Breast ultrasound
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Breast ultrasound

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Breast ultrasound Breast ultrasound Presentation Transcript

  • ULTRASOUND OFULTRASOUND OF BREASTBREAST By Dr AttiyaBy Dr Attiya
  •  Breast ultrasound uses high-frequencyBreast ultrasound uses high-frequency sound waves to map the internalsound waves to map the internal structures of the breast.structures of the breast.
  • ApplicationsApplications  Though ultrasound is successfully used to aid assessment ofThough ultrasound is successfully used to aid assessment of abnormalities detected by mammography, it should not be usedabnormalities detected by mammography, it should not be used as a sole modality for screening as ultrasound does not alwaysas a sole modality for screening as ultrasound does not always detect cancers that are visualised mammographically.detect cancers that are visualised mammographically.  Conversely, used in conjunction with mammography, ultrasoundConversely, used in conjunction with mammography, ultrasound can detect clinically and mammographically occult cancerscan detect clinically and mammographically occult cancers particularly when there is a higher possibility of cancer.particularly when there is a higher possibility of cancer.  With new high-frequency transducers, it is also possible to detectWith new high-frequency transducers, it is also possible to detect malignancy associated with mammographically detectedmalignancy associated with mammographically detected clustered microcalcifications.clustered microcalcifications.  These lesions may be evident as irregular masses, abnormalThese lesions may be evident as irregular masses, abnormal dilated ducts or clustered foci of increased echogenicity withdilated ducts or clustered foci of increased echogenicity with increased Doppler vascularity.increased Doppler vascularity.
  • ULTRASOUND OF BREASTULTRASOUND OF BREAST  TechniqueTechnique  High-quality images of the normal andHigh-quality images of the normal and abnormal breast can be obtained with modernabnormal breast can be obtained with modern ultrasound equipmentultrasound equipment.. Initial examinationInitial examination –– Machine to patient’s rightMachine to patient’s right –– Image with right handImage with right hand –– Operate machine with left hand.Operate machine with left hand.
  • Patient PositionPatient Position MEDIAL LESIONSMEDIAL LESIONS  patient is supinepatient is supine  ipsilateral arm is placed over the patient’sipsilateral arm is placed over the patient’s head.head. LATERAL LESIONSLATERAL LESIONS  patient is opposite.patient is opposite. SUPERIOR LESIONSSUPERIOR LESIONS  patient is SITTINGpatient is SITTING
  • Equipment selection:Equipment selection:  TransducerTransducer  At the minimum, a 7.5At the minimum, a 7.5 MHz linear array probeMHz linear array probe should be used.should be used.
  • Apply gentle uniform pressureApply gentle uniform pressure with the ultrasoundwith the ultrasound transducertransducer Increase transducer pressure for:Increase transducer pressure for: –– greater penetrationgreater penetration –– scanning the subareolar region.scanning the subareolar region. Scanning is done inScanning is done in three directions.three directions. 1.1. RadialRadial 2.2. TransverseTransverse 3.3. LongitudinalLongitudinal
  •  Localization is by theLocalization is by the clock face.clock face. 12 3 66 39
  • Ultrasound of the BreastUltrasound of the Breast  Recent studies show if strict criteria forRecent studies show if strict criteria for lesion analysis are followed, specificity oflesion analysis are followed, specificity of ultrasound in determining benign orultrasound in determining benign or malignant reaches 70%.malignant reaches 70%.
  •  All macroscopic breast structures can be easilyAll macroscopic breast structures can be easily imaged with adequate sonographic equipment.imaged with adequate sonographic equipment. The breast can be divided into four regionsThe breast can be divided into four regions  skin, nipple, subareolar tissuesskin, nipple, subareolar tissues  subcutaneous regionsubcutaneous region  parenchymaparenchyma (between the subcutaneous(between the subcutaneous and retromammary regions)and retromammary regions)  retromammary region.retromammary region. Sonographic BreastSonographic Breast AnatomyAnatomy
  • Ultrasound interpretationUltrasound interpretation  TheThe subcutaneous fat layersubcutaneous fat layer is demonstratedis demonstrated superficially as hypoechoic tissue compared to thesuperficially as hypoechoic tissue compared to the glandular tissue from which it is separated by a well-glandular tissue from which it is separated by a well- defined scalloped margin.defined scalloped margin.  NormalNormal ductsducts are often visible, particularly in theare often visible, particularly in the subareolar region, as anechoic tubular structures.subareolar region, as anechoic tubular structures.  Deep to the glandular tissue,Deep to the glandular tissue, a retromammary fata retromammary fat layerlayer is usually visible and, behind this, the structuresis usually visible and, behind this, the structures of theof the chest wallchest wall..
  • Sonographic BreastSonographic Breast AnatomyAnatomy  SkinSkin  Subcutaneous fatSubcutaneous fat  Cooper’s LigamentsCooper’s Ligaments  Breast parenchymaBreast parenchyma  Retromammary fatRetromammary fat  Pectoralis musclePectoralis muscle  RibsRibs  PleuraPleura  NippleNipple
  • Cooper's ligamentskin fibroglandular tissue
  • Nipple • Consists of both dense connective tissue and connective tissue of the duct which can cause posterior acoustic shadowing
  • Ribs • Easily identified bone attenuates causing an acoustic shadow
  • Duct • Tubular branching structures
  • Ultrasound showing dilated ducts (lactating) The duct appears as branching hypoechoic structure within echogenic glandular tissue.
  • Intramammary vessel running branching under the skin.
  • Lymph Node • Solid nodule • Ovoid • Echogenic fatty hilum
  • INDICATIONSINDICATIONS  Symptomatic breast lumps in women aged less than 35Symptomatic breast lumps in women aged less than 35 years.years.  Breast lump developing during pregnancy or lactation.Breast lump developing during pregnancy or lactation.  Assessment of mammographic abnormality (± furtherAssessment of mammographic abnormality (± further mammographic views)mammographic views)  Assessment of MRI or scintimammography detectedAssessment of MRI or scintimammography detected lesions.lesions.  Clinical breast mass with negative mammograms.Clinical breast mass with negative mammograms.  Breast inflammation.Breast inflammation.  The augmented breast (together with MRI).The augmented breast (together with MRI).  Breast lump in a male (together with mammography).Breast lump in a male (together with mammography).  Guidance of needle biopsy or localisation.Guidance of needle biopsy or localisation.  Follow-up of breast cancer treated with adjuvantFollow-up of breast cancer treated with adjuvant chemotherapy.chemotherapy.
  • INDICATIONSINDICATIONS  The original role of breast sonography is inThe original role of breast sonography is in the differentiation ofthe differentiation of cysticcystic andand solidsolid lesions.lesions.  Ultrasound complements both clinicalUltrasound complements both clinical examination and mammography.examination and mammography.  It is also successfully used as a 'second-look'It is also successfully used as a 'second-look' procedure where an abnormality has beenprocedure where an abnormality has been identified using MRI or scintimammography.identified using MRI or scintimammography.
  • INDICATIONSINDICATIONS  Because it does not use ionising radiation, it isBecause it does not use ionising radiation, it is the examination of choice in young women andthe examination of choice in young women and is valuable in the assessment of theis valuable in the assessment of the mammographicallymammographically ``dense'dense' breast.breast.  Ultrasound plays an important role in the tripleUltrasound plays an important role in the triple assessment of symptomatic lesions.assessment of symptomatic lesions.  Being the only `real-time' imaging modality alsoBeing the only `real-time' imaging modality also means it can be used to accurately localise ormeans it can be used to accurately localise or biopsy breast lesions.biopsy breast lesions.
  • Breast Ultrasound andBreast Ultrasound and Mammographic CorrelationMammographic Correlation Dense breast
  • Fatty breast
  •  The echotexture of any lesion is comparedThe echotexture of any lesion is compared relative to the echotexture of therelative to the echotexture of the intramammary fat.intramammary fat.  CystsCysts are typically well-defined roundedare typically well-defined rounded anechoic lesions with posterior acousticanechoic lesions with posterior acoustic enhancement, though the presence of debrisenhancement, though the presence of debris can increase the overall internal echogenicity.can increase the overall internal echogenicity.  Wall thickening, irregularity or mural nodulesWall thickening, irregularity or mural nodules should be treated with suspicion andshould be treated with suspicion and aspiration should be performed.aspiration should be performed.
  • Simple Cysts – anechoic – smooth, thin margins – posterior acoustic enhancement
  •  In practice,In practice, needle biopsyneedle biopsy should be performed asshould be performed as part of triple assessment in the presence of a discretepart of triple assessment in the presence of a discrete solid mass.solid mass.  Not all breast pathology presents as a discrete lesion.Not all breast pathology presents as a discrete lesion. Inflammatory or lobular cancers may present as areasInflammatory or lobular cancers may present as areas of scattered indeterminate attenuation.of scattered indeterminate attenuation.  The use of colour and power Doppler can also aid inThe use of colour and power Doppler can also aid in benign-malignant differentiation of solid masses.benign-malignant differentiation of solid masses.  In general, malignant masses tend to show anIn general, malignant masses tend to show an increased number of vessels that penetrate deep intoincreased number of vessels that penetrate deep into the tumour with a branching morphology.the tumour with a branching morphology.
  • Breast UltrasoundBreast Ultrasound Imaging CharacteristicsImaging Characteristics  sizesize  shapeshape  border definitionborder definition  internal echogenicityinternal echogenicity  posterior enhancementposterior enhancement  architectural changesarchitectural changes
  • Analytic CriteriaAnalytic Criteria •• MarginsMargins •• Retrotumoral acoustic phenomenaRetrotumoral acoustic phenomena •• Internal echo patternInternal echo pattern •• EchogenicityEchogenicity •• Compression effect onCompression effect on SHAPESHAPE •• Compression effect onCompression effect on INTERNALINTERNAL ECHOESECHOES
  • Benign CharacteristicsBenign Characteristics  Ellipsoid shapeEllipsoid shape  Thin definableThin definable capsulecapsule  Two or threeTwo or three lobulationslobulations  Hyperechogenicity.Hyperechogenicity.
  • Solid Mass -Solid Mass - MalignantMalignant • Irregular shape • Irregular/ill-defined borders • Almost anechoic • Angular margin • Taller than wide
  • Irregular shape • Irregular/ill-defined borders • Almost anechoic • Thick echogenic rim • Posterior shadowing
  • BenignBenign MalignantMalignant ShapeShape Oval/ellipsoidOval/ellipsoid VariableVariable AlignmentAlignment Wider than deep; aligned parallel toWider than deep; aligned parallel to tissue planestissue planes Deeper than wideDeeper than wide MarginsMargins Smooth/thinSmooth/thin echogenic pseudocapsule withechogenic pseudocapsule with 2-3 gentle lobulations2-3 gentle lobulations Irregular or spiculated; echogenic 'halo'Irregular or spiculated; echogenic 'halo' EchotextureEchotexture Variable to intenseVariable to intense hyperechogenicityhyperechogenicity Low-levelLow-level Marked hypoechogenicityMarked hypoechogenicity Homogeneity ofHomogeneity of internal echoesinternal echoes UniformUniform Non-uniformNon-uniform LateralLateral shadowingshadowing PresentPresent AbsentAbsent Posterior effectPosterior effect Minimum attenuation/posteriorMinimum attenuation/posterior enhancementenhancement Attenuation with obscured posteriorAttenuation with obscured posterior marginmargin Other signsOther signs ---------------------------- CalcificationCalcification MicrolobulationMicrolobulation Intraductal extensionIntraductal extension Infiltration across tissue planes and increasedInfiltration across tissue planes and increased echogenicity of surrounding fatechogenicity of surrounding fat
  • A typical fibroadenoma with homogeneous internal echoes with an ovoid shape and circumscribed margins -- benign. There is posterior acoustic enhancement..
  • A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.
  • An invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.
  • Inflammatory breast cancer with secondary signs. increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.
  • A power Doppler image of an invasive grade 3 breast cancer. irregular tortuous and branching vessels penetrating into the centre of the lesion.
  •  The sonographic pattern varies with ageThe sonographic pattern varies with age and individually, and depends on theand individually, and depends on the amount and type of contents, i.e. fat,amount and type of contents, i.e. fat, fibrous and glandular tissues.fibrous and glandular tissues.  The fibrous and glandular componentsThe fibrous and glandular components are variably echogenic, while fat isare variably echogenic, while fat is hypoechoic.hypoechoic.
  • Benign ??Benign ?? Malignant ??Malignant ??
  • Benign vs. MalignantBenign vs. Malignant
  • Benign ??Benign ?? Malignant??Malignant??
  • THANKYOUTHANKYOU