quick and easy to perform in trained hands; well-tolerated by most patients (often even without the use of local anaesthetic); and low chance of bleeding due to fine gauge needle used.

Question 88

What are the disadvantages of FNA?

Answer 88

only a cytological specimen | cellular material may be very sparse, even insufficient, especially in some benign lesions.

Question 89

What are the clinical indication of core biopsy?

Answer 89

lesion is suspected to be malignant or inconclusive | And where a previous FNA has been inconclusive.

Question 90

What are the advantages of core biopsy?

Answer 90

histological specimen which has the potential to demonstrate the invasiveness of the tumour usually quite well-tolerated by outpatients with local anaesthetic to the breast.

Question 91

What are the disadvantages of core biopsy?

Answer 91

technically more demanding for the operator and patient; more traumatic to the patient; greater propensity for the breast to bleed (haematoma development due to larger gauge needle used); a chance of tumour seeding along track of needle possible (sometimes disputed).

Question 92

What are some reasons you might scan a patient with a breast implant?

Answer 92

routine mammogram and follow-up palpable mass for evaluation concern of implant rupture, thickening or capsular fibrosis.

Question 93

What are some early complications of breast implants?

Answer 93

usually clinically obvious fluid collections small anechoic fluid collections may have a simple appearance soon after surgery size and position of the collection should be noted Peri-implant fluid collections may be present for some time with the saline implant.

Question 94

What are some late complications of breast implants

Answer 94

deformity due to leakage or rupture capsular fibrosis echogenic masses contraction

Question 95

Describe deformity due to leakage or rupture

Answer 95

distortion or lobulation cystic spaces around the implant Unencapsulated implants may bulge and distort under normal tissue pressures and still not be ruptured Free silicone may be diffusely extravasated or appear in lumps Free silicone rupture may give a classical „snow storm‟ appearance – diffuse fine low-level echo shadowing A ruptured implant will deflate rapidly and may be due to trauma or totally unexpected. Silicone may extravasate into the surrounding tissue (extracapsular rupture) or be contained within the fibrous capsule formed around the implant (intracapsular rupture) very difficult to determine whether it is an encapsulated rupture or merely a bulge in the implant. A sign of an early rupture is the „linguine‟ sign, whereby the recoil of the envelope causes it to contract into the centre of the bag. Implant rupture may also give the ultrasound appearance of multiple echogenic lines either within or below the anterior surface Fragmentation of polyurethane bags may also cause long-standing fluid collections, thought to be due to a chronic inflammatory reaction.

Question 96

Describe capsular fibrosis

Answer 96

more of a clinical diagnosis implant capsule becomes firm and hard may appear as bright parallel lines at the surfaces of the prosthesis implant may appear distorted.

Question 97

describe some echogenic masses that may occur with breast implants

Answer 97

Calcification and oil cysts may be present. may appear as echogenic masses of variable hyperechogenicity Silicone granulomas are a reasonably common appearance, forming at the surface of the silicone bag usually quite palpable Echogenic well-circumscribed rounded structure close to the edge of the prosthesis Posterior shadowing Fragmentation of polyurethane bags may cause debris within fluid collections around the implant.

Question 98

Describe contraction of a breast implant

Answer 98

Due to tissue pressures, undulations and folds may appear within the implant. It may be sometimes difficult to determine if the appearances are of folds or rupture of an implant. Some folds are normal due to tissue moulding.

Question 99

Describe male breast enlargement

Answer 99

Benign hyperplasia involving breast parenchyma Uniltateral or bilateral Painful swelling, may ba a localised mobile lump also Inactive/fibrous type or active/florid type Nipple discharge is rare Can resolve without treatment

Question 100

Causes of male breast enlargement

Answer 100

``` idiopathic (in approximately one third of cases, the aetiology is unknown). Klinefelter's syndrome. excess oestrogen (neonatal, puberty, cirrhosis, adrenal tumour, exogenous oestrogens). gonadotrophin excess (testicular tumour). prolactin excess (hypothalamic or pituitary disease). drug related (for example, digitalis). ```

Question 101

Ultrasound appearance of gynaecomastia

Answer 101

Can appear as diffuse echogenicity similar to a mature female breast, common for inactive gynaecomastia Can also appear as a hypoechoic, oval well circumscribed mass in the retroareola region. Common for active gynaecomastia

Question 102

Advantages of MRI of breast iplants over mammography and ultrasound.

Answer 102

more reliable in demonstrating implant rupture; breast tissue/chest wall posterior to the implant is well demonstrated; implant internal anatomy well imaged; excellent detection of free silicon in soft tissues remote from the implant; and silicon uptake in regional lymph nodes can be detected.

Question 103

Ultrasound guided pleural drainage Indications

Answer 103

to take a sample of a pleural fluid of unknown origin for diagnosis; to remove as much pleural effusion as possible as a therapeutic procedure so that the patient can breathe more easily and comfortably; and to sample a pleural, chest wall or mediastinal mass (dependent on easy access under ultrasound control).

Question 104

Ultrasound guided pleural drainage advantages

Answer 104

usually quick to perform; real-time visualisation (as opposed to CT); optimal plane easily identified; can be performed with patients in varying positions (often sitting is easier for the patient with breathing difficulties and gravity helps the fluid to settle in the sampling region); portable, therefore can be performed at the patient‟s bedside; no use of ionising radiation; and usually well-tolerated by the patient.

Question 105

Ultrasound guided pleural drainage disadvantages

Answer 105

if the fluid cannot be visualised and a good path for access identified pneumothorax risk