breast ultrasound

1. Breast U/S&Mammography

2. Introduction :
Anatomy:
The breast consists of three types of tissue: the skin,
subcutaneous adipose tissue and the functional
glandular tissue. Centrally, there is the nipple–
areolar complex. Collecting ducts open into the tip
of the nipple. There are sebaceous glands within
the nipple–areolar complex called Montgomery's
glands. Small raised nodular structures called
Morgagni's tubercles are distributed over the
areola, representing the openings of the ducts of
Montgomery's glands onto the skin surface.

3. • The number of lobules per lobe varies according to age, lactation, parity and
hormonal status. At the end of reproductive life there is an increase in the amount of
adipose tissue and, although the main duct system is preserved, there is
considerable loss of lobular units. These changes in breast composition are
manifested by changes in the breast density on mammography.
• Usually, younger women tend to have more of the dense glandular breast tissue. In
older women, the mammographic density tends to decrease, with replacement of the
glandular tissue by fatty tissue. However, there are young women who have very
fatty-appearing breasts on mammography and older women with mammographically
dense breasts. Classifications systems have been developed to describe the density
of breast tissue on mammography
• One of the best known is the Wolfe classification:
•
• •
-Wolfe N1 pattern refers to a breast containing a high proportion of fat
- Wolfe DY pattern refers to extremely dense breast tissue
-Wolfe P1 pattern refers to a predominantly fatty breast with< 25% visible glandular
tissue•
-Wolfe P2 pattern refers to a breast with > 25% visible glandular tissue.

4. • There is some evidence suggesting that there is a
relationship between the mammographic parenchymal
pattern and the risk of developing breast cancer. Women
with dense breast tissue have a higher than average risk
of developing breast cancer. In addition, dense breast
tissue may hide abnormalities in the breast, making
cancer detection more difficult. The sensitivity of
mammography for detecting breast cancer is directly
related to the density of the breast tissue. In general,
mammography is more sensitive at detecting breast
cancer in older, post menopausal women because the
breast tends to be composed of greater amounts of fatty
tissue.

5. • Blood supply
• Arterial supply:
• Medial: internal mammary artery
• Lateral: axillary artery
lateral thoracic
thoracodorsal
intercostals
Venous drainage:
• Internal mammary v: direct communication with pulmonary capillary bed,
providing major routes for hematogenous metastases
• Axillary vein
• Intercostal vein: direct communication.
Lymphatic drainage
• Drainage from deeper
tissues of the breast
Ù surface Ù skin
subareolar plexus Ù
axilla
• Small % : drain to
upper abdomen
medially to internal
mammary lymphatics

6. Indications of U/S:
• Differentiation of cysts from solid masses
• Evaluation of a palpable mass not visible in
radiographically opaque breast
• Evaluation of palpable mass in young patient
• Evaluation of an inflammed breast for the presence of an
abscess
• Evaluation of a mass that cannot be completely
evaluated by mammography because of its deep
location
• Guidance for interventional procedures
• For duplex colour flow.

7. Breast mass lesion:
According to U/S finding

8. Cystic lesion :
• reast cysts are common between age 20-50 and classified into :
• -simple -complex -complicated.
• Simple cyst:
• U/S criteria:
• anechoic center.
• Thin echogenic capsule.
• Acrostic enhancement.
• Thin edge shadow.
• Mamoghrpahic appearance:
• Round,ovel ,well defined.
• Halo surrounded lesion.
• On follow up there is mas be disappeared, decrease or increase in size.
• N.B : carcinoma can occurs I immediate vicinity of cyst so it is necessary to
survey the tissue surrounding the cyst and cyst itself.

10. Complex and complicated cysts:
complex cysts demonstrated by at least one of
these criteria:thick wall ,thick septation, moral
nodules.
Categorization complex and complicated cysts into
categories help assess their risk infection and
neoplasm. Complex cyst asteroids include:
• -diffuse low-level internal echoes.
• -fluid -derbies level.
• - septation.
• -eccentric wall thickness.

11. 1.Low -level internal echoes:
• complicated cyst with low internal echoes should be evaluated for
wall thickness and particle morbidity.
• If cyst has normal thin echogenic wall (isoechoic wall indicate
inflammation).
• If cyst has thick wall consider acute inflammation, and should be
aspirated.
• If cyst contain subcellular particle is part of spectrum of fibrocystic
changes.
2.Fluid -debris level:
• cysts with fluid -debris level have wall thickness indicated
inflammation and tender , debris shift with change of patient
position.

12. 2.Septation:
• Thin septation : cluster or simple cyst.
• Thick septation : complex cyst(N.B: aspiration not prefer
)
3.Eccentric wall thickening:
• Evaluate the wall surface characteristics , the eccentric
wall thickening is assumed to be solid nodules.
• -if there is thin ,smooth echognic capsule
indicates non infiltrating leading edge more typical
benign lesion.
• -If there is lake of thin capsule increase
infiltrating leading age a sign of malignancy.

13. Solid Nodules:
All solid nodules should be consider malignant lesion ,even single malignant
feature is present the nodule can't be calcified benign
lesion ,if no malignant feature are found specific, and feature of benign are
found benign lesion is consider. If not found benign feature the lesion
classified as intermediate type .
Malignant lesion:
sure U/S criteria :
-spiculation. -angular margin -microobulation
-taller than wise - hypoechoic -branch pattern.
-shadowing - calcification - duct extension
Doppler examination show abnormal vessels and centenary penetrating. In
contrast benign tumour as fibroadenoma show displacement of norrmal
vessels around the edge of lesion.
mamoghrphic criteria :
ill defined spiculated mass, many breast cancer araise from DCIS associated
with microcalcification,
Architectural distortion may only clue for presence of invasive tumour.

16. Special type tumours can have particular
mammographic characteristics:
1.Lobular carcinomas can be difficult to perceive on a mammogram
due to their tendency to diffusely infiltrate fatty tissue. Compared
with ductal NST tumours, lobular cancers are more likely to be seen
on only one mammographic view, are less likely to be associated
with microcalcifications, and are more often seen as an ill-defined
mass or an area of asymmetrically dense breast tissue.
2.Tubular and cribriform cancers often present as architectural
distortions or small spiculated masses.
3.Papillary, mucinous and medullary neoplasms may appear as new or
enlarging multilobulated masses and may be well defined,
simulating an apparently benign lesion .
4.A small spiculated mass will be easily visible in a fatty breast,
whereas even large lesions can be obscured by dense breast
parenchyma

17. DD a) Postsurgical scar
Looks different between the ML and CC projections
while Ca looks the same on both
b) Fat necrosis
This patient had a biopsy with benign results 4yrs earlier.
This spiculated mass, with no distinct ceneral mass with
skin retraction proved to be fat necrosis.
c) Radial scar
Benign scarring process characterized by dramatic
spiculation . It is idiopathic, unrelated to known trauma or
surgery Excisional biopsy.

18. Benign lesion:
only if only suspicious malignancy finding not
prsent.
U/S finding:(all are smooth and well circumscribed)
-pure and marked hyperechogencity(hyperechoic)
-elliptical wider than tall.
-thin echogenic capsule.
-three or fewer lobulation.

20. Most common benign lesion:
Fibroadenoma:
U/S:smooth well defined , oval lobulated ,wider
than taller mass . with thin echogenic pseudo
capsule
Mamoghrphic appearance: well defined ,oval
mass , may show coarse calcification.
N.B:Phyloid tumour is suggested by large well
defined mass with several cystic space

22. Lipoma.
Benign tumour composed of fat , they
present clinically as soft lobulated mass.
U/S:well defined hyperechoic lesion in
compared to adjacent fat .
Mamoghraphic appearance: well difined
mass of fat density contained within thin
capsule.

23. Paplioma.
Benign proliferation of ductal epithelium that projects into lumen of the duct& is connected to the epithelium by a
fibrovascular stalk.
Within major ducts= subareolar in location.
Usually single, when multiple they occur in peripheral ducts.
They extend longitudinally in the duct lumen.
The duct around it can dilate forming a cyst.( Origin of “intracystic papilloma”).
Presentation: serous or bloody nipple discharge ( due to their fragile blood supply leading to necrosis, infarction and
bleeding).
Mammogram:
- usually Ù invisible
- rarelyÙ retroareolar mass
- sometimes Ù subareolar
microcalcification clusters lucent centered
calcification
Galactography: filling defect
U/S: solid, hypoechoic, usually lobulated masses within cystically dilated ducts.
N.B. papillomatosis = epithelial hyperplasia

24. Duct ectasia.
1ry affects the major ducts in the subareolar region.
The distended ducts are filled with fluid or thick unresorbed
secretions and cellular debris.
Etiology: 2ry to periductal inflammation.
The duct may be weakened by surrounding inflammation
become patulous, filled with unresorbed debris which
may calcify.
Mammogram: Tubular, serpentine structures converging to
the nipple in the subareolar region
U/S: anechoic fluid filled tubular structures.
With debris

25. Mammary dypalsia.
Definition: Benign proliferation of breast stroma.
Types:
a)cystic form: when lactiferous ducts consist of cystic dilatation of
varying size.
b)Fibrous form when changes are predominantly periductal fibrosis.
c) Adenosis form: enlargement of the lobule 2ry to a benign
proliferation of the acini.
This proliferation within the TDLU is 1ry an elongation and
multiplication of the acini accompanied by an overgrowth of the
epithelial &myoepithelial and connective tissue elements in the
lobule.
cystic dilatation of the acini is where Ca+ ppt. (D.D. Ca)

26. Galactocele,
Occasionally a milk containing cystic structure develops
during lactation or in the months after the cessation of
nursing.
Age: 20’s-30’s
Etiology:
Obstruction of a duct .
The proximal (lobular) segment becomes distended with
inspissated milk.
Clinically: it is indistinguishable from other causes of a
rounded mass.
Mammogram: if the milk filled cystic mass has enough fat
content Ü well circumscribed radiolucent mass.

27. Placema cell mastis.
These appear in one of these patterns.
a) thick continuous solid, rod-shaped deposits
oriented along duct lines diffusely or
segmental distribution
b) Lucent centre rod-shaped calcification
c) Lucent centered globular calcification
They are called plasma cell mastitis because of
the plasma cell infiltrate that are histologically
part of the inflammatory process.
D.D. Ca calcification

28. Hamartoma.
roliferation of fibrous and adenomatous
elements in fat surrounded by a capsule of
connective tissue