Surgeon performed ultrasound


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  • Breast Ultrasound requires the use of high end equipment utilizing high frequency linear transducers in order to provide superior resolution. These high-end equipment provide many technologies that improve and enhance the IQ enabling easy detection and characterisation of breast lesions and breast tissue changes.
  • Enhanced image uniformity, improved continuity of structures, improved lateral resolution, reduction of speckle
  • Surgeon performed ultrasound

    1. 1. Surgeon-Performed Ultrasound Breast and Thyroid Center Chungmoo General hospital Cheonan Korea Jin Woo Ryu, M.D. [email_address]
    2. 2. 참고도서
    3. 3. Hertz (Hz) = cycles per second Megahertz (MHz) = millions of cycles per second The frequency of a transducer is labeled in Megahertz
    4. 4. . The tranduce r contains an element that is made of a piezo-electric(pressure-electric) crystal. When an electric charge is applied to the piezoelectric crystal , the crystal will expand and contract emitting a sound wave.
    5. 5. Thicker crystal produces bigger sound waves for more penetration ,Bigger sound waves travel farther , and less the resolution 7.5 MHz 3.5 MHz Thinner crystal produces small sound waves for less penetration, Smaller sound waves travel less , and better the resolution Ultrasound Transducer
    6. 6. 7.5MHz 13.5MHz
    7. 7. STC: Sensitivity Time Control
    8. 9. Gain - Gain +,
    9. 10. Positioning the Patient
    10. 11. Keeps Cooper ligament under tension, speeds the examination Probing direction
    11. 13. Nomal anatomy 1.Interobular stroma, connective tissue 4. Ribs 5. Skin 6. Mammary gland 8. Fat 10. Pectoral muscle 13. Pectoral fascia 15. Prepectoral fat
    12. 15. Echogenecity Hyperecho isoecho hypocho
    13. 16. Breast Ultrasound lexicon <ul><li>Shape: oval, round, irregular </li></ul><ul><li>Orientation to skin line : not parallel, parallel </li></ul><ul><li>Margins: circmscribed, </li></ul><ul><li>not circumscribed; </li></ul><ul><li>indistinct, angular, microlobulated, </li></ul><ul><li>spiculated </li></ul><ul><li>Lesion boundary: abrupted interface, echogenic halo </li></ul><ul><li>Echopattern: anechoic, hyperechoic, hypoechoic, complex, isoechoic </li></ul><ul><li>Posterior acoustic features: no features, enhanced, shadowing(excluding edge shadows), combined. </li></ul><ul><li>Surrounding tissue: duct(abnormal caliber or arborization), Cooper ligament(straighting or thickening), edema, aechitectural distortion, skin thickening </li></ul><ul><li>(BIRAD Ultrasound, 1rst edn. American College of Radiology, Reston, 2003) </li></ul>A Mass;
    14. 17. 1. Interpretation of breast lesions <ul><li>Is it real? ---fat 과의 구별 </li></ul><ul><li>Cyst or solid – 필요시 aspiration </li></ul><ul><li>Benign or malignant </li></ul><ul><li>Specific entity? </li></ul><ul><li>Fibroadenoma, </li></ul><ul><li>papilloma, phyllodes, hamartoma, </li></ul><ul><li>Fat necrosis, abscess, granulomatous </li></ul><ul><li>mastitis, lipoma, radial scar, DCIS, </li></ul><ul><li>Invasive cancer </li></ul>
    15. 18. <reporting system> <ul><li>1. reason for exam </li></ul><ul><li>2. comparison with previous US </li></ul><ul><li>3. lesion analysis; </li></ul><ul><li>size, location, mass type and modifier, </li></ul><ul><li>associated calcification or findings, </li></ul><ul><li>how changed if previously present </li></ul><ul><li>4. comparison with P/E, MMG, MR </li></ul><ul><li>5. summary and BI-RAD code(0-6) </li></ul>
    16. 19. 2. Differentiation of benign and malignant lesions <ul><li>1) Stavros ’ criteria </li></ul><ul><li>1. no malignant characteristics </li></ul><ul><li>2. Intense homogeneous hyperechogenicity or Thin echogenic pseudocapsule with ellipsoid shape or Thin echogenic pseudocapsule with bi- or tri gentle lobulation </li></ul><ul><li>Radiology 1995; 196:123 </li></ul><ul><li>Solid breast nodules: use of sonography to distinguish between </li></ul><ul><li>benign and malignant lesions </li></ul>
    17. 20. Characteristic US findings of breast cancer(Jpn) L/T ratio (>1; cancer in 95.5%, FA in 3.3%) Irregular or rough margin( Ca in 55.5%, FA in 30%) Connetive tissue sign(cancer in 55%-77%) Heterogenous internal echoes(Ca in 52%) Thick boundary echoes Echogenic spot(Ca in 30-40%, FA in 10%) Posterior echo attenuation(Ca in38.7%, FA in 8.2%) <ul><ul><li>. </li></ul></ul>
    18. 21. Spiculation
    19. 22. Taller than Wide 1; Carcinoma arising from 1,anterior lobule, 2, from posterior lobules, 3; from terminal lobules Taller than wide carcinomas are primarily small lesions with maximum diameters less than 1.5 cm
    20. 23. Angular margin <ul><li>In some circumscribed malignant, angular margins are the only hard suspicious findings present </li></ul>
    21. 24. Connective tissue sign 유방암 조직소견 중 그 변연에서 내부로 파고 들어가는 섬유성 결합조직이 특징이다 . 이것의 초음파 소견을 connective tissue sign 이라고 한다 .
    22. 25. Rough and heterogenous internal echoes
    23. 26. Thick boundary echoes Inflammmatory infiltates Lymphcystic host response …peritumoral inflammatory echogenic edema
    24. 27. Calcification
    25. 28. Posterior acoustic shadowing Lt: Mass with calcification Rt: scar … . obliteration of shadowing Cancer: attenuated Cyst: enhanced
    26. 29. Benign characteristics <ul><li>Absent malignant findings </li></ul><ul><li>Intense hyperechogenicity </li></ul><ul><li>Ellipsoid shape </li></ul><ul><li>Gentle bi- or trilobulations </li></ul><ul><li>Thin, echogenic pseudocapsule </li></ul>
    27. 30. 2) ACR-BI-RADS US <ul><li>1. shape ; oval, round, irregular </li></ul><ul><li>2. orientation ; parallel, nonparallel </li></ul><ul><li>3. margin ; circumscribed, noncircumscribed (indistinct, angular, microlobulated, spiculated) </li></ul><ul><li>4. lesion boundary ; abrupt interface, echogenic halo </li></ul><ul><li>5. echopattern; anechoic, hyperechoic, complex, hypoechoic, isoechoic </li></ul>
    28. 31. 2) ACR-BI-RADS US <ul><li>6. posterior acoustic features; no, enhancement, shadowing, combined </li></ul><ul><li>7. surrounding tissues; ducts, changes in cooper ’ s ligament, edema, architectual distortion, skin thickening, skin retraction/irregularity </li></ul><ul><li>8. calcification; macrocalcification, </li></ul><ul><li>microcalcifications </li></ul><ul><li>9. vascularity; present (immediately adjacent at lesion, diffusely increased in surrounding tissue) or no present </li></ul>
    29. 32. 3. Benign breast disease <ul><li>Cysts </li></ul><ul><li>no internal echo, sharp </li></ul><ul><li>anterior and posterior </li></ul><ul><li>border, posterior </li></ul><ul><li>enhancement </li></ul><ul><li>Cyst with internal echo </li></ul><ul><li>proteinaceous material </li></ul><ul><li>cellular debris, </li></ul><ul><li>hemorrhage, </li></ul><ul><li>cholesterol crystal, </li></ul><ul><li>inspissated secretion, </li></ul>
    30. 33. 3. Benign breast disease <ul><li>2. fibroadenoma </li></ul><ul><li>most common breast mass between 10-30 th </li></ul><ul><li>Giant fibroadenoma </li></ul><ul><li>> 6cm sized </li></ul><ul><li>Pseuodoencapsulated mass with epithelial & stromal component </li></ul><ul><li>Carcinoma from FA </li></ul><ul><li>FA 주변에 DCIS or LCIS or within the FA </li></ul>
    31. 34. 3. Benign breast disease <ul><li>3. Fibrocystic change </li></ul><ul><li>proliferation of fibrous connective tissue, cystic dilatation of ducts, hyperplasia of ductal and lobular cells </li></ul><ul><li>solid mass, solid and cystic mass, cyst(s), inhomogeneous bulging parenchyma with attenuation of subcutaneous fat, shadowing, calcification </li></ul>
    32. 35. 3. Benign breast disease <ul><li>4. Phyllodes tumor </li></ul><ul><li>large solid mass, </li></ul><ul><li>not different from fibroadenoma </li></ul><ul><li>Fluid-filled cysts or clefts </li></ul>
    33. 36. 3. Benign breast disease <ul><li>5. Adenolipoma </li></ul><ul><li>(hamartoma) </li></ul><ul><li>well circumscribed, oval, mixed echoic </li></ul><ul><li>Variable tissue composition </li></ul>
    34. 37. 3. Benign breast disease <ul><li>6. Papilloma </li></ul><ul><li>intraductal or </li></ul><ul><li>intracystic; anechoic rim </li></ul><ul><li>Pure solid mass </li></ul>
    35. 38. 3. Benign breast disease <ul><li>7. mastitis and abscess </li></ul><ul><li>Uncomplicated mastitis; normal or area of increased echogenicity </li></ul><ul><li>Abscess; poorly </li></ul><ul><li>marginated or well </li></ul><ul><li>marginated fluid </li></ul><ul><li>collection of variable </li></ul><ul><li>echo+surrounding </li></ul><ul><li>hyperechoic reactive tissue </li></ul>
    36. 39. 3. Benign breast disease <ul><li>8. fat necrosis </li></ul><ul><li>Hyperechoic mass with occasional small anechoic foci </li></ul><ul><li>Subcutaneous fat layer </li></ul><ul><li>Trauma history </li></ul>
    37. 40. 3. Benign breast disease <ul><li>9. intramammary L/N </li></ul>
    38. 41. High end equipment
    39. 42. Tissue Harmonic Imaging <ul><li>Pulse-subtraction THI, Differential THI </li></ul><ul><ul><li>Reduction in side lobe artifacts </li></ul></ul><ul><ul><li>Improved tissue contrast resolution </li></ul></ul>Dr. Siti Fatimah, Melaka General Hospital , Malaysia
    40. 43. Compounding Technology <ul><li>Aplipure, Aplipure+ </li></ul>
    41. 44. Compounding Dr. Fischer, Charite University, Berlin Germany Breast tumour <ul><li>Enhanced image uniformity </li></ul><ul><li>Improved continuity of structures </li></ul><ul><li>Improved lateral resolution </li></ul><ul><li>Reduction of speckle </li></ul>Aplipure + Aplipure +