Evaluasi stase USG 4

BREAST ULTRASOUND

Mellissa

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Positioning the patient :
• Supine
• Arms elevated
• Hands clasped behind the neck
• Large breast  elevated with cushion or
triangular wedge
 Flattening of the breast, immobilize, reduce
tissue thickness

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Holding the Transducer

• Held at base
• Maximal contact with fingers & palm
• Transducer movement controlled with wrist
• Forearm rest gently on the patient
• Just enough pressure is applied to maintain
full contact
• Examiner sits at the level of the patient
• Linear transducer; 7-8 MHz
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 Standard scan planes
• Sagittal scan
• Transverse scan
• Radial and antiradial scan
• Parasternal sagittal scan (internal thoracic artery)
• Parasternal transverse scan (intercostal)
• Transverse axillary scan (axillary vein)
• Sagittal axillary scan (thoracodorsal artery and
vein)

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Normal breast tissue showing: the premammary zone (skin and
overlying breast fat)
the mammary zone (fibroglandular tissue)
the retro-mammary zone (predominantly fat and the muscles of
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the chest wall
Normal lactating breast tissue.
The prominant fluid filled ducts and their echogenic epithelial
lining is readily visible.

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 CLASSIFICATION CATEGORIES IN THE
BI-RADS US SYSTEM
BACKGROUND ECHOTEXTURE
• Homogenous
• Fat lobules
• Fibroglandular tissue
• Heterogenous

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM
MASSES  seen in 2 different projections
• Shape
• Oval : elliptical / egg shaped, may be
undulated
• Round : spherical, ball shaped, circular, or
globular.  AP =  transverse
• irregular

Oval 9
Round Irregular
CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM
• Orientation  unique to US imaging, to skin line
• Parallel : wider-than-tall, horizontal
orientation, long axis parallels the skin line
• Not parallel : taller-than-wide, vertical
orientation, AP dimension > transverse
dimension

Parallel 10
Not Parallel
CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM
• Margin  edge / border of the lesion
• Circumscribed : well defined / sharp, abrupt transition
between lesion & surrounding tissue
• Not circumscribed
• Indistinct : no clear demarcation between a mass and
surrounding tissue
• Angular : sharp corner, often forming acute angle
• Microlobulated
• Spiculated : sharp line projecting from the mass

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Circumscribed Not Circumscribed
Indistinct Angular

Microlobulated Spiculated 12
CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM
• Lesion boundary  transition zone between the
mass and surrounding tissue
• Abrupt interface : sharp demarcation between
lesion and surrounding tissue, well-defined
echogenic rim of any thickness
• Echogenic halo : no sharp demarcation
between mass and surrounding tissue, bridged
by an echogenic halo

Abrupt transition Echogenic halo 13

CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM
• Echo pattern
• Anechoic : without internal echo
• Hyperechoic : increased echogenicity relative
to fat or equal to fibroglandular tissue
• Complex : contains both anechoic (cystic) &
echogenic (solid) components
• Hypoechoic : relative to fat
• Isoechoic : same echogenicity as fat

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 Isoechoic Anechoic
Hyperechoic

Complex 15
Hypoechoic
CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

• Posterior acoustic feature  attenuation

characteristics of mass with respect to its
acoustic transmission
• No posterior acoustic feature
• Enhancement
• Shadowing
• Combined pattern

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No posterior acoustic feature Enhancement

Mixed 17
Shadowing
CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

• Surrounding tissue
• No effects
• Effects : intraductal mass, ducts (abnormal
caliper), Cooper ligament changes, edema,
architectural distortion, skin thickening
(normal skin 2 mm / less, except in
periareolar & lower breast), skin retraction
/ irregularity

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

CALCIFICATION  poorly characterized with US,

echogenic foci

• Macrocalcification  coarse calcification  >

0,5mm
• Microcalcification  out of a mass, in a mass

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES

Clustered Microcysts
Cluster of tiny anechoic foci, smaller than 2-3 mm,
thin (< 0.5mm) intervening septation, no discrete
solid components.

If nonpalpable  probably benign

Causes : fibrocystic changes, apocrine metaplasia
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Clustered microcysts, apocrine metaplasia.
Radial sonogram (10 MHz) obtained in a
50-year-old woman shows an incidental
aggregate of tiny cystic foci (arrowheads)
without a discrete solid component. In our
experience, these sonographic features
have been shown to correspond to benign
breast disease, such as apocrine
metaplasia, or fibrocystic changes without
apocrine metaplasia. At histopathologic
examination of the 14-gauge CNB
specimen, dilated acini were
demonstrated, lined by apocrine
metaplastic epithelium. We now classify
such nonpalpable lesions as probably
benign with a 6-month follow-up.

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Complicated cysts
Homogenous low level internal echo, fluid
debris level (shift with change in patient
position). May contain bright echogenic foci.
No solid mural nodule.
Solid component in cystic lesion  complex
mass
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Complicated cyst, apocrine metaplasia.
Radial sonogram (7.5 MHz) obtained in a
43-year-old woman shows mobile debris
with a fluid-debris level (arrow) in a
symptomatic cyst that otherwise met the
criteria of simple cyst. Aspiration yielded
apocrine metaplasia.

Complicated cyst with inflammatory

changes. Transverse sonogram (10 MHz)
of palpable mass obtained in a 53-year-old
woman demonstrates a well-defined mass
with homogeneous mobile low-level
internal echoes and posterior acoustic
enhancement (arrows). Aspiration yielded
benign cyst with inflammatory changes.
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Cyst with thin septations. Transverse sonogram (7.5 MHz) obtained in a 48-
year-old woman shows a large cyst with thin (<0.5 mm) septations
(arrowheads) that otherwise met the criteria for a simple cyst. This finding may
represent the continuum of the spectrum from apocrine metaplasia as the acini
fuse. Because it was large and tender, the cyst was aspirated to complete
resolution, and results of cytologic examination yielded benign cyst contents.
This recurred at 1-year follow-up.
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A complex breast cyst:
Sedimentary movement may be
visible by scanning the patient
erect.
Fine needle aspiration and
cytological assessment can
confirm the diagnosis. At the
least, a follow-up ultrasound
should be performed.

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Mass in or on the Skin
Usually clinically apparent, include : sebaceous
or epidermal inclusion cysts, keloids, moles,
neurofibromas, and accessory nipples.
Important to recognize the interface between
skin & parenchyma, and to establish that the
mass is at least partially within the thin
echogenic bands of skin.
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Breast cancer, ultrasonography.
Sonogram of the mass in Image 19
demonstrates a superficial, well-
circumscribed mass that was
pathologically a dermatofibrosarcoma.
It has a wider-than-tall orientation that
parallels the skin surface.
Breast cancer, ultrasonography.
Color flow Doppler image (displayed
in black and white) shows blood flow
in vessels within the mass (arrows).
The internal blood flow is consistent
with a solid mass, such as this
patient's dermatofibrosarcoma, but
not with a superficial sebaceous
cyst, protein-containing cyst, or
hematoma.
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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Foreign Bodies
Include marker clips, coils, wires, catheter slips,
silicone, metal / glass related to trauma.
History is helpful.

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Lymph Nodes - Intramammary
Oval masses resembling miniature kidneys.
Usually in posterior upper two thirds.
Size : 3-4 mm up to 1 cm.
Hypoechoic cortex and echogenic fatty hilum.
Cortex focal / diffusely thickened, or microcalcification (+)
 consider metastatic disease, infectious / inflammatory
process, lymphoma, leukemia, granulomatous disease,
connective tissue disordees

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The sonogram was obtained through
the long axis of a normal intramammary
lymph node in a woman's right breast
(arrow). The normal lymph node is oval,
not round, and has a normal relatively
thin, peripheral, hypoechoic cortex and
a prominent normal hyperechoic hilus.
This appearance has been compared to
the sonographic appearance of a
normal kidney.

This sonogram was obtained

though the short axis of the
intramammary lymph node shown
in Image 36. The relatively
hypoechoic cortex (white arrow)
surrounds the lymph node except
at the hilum (black arrow).

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Small intramammary lymph nodes are commonly seen.

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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Lymph Nodes - Axillary
Normal nodes : < 2 cm, hyperechoic fatty hilar.
Larger nodes normal if very thin cortical rim is seen
around the hilar fat.
Enlarged round LN or small / no fatty hilar abN
No special feature to distinguish a nodal metastasis
from a benign reactive node
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CLASSIFICATION CATEGORIES IN THE BI-RADS US SYSTEM

SPECIAL CASES
Vascularity
Comparison with contralateral normal area or
unaffected site in the same breast
No pattern in specific for diagnosis.
Vascularity : present or not present.
Vascularity immediately adjacent to the lesion,
diffuse increased vascularity in the tissue
surrounding the lesion, no vascularity. 35
 Echogenicity of various breast tissue
• Skin – hyperechoic
• Nipple – hypoechoic
• Parenchyma – hyperechoic
• Connective tissue – hyperechoic
• Subcutaneous fat – hypoechoic
• Fatty infiltration – hypoechoic
• Retromammary fat – hypoechoic
• Cooper ligament – hyperechoic
• Lactiferous ducts - anechoic
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 Principal components of the female
breast
• Fat
• Parenchyma : alveoli, lactiferous ducts,
intralobar connective tissue
• Interlobar connective tissue

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 Parenchymal pattern in breast
ultrasound
• Homogenous hyperechoic pattern : young
women, good readability
• Heterogenous hyperechoic pattern : scant fatty
infiltration, middle-aged women, good /
moderate readability
• Partially involuted or involuted pattern :
predominantly hypoechoic with connective tissue
septa, older women, moderate readability
• Fibrotic pattern (heterogenous hypoechoic) :
young and middle-aged women, poor readability
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 Interpretation of mammographic
findings
Breast parenchyma ACR density I, III, III. IV

Focal densities Round, oval, smooth, sharp,

ill-defined, spiculated

Macrocalcifications and Disseminated, focal clusters,

microcalcifications clumped, rounded,
pleiomorphic
Benign-malignant BI-RADS categories I-V
differentiation

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 Interpretation of US findings
Architecture Homogenous / heterogenous

Background echotexture Fat

Fibroglandular
Mixed
Proportions of fat According to ACR
mammography classification
(I-IV)
Ducts Diameter (mm)
Smooth, irregular
Anechoic, low-level internal
echoes
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 LYMPH NODES
• Size  unreliable predictor of malignancy
• Sizes of normal & metastatis LN are highly
variable
• Level I : lateral to pectoralis minor
• Level II : behind the pectoralis minor muscle
• Level III : infraclavicular LN medial to the
pectoralis minor

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 Gross anatomy of the female breast
• Skin
• Subcutaneous fat
• Cooper ligaments
• Superficial mammary fascia
• Breast parenchyma with : lobules, lactiferous ducts,
interlobar connective tissue, fat
• Deep mammary fascia
• Retromammary fat
• Muscle fascia
• Pectoralis major muscle
• Pectoralis minor muscle
• Ribs and intercostal muscle
• Pleura
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 Standard protocol for Breast US
Examination
INFORMATION INCLUDED IN THE CLINICAL HISTORY
• Menarche, menopasue
• Menstrual history
• Obstetric history
• Medications, including hormones
• Family rick factors
• Prior operations and histology
• Prior gynecologic disorders
• Reasons for seeking medical attention
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44
 References
• The Practice of Breast Ultrasound
• www.emedicine.com
• www.ultrasound-images.com
• www.ultrasoundpaedia.com

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shows prominent and dilated
mammary ducts in the lactating
breast. The ducts are seen as
tubular hypoechoic structures,
which widen as they approach the
nipple. Sometimes, it may be
possible to see fat drops within the
milk secretions in the ducts. These
appear as mildly echogenic debris
within the ducts

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These ultrasound images reveal a hypoechoic, poorly
defined, irregular mass in the breast. There is also
evidence of acoustic shadowing posteriorly. These
findings on sonography suggest malignant mass of the
breast.

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The above ultrasound images show a
typical proven case of cancer of the
left breast. The tumor is seen as a well
defined hypoechoic mass with
microlobulation or fine irregularities of
the margins. In addition, the mass
shows multiple echogenic areas along
the rim a clear sign of malignancy in
breast carcinoma.
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The breast in this patient showed multiple cystic lesions on sonography.
Remarkably, there is acoustic shadowing posterior to the cyst. Clear fluid
contents are seen within the cystic lesions. Mammogram of the breast shows
rounded lesions with rim calcification, which can explain the acoustic
shadowing on sonography. Ultrasound images and mammogram suggest
calcific oil cysts of the breast. Oil cysts are produced due to fat necrosis with
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liquefaction and subsequent cyst formation, usually following trauma.
This young female, lactating patient presented
with slowly enlarging mass of the right breast. It
was non tender and patient had no h/o pyrexia.
Sonography of the breast shows a 3 cms. sized
hypoechoic (almost cystic) lesion with through
transmission. Color doppler images of the breast
showed no signficant enhancement of
vascularity. These ultrasound images of the
breast suggest Galactocele. Galactoceles are
formed by cystic dilatation of the lactiferous
ducts and contain milk. They are seen in
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lactating women.
This ultrasound image
shows a galactocele with
a fat-fluid level s/o
galactocele. The
echogenic material is
seen to move with change
in posture (arrowed).

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Ultrasound imaging of the right breast was done on this your lactating female. She
presented with pain and swelling of the right breast and underwent drainage of an
abscess. The symptoms recurred for which she underwent sonography. Ultrasound
images of the breast reveal a rounded, almost anechoic lesion with posterior acoustic
enhancement. The lesion measures 2 cms. and has irregular but well defined walls. No
internal septae are present. Color Doppler images suggest some increase in vascularity
along the rim of the lesion. However, the vascularity may not be prominent due to
medication with anti-inflammatory drugs and antibiotics. These ultrasound findings
suggest an abscess of the breast.
Another similar lesion is a simple cyst of the breast, which would have well defined but
smooth walls. It may also be difficult to differentiate abscess from galactocele of the
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breast. Carcinoma of breast would appear hypoechoic but not anechoic (as in abscess).
This young female patient presented with a palpable,
non-tender, freely mobile small mass of the right
breast. On sonography of the breast, the mass
appeared, oval, measured 10 x 5 mm. and showed
smooth margins which were well defined. The lesion
was non-calcific and seemed extremely mobile on
probe pressure. These ultrasound images are
suggestive of fibroadenoma of the breast. The Power
Doppler image (bottom right), shows poor vascularity
of the lesion.

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These ultrasound images of the left breast in a 15 yr. old female patient show
a large (the mass measured 8.2 cms.), more or less homogenous, well
defined mass with posterior acoustic enhancement. These findings suggest a
diagnosis of giant fibroadenoma of the left breast. The main differential
diagnosis in such a case would be phyllodes tumor. However, phyllodes
tumor is seen in females over 30 yrs. of age. Despite the rapid increase in
size of the mass, in this case, the potential for malignancy is very low.

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his young female patient presented with
pain in the right breast and "lumpy feeling"
on palpation. Sonography of the right
breast showed a hypoechoic, lobulated,
well defined mass in the breast. A few
anechoic spaces (cystic areas) were also
present. Such ultrasound images
(appearances) are usually seen in
fibroadenosis of the breast. Fibroadenosis
is characterized by pain breast with or
without palpable masses (lumps). On
histopathology, there may be microcysts,
fibrosis, adenosis of hyperplastic changes
of the breast epithelial tissue. Repeat/
follow up ultrasound would usually show
resolution of the mass (usually after 1 to 2
months). It is often difficult to distinguish
fibroadenoma from fibroadenosis purely on
the basis of sonography alone.

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Breast implants are mainly of two types- the older silicon gel implants and
the newer saline implants. The ultrasound image (see case-1)
shows the silicon gel implant in the right breast. A small amount of fluid
(seroma) is commonly seen around the breast implant for some time after
the procedure

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Case -2, shows more ultrasound images
(panoramic view) with the implant seen as
a large hypoechoic sac in the breast. Again
some fluid is seen around the implant. This
appearance (fluid around the breast
implant) may signify the presence of a
small leak from the implant. However this
patient did not show more specific signs of
implant rupture such as radial folds from
the implant surface
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