Breast Flashcards
What are the vessel responsible for arterial supply of the breast?
nternal thoracic artery, via the medial mammary and anterior intercostal branches;
lateral thoracic and thoracoacromial arteries; and
posterior intercostal arteries.
What are the vessels responsible for venous drainage of the breast?
mainly to the axillary vein via the lateral thoracic and lateral mammary veins; and
also the internal thoracic and medial mammary veins.
Describe the lymphatic drainage of the breast
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.
What does the pre-menopausal breast look like
Largely consists of fat and glandular tissue.
What does the post-menopausal breast look like
Decreased fat and glandular tissue. Proportionally the breast is mainly fibrous tissue.
Describe the young, non-lactating patient breast
Breast is mainly composed of hyperechoic glandular tissue with little to no subcut fat
Describe the breast as patient ages and has children
Fat is deposited in subcut and retromammary layers
Describe the pregnant breast
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
Describe the breast of a non pregnant patient
can have cyclic changes
Mild duct dilation in the last half of cycle
Glandular prominence with or without associated tenderness
What happens to the breast as it ages?
Glandular tissue slowly regresses with age and there is increased fatty replacement
Describe Glandular tissue/parenchyma of the breast
usually homogeneously echogenic; some hypoechoic areas within may represent ducts or fat lobules.
Describe Subcutaneous fat/fat lobules of the breast
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.
Describe the appearance of the pectoral muscle
hypoechoic with striations.
Describe the ultrasound appearance of coopers ligaments
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.
Describe the ultrasound appearance of breast skin
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.
Describe the TDLU
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.
How does compound imaging assist breast scanning
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
How does harmonic imaging assist breast scanning?
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
What are the four main roles for sonography in breast imaging?
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.
In what areas is breast ultrasound becoming an increasingly used tool?
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
What are the benefits of breast ultrasound over mammo?
Non-ionising radiation
Good for dense breasts
Younger, denser breasts are more suited to U/S
Used to aid FNA and core biopsies
What are some indications for breast ultrasound?
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
What are some aspects of patient hx you should find out
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
Why is examination/palpation important
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
Briefly go through scanning technique
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
Primary characteristics to assess in a breast lesion are:
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.
What is the significance of the width to depth ratio?
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.
What are some likely benign characteristics of breast lesions?
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
What are some likely malignant attributes of breast lesions
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
What are some developmental abnormalities of the breast?
Hypoplasia- idiopathic or due to ovarian dysfunction (eg. Turner's syndrome) Hyperplasia Precocious puberty Gynaecomastia Early development Hypertrophy
What are some formative abnormalities of the breast?
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
What are some causes of infectious mastitis?
Lactation
Inverted nipples
Sebaceous cysts
Infected montgomery’s glands of areola
What is the patient presentation for infectious mastitis?
Diffuse swelling/cellulitis
Multiple abscess nodules
Large abscess
What is the ultrasound appearance for infectious mastitis?
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
What are some causes of non infectious mastitis?
Duct dilation- leads to duct ectasia/comedo mastitis Trauma- leading to fat necrosis Malignancy- inflammatory carcinoma Radiation therapy CCF
What is the ultrasound appearance of non infectious mastitis?
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
What is the cause of a traumatic breast injury
Biopsy
Surgery
accident.
A patient history is therefore necessary.
What are some ultrasound appearances of breast trauma
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).
What re the ultrasound appearances of a breast haematoma
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.
What are some focal benign breast diseases?
Cyst Sebaceous cyst Fibroadenoma Lipoma Hamartoma/fibroadenolipoma Intraductal papilloma Galactocele Cystosarcoma phyllodes Focal fibrosis/radial scar
Discuss fibrocystic breast change
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.
What are the typical features of fibrocystic change?
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.
